TUBERCULOSIS 
 
 as a Disease of the Masses 
 &.nd How to CombaJ it 
 
 PRIZE ESSAY 
 
 OF THE INTERNATIONAL TUBERCULOSIS CONGRESS 
 Berlin 1899 
 
 S. ADOLPHUS KNOPF, M.D 
 
 NEW YORK 
 
 FIFTH AMERICAN EDITION 
 
 Revised and Enlarged. 1908
 
 I 
 
 [x&x^xxxjL&xjLXJtXfZ 
 
 Presented by 
 Thomas F. Dailey 
 
 COLLEGE OF OSTEOPATHIC PHYSICIANS 
 AND SURGEONS LOS ANGELES, CALIFORNIA
 
 TUBERCULOSIS 
 
 AS A DISEASE OF THE MASSES 
 AND HOW TO COMBAT IT 
 
 FIFTH EDITION REVISED 
 AND ILLUSTRATED 
 
 With Supplement on Home Hygiene, School 
 Hygiene, Installation of the Sanatorium 
 Treatment at Home, and a Histor- 
 ical Review of the Anti -Tu- 
 berculosis Movement in 
 the United States 
 
 Motto: To combat consumption as a disease of the masses 
 successfully requires the combined action of a Wise govern- 
 ment, well trained physicians, and an intelligent people. 
 
 PRIZE ESSAY 
 S.^DOLPHUS 
 
 ft? 
 
 NOPF, M.D., New York 
 
 Professor of Phthisio-therapy at the New York Post-Graduate Medical School 
 
 and Hospital ; Director in the National Association for the Study and 
 
 Prevention of Tuberculosis ; Associate Director of the Clinic for 
 
 Pulmonary Diseases of the Health Department ; Visiting 
 
 Physician to the Riverside Sanatorium for Con- 
 
 sumptives of the City of New York, etc. 
 
 The "International Congress to Combat Tuberculosis as a Disease of the 
 Masses," which convened at Berlin, May 24th to 27th, 1899, awarded the 
 International Prize to this work through its Committee on July 31st, 1900 
 
 AMERICAN EDITIONS 
 
 Fir* Edition. 1901; Second Edition. 1 903 ; Third Edition. 1905 ; Fourth Edition. 1 907 ; 
 Fifth Edition. Revised and Enlarged, with Supplement. 1 908 
 
 Published by FRED. P. FLORI, 16 W. 95th St., New York 
 
 Also for Sale by "THE SURVEY" formerly 
 
 "CHARITIES AND THE COMMONS" 
 105 E. 22d St., New York, and 628 Unity Bldg., Chicago 
 
 1909
 
 V\J 
 
 
 Copyright, 1901 
 By S. A. KNOPF. M.D. 
 
 NEW YORK 
 
 LIST OF TRANSLATIONS 
 
 The American edition is translated by the Author and published 
 
 by Fred. P. Flori, 16 West 95th Street, New York. 
 The Arabic Edition is translated by Dr. Mary P. Eddy, Beirut, 
 
 Syria, and published by the Board of Foreign Missions of 
 
 the Presbyterian Church. 
 The Brazilian edition is translated by Dr. Clemento Ferreira, and 
 
 published by the " Revista Medica de Sao Paulo," Brazil. 
 The Bulgarian edition is translated and published by Professor 
 
 A. Bezenseck, of Philippopel. 
 The Chinese edition is translated by Dr. Geo. A. Stuart, of the 
 
 Nankin University, and published by the Chinese Medical 
 
 Missionary Association, Nankin. 
 The Dutch edition is translated by Dr. J. W. F. Donath, and 
 
 published by F. Van Rossen, Amsterdam. 
 The English edition is adapted for use in England by Dr. J. 
 
 M. Barbour, and published by Rebman, Limited, 129 
 
 Shaftesbury Avenue, London. 
 The Finnish edition is translated by Dr. Johannes Moving and 
 
 L. Rosendahl, P.M., and published by Dr. Johannes 
 
 Moving, New York. 
 
 The French edition is translated by Dr. Q. Sersiron, and pub- 
 lished at Paris by G. Masson, 120 Boulevard Saint Germain. 
 The German edition is published by the "German Central Com- 
 mittee for the Combat of Tuberculosis," at Berlin, 9 Eich- 
 
 horn Strasse. 
 The Hebrew edition is translated by Dr. L. W. Zwisohn, and 
 
 published by E. Zunser, 1 58 East Broadway, New York. 
 The Hungarian edition is translated by Dr. Wm. Roth-Schulz, 
 
 and published by Mai Henrik es Fia, Budapest. 
 The Icelandic edition is translated by Dr. G. Bjornsson, and 
 
 published by the Danish Government at Reykjavik. 
 The Italian edition is translated by Prof. Dr. Roberto Massa- 
 
 longo, of Verona, and published at Milan by Francesco 
 
 Valardi. 
 Another Italian edition is translated by Dr. Giovanni Galli, and 
 
 published by the Societa Editrice Dante Aligliieri, at Rome. 
 The Japanese edition is translated by Dr. Goro Shibayama, 
 
 Tokio. 
 The Mexican edition is translated by Dr. D. Vergara Lope, and 
 
 published by Eduardo Murguia, Mexico. 
 The Norwegian edition is translated and published by Dr. A. 
 
 C. Amundson, of Cambridge, Wisconsin, U. S. A. 
 The Polish edition is translated by Dr. Stanislaus Lagowsky, 
 
 and published by E. Wende i S-ka, Warsaw. 
 The Russian edition is translated by Dr. F. M. Blumenthal, and 
 
 published under the auspices of the Pirogoff Society of 
 
 Russian physicians by A. A. Levenson, at Moscow. 
 The Second Russian edition is translated by B. I. Wender, and 
 
 published by P. I. Makuschin, Tomsk, Siberia. 
 The Serbian edition is translated by Drs. V. P. Popovic and V. 
 
 Vojislav Mihailovic, Graz, and published by Paher & Kick, 
 
 at Mostar. 
 The Spanish edition is translated by Dr. Ernesto Sanchez y 
 
 Rosal, and published by Ernst Litfass' Erben, Berlin C. 
 The Swedish edition is translated and published by Dr. Johannes 
 
 Hoving, New York. 
 The Turkish edition is translated by Dr. Mary P. Eddy, of 
 
 Beirut, Syria, and published by the Translator. 

 
 PREFACE TO THE GERMAN EDITION. 
 
 (By GEH. MED. -RATH PROFESSOR B. FRANKEL, of Berlin, Germany, setting 
 forth the conditions under which the prize was awarded.) 
 
 AT the meeting of the " International Congress for the Study 
 of the Best Way to Combat Tuberculosis as a Disease of the 
 Masses " which convened at Berlin, May 24-27, 1899, the sum 
 of 4,000 marks was donated by two Berlin merchants, lay mem- 
 bers of the Congress, as a prize to be offered for the best essay on 
 the subject " Tuberculosis as a Disease of the Masses and How to 
 Combat It " (" Die Tuberkulose als Volkskrankheit und deren 
 Bekampfung "). 
 
 The Congress decided on the following regulations concerning 
 this prize: 
 
 1. The best popular essay on the subject "Tuberculosis as a Disease 
 
 of the Masses and How to Combat It," comprising not more 
 than eighty, and not less than forty-eight, printed pages, shall 
 receive the prize of 4,000 marks. In case the jury of the 
 prize committee should decide that two essays deserve the 
 prize, the best may receive 3,000 marks, and the second best 
 1,000 marks. Or, should the decision of the judges find two 
 essays of equal value, each shall receive 2,000 marks. 
 
 2. The following gentlemen have consented to act as judges : Ge- 
 
 heimrath Prof. Dr. B. Frankel; Geheimrath Prof. Dr. Ger- 
 hardt; Kapitan z. S. Harms; Wirkl. Geh. Ober Eeg.-Kath 
 President Kb'hler; Generalarzt Prof. Dr. von Leuthold, 
 Excellenz; Geheimrath Prof. Dr. von Leyden; Freiherr Dr. 
 Lucius von Ballhausen, Excellenz; Geheimrath Dr. Nau- 
 mann ; Oberstabsarzt Dr. Pannwitz ; Dr. Graf von Posadow- 
 sky-Wehner, Excellenz; Se. Durchlaucht der Herzog von 
 Ratibor.
 
 ^ * v 
 
 x \ 
 
 \| PREFACE ^TO THE GERMAN EDITION. 
 
 ^ ^ vS >* Nt, < V 
 
 3. All essays must be sentNpy jbecemoer 1, 1899, to Privy- 
 
 \Councillor Prof. Dr. B. FrankqJ, 4 Bellevue yStrasse.^ Berlin, 
 and eacji essVy must bear -t^mo'tto, Selected ^ the writer, 
 who shall insert his name within a sealed envelope having the 
 motto on the cover. 
 
 4. The essay, or essays (see 1), to which has been awarded 
 
 the prize, become the property of the "German Central Com- 
 mittee for the Erection of Sanatoria." The latter will take 
 upon itself the printing of the essay and the least expensive 
 method of distribution. 
 
 5. The decision of the judges is to be announced through the 
 
 public press. 
 
 The foregoing regulations were published in the medical and 
 lay papers, and as a result eighty-one essays were received by 
 December 1st. The essays were distributed among the judges 
 with the request to select from them such as were deserving of 
 closer examination. The judges recommended twenty-six for that 
 purpose. 
 
 The fifty-five rejected essays were once more examined by the 
 indersigned and his assistants, Drs. Edmund Meyer, Alexander, 
 Finder, Claus, and Elwert, but these gentlemen could not recom- 
 mend any of the fifty-five essays for further consideration. 
 
 At the meeting of the jury on February 25, 1900, under the 
 presidency of his Serene Highness the Duke of Piatibor, it was 
 decided that the twenty-six selected essays should be once more 
 carefully examined by Drs. Frankel, Gerhardt, Harms, Kb'hler, von 
 Leuthold, von Leyden, Freiherr von Lucius and Pannwitz, and the 
 result was that three were ultimately selected for closer choice. 
 
 At the next meeting of the judges, on June 15th, it was decided 
 to form a sub-committee composed of Drs. Frankel, Gerhardt, 
 Harms, Kbhler, and Pannwitz, to decide upon final action. After 
 careful consideration this committee came to the conclusion that 
 the work bearing the motto, 
 
 "To combat consumption successfully requires the combined action of a 
 wise government, well-trained physicians, and an intelligent people," 
 
 so much surpassed all the others in excellence, that it should be
 
 PREFACE TO THE GERMAN EDITION. $ 
 
 awarded the Congress prize. It was then found that Dr. S. A. 
 Knopf, of New York, was the author of this work. 
 
 A few changes, as recommended by the judges, were accepted by 
 Dr. Knopf, and have been incorporated in the present work. 
 
 At a .subsequent meeting of the German Central Committee it 
 was resolved to publish this essay and arrange for its widest dis- 
 tribution. 
 
 PROFESSOR B. FRANKEL. 
 
 BERLIN, October 1, 1900. 
 
 PREFACE TO THE FIRST ISSUE OF THE 
 AMERICAN EDITION. 
 
 IN presenting to the English-speaking world, and particularly 
 to the people of the United States, a translation of the essay, 
 originally written in German, the author desires to state that, 
 while having endeavored to make as exact a translation as possi- 
 ble, he found it necessary to change several passages, making 
 some additions and omissions. His reasons for having done so 
 will be obvious to all who have studied pulmonary tuberculosis or 
 consumption, not only in its medical, but also in its sociological 
 aspects, and who will bear in mind the fact that the habits of na- 
 tions differ, and that in a popular essay it is absolutely necessary to 
 take these differences into account. Thus it was even necessary, 
 before the original German essay could appear in print, that the 
 author should consent to make certain changes bearing on the 
 particular local conditions and situation of the consumptive poor 
 in Germany. These changes were suggested in detail by the 
 judges who awarded the prize. With a generosity which cannot 
 be lauded too highly, these gentlemen did not expect to find in the 
 essays, submitted to them for competition from all over the world, 
 a complete knowledge of the sanitary laws and regulations which 
 are now in vogue in the German empire, nor did they expect the 
 essayists to be familiar with local conditions to the extent of
 
 6 PREFACE TO THE ENGLISH TRANSLATION. 
 
 knowing all that would or would not be practicable in the cany- 
 ing out of suggestions to prevent the spread or the development of 
 tuberculous diseases. 
 
 The social conditions in Germany differ very much from those 
 in the United States, and the author felt it his duty to speak in 
 this American edition of all the important points bearing directly 
 on the question of tuberculosis as a " social disease " in America. 
 The evils of alcoholism, of the overcrowding of tenement houses 
 and of unsanitary dwellings of the poor in general, also some of 
 the causes of malnutrition or underfeeding of the laboring classes, 
 are treated as fully as the nature of such an essay permits. 
 
 As an example of the necessity of making certain changes in 
 this work, intended for an American public, I may be permitted 
 to state the following : in Germany every laboring man and wom- 
 an must be insured against old age, accident, and disease, includ- 
 ing tuberculosis, and the employer is held responsible for the 
 compliance with this law. No such laws exist in the United 
 States, where even private insurance companies will not insure a 
 tuberculous invalid. As another illustration of the vastly different 
 conditions here and in Germany regarding our subject, we must 
 consider that every one of the forty-seven States of the Union has 
 its own sanitary laws and regulations. They differ widely in rigor 
 and completeness in regard to the prevention of tuberculosis in 
 man as well as in beast. In Germany there is one homogeneous 
 law for all the states and provinces ; there is a ministry for " Medic- 
 inal Angelegenheiten " (medical affairs) with a cabinet officer at 
 the head, who has for his advisers the highest medical authorities 
 connected with the " Eeichs-Gesundheitsamt " (imperial office of 
 health). I hope the time is not far distant when our own be- 
 loved country will have similar institutions ; when all the State, 
 county, and city boards of health will look to Washington, the 
 seat of the future secretary of public health, as their supreme head 
 and guide in medical and sanitary matters. In the mean time let 
 us kbor as best we can ; let each State, county, and city board of 
 health do its best toward an intelligent, rigorous, and yet not too 
 oppressive public prophylaxis of bovine and human tuberculosis; 
 and let the people at large lend a willing hand in this combat 
 against our common foe, the "Great White Plague." 
 
 S. A. KNOPF, M.D. 
 
 16 WEST NINETY-FIFTH STREET. NEW YORK, January, 1901.
 
 PREFACE TO THE FOURTH AMERICAN EDITION. 
 
 AFTER three issues of the American edition of this essay have 
 been printed without any material change from the original trans- 
 lation of the German edition, I am confronted with the problem 
 of either writing a new edition or making a supplement which will 
 contain what is new and of interest to the Medical Profession and 
 the Public. I have decided to present the matter in the form of 
 a supplement which will contain what had to be left out of the 
 original edition because the jury of the Berlin tuberculosis congress 
 limited the number of printed pages, and also the most important 
 things that the experience of seven more years in tuberculosis 
 work has taught me. Thus I have added two paragraphs, one on 
 Home Hygiene, and one on School Hygiene. An equally valuable 
 addition I hope will be found in the chapter added on the Instal- 
 lation for the Sanatorium Treatment at Home. Lastly, there 
 will be a short historical review of the anti-tuberculosis movement 
 in the United States from its beginning to the present day. 
 
 My reason for adding these four new chapters in the form of a 
 supplement, instead of inserting them in the text, is purely an eco- 
 nomical one. Inserting them would increase the cost of the book 
 materially, while by writing a supplement the book can still be 
 sold at retail for $0.25 paperbound and $0.50 clothbound, and at 
 wholesale correspondingly cheaper. There are enough good books 
 on tuberculosis in the market costing $2.00, $3.00, and $5.00, in- 
 tended to inform the layman; but for the masses, who need this 
 information most, there are few at a price within their reach. 
 
 In this connection I must explain why this essay has not been 
 published by one of the well-known firms handling medical and 
 popular scientific books. The low price at which I insisted the 
 book should be put on the market seemingly did not insure suffi- 
 cient remuneration to the various firms to whom I applied. But 
 I was fortunate enough to interest a former secretary of mine, Mr. 
 Fred. P. Flori, who has undertaken the publishing and selling of 
 the book at this low price. I desire to thank him for the interest 
 and devotion which he has brought to the task. 
 
 I must not send out this little volume without expressing my 
 sincerest thanks and appreciation to Drs. Barbour, Bezenseck, 
 Bjornsson, Blumenthal, Donath, Eddy, Ferriera, Galli, Hoving, 
 Lagowsky, Lope, Massalongo, Mihailovic, Popovic, Rosendahl, 
 Roth-Schulz, Rosal, Sersiron, Shibayama, Wender, and Zwieshon, 
 who have honored me by translating the essay into their native 
 languages. "Tuberculosis as a Disease of the Masses and How to
 
 8 PREFACE TO THE AMERICAN TRANSLATION. 
 
 Combat it" is now printed in twenty-one different languages, thus 
 reaching people in all parts of the civilized world. 
 
 It is particularly gratifying to me that the much needed infor- 
 mation which this little book is intended to give, has been so far- 
 reaching. The original German edition has been reprinted many 
 tunes and largely distributed by the German Government, for 
 which I have now a second edition in preparation. Five thousand 
 copies of this present issue are to be sent to the Health Officers 
 of this State for distribution. I wish to thank Dr. Eugene H. Porter, 
 the present Commissioner of the Department of Health of the State 
 of New York, for his efforts in causing this to be done, thus giving 
 his official approval to the work. 
 
 May this edition meet with the same kind reception accorded to 
 the previous editions, and may the information which the book is 
 intended to convey be helpful to physicians and patients, teachers 
 and parents, statesmen, employers and employees, to rich and poor, 
 in short to all able and willing to help in the solution of the tu- 
 berculosis problem, and thus add to the health, prosperity and 
 happiness of all the people. S. A. KNOPF, M.D. 
 
 16 WEST NINETY-FIFTH STREET, NEW YORK, April 1, 1907. 
 
 PREFACE TO THE FIFTH EDITION. 
 
 There has been of late in the United States a decidedly increased 
 awakening in the field of the antituberculosis work. Educational 
 propaganda, too, has received a great deal of attention. The fourth 
 edition of this little work, which appeared in April, 1907, and of 
 which 10,000 copies were issued, was exhausted before the year 
 came to an end. I am deeply grateful to the Medical Profession and 
 the Public at large for the continued kind reception of my modest 
 contribution. The present fifth edition has been again carefully 
 revised, changes made where that was necessary, and important 
 events relating to antituberculosis work in the United States have 
 been added to the historical chapter of the book. 
 
 May this edition, like its predecessors, continue to have its little 
 share in the combat against the great white plague, and may the 
 total eradication of this disease at last become a reality. 
 
 S. A. KNOPF, M.D. 
 
 NEW YORK, February, 1908.
 
 TABLE OF CONTENTS. 
 
 CHAPTER PAGK 
 
 Preface to the German Edition 1 
 
 Preface to the First American Edition 5 
 
 Preface to the Fourth American Edition (with Supplement) .... 7 
 
 Preface to the Fifth American Edition 8 
 
 Introduction 11 
 
 I. What Is Consumption ? 15 
 
 II. How may the Germ of Consumption (Bacillus Tuberculosis) Enter 
 
 the Human System ? 16 
 
 III. How does the Inhalation of the Bacilli Take Place ? 16 
 
 IV. What must be Done to Check the Spread of Consumption Caused 
 
 by the Expectoration of Pulmonary Invalids ? 17 
 
 A. Destruction of Tuberculous Expectoration. 
 
 B. Disinfection of the Sick-Room. 
 
 V. What can be Done to Protect Ourselves from the Small Particles of 
 Saliva Containing Bacilli, Thrown Out by the Consumptive Dur- 
 ing Dry Cough, Loud Speaking, or Sneezing ? 23 
 
 VI. How may Man Give Tuberculosis to Animals ? 24 
 
 VII. How can We Guard Against Germs of Tuberculosis in Our Food ? 25 
 VIII. In What Other Ways may the Bacilli or Germs of Consumption 
 
 Enter the Intestinal Tract ? 26 
 
 IX. How may Tuberculosis be Contracted through Inoculation (Pene- 
 tration of Tuberculous Substances through the Skin)? 27 
 
 X. What Other Forms of Tuberculosis Exist, and What are Their 
 
 Principal Symptoms ? 28 
 
 XI. What Protects the Healthy Individual from Contracting Tubercu- 
 losis ? 30 
 
 XII. How may One Successfully Overcome a Hereditary Disposition to 
 
 Consumption ? 31 
 
 XIII. How can a Predisposition to Tuberculosis, Other than Hereditary, 
 
 be Created or Acquired ? 41 
 
 XIV. How may an Acquired Predisposition be Overcome, and Seemingly 
 
 Unhealthy Occupations Made Relatively Harmless ? 42 
 
 XV. What can Well-Meaning and Conscientious Employers in City and 
 
 Country Do to Help Combat Tuberculosis ? 43 
 
 XVI. What can the Farmer and Dairyman Do to Diminish the Frequency 
 of Tuberculosis among Animals, and Thus Indirectly Stop the 
 Propagation of the Disease among Men ? 45 
 
 XVII. What are the Occupations in Which Tuberculous Invalids, Even 
 
 in the First Stages of the Disease, Should Not be Employed ?. . 65 
 
 XVIII. What are the Main Signs and Symptoms of the Beginning of Tuber- 
 culosis of the Lungs or Consumption ? 66
 
 10 TABLE OF CONTENTS. 
 
 CHAPTER PAGE 
 
 XIX. What are the Early Symptoms of Other Forms of Tuberculosis ? 57 
 XX. How can Children be Protected from Scrofula and Other Forms 
 
 of Tuberculosis ? 69 
 
 XXI. Can Tuberculosis, Especially in Its Pulmonary Form, or Con- 
 sumption of the Lungs, be Cured? 61 
 
 XXII. Have the Former Patients Who Left Sanatoria or Special Insti- 
 tutions for the Treatment of Consumption as Cured, Kemained 
 Lastingly So ? 62 
 
 XXIII. What are the Modern Methods to Treat and Cure Consumption ? 63 
 
 XXIV. What is a Modern Sanatorium for Consumptives? And can Such 
 
 a Sanatorium Become a Danger to the Neighborhood ? 65 
 
 XXV. What are State Sanatoria? And What are " Volksheilanstalten 
 
 or People's Sanatoria ? 71 
 
 XXVI. What Evidence Exists That by Taking Care of Consumptives in 
 Special Institutions and by Hygienic Measures, Tuberculosis 
 as a Disease of the Masses can Really be Successfully Com- 
 bated ? 72 
 
 XXVII. Can the Treatment of Consumption be Carried Out with Satis- 
 factory Results Outside of an Institution ? 73 
 
 XXVIII. What can Philanthropists and Other Men and Women of Good 
 Will Do to Help Combat Tuberculosis as a Disease of the 
 
 Masses ? 76 
 
 XXIX. How Might the Tuberculosis Problem in the United States be 
 Solved by Judicious Legislation and a Combination of Public 
 
 and Private Philanthropy ? 80 
 
 XXX. Conclusions , 86 
 
 SUPPLEMENT. 
 
 A. Home Hygiene to Prevent Tuberculosis 87 
 
 B. School Hygiene as a Factor in the Prevention of Tuberculosis. . . 89 
 
 C. Installation for the Sanatorium Treatment of Consumptives at 
 
 Home 95 
 
 D. Historical Review of the Antituberculosis Movement in the 
 
 United States.. . 101
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 AND HOW TO COMBAT IT. 
 
 INTRODUCTION. 
 
 TUBERCULOSIS has been called a disease of the masses on account 
 of its great prevalence among all classes of people. It has been " onca 
 known for hundreds of years as the most feared, most prevalent, 
 and, alas ! also as the most fatal of all diseases. Hippocrates, the 
 most celebrated physician of antiquity (460 to 377 B.C.), and the 
 true father of scientific medicine, described pulmonary tuberculosis 
 or consumption as the disease which is " the most difficult to treat, 
 and which proves fatal to the greatest number." Isocrates, also a 
 Greek physician, who Eved about the fifth century before Christ, 
 was the first to write of tuberculosis as a disease transmissible 
 through contagion. In the middle ages (1550) the celebrated 
 physician Montano declared consumption to be one of the most 
 dangerously contagious and most easily contracted of diseases. An 
 equally strong advocate of the theory of contagion was the cele- 
 brated anatomist Morgagni (1682-1771), who never performed an 
 autopsy on an individual who had died from tuberculosis. Toward 
 the end of the eighteenth century the sanitary authorities of some 
 cities of Italy and France considered consumption a highly in- 
 fectious and contagious disease, and a French medical author of 
 the name of Janett de Langrois reports that the municipal au- 
 thorities of Nancy had caused the furniture and bedding of a wom- 
 an who had died from consumption, to be destroyed by fire. The 
 contagion in this case had actually been demonstrated, inquiries 
 revealing that the deceased woman had slept frequently with a 
 consumptive girl friend until she finally succumbed to the same 
 disease.
 
 12 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 In Naples a royal decree, dated September 20, 1782, ordered 
 the isolation of consumptives and the disinfection of their apart- 
 ments, personal effects, furniture, books, etc., by means of vinegar, 
 brandy, or lemon juice, sea-water, or fumigation. Any violation 
 of this law was punished, if the individual was an ordinary mor- 
 tal, with three years in the galleys, and if he happened to be a 
 nobleman he was sent for the same time to the fortress and had 
 to pay 300 ducats. The physician who failed to notify the au- 
 thorities of the existence of a tuberculous patient was fined 300 
 ducats for the first offence, and a repetition of the neglect would 
 banish him from the country for ten years. According to Portal 
 (1742-1832), there was a kw in Spain and Portugal which obliged 
 the parents or nearest relative of a consumptive to notify the au- 
 thorities when the patient had arrived at the last period of the dis- 
 ease. This was done for the purpose of making sure of the disin- 
 fection of the personal effects of the patient after his death. 
 
 In the first half of the nineteenth century little attention was 
 paid to the infectious theory of tuberculosis even by medical men. 
 The contagiousness or communicability of the disease could not be 
 scientifically demonstrated, and although there were physicians 
 here and there who believed in the iufectiousness of the disease, 
 nothing positive was taught in regard to it at the centres of medi- 
 cal learning. 
 
 At last, in 1865, the French physician Villemm demonstrated 
 beyond a shadow of doubt that tuberculosis could be transmitted 
 from one individual to another. He inoculated animals with tu- 
 berculous substances and reproduced tuberculosis not only in the 
 lungs but also in other portions of the body. Since this discovery 
 and its verification by numerous experimenters, such as Cohnheim, 
 Welch, Prudden, Straus, and others, it has been generally ac- 
 knowledged that tuberculosis is an infectious disease, and that for 
 its production a specific germ is essential. The discovery of this 
 specific organism (bacillus tuberculosis) was reserved to the great 
 German scientist Eobert Koch (1882). 
 
 Consumption is an endemic disease, that is to say, habitually 
 prevalent, and it exists in all civilized countries. Wild tribes and 
 less civilized people succumb to the disease, as a rule, very rapidly
 
 AND HOW TO COMBAT IT. 
 
 13 
 
 as soon as they come in contact with civilization. The proof of 
 this we might find among the North American Indians and among 
 the negroes and their descendants now living in the United States. 
 According to the recent report of the Board of Health of Toronto 
 (Canada), pulmonary tuberculosis is dangerously prevalent among 
 the Blood Indians of the Dominion of Canada. Of every hundred 
 deaths which occurred among this tribe in the year 1898, twenty- 
 three were due to consumption. Since these Indians are kept on 
 a reservation under the supervision of the Canadian Government, 
 these statistics should be considered reliable. 
 
 The mortality from tuberculosis among the colored population of 
 the United States is nearly twice that of the white population. 
 However, let us state right here that the cause of this increased 
 mortality among Indians and negroes is to be ascribed not to the 
 blessings of civilization, but rather to the vices, such as alcoholism 
 and excesses of all kinds, which, alas ! too often accompany civil- 
 izing agents. 
 
 There have been so many statistics published concerning the 
 general mortality from tuberculosis in the United States and Eu- 
 rope, that we do not think it necessary to reproduce in detail any 
 of the published tables, but will content ourselves with some gen- 
 eral statements. It is now universally admitted that tuberculosis 
 is the most frequent cause of death. According to some statistics 
 every seventh, according to others every sixth, death is due to tu- 
 berculosis in one form or other. According to Dr. George F. 
 Keene, of Ehode Island, who is a very close observer, the annual 
 tribute of the United States to this scourge is over 100,000 of its 
 inhabitants. Each year the world yields up 1,095,000, each day 
 3,000, each minute 2 of its people as a sacrifice to this plague. 
 
 Tuberculosis occurs most frequently in its pulmonary form, com- 
 monly known as consumption. According to the Imperial Sani- 
 tary Office of Berlin, thirteen per cent, of the deaths (during the 
 years from 1888 to 1892) were due to pulmonary consumption. 
 However, it must be stated that of late the mortality from tuber- 
 culosis has decreased in some European and American cities (Ber- 
 lin, London, New York, Philadelphia, etc.), thanks to better pre- 
 ventive measures and more rational methods of treatment. In one 
 
 Consump- 
 tion an 
 
 Endemic 
 Disease. 
 
 A Few 
 
 Statistics.
 
 14: 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Congresses 
 
 for the 
 Study and 
 Combat of 
 Tuberculo- 
 sis. 
 
 of the succeeding chapters we shall speak more in detail of public 
 prophylaxis and special institutions for consumptives in the combat 
 against tuberculosis. In relation to statistics we desire, lastly, to 
 mention only some interesting facts gleaned from a pamphlet pub- 
 lished last year by the Imperial Health Office of Berlin. Accord- 
 ing to this latest report the mortality from tuberculosis is greatest 
 in Eussia and Austria, being more than 3,500 per million inhabi- 
 tants. It is lowest in England, being less than 1,500 per million. 
 Germany occupies about the middle, while France comes immedi- 
 ately after Austria.* 
 
 The researches of recent years have demonstrated that consump- 
 tion and also many other forms of tuberculosis may not only be 
 prevented, but can in many cases be arrested and lastingly cured. 
 The governments and the medical profession are aware of this, and 
 have laboriously, energetically, and most unselfishly worked in the 
 direction of solving this important problem, which means so much 
 to the welfare of the people. The Congresses for the Study of 
 Tuberculosis, which have met biennially since 1888 in Paris; the 
 International Congress, which convened at Berlin in May, 1899, 
 under the protection of her Majesty the Empress of Germany, and 
 the Italian Congress, which was called together for the same pur- 
 pose last year in Naples, give the best proof of the zeal of the 
 medical profession and the governments to combat tuberculosis 
 with all possible means. 
 
 But, as the motto of this essay expresses it, the intelligent co- 
 operation of the people in this work is indispensable. To enable 
 all men and women to participate intelligently in this combat 
 against a common foe is the purpose of this essay. 
 
 We shall now give a brief description of the form of tuberculosis 
 known as tuberculosis of the lungs, pulmonary tuberculosis, or 
 consumption. 
 
 * The United States was not included in this table, but would probably 
 oome close to Germany.
 
 AND HOW TO COMBAT IT. 
 
 15 
 
 CHAPTER I. 
 
 WHAT is CONSUMPTION? 
 
 Pulmonary consumption, or tuberculosis of the lungs, is a chronic 
 disease caused by the presence of the tubercle bacillus, or germ 
 of consumption, in the lungs. The disease is locally charafc- 
 terized by countless tuber- 
 cles, that is to say, small 
 rounded bodies, visible to the 
 naked eye. The bacilli can 
 be found by the million in 
 the affected organ. It is 
 this little parasite, fungus, 
 or mushroom, belonging to 
 the lowest scale of vegetable 
 life, which must be consid- 
 ered as the specific cause of 
 all tuberculous diseases. This 
 parasite not only gradually 
 destroys the lung substance 
 through ulcerative processes, 
 but gives off at the same time certain poisonous substances called 
 toxins which give rise to various, and often serious, symptoms. 
 
 The important symptoms of pulmonary tuberculosis are cough, 
 expectoration (spitting phlegm), fever (increased temperature of 
 the body, especially in the evening hours), difficulty in breathing, 
 pains in the chest, night-sweats, loss of appetite, hemorrhages (spit- 
 ting of blood), and emaciation (loss of flesh). 
 
 In the matter expectorated, it is often possible to find the tubercle 
 bacillus with the aid of the microscope and certain coloring matters. 
 It appears in the form of small, slender rods. To give an idea of the 
 minute size of these bacilli or bacteria, we reproduce here what is 
 called a microscopic field twelve hundred times enlarged ; in other 
 words, just what one sees after having prepared a small portion 
 of expectorated tuberculous matter under the microscope. The 
 
 FIG. 1. Tubercle Bacilli in Expectorated Matter. 
 1,300 times enlarged.
 
 16 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 rods represent the bacilli; the round or irregular bodies represent 
 other substances which have been ejected along with the bacilli 
 (Fig. 1). 
 
 CHAPTER II. 
 
 HOW MAY THE GERM OF CONSUMPTION (BACILLUS TUBERCU- 
 LOSIS) ENTER THE HUMAN SYSTEM? 
 
 1. By being inhaled ; that is, breathed into the lungs. 
 
 2. By being ingested ; that is, eaten with tuberculous food. 
 
 3. By inoculation ; that is, the penetration of tuberculous sub- 
 stance through a wound in the skin. 
 
 Of these three ways in which the bacilli may enter, the first one 
 seems to be the most important. 
 
 Multitudes 
 of Bacilli 
 
 in the 
 Expectora- 
 tion. 
 
 CHAPTER HI. 
 
 HOW DOES THE INHALATION OF THE BACILLI TAKE PLACE? 
 
 A consumptive individual, even at a period when he is not con- 
 fined to his bed, may expectorate enormous quantities of bacilli. 
 Now if this expectoration, or spittle, is carelessly deposited here 
 and there, so that it has an opportunity to dry and become pulver- 
 ized, the least draught or motion in the air may cause it to mingle 
 with the dust, and the individual breathing this dust-laden atmos- 
 phere is certainly exposed to the danger of becoming tuberculous, 
 if his system offers a favorable soil for the growth of the bacilli. 
 By " favorable soil for the growth of the bacilli " must be understood 
 any condition in which the body is temporarily or permanently en- 
 feebled. Such a condition may be inherited from parents, or ac- 
 quired through alcoholism or drunkenness or other intemperate 
 habits, through privation or disease. 
 
 Besides the danger arising from carelessly deposited sputum, or 
 spittle, the inhalation or ingestion of the small particles of saliva 
 which may be expelled by the consumptive during his so-called 
 dry cough, or when speaking quickly or loudly, or when sneezing, 
 must also be considered as dangerous for those who come in close
 
 AND HOW TO COMBAT IT. 17 
 
 contact with the invalid. These almost invisible drops of saliva 
 may contain tubercle bacilli. Recent experiments in this direc- 
 tion have shown the possibility of infection by this means. 
 
 CHAPTEE IV. 
 
 WHAT MUST BE DONE TO CHECK THE SPREAD OF CONSUMPTION 
 CMJSED BY THE EXPECTORATION OF PULMONARY INVALIDS ? 
 
 A. Destruction of Tuberculous Expectoration. Consumptives 
 and those living with them must know that all precautionary meas- 
 ures are instituted in the interest of the invalid as well as of his 
 fellowmen. These measures protect the patient from reinfection 
 and others from the danger of contracting the disease. 
 
 A patient suffering from pulmonary consumption should know 
 that, no matter in what stage of the disease he may be, his expec- 
 toration or spittle may spread the germ of the disease if the matter 
 expectorated is not destroyed before it has a chance to dry and be- 
 come pulverized. The patient should, therefore, always spit in some 
 receptacle intended for the purpose. It is best to have this vessel 
 made of metal so as not to break. It should be half filled with 
 water or some disinfecting fluid, the main thing being to make it 
 impossible for the expectoration to dry. 
 
 In factories, stores, railroad cars, waiting-rooms, court-rooms, 
 restaurants, saloons, meeting-places, theatres, menageries in short, 
 wherever many people congregate there should be a sufficient 
 number of cuspidors well kept and regularly cleaned. They 
 should be made of unbreakable material and have wide openings. 
 If such measures are carried out, there will be no excuse for any 
 one to expectorate on the floor and thus endanger the lives of his 
 fellow-men. 
 
 In the sick-room of a private home, at hospitals or sanatoria, 
 only covered cuspidors should be used, and it is better to have them Spittoons. 
 placed on stands, in niches, or in elevated boxes. We give an ex- 
 ample of the last-named kind in Fig. 2, showing a blue enamelled 
 iron spittoon in a box elevated on a stand. The spittoon is fast- 
 ened by a clamp to the door of the box, and can be easily removed 
 2
 
 18 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 for cleaning. The stand is most convenient when about three feet 
 in height. Such an arrangement, besides making it more sure that 
 the sputum will all reach the inside of the spittoon, has the addi- 
 tional pleasant feature of making 
 the cuspidor visible only while 
 it is being used by the patient. 
 The cover of the receptacle pre- 
 vents flies and other insects from 
 coming in contact with the spu- 
 tum. It has been proved that 
 insects, especially flies, often carry 
 the bacillus out of the sick-rooms 
 of consumptives when sufficient 
 care is not taken to cover the ex- 
 pectoration. The fly which has 
 come in contact with tuberculous 
 matter may spread the disease in 
 three ways. First, it may carry 
 small particles of spittle on its feet, 
 and leave them wherever it may 
 alight. Secondly, if it has partaken 
 of tuberculous matter, it deposits 
 its excrement at the next oppor- 
 tunity on some article of food, and 
 thus the bacilli 
 
 FIG. 2. Elevated Spittoon. 
 
 find their way into the digestive organs of man 
 or beast. Thirdly, these insects may dry and 
 irumble to dust which contains the bacilli, and 
 the germs of the disease may thus enter the 
 lungs. 
 
 The cuspidor of metal elevated and covered, 
 presents further advantages over the usual un- 
 covered vessel of porcelain or earthenware. Ani- 
 mals, such as dogs, cats, etc., will not be able 
 to reach the contents of the cuspidor ; and there 
 is less danger of its bursting when placed out- 
 doors at freezing temperature if enclosed in abox. FIQ - 3 - ~ m ' s Splt "
 
 AND HOW TO COMBAT IT. 
 
 19 
 
 FIG. 5 a. Knopfs Nickel- 
 plated Flask (Closed). 
 
 For factories, workshops, etc., Predohl's enamelled iron spittoon, 
 nine inches high, eight inches in its largest and three inches 
 in its smallest diameter, 
 seems to answer all prac- 
 tical purposes. As the 
 accompanying drawing 
 (Fig. 3) indicates, it can 
 be suspended at any height, 
 and is very easily cleaned 
 and disinfected. 
 
 When outdoors, the pa- 
 tient should use a pocket 
 flask to receive the spittle. 
 There are numerous flasks 
 in the market, and I repro- 
 duce a few of them : Dett- 
 weiler's, of blue glass and 
 in three pieces (Fig. 4) ; Knopf 's,of nickel-plated 
 metal (Figs. 5 and 6); Liebe's, of blue glass 
 in two pieces (Fig. 7). The directions for use usually accompany 
 each flask. The more expensive ones (Figs. 4 and 5) can be 
 manipulated with one hand. The cleaning of 
 
 all of them is easy. The 
 
 expectoration received in 
 
 any receptacles, large 
 
 spittoons or pocket flasks, 
 
 should be so disposed of 
 
 that the bacilli are killed. 
 
 Where there is a good 
 
 sewerage system the con- 
 
 tents of these cuspidors 
 
 may, without danger, be 
 
 poured into the water- 
 
 closet. Where there are 
 running water and 
 
 FIG. 4. Dettweiler's 
 Pocket Flask. 
 
 Pocket 
 
 FIG. 5 1). Funnel and Cover 
 to Fig. 5 a. 
 
 no 
 
 perfect sewerage, it is better to boil the con- 
 tents of the spittoons before pouring them into 
 
 FIG. 6. Knopfs Alumi- 
 num Flask with Plain 
 Cover.
 
 20 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 the water-closet, or disposing of them otherwise. Thus, whenever 
 possible, the tuberculous expectoration, that is to say, the entire 
 contents of all classes of cuspidors, should be pkced in a pot 
 kept for that purpose which is partially tilled 
 with water. Every twenty-four hours or so this 
 pot should be put on the fire and the contents 
 brought to a boil. To raise the boiling point it 
 might be well to add to each quart of water one 
 or two teaspoonfuls of washing soda. After the 
 mixture has boiled for about five minutes, it can 
 be considered totally harmless, for all the ba- 
 
 FlG. 7. Llebe's Pocket .,,. .-,, -, -. , .,, , ml ,. . f ,. . 
 
 spittoon.. ciili will nave been killed, ihe disinfection or 
 
 tuberculous expectoration by carbolic acid (5 per cent.) or mercu- 
 Disinfec- r ^ som ti ns (1 : 2,000) is not so certain, since these substances 
 tion and cause the albumen in the expectoration to coagulate, and thus 
 Destruction form, in a measure, a protective cover for the bacilli and make 
 m /* their total destruction more difficult. Ordinary commercial wood 
 
 lousMatter. vinegar is a better and more con- 
 venient disinfectant and need not 
 be diluted when used. 
 
 When people are so situated 
 as not to be able to dispose of 
 the contents of the pocket spittoons 
 by boiling or disinfection, we 
 would recommend the following 
 method : pour the contents of the 
 flask on several layers of news- 
 per, gathering up the edges and 
 being careful not to spill any, and 
 throw the whole at once into the fire. 
 A handkerchief should never be 
 used as a receptacle for sputum. Patients who are too sick to 
 make use of light porcelain or aluminum cups (Fig. 8), Seabury 
 & Johnson's spitting-cup of pasteboard (Fig. 9), or the Kny- 
 Scheerer pressed-paper cup (Fig. 10) should have a number of moist 
 rags within easy reach. Care should be taken that the rags always 
 remain moist, and that the used ones are burned before they have 
 
 FIG. 8. Spit-Cup of Aluminum or Porce- 
 lain.
 
 AND HOW TO COMBAT IT. 
 
 21 
 
 a chance to dry. The paper spit-cups with their contents should, 
 of course, also be destroyed by fire. 
 
 There will always be some consumptives who cannot be per- 
 suaded to use the pocket flask, for the simple reason that they do 
 not wish to draw attention to their 
 malady. The only thing for these 
 people to do is to use squares of soft 
 muslin, cheese-cloth, cheap handker- 
 chiefs, or Japanese paper handker- 
 chiefs specially manufactured for that 
 purpose, which can be burned after 
 use. They should also place in their 
 pockets a removable lining of rubber 
 or other impermeable substance which 
 can be thoroughly cleaned. This ad- 
 ditional pocket could be fastened to 
 the inside of the ordinary pocket by 
 
 clamps, and would thus be of no inconvenience to the patient. 
 A pouch of vulcanized rubber or an Oriental tobacco-pouch may 
 be used in place of the extra pocket of impermeable material. 
 
 FIG. 9 a. Frame of Seabury & John- 
 son's Spitting-Cup. 
 
 FIG. 9 b. Folded Cardboard, to 
 be Burned Alter Use. 
 
 Fio. 10. Kny-Scheerer's Sanitary Spittoon Cup. 
 
 In any case it is well to have more than one of these pockets 
 or pouches, so that the patient is never without one while they 
 are being cleaned and immersed in some disinfectant solution or 
 boiling water. Of course, all invalids using handkerchiefs, rags, 
 or Japanese paper as receptacles for expectoration, are in danger of
 
 22 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 infecting their hands, and should always wash them thoroughly 
 before touching food. 
 
 B. Disinfection of the Sick-Room. The rooms occupied by a 
 tuberculous patient should be thoroughly disinfected at regular in- 
 tervals, since it is possible that even with great care the furniture, 
 floors, walls, etc., may have been infected. Even the occasional 
 disinfection of the personal effects of the patient is advisable. In 
 case of decease it is, of course, self-understood that everything the 
 consumptive might have come in contact with, particularly furni- 
 ture, bedding, clothing, books,* etc., should be thoroughly disin- 
 fected. In many communities such disinfection is now attended 
 to by the board of health. Where the aid of the health board 
 caimot be secured, the following directions will enable one to make 
 a thorough disinfection by formaldehyde gas: 1. All cracks or 
 Fonnalde- openings in the plaster, in the floor, or about the doors and win- 
 T) . 7 dows should be caulked tight with cotton or strips of cloth, 
 tion of 2. The linen, quilts, blankets, carpets, etc., should be stretched 
 looms, etc. out on a line in order to expose as much surface as possible to the 
 disinfectant. 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 and 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 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 cubic centimeters (five ounces) of the com- 
 mercial 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 keyhole and spaces about 
 the door should then be packed with cotton or cloth. 5. The 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 
 distillation of formaldehyde should be made at intervals of two or 
 three hours. 
 
 *The possibility of transmitting tuberculosis through books has been de- 
 monstrated, particularly if the patient has been in the habit of moistening his 
 fingers with saliva while turning the leaves.
 
 AND HOW TO COMBAT IT. 23 
 
 To be sure that the work is well done, it is always best to have 
 it supervised by a physician. To managers of hotels and boarding- 
 houses in health resorts, this method of disinfection is particularly 
 to be recommended, and the disinfection of rooms occupied by con- 
 sumptive guests should always take place immediately after their 
 removal. 
 
 In some cities and villages tuberculosis seems to cling to certain 
 localities and houses. The disease appears in a veritable endemic 
 form, that is to say, it is always present there, either from the fact Permanent- 
 that careless tuberculous patients have lived for years in these ly Infected 
 houses, or owing to the equally important fact that the soil on Houses. 
 which they are built, or the manner in which they have been con- 
 structed, is such as to favor the retention of the tuberculous infec- 
 tion indefinitely. When a thorough sanitary overhauling does 
 not suffice to stamp out these sources of infection, the destruction 
 of such dwellings seems the only remedy. 
 
 CHAPTER V. 
 
 There is real danger from this source of infection only when 
 one remains a considerable length of time very near the tuberculous 
 patient while he coughs or speaks. At a distance of three or four 
 feet the danger practically ceases. The relatively few bacilli which 
 are expelled with the saliva during the dry cough, sneezing, or loud 
 speaking, are probably never thrown farther than three feet, and 
 fall rapidly to the ground. 
 
 But even the lesser danger which may arise from the bacilli 
 having fallen to the floor with the particles of saliva must be pre- 
 vented. They must not be allowed to accumulate and so be blown 
 up with the dust into the air. Therefore the floor of the room of 
 a tuberculous patient should never have any fixed carpet ; and even 
 the wooden floor should never be swept with a broom, but should be 
 frequently wiped up with a wet cloth or with crude oil Dusty fur-
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Arrange- 
 ment of the 
 Consump- 
 tive's 
 
 Room. 
 
 Precau- 
 tions to be 
 taken by 
 Nurses. 
 
 Precau- 
 tions with 
 
 the 
 Washing. 
 
 niture should be cleaned in the same way. Plush, velvet, or 
 cloth-covered furniture, heavy curtains or other fancy decorations, 
 which might serve as dust-catchers, should not be allowed in the 
 room of a tuberculous patient. Leather-covered, rattan, and plain 
 wooden furniture are certainly the best, and the curtains should 
 always be of washable material. Fancy curtains of cloth, velour, 
 or silk, which accumulate dust and keep the air and sun out of the 
 rooms, should be discarded. 
 
 If at all possible, every patient should have his own room, but 
 he should always have his own bed. For a well person to sleep 
 in a bed very close to a tuberculous patient is almost as danger- 
 ous as to sleep together in one bed. 
 
 Friends, relatives, and nurses should not remain very near the 
 patient longer than necessary, and the tuberculous invalid should 
 be urged always to hold a handkerchief before his mouth and nose 
 while coughing or sneezing. He should, furthermore, be advised 
 to carry two handkerchiefs with him always : one to hold before 
 his mouth and to wipe it with after having expectorated ; the other 
 to use only to wipe his nose. By being careful with the use of his 
 handkerchiefs, the danger of infecting his nose and bronchial tubes 
 will be materially lessened. 
 
 All soiled linen (sheets, pillow-eases, underwear, napkins, hand- 
 kerchiefs, etc.) used by the consumptive, should not be handled 
 more than necessary, but should be placed in water as soon as 
 possible after removal from bed or body. It is better to wash 
 these articles separately, and only after having been thoroughly 
 boiled should they be put with the common laundry. Wherever 
 it is not possible to carry out these precautionary measures in 
 their entirety, one should strive to follow them as far as it is in 
 one's power. 
 
 CHAPTER VI. 
 
 How MAY MAN GIVE TUBERCULOSIS TO ANIMALS? 
 
 In one of the preceding chapters we have spoken of the im- 
 portance of elevated spittoons to protect domestic animals, such as 
 cats, dogs, etc., from the danger of becoming tuberculous by lick- 
 ing up tuberculous expectoration. By the careless expectorating
 
 AND HOW TO COMBAT IT. 25 
 
 of consumptives in meadows, fields, or stables, animals may be- 
 come infected with the disease. The following very instructive 
 fact came to the notice of the author of this essay : In an institu- 
 tion for the treatment of consumptives, managed by Sisters of 
 Charity, and where, I am sorry to say, there was not enough strict 
 medical supervision, there existed only certain rules concerning the 
 care of the expectoration within doors; outside of the institution 
 the patients were at liberty to do as they liked, and they expec- 
 torated wherever they pleased in their daily walks in the near- 
 by meadows. A neighboring farmer who, some time before, had 
 bought five healthy cows, had them retested, with the result that 
 two were found to be tuberculous. He had the tuberculous cows 
 killed, the stable cleaned and disinfected, and no longer allowed 
 the patients of the neighboring sanatorium to promenade in the 
 meadows where his cows pastured, and no more tuberculosis ap- 
 peared among his cattle. 
 
 Now, although it is true that the sun and the air ultimately 
 destroy the germs of the tuberculous sputum, it is not wise to rely 
 upon this. Tuberculous substances may do harm by being licked 
 up by animals before the sun and air have had time to kill the 
 bacilli, and in dark and damp places it often takes a long time be- 
 fore atmospheric influence renders the tuberculous matter absolute- 
 ly inoffensive. 
 
 The stools of patients suffering from tuberculosis of the intes- Danger of 
 tines should be disinfected by a five-per-cent. solution of carbolic Superficial 
 acid. The superficial burying of tuberculous meat or tuberculous T U ij 
 expectorations without previous thorough disinfection must be JQUS 
 considered as dangerous. Substances. 
 
 CHAPTEE VII. 
 
 How CAN WE GUARD AGAINST GERMS OF TUBERCULOSIS IN 
 
 OUR FOOD? 
 
 Whenever one is not reasonably certain that the meat he eats 
 has been carefully inspected and declared free from disease germs, 
 it should be very thoroughly cooked. By this means one is cer- 
 tain to kill all the dangerous micro-organisms. Against the sale
 
 26 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Boiling or 
 
 Sterilizing 
 
 Milk. 
 
 Infection 
 by Saliva. 
 
 of tuberculous milk there are very excellent laws in some States 
 of the Union, which are rigorously enforced. In some the laws 
 are less good, and in some there are no laws at the present time. ' 
 
 In justice to farmers and dairymen it must, however, be said 
 that there are many who do their very best to protect themselves 
 and their fellow-men from the danger of tuberculosis. They have 
 their cows tested regularly, destroy the animals which are found 
 to be tuberculous, and keep their stables and utensils for milk as 
 clean as possible. 
 
 Unless one can be reasonably sure that the cows from which the 
 milk is derived are healthy and not tuberculous, the milk should 
 be boiled or sterilised before use, more especially when it is in- 
 tended as food for children. Milk obtained from stores and from 
 milk peddlers should invariably be submitted to boiling or steril- 
 ization. When milk is kept slowly boiling for five minutes, all 
 the bacilli are killed, and the same result is obtained by the steril- 
 izing process, that is to say, to keep the milk heated for at least 
 half an hour at a temperature of about 70 C. or 160 F. There 
 are now in the market a number of cheap and practical apparatuses 
 for sterilizing milk, which can be obtained at almost any drug store. 
 
 CHAPTER VIII. 
 
 IN WHAT OTHER WAYS MAY THE BACILLI OR GERMS OF CON- 
 SUMPTION ENTER THE INTESTINAL TRACT? 
 
 Since the tubercle bacillus may be found in the saliva of a tu- 
 berculous patient, it is best never to kiss such a person on the 
 mouth. The habit of caressing or kissing domestic animals (par- 
 rots, canary-birds, dogs, cats), many of whom are tuberculous, is 
 equally dangerous, for through such habits these animals can cer- 
 tainly transmit tuberculosis to man. 
 
 Tuberculous patients should have their own drinking glasses, 
 spoons, forks, etc. ; or, at least, all table utensils which have served 
 the tuberculous patient should be boiled after use. 
 
 The patient should never, out of false modesty, swallow his ex- 
 pectoration. He will thus avoid the danger of contracting intes- 
 tinal tuberculosis. How important this warning is may become
 
 AND HOW TO COMBAT IT. 
 
 27 
 
 evident from observations of the tuberculous insane. These un- Danger of 
 fortunate people, with whom hygienic education is impossible, Swallowing 
 often swallow their expectoration, and as a consequence intestinal Tubercu- 
 tuberculosis or consumption of the bowels is very frequent among 
 them. Every consumptive patient should remember never to 
 touch food before having washed his hands very thoroughly. 
 Even with the greatest care, it is possible that he may have soiled 
 his hands with tuberculous expectoration. 
 
 Sputum. 
 
 CHAPTER IX. 
 
 How MAY TUBERCULOSIS BE CONTRACTED THROUGH INOCULA- 
 TION (PENETRATION OF TUBERCULOUS SUBSTANCES THROUGH 
 THE SKIN)? 
 
 Inoculation of tuberculosis happens perhaps most frequently- 
 through injuries received while cleaning nicked or chipped glass or 
 porcelain cuspidors which had been used by consumptives.- It is 
 also possible for the bacilli to enter the circulation if the person 
 cleaning the spittoons happens to have a wound or open sore on 
 his hand. Persons entrusted with the care of the spittoons in a 
 private home or an institution for consumptives should wear rubber 
 gloves while cleaning these vessels. 
 
 At times the patient may inoculate himself by placing an acci- 
 dentally injured finger in his mouth, or by carelessly soiling an 
 open wound with his expectoration. 
 
 Physicians, students of medicine or veterinary science, butchers, 
 etc., are also exposed to the danger of wounding themselves with 
 instruments which may have come in contact with tuberculous 
 matter. Extreme care is the only remedy for all persons thus 
 exposed. 
 
 If one has been unfortunate enough to receive an injury and 
 tuberculous inoculation is feared, the best thing to do is to let the 
 wound bleed freely, wash it thoroughly with water that has been 
 boiled, with a five-per-cent. solution of carbolic acid, or with pure 
 alcohol; dress the wound with a clean rag dipped in any of these 
 liquids, and seek as soon as possible the advice of the physician. 
 
 By tattooing tuberculosis has been transmitted in various in- 
 
 Care to be 
 Taken in 
 Cleaning 
 Spittoons.
 
 28 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 stances, because the operator was a consumptive. Men who follow 
 the profession of tattooing have, as a rule, the habit of dissolving 
 the colors, necessary for their work, with their own saliva, hence 
 the infection. The best thing, therefore, is never to permit such 
 barbaric decorations on one's body. 
 
 Of less frequent causes of propagating tuberculosis, but which, 
 in the light of modern sanitary science, can and should be pre- 
 vented, we will cite the ritual act of circumcision, practised 
 according to Jewish rites, when the operator happens to be con- 
 Circumci- sum ptive. It is also well known that, through lack of skill in 
 sion, after-treatment, secondary hemorrhage and wound infection have 
 ensued. Too many a young life has thus been needlessly sacri- 
 ficed. 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 measure against the possibility of inoculating 
 the child, when the parents insist upon the orthodox method of 
 circumcision, is the suction by the aid of a glass tube, as practised 
 in France and Germany. 
 
 CHAPTER X. 
 
 WHAT OTHER FORMS OF TUBERCULOSIS EXIST, AND WHAT ARE 
 THEIR PRINCIPAL SYMPTOMS ? 
 
 In the foregoing chapters we have treated of the bacillus of 
 tuberculosis, its mode of entrance into the system, and of the 
 symptoms of the most frequent form of the disease that is to say, 
 consumption or pulmonary tuberculosis. Now we will consider 
 some of its other forms or manifestations.
 
 AND HOW TO COMBAT IT. 
 
 29 
 
 More closely related to consumption than any other form of 
 tuberculosis is laryngeal tuberculosis, also called tuberculosis of 
 the larynx, or tuberculosis of the throat. This disease is not 
 nearly so frequent as pulmonary tuberculosis, but sometimes oc- 
 curs with it. Besides all the symptoms which tuberculosis of 
 the throat has in common with tuberculosis of the lungs, such as 
 fever, nightsweats, emaciation or loss of flesh, difficulty in breath- 
 ing, cough, etc., there are in this disease additional symptoms, 
 such as more or less pronounced hoarseness and frequent and 
 intense pain during the act of swallowing, which makes eating 
 bread, meat, and other solid food exceedingly difficult. The inter- 
 nal appearance of the throat shows little tuberculous growths and 
 ulcers in the region of the vocal cords and neighboring tissue. 
 
 Tuberculosis of the bones, which not infrequently leads to a 
 total necrosis that is, a softening and final decay of the bones is 
 not a rare disease. If the seat of the disease is the spinal column, 
 the decay of one or more vertebrae may result in the deformity 
 commonly known as hunchback. If through this breaking down 
 there should result a compression of the spinal marrow, paralysis 
 of arms or legs, and other disturbances, such as difficulty in retain- 
 ing the urine and the stools, may be observed. 
 
 While tuberculosis of the bones and joints is almost painless at 
 the beginning, it may gradually lead to loss of the use of the joints, 
 to maturation and destruction, which may become extensive 
 enough to make even amputation necessary. 
 
 In younger children tuberculous spinal meningitis is not rare, 
 and, alas ! very often proves fatal. The essential symptoms of this 
 disease are digestive disturbances (vomiting or constipation), 
 uneasiness and depression, later on paralysis of the extremities, 
 delirium, and sometimes coma (profound insensibility). 
 
 More frequent and almost as dangerous as tuberculous menin- 
 gitis in children, is tuberculosis of the intestines and the perito- 
 neum (the lining of the abdominal cavity). This affection is 
 sometimes also called consumption of the bowels. The most pro- 
 nounced symptom in such cases is very often a protracted 
 diarrhoea, which cannot be easily controlled by dieting or medica- 
 tion. 
 
 Tuberculo- 
 sis of the 
 Throat. 
 
 Tuberculo- 
 sis of the 
 Bones. 
 
 Tubercu- 
 lous 
 Meningitis. 
 
 Consump- 
 tion of the 
 Bowels.
 
 30 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Hasty 
 Consump- 
 tion. 
 
 lupus. 
 
 Scrofula. 
 
 At times the whole body is invaded by the tuberculous disease, 
 and countless little tubercles are distributed in all the organs. 
 This disease is then called " miliary tuberculosis " because the tu- 
 bercles are like millet seeds. The origin of this disease is probably 
 always due to the sudden outbreak of a localized tuberculous lesion, 
 which had been at a standstill before. The first symptoms of mil- 
 iary tuberculosis resemble those of typhoid fever. They are gen- 
 erally depression, lassitude, and fever. This is also one of the 
 forms of tuberculosis which often prove fatal. 
 
 Of the so-called localized tuberculous diseases, we must mention 
 the form which manifests itself as a skin disease and is known as 
 lupus, showing itself as ulcerous patches mainly on the face. 
 
 So-called scrofulosis, or scrofula, is now considered also as a 
 form of tuberculosis. It appears almost exclusively during child- 
 hood. It is a milder disease than the other forms of tuberculosis, 
 and manifests itself mainly in swelling of the glands, eruption of 
 the skin, and inflammation of eyes and ears. 
 
 CHAPTER XI. 
 
 WHAT PROTECTS THE HEALTHY INDIVIDUAL FROM CONTRACTING 
 
 TUBERCULOSIS ? 
 
 After all that we have said of the contagiousness, or rather the 
 communicability, of tuberculosis, and consumption in particular, 
 one must not think that a breath in an atmosphere accidentally 
 laden with bacilli would certainly render a healthy individual 
 consumptive, or that by a swallow of tuberculous milk or a lit- 
 tle injury from a broken cuspidor one must necessarily become 
 tuberculous. The secretions of our nasal cavities, doubtlessly also 
 the blood, and the secretions of the stomach of a healthy individ- 
 ual, have bactericidal properties; that is to say, they kill the dan- 
 gerous germs before they have a chance to do harm. Therefore, 
 the healthy man and woman should not have an exaggerated fear of 
 tuberculosis, but they should, nevertheless, not recklessly expose 
 themselves to the danger of infection.
 
 AND HOW TO COMBAT IT. 
 
 31 
 
 CHAPTER XH. 
 
 How MAY ONE SUCCESSFULLY OVEECOME A HEREDITARY DIS- 
 POSITION TO CONSUMPTION ? 
 
 The mother who fears for her future child a hereditary dispo- 
 sition to tuberculosis should lead a very healthful life. She should 
 be as much in the open air as possible, breathe deeply and eat 
 regularly of plain but nourishing food. Never should she wear 
 garments which constrict any of her chest or abdominal organs. 
 She should replace the corset by a comfortable waist which 
 permits free and deep respiratory movements. Instead of tying 
 her skirts around her waist, she should have them suspended from 
 the shoulders, which can easily be done by attaching buttons to 
 the waist. By wearing a close-fitting union suit for underwear, of 
 wool or cotton according to the season, it will be possible to get 
 along with less skirts, and thus lessen the weight around the waist. 
 The whole dress of the mother should be so arranged that there are 
 no constricting bands, and that no organ in the body should be 
 hindered in its free physiological functions. How important a 
 more healthful and natural dress really is for the welfare and de- 
 velopment of mankind in general, a mother seldom realizes either 
 for herself or for her daughters. They are all only too often the 
 slaves of fashion. The tightly laced corset should be banished 
 forever from the dress of women. Not only is free and natural 
 breathing interfered with by this article of dress, but indiges- 
 tion and disturbances in the circulation follow excessively tight 
 lacing. Anaemia, or poverty of the blood, so often observed in 
 young girls, can very frequently be ascribed to this unnatural 
 mode of dress, which does not permit either a free circulation or 
 sufficient oxygenation of the blood. 
 
 We reproduce here three pictures better to illustrate the result 
 of excessive lacing. Fig. 1 1 shows the situation of the organs in 
 chest and abdomen in a normal thorax. Fig. 12 shows lungs, 
 heart, and intestines as they appear in a thorax constricted by 
 bearing a tightly laced corset for a number of years. Fig. 13 
 shows the skeleton of a chest deformed by tight lacing. 
 
 Hygiene 
 
 and Dress 
 for 
 
 Tubercu- 
 lous 
 
 Mothers, 
 
 Tight 
 Lacing.
 
 32 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Belts. 
 
 The wearing by men of belts instead of suspenders is not to be 
 recommended. In order to keep the trousers in place the belt 
 must be considerably tightened, the result is constriction of the 
 abdomen, hindering the natural action of the intestines which is 
 essential to good digestion. Hernias (ruptures) may also be the 
 result of this mode of dress. It cannot be insisted upon too often 
 that in an individual predisposed to tuberculosis nothing can be 
 more injurious than an interference with proper digestion and as- 
 similation. To keep stomach and bowels in good order is one of 
 the best safeguards against taking the disease. 
 
 Neckwear, for men as well as for women, should be loose. 
 Tight and constricting collars or bands around the neck may cause 
 
 FIG. 1L 
 
 FIG. 12. 
 
 FIG. 13. 
 
 an insufficient air-supply, congestion of the arteries of the brain, 
 Neckwear, and subsequently headache and dizziness. To dress the neck too 
 warmly lessens the power to resist taking cold when there happens 
 to be a change in the atmosphere. The less one is accustomed to 
 bundling up the neck, the less liable will he be to take cold. 
 
 Ladies cannot be told too often to abandon the unhygienic fash 
 ion of trailing dresses, at least in the street. They should be 
 brave and show the world that they care for the health and wel- 
 fare of others. When one considers how many millions of dan- 
 gerous bacilli and micro-organisms are gathered up with the dust 
 and brought into the house by this unhealthy mode of dress, further 
 argument is hardly necessary to prove that the wearing of trains 
 is absolutely dangerous to health. As the poet of the London Truth 
 
 Trailing 
 Skirts.
 
 AND HOW TO COMBAT IT. 
 
 33 
 
 puts il in his "Song of the Skirt," why should dresses be made to 
 do "the scavenger's dirty work ": 
 
 " Sweep sweep sweep 
 Where the waste of the street lies thick, 
 Sweep sweep sweep 
 However our path we pick ; 
 Dust, bacillus, and germ, 
 Germ, bacillus, and dust, 
 Till we shudder and turn from the sorry sight 
 With a gesture of disgust. 
 
 "Oh, men with sisters dear ! 
 Oh, men who have well-dressed wives, 
 It is not alone an expensive mode, 
 It is one that hazards lives ! 
 For malignant microbes swarm 
 In the triturated dirt, 
 And the dress that sweeps it up may prove 
 A shroud as well as a skirt ! " 
 
 Footwear is also a matter of importance. Shoes should never 
 be worn too tight. They not only hinder free movements, but the 
 constriction of the blood-vessels causes impaired circulation and 
 coldness of the extremities. 
 
 If i't is found necessary to wear underwear at night, a different 
 set should be kept for that purpose, which, with the night-dress or 
 night-shirt, should be well aired during the day-time. 
 
 Whenever a mother has a tendency to tuberculous disease, the 
 child should be given a healthy wet-nurse, or be fed artificially 
 with modified cow's milk. The advice of the physician is indis- 
 pensable under such circumstances. The child should have its 
 own bed, and should never, never sleep in the same bed with the 
 mother. The bedroom should always be well ventilated, and the 
 child should be taken into the open air as soon as practicable. 
 The old-fashioned habit of enveloping the child's head in a thick 
 veil should be abandoned. It is a good plan to let the little one 
 run about naked or with only a little shirt on, for a while every 
 day in a warm, sunny room. A bare wooden floor or a square of 
 closely woven matting, that can be kept scrupulously clean, is 
 much to be preferred to dust-collecting carpets. 
 
 From the tenth to the twelfth month one should accustom the 
 3 
 
 Footwear. 
 
 Hygiene 
 and Care of 
 the Child of 
 a Tubercu- 
 lous 
 
 Mother. 
 
 Sun and 
 Air Baths 
 for Little 
 Children.
 
 TUBERCULOSIS AS A DISEASE OP THE MASSES 
 
 child gradually to cold baths. The best way to begin is after its 
 Use of Cold daily warm bath to rub the child a few times with the hands 
 Water. dipped in cold water, and then wipe it rapidly. By and by one 
 may begin with cold sponging, and later on with a little douche. 
 In the use of cold water it is absolutely necessary that the reaction 
 should rapidly follow. This reaction is manifested by a pleasant 
 warmth perceived by the child, and externally is made visible by 
 a reddish appearance of the skin. Whenever cold water is applied 
 to the skin one will notice at first a certain whiteness or pallor, 
 which is caused by a contraction of the external blood-vessels. 
 The return of the blood to the external surface causes the redden- 
 ing of the skin. Whenever reaction is lacking or tardy, the 
 advice of the physician should be sought. 
 
 Though the application of cold water is beneficial, one should 
 never forget that there are people whose constitutions differ, and 
 that a routine treatment is not applicable to every individual. 
 The careful, judicious, and regular application of cold water is 
 perhaps one of the best preventive measures against taking cold, 
 for children as well as adults, and its use generally should be more 
 recommended. Persons not accustomed to the use of cold water 
 can easily become so by being rubbed every day with alcohol 
 for a week or so. During the second week they should be rubbed 
 with half alcohol and half water, and the third week with water 
 alone. By this means one gradually educates one's self to the use 
 of cold sponge baths, ablutions, and douches. 
 
 Every family does not have the luxury of a douche apparatus, 
 and sometimes not even a bathroom. For such I wish to describe 
 a simple method which will answer the purpose. Take a large 
 circular English bath-tub, about three feet in diameter and ten 
 inches high, and pour about five inches of cold or tepid water into 
 it. The bather jumps into the water, keeping his feet in motion 
 for a few seconds, and pours one or two pitcherfuls of water quick- 
 ly over each shoulder, thoroughly wetting the whole body. It is 
 not at all essential that the head should be wet at the same time. 
 The douche can be made easier by the help of a second person to 
 pour the water from the pitcher or watering-pot. If a hose can be 
 attached to a nearby faucet, a douche, needle bath, or direct jet 
 
 Improvised 
 Douche.
 
 AND HOW TO COMBAT IT. 
 
 35 
 
 can be improvised. The temperature of the water may vary from 
 60 to 40 F. The room in which the bath is taken should be 
 warmed in cold weather. The best and, perhaps, also most con- 
 venient time to take a cold bath is in the morning before dressing, 
 or in the evening before retiring. Whenever reaction is feeble, 
 that is to say, when a pleasant feeling of warmth after the bath 
 does not come quickly enough, one should proceed as follows: If 
 the bath is to be taken in the morning rise half an hour earlier, 
 cover the bed so that the warmth is retained; then, after the ap- 
 plication of cold water has been taken rapidly in the manner 
 above described, rub with a rough Turkish towel and return as 
 quickly as possible to the warm bed. If it is not practicable to 
 take the bath in the morning, one can obtain the same result by 
 going to bed half an hour earlier, and when the bed is warm rise 
 again to take the cold-water application. In most cases the return 
 to the warm bed will assure a thorough reaction ; but if these pre- 
 cautions, in addition to vigorous friction after the bath, do not 
 suffice to produce a proper reaction, it is a sign that the body has 
 not enough resistance for this kind of treatment, and the physician 
 should be consulted. 
 
 Cold baths, especially bathing in a river or in the ocean, are, of 
 course, to be recommended in warm weather. Weakly and elderly 
 persons should not take cold baths, no matter at what season, un- 
 less permitted to do so by then- physician. 
 
 To keep the skin clean and in good condition, cold baths, even 
 when taken every day, are not always sufficient, and soap and 
 warm water should be used at least once a week. The warm bath 
 should always be followed by a rapid sponging off with cold water. 
 
 As soon as the intelligence of the growing child will permit, it 
 should be taught to breathe deeply, and later on be taught to take 
 the following breathing exercises, which the child should learn to 
 love as the average boy or girl loves general gymnastics. In front 
 of the open window or out of doors assume the position of the 
 military "attention," heels together, body erect, and hands on the 
 sides. With the mouth closed take a deep inspiration (that is, 
 breathe in all the air possible), and while doing so raise the arms 
 to a horizontal position : remain thus holding the air inhaled for 
 
 How to 
 
 Help 
 Reaction, 
 
 Warm 
 Baths. 
 
 Respira- 
 tory 
 
 Exercises 
 
 with 
 Movement 
 
 of Arms.
 
 36 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 may 
 the 
 
 about three seconds, and while exhaling (breathing out) bring the 
 arms down to the original position. This act of exhalation, or 
 expiration, should be a little more rapid than the act of inspiration. 
 
 When the first ex- 
 ercise is thorough- 
 ly mastered and 
 has been prac- 
 tised for several 
 days, one 
 begin with 
 second exercise, 
 which is like the 
 first, except that 
 the upward move 
 ment of the arms 
 is continued until 
 the hands meet 
 over the head. 
 
 The a c c o m - 
 panying illustra- 
 tion (Fig. 14) 
 shows the posi- 
 tions which are to 
 be taken during 
 those two exer- 
 
 cises. The third breathing or respiratory exercise, which requires 
 more strength and endurance, should not be undertaken until the 
 first two have been practised regularly several times a day for a few 
 weeks, and until an evident improvement in breathing and general 
 well-being has been observed. We will endeavor to make this third 
 exercise, which might be called a dry swim, more comprehensible 
 by the illustration (Fig. 15). Take the same military position of 
 "attention," and then stretch the arms out as in the act of swim- 
 ming, the backs of the hands touching each other. During the in- 
 spiration move the arms outward until they finally meet behind the 
 back. Remain in this position a few seconds, retain the air, and 
 during exhalation bring the arms forward again. This somewhat 
 
 FIG. 14. First and Second Breathing Exercises.
 
 AND HOW TO COMBAT IT. 
 
 37 
 
 difficult exercise can be facilitated and be made more effective by 
 rising on the toes during the act of inhalation, and descending 
 during the act of expiration. 
 
 Of course, when out of doors one cannot always take these ex- 
 ercises with the movement of the arms without attracting atten- 
 tion; under such conditions raise the shoulders, making a rotary 
 backward movement during the act of inhaling ; remain in this 
 position, holding the breath for a few seconds, and then exhale 
 while moving the shoulders forward and downward, assuming again 
 the normal position. This exercise (Fig. 16) can be easily taken 
 while walking, sitting, or riding 
 in the open air. 
 
 Young girls and boys, and es- 
 pecially those who are predisposed 
 to consumption, often acquire a 
 habit of stooping. To overcome 
 this the following exercise (Fig. 
 17) is to be recommended. The 
 child makes his best effort to 
 stand straight, places his hands 
 on his hips with the thumbs in 
 front, and then bends slowly 
 backward as far as he can during 
 the act of inhaling. He remains 
 in this position for a few seconds, 
 while holding the breath, and then 
 rises again somewhat more rapid- 
 ly, during the act of exhalation. 
 
 The following general rule con- 
 cerning breathing exercises should 
 always be remembered. Com- 
 mence with the easier exercises 
 (Figs. 14 and 16), and do not begin with the more difficult ones (Figs. 
 15 and 17) until the former are completely mastered. Take from 
 three to six respiratory exercises, either of one kind or the other, 
 every half hour, and continue this practice until deep breathing has 
 become a natural habit. These exercises should always be taken in 
 
 FIG. 15. Third Breathing Exercise. 
 
 Respira- 
 tory 
 
 Exercises 
 
 without 
 
 Movement 
 
 of Arms. 
 
 General 
 Rules 
 Concerning 
 Respira- 
 tory 
 Exercises.
 
 38 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 an atmosphere as fresh and as free from dust as possible. Never 
 take these exercises when tired, and never continue so long as to 
 become tired. 
 
 Mouth -breathing in children, and sometimes in adults, is often 
 caused by certain growths in the throat (adenoid vegetation), by 
 enlarged tonsils, or by growths in the nose (polypi, etc.) The re- 
 moval of these 
 
 obstructions by 
 
 surgical aid is 
 
 perhaps the only 
 
 rational method 
 
 to assure natural 
 
 breathing. In- 
 cidentally, w e 
 
 may be permit- 
 ted to say that 
 
 these operations 
 
 are not at all 
 
 dangerous ; but 
 
 by the presence 
 
 of these vegeta- 
 
 t i o n s in the 
 
 throat (retro- 
 
 pharynx) the 
 
 hearing and the 
 
 intellectual and 
 
 bodily develop- FIG. 17. Exercise for People in the 
 e i.i. \.-u Habit of sto P in S- 
 
 ment of the child 
 may become seriously impaired. The early removal of such growths 
 should be earnestly recommended. The respiratory exercises just 
 described are particularly useful for such children after operation, 
 otherwise they might retain the habit of imperfect breathing which 
 they had acquired. 
 
 Among exercises which have a tendency to develop and 
 strengthen lungs and throat, we will also mention singing and re- 
 citing in the open air. 
 
 Not only during the day, but also at night, there should be a 
 
 FIG. 16. Breathing Exercise 
 with Rolling of Shoulders.
 
 AND HOW TO COMBAT IT. 
 
 39 
 
 HUMIDIFIER 
 
 1 FLOOU DE01STEH 
 
 JZ WATER TANK ij 
 
 3 SHEETS OF 
 KOTTON FF.LT. ; 
 
 desire for fresh air. The still very prevalent idea that night air is 
 injurious is wrong. The night air is purer than that of the day, 
 particularly in great cities, therefore one should always keep at 
 least one window open in the bedroom or in an adjoining room, 
 and thus assure a sufficient and permanent ventilation. Of course, 
 it is always wise to protect one's self against direct draughts from 
 the open window. When it is not possible to place the bed so 
 that it will be out of the draught, a screen in front of the open 
 window will suffice for protection. 
 
 It is, of course, self-understood that all individuals who have 
 an inherited disposition to tuberculosis should always endeavor to 
 live as much as pos- 
 sible in good, fresh, 
 pure air. To visit 
 dancing-halls, saloons, 
 and smoking-rooms 
 can only be deleterious 
 to such people. Smok- 
 ing should be abso- 
 lutely prohibited for 
 young men with weak 
 chests, and for all peo- 
 ple having a tendency 
 to tuberculosis. The 
 smoking of cigarettes is particularly dangerous, since the habit once 
 acquired tends to undermine even a strong constitution. 
 
 Many of our American dwellings in winter are heated altogether 
 too much. A temperature of from 65 F. to 68 F. should be suf- 
 ficient, especially when care is taken that the heat produced by 
 the furnace is not too dry. The excessively dry atmosphere in 
 winter of many city and country homes often gives rise to nasal 
 catarrh, a condition which everybody, but especially those suffer- 
 ing from pulmonary diseases, or prone to them, should be anxious 
 to avoid. Besides keeping the water pan in the furnace con- 
 stantly filled, there should be in the sitting-room and sleeping- 
 rooms some humidifying arrangement such as is pictured here 
 (Fig. 18). More simple evaporating devices, however, as a vessel 
 
 Relative 
 
 Purity of 
 
 Night Air. 
 
 Crowded 
 
 Rooms and 
 
 Smoking. 
 
 Excessive 
 Dryness 
 and Heat 
 
 in 
 Dwellings.
 
 4:0 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 filled with water and a cloth suspended above it touching the 
 water so as to produce capillary attraction, will answer the purpose 
 of rendering the atmosphere sufficiently humid. 
 
 The proper bringing up of children that have a tendency to become 
 
 tuberculous is of the greatest importance. Many are poor eaters 
 
 Raising from the day of their birth. Discipline, not to allow too many 
 
 Educating sweets, to observe regular meal-times and to keep the bowels in good 
 
 Predisposed condition, are the best means to combat a dislike for eating. As 
 
 Children, early as possible children should be taught to clean their teeth 
 
 thoroughly after each meal, for a good digestion is dependent upon 
 
 the condition of the teeth. The dislike to play outdoors, which is 
 
 so characteristic of the little candidates for tuberculous diseases, 
 
 can also only be overcome by discipline. To dress them too 
 
 warmly and bundle them up all the time is as injurious as having 
 
 them remain most of the time indoors. Such children should not 
 
 work too hard during their school age. To spend too many hours 
 
 sitting down, to do too much brain work, to spend too much time 
 
 at the piano or in other musical studies, have a tendency often to 
 
 weaken seriously the child predisposed to tuberculosis. 
 
 Gymnastic exercises should be recommended to young people 
 of both sexes, and young girls especially should continue their 
 healthful outdoor sports after they have left school. Of course, 
 excesses are injurious in everything, and we wish to say here that, 
 no matter how healthful a sport may be, if carried on too violently 
 or for too long, it must ultimately prove injurious. To be cheerful, 
 to live a regular life, to eat plain but good food, to avoid all alco- 
 holic beverages, to see that the bowels move freely every day, to 
 keep the whole body clean, and to sleep at least eight hours out of 
 twenty-four, is the best way to remain well. 
 
 Once more we desire to call attention to the clothing of growing 
 girls and boys. The thickness of the garments should be accord- 
 ing to the season, and they should always be made so that every 
 movement of the body may be free, and none of its functions, such 
 as respiration, digestion, etc., in any way interfered with. 
 
 When the time comes to choose a profession or trade for a young 
 
 Choice of man who has a tendency to tuberculosis, one should bear in mind 
 
 Occupation. t na k gardening, farming, forestry, and all occupations which de-
 
 AND HOW TO COMBAT IT. 41 
 
 mand an outdoor life, are the most likely to make him a strong 
 man and a useful member of society. 
 
 In connection with the precautions which should be taken to 
 combat a tendency to tuberculosis, we must say a few words con- 
 cerning the curability of consumption or pulmonary tuberculosis. Hereditary 
 The old idea still, alas ! very prevalent and deeply rooted in the Consump- 
 minds of many people that a tuberculous individual who has seem- ? , as 
 ingly inherited his tendency to the disease, can have no hope of Acquired 
 cure, is wrong. We desire to emphasize the fact that the chances Consump- 
 for a cure of the consumptive individual does not at all depend ' 
 
 upon whether he had a hereditary tendency, or has accidentally 
 acquired the disease. There are hundreds of cases of healed tuber- 
 culosis in men and women who have lived to old age, and never- 
 theless their fathers or mothers had succumbed to consumption. 
 
 The assumption that tuberculosis is often directly transmitted 
 from parent to child is equally erroneous. Of course, there are in Hereditary 
 medical literature a few cases which show that such direct trans- Transmis- 
 mission is possible, but they are exceedingly rare. When little 
 children have become tuberculous the infection can almost always 
 be traced to the child having slept or been much in contact with 
 a consumptive mother or other consumptive individuals, having 
 been kissed on the mouth, or having played on the dirty, infected 
 floor, etc. All this shows the importance of absolute cleanliness 
 and the strictest hygiene from early infancy. 
 
 CHAPTEK XIII. 
 
 How CAN A PKEDISPOSITION TO TUBERCULOSIS, OTHER THAN 
 HEREDITARY, BE CREATED OR ACQUIRED? 
 
 1. By the intemperate use of alcoholic beverages, a dissipated 
 life, excesses of all kinds, etc. 
 
 2. By certain diseases which weaken the constitution; for ex- 
 ample, pneumonia, typhoid fever, smallpox, measles, whooping 
 cough, syphilis, influenza, etc. 
 
 3. By certain occupations, trades, and professions, such as print- 
 ing, hat-making, tailoring, weaving, and all occupations where the 
 worker is much exposed to the inhalation of various kinds of dust,
 
 42 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 as bakers, millers, confectioners, cigar-makers, chimney-sweepers, 
 and the workers in lead, wood, stone, metals, etc. 
 
 Tuberculo- 
 sis and 
 Venereal 
 Diseases. 
 
 Hygiene in 
 
 Factories, 
 
 Workshops, 
 
 etc. 
 
 CHAPTEK XIV. 
 
 How MAY AN ACQUIRED PREDISPOSITION BE OVERCOME, AND 
 SEEMINGLY UNHEALTHY OCCUPATIONS MADE RELATIVELY 
 HARMLESS ? 
 
 All persons who have been weakened through intemperance or 
 excesses, who are convalescent from serious diseases, or who are suf- 
 fering from the effects of harmful occupations, should not associate 
 with consumptives. For the intemperate man, the fast liver, or 
 one inclined to excesses, there is no remedy except to change his 
 mode of life. The unfortunate who by his own fault or the care- 
 lessness of others has fallen a victim to a venereal disease (syphilis, 
 etc.) we would urgently recommend to submit himself to thorough 
 treatment by a competent physician. For the comfort of these 
 unfortunate sufferers, we desire to say that all venereal diseases can 
 be successfully treated when the patient seeks timely medical ad- 
 vice and obeys the physician's instructions faithfully. Since ven- 
 ereal diseases are highly contagious, the physician's instructions 
 will also protect others from becoming infected, and the patient 
 himself from reinfection. The necessity of seeking medical advice 
 holds good for all those who by intemperance or excesses of any 
 kind have undermined their constitution, and thus diminished their 
 natural resistance to the invasion of the tubercle bacilli. 
 
 In many States of the Union there now exist laws whereby the 
 sanitary conditions of factories, workshops, department-stores, etc., 
 are assured. Of course, there is room for much improvement in 
 this respect, especially in regard to light and sufficient ventilation 
 in factories where dust and gases are a constant menace to the 
 laborer. Whenever practicable, respiratory masks for protection 
 against particularly irritating dust, should be worn. People much 
 exposed to the inhalation of flour dust should clean their teeth 
 thoroughly (the inside as well as the outside). By removing the 
 flour dust from the spaces between the teeth, the formation of 
 glucose (sugar) through the action of the saliva on the flour is
 
 AND HOW TO COMBAT IT. 43 
 
 avoided, and thus the germs of fermentation are deprived of a 
 favorable soil for development. 
 
 In all these matters the laborer can help himself a good deal by 
 his own efforts to make a seemingly dangerous occupation more safe. 
 During the hours of recess, and before he goes to work as well as 
 afterward, he should always strive to be as much as possible in the 
 open air, drink plenty of pure, clean water, keep early hours, live 
 as regular a life as possible, avoid the saloon, and never take alco- 
 holic beverages. 
 
 All the other hygienic precautions and means of improving the 
 general health of which we have spoken in Chapter XII., "How 
 may one successfully overcome a hereditary disposition to tuber- 
 culosis?" such as breathing exercises, the use of cold water, etc., 
 are, of course, just as essential to combat a disposition to tuber- 
 culosis which has been acquired. 
 
 Self-Help 
 
 of the 
 Laborer. 
 
 CHAPTEE XV. 
 
 WHAT CAN WELL-MEANING AND CONSCIENTIOUS EMPLOYERS IN 
 CITY AND COUNTRY Do TO HELP COMBAT TUBERCULOSIS? 
 
 All who employ a number of people and provide their lodgings 
 should bear in mind that unhealthy, dark, damp, and badly venti- 
 lated rooms are powerful factors in the propagation of tuberculosis. 
 The soil upon which a dwelling for human beings is to be built, 
 should be dry, free from miasms and dangerous exhalations. High, 
 porous ground is particularly to be recommended. It is sometimes 
 possible to render a damp soil healthful by thorough drainage and 
 cementing. The house should always be built of good material, 
 and all the rooms should receive the light of day and as much 
 sunshine as possible. In winter the rooms should be well 
 warmed, but not overheated, and at the same time free ventilation 
 should be made possible. Bathrooms in sufficient number should 
 be in all model tenement houses, and each family should have its 
 own water-closet, which, of course, must always be kept in good 
 condition. 
 
 In labor colonies and densely populated tenement districts, where 
 modern bathing facilities cannot be easily installed, there should 
 
 Sanitary 
 Dwellings.
 
 44 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 be public places where, for a moderate price, people can enjoy the 
 Bathing cleansing and refreshing luxury of a warm or cold bath. 
 Facilities. In factories, workshops, big stores, etc., there should always be 
 a sufficient number of spittoons, preferably elevated and of un- 
 breakable material. Wherever such precautions are taken and 
 some conspicuous signs, forbidding expectorating on the floor, put 
 up, and if necessary making it punishable by law, promiscuous 
 spitting will soon cease, and an important point in the combat of 
 tuberculosis will be gained. 
 
 All employees, men and women of whatever class, should be 
 allowed ample and regular time for their meals, which should 
 never be taken in the workshops. Special rooms should be kept 
 for that purpose. Opportunity should be given to the workers to 
 Regularity rest or walk in the open air for a little while after their meal. It 
 of Meals. j g a jg O importance for the health of the laborer to wash his 
 hands thoroughly before touching food, and proper conveniences 
 should be provided for that purpose. Factories, workshops, large 
 stores, etc., should, of course, be well ventilated, but it is par- 
 ticularly necessary that they should be thoroughly aired after 
 working hours. These precautions apply not only to large estab- 
 lishments, but to the smallest concern with one or two employees 
 as well, and every employer should bear in mind that a healthy 
 laborer is of greater value than one who is overworked, underfed, 
 or badly housed. Lastly, employees should not be overworked. 
 There should be reasonable hours for all, so that the laborer may 
 enjoy the bodily and menta] rest which is essential to the preser- 
 vation of health. The germs of any disease, but particularly those 
 of tuberculosis, will always find a more congenial soil for develop- 
 ment in an overworked and enfeebled system. Child-labor, that 
 is to say, the employment of children under fourteen years of age, 
 in factories, workshops, mines, etc., should be prohibited by law. 
 Child-labor. The child is more susceptible to tuberculosis than the adult, 
 especially when its delicate growing organism is subject to con- 
 tinued physical strain.
 
 AND HOW TO COMBAT IT. 45 
 
 CHAPTEE XVI. 
 
 WHAT CAN THE FARMER AND DAIRYMAN Do TO DIMINISH THE 
 FREQUENCY OF TUBERCULOSIS AMONG ANIMALS, AND THUS 
 INDIRECTLY STOP THE PROPAGATION OF THE DISEASE AMONG 
 MEN? 
 
 The farmer or dairyman who employs help should, of course, be 
 as anxious for their physical welfare, their proper housing and 
 proper food, as the employer in the city. The dairyman or the 
 farmer who keeps cows, should, however, be particularly desirous 
 to help in combating tuberculosis among animals. 
 
 Everybody who has anything to do with cows should be ac- 
 quainted with the nature of tuberculosis in cattle, also known T . ,. 
 by the name "bovine tuberculosis." In animals as well as in man O f Cattle, 
 the direct cause of this disease is the tubercle bacillus. Bovine 
 tuberculosis is prevalent in nearly every country. The symptoms 
 of the disease are much like those in man. They begin with rela- 
 tively slight functional disturbances. The way the germ of tuber- 
 culosis is transmitted from animals to men, and also from men 
 to animals, has already been explained. The contagion, or rather 
 the propagation, of the disease among animals takes place in vari- 
 ous ways : First, by drop infection, that is to say, little particles 
 which are expelled during the seemingly dry cough. Secondly, 
 by the discharge from the lungs, or also from the glands of the 
 throat, coughed up in the ordinary way. Thirdly, through tuber- 
 culous matter coming from the bowels. Fourthly, through secre- 
 tions coming from the sexual organs (vagina and uterus). Fifthly, 
 through the milk if the udder is tuberculous, or if the whole body 
 of the animal is invaded by the disease. Finally, the disease may 
 be directly transmitted from the tuberculous cow to the calf. 
 
 As to the frequency of the various ways in which the contagion 
 takes place and the best methods of prevention, the author does 
 not believe that he can do better than to copy some of the very 
 "Practical Suggestions for the Suppression and Prevention of Bo- 
 vine Tuberculosis," issued by Dr. Theobald Smith, of the Bureau 
 of Animal Industry in Washington :
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 "Fully nine-tenths of all diseased animals examined have been 
 infected by inhaling the tubercle bacilli, dried or suspended in the 
 
 and 
 Prevention 
 of Bovine 
 Tuberculo- 
 sis. 
 
 air. 
 
 " Fully one-half of all diseased animals examined have been in- 
 fected by taking tubercle bacilli into the body with the food. 
 This implies that both food and air infection are recognizable in the 
 same animal in many cases. 
 
 "Animals are infected, though rarely, during copulation. In 
 such cases the disease starts in the uterus and its lymph glands, 
 or in the sexual organs and corresponding lymph glands of the 
 bull. 
 
 "Perhaps from one to two per cent, of all calves of advanced 
 cases are born infected. Among the two hundred cases of tuber- 
 culosis, including all ages, which have been examined by the 
 writer, there are about two per cent, in which the disease is best 
 explained as having been directly transmitted from the mother dur- 
 ing or before birth. 
 
 "We may define the dangers of infection somewhat more defi- 
 nitely by the statement that in any herd, even in those extensively 
 infected, only a small percentage of the diseased animals, namely, 
 those which are in an advanced stage, or such as have the disease 
 localized from the very beginning in the udder, or the uterus, or 
 the lungs, are actively shedding tubercle bacilli. It is these that 
 are doing most, if not all, of the damage by scattering broadcast 
 the virus. 
 
 "Disease of the udder is particularly dangerous, because the 
 milk at first appears normal for some weeks, and therefore would 
 be used with impunity. Moreover, the tubercle bacilli in the dis- 
 eased gland tissue are usually numerous. 
 
 " Similarly, in tuberculosis of the uterus the vaginal discharges 
 may contain many tubercle bacilli. These deposited anywhere may 
 lead to the extensive dissemination of the virus, or it may be car- 
 ried by the bull to other cows. A diagnosis may be made by the 
 examination of any existing discharge for tubercle bacilli. 
 
 "The foregoing statements apply to individual herds only. To 
 what extent does the danger extend beyond the diseased herd to 
 others in the neighborhood? To this we may give the general
 
 AND HOW TO COMBAT IT. 47 
 
 answer that there is no danger unless the animals mingle on the 
 pasture or in the stable. Tubercle bacilli are not carried in the 
 open air, or if they are their numbers are so small that the danger 
 of infection is practically absent. 
 
 "It is also highly doubtful whether they are ever carried in 
 sufficient numbers by third parties from place to place to become 
 in a sense a danger. The reasons for this must be sought for in 
 the tubercle bacillus itself. The diseased animal is the only 
 manufacturer of tubercle bacilli, as well as the chief disseminator. 
 Tubercle bacilli, after having left the body of the cow (and usually 
 in small numbers), do not increase in nature, but suffer a steady 
 decrease and final extermination in four to six months at the long- 
 est. Only after they have entered the bodies of susceptible ani- 
 mals, do they again begin to multiply. Hence, with this disease, 
 the only danger to other herds lies in direct association, or in the 
 transfer of a diseased animal or of milk from such an animal. 
 The great danger exists in the immediate surroundings of the in- 
 fected, and loses itself as the distance increases. 
 
 "PREVENTIVE MEASURES. 
 
 " The suggestions to be recommended are not to be considered 
 as taking the place of any more sweeping and radical measures 
 which have been contemplated by some States, and are actually 
 being tried in others. We wish them to be considered simply as 
 of educational value to the owners of cattle in their efforts to re- 
 press and stamp out the disease. The aid of the Government in 
 this matter is a question to be discussed by itself. Without in- 
 dividual co-operation and sacrifice, directed by an intelligent under- 
 standing of the disease in its various aspects, any efforts on the part 
 of the Government are likely to prove abortive, owing to the enor- 
 mous interests involved. 
 
 "Removal of Diseased Animals. This is the essential require- 
 ment in the suppression of tuberculosis. We have already stated 
 that only in the diseased animals the tubercle bacilli multiply. 
 Hence, if these are removed and the stables thoroughly disinfected, 
 so that any germs shed by them are destroyed, we are safe in con- 
 cluding that the disease has been suppressed.
 
 48 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 "The disease in the early stages can be detected only with the 
 aid of tuberculin. In the advanced stages most careful observers 
 will probably recognize it, or at least suspect it, without the use 
 of tuberculin. Tuberculin, therefore, has become indispensible in 
 giving the owner an idea of the inroads the disease is making in 
 his herd, and in distinguishing the infected from the non-infected. 
 Tuberculin reveals to us all stages, from the earliest, most insig- 
 nificant changes, when the animal is outwardly entirely well, to 
 the gravest and most dangerous types of the disease. Tuberculin 
 does not, as a rule, discriminate between these cases. Hence, those 
 who use it as a guide must not be disappointed when, after having 
 killed the suspected ones, they find that many are in the earlier 
 stages of the malady. Tuberculin, moreover, is not infallible. A 
 small percentage of cases of disease are not revealed by it. On 
 the other hand, a sound animal now and then gives the reaction 
 of tuberculosis. These lapses must be borne in mind in using 
 tuberculin. In spite of them, however, tuberculin must be con- 
 sidered as of great value in revealing tuberculosis not recognizable 
 by any other means during life. 
 
 " The question next arises, What shall be done with the infected 
 animals ? This question is really composed of two distinct ques- 
 tions whose combination is mainly the cause of the present per- 
 plexity. From the standpoint of the agriculturist alone the matter 
 is simple enough. The infected animals might be separated at once 
 from the non-infected. The worst cases should be killed and buried 
 leeply or burned. Those without outward signs of disease might 
 be fattened for the butcher and inspected at the abattoir. This is 
 the recommendation given by JSTocard, a prominent French author- 
 ity, and generally followed in European countries. But at this 
 point public health appears and demands the prompt and complete 
 destruction of all infected animals, however mild the disease, or, if 
 the animal be not destroyed, the rejection of the milk of all in- 
 fected animals. The interests of the stock owner and of public 
 health are thus diametrically opposed. If the demands of public 
 health were in every sense justifiable, from a strictly scientific 
 standpoint, there could be no question as to an entire submission 
 to its demands. But the case is not so simple, and gives room for
 
 AND HOW TO COMBAT IT. 49 
 
 diversity of opinion. Leaving the public-health aspect of the 
 question aside for the moment, let us return to the farmer's side of 
 it. After all infected animals have been segregated or killed, as 
 the case may be, and the stables disinfected, the remaining healthy 
 animals should be retested with tuberclin within a certain period of 
 time, from three to six months after the first test, to make sure 
 that no disease has been overlooked. Future repetitions must be 
 recommended, according to our present knowledge, for some cases 
 may have been missed by the tuberculin, or the disease germs may 
 possibly be reintroduced by tuberculous human beings, or by tuber- 
 culous cats, dogs or other domesticated animals. 
 
 "All animals introduced into a herd must have been tested and 
 found to be sound beforehand. This is such a self-evident prop- 
 osition that it needs no comment. 
 
 " In the absence of the tuberculin test, or of organized official 
 inspection, the stock owner should carefully and promptly remove 
 from his herd and have destroyed : 
 
 " (1) All animals which show emaciation, with coughing, and 
 any suspicious discharges from the nose. 
 
 " (2) Those animals with enlarged, prominent glands about the 
 head (in front of the ears, under or behind the lower jaw), or en- 
 larged glands in front of the shoulder, in the flank, and behind the 
 udder, and all animals having swellings on any part of the body 
 which discharge a yellowish matter and refuse to heal. 
 
 " (3) Animals with suspected tuberculosis of uterus and udder. 
 
 "Disinfection and other Preventive Measures. It will probably 
 require more or less time before the use of tuberculin will have 
 become generally established. Hence, preventive measures of a 
 general character must still be kept in view for some time to come. 
 These measures partly suffer shipwreck from the fact that it is 
 difficult without tuberculin to recognize even advanced disease 
 during life. Still, much can be done to reduce the amount of in- 
 fection by following out certain general and specific suggestions 
 which the renewed study of the disease has either originated or 
 else placed on a more substantial basis. 
 
 " Perhaps the most important preliminary suggestion to be made 
 is, that the owner of cattle should endeavor to familiarize himself 
 4
 
 50 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 as much as possible with the general nature of tuberculosis, its 
 cause, the ways in which the virus may leave the body of the sick 
 and enter that of the well, and, lastly, the ways in which it 
 spreads within the body. He will, by the acquisition of such fun- 
 damental knowledge, lift himself above the plane where quackery 
 and specifics abound, and understand precisely what to expect after 
 the disease has entered his herd, and how to meet the demands 
 of public health. He should, however, make himself acquainted 
 with the peculiar appearance of tuberculous growths in the body, 
 and open every animal that dies, so that he may know to what ex- 
 tent his animals are dying of this malady. Wherever possible the 
 services of the skilled veterinarian should be made use of. Sani- 
 tary precautions should begin with the removal of diseased and 
 suspected animals, as stated above. This is the most essential 
 requirement, for diseased animals are the only breeding places of 
 the specific virus. 
 
 "After the removal of these, attention should be paid first of all 
 to the stables. Here, during the long confinement of the winter 
 months, when ventilation is all but suppressed, we may look for 
 the source of most of the inhalation diseases so common in tuber- 
 culous cattle. Even when only a few cases of tuberculosis have 
 been found, the stables should be disinfected by removal of all dirt 
 and the subsequent application of disinfectants. Since tubercle 
 bacilli are more resistant than most other disease germs, the 
 strength of the disinfecting solution must not be less than as 
 given. The following substances may be used : 
 
 " (a) Corrosive sublimate (mercuric chloride), one ounce in about 
 sight gallons of water) one-tenth of one per cent.). The water 
 should be kept in wooden tubs or barrels and the sublimate added 
 to it. The whole must be allowed to stand twenty-four hours, so 
 as to give the sublimate an opportunity to become entirely dis- 
 solved. Since this solution is poisonous, it should be kept well 
 covered and guarded. It may be applied with a broom or mop 
 and used freely in all parts of the stable. Since it loses its virtue 
 in proportion to the amount of dirt present, all manure and other 
 dirt should be first removed, and the stables well cleaned before 
 applying the disinfectant. After it has been applied, the stable
 
 AND HOW TO COMBAT IT. 51 
 
 should be kept vacant as long as possible. Before animals are 
 allowed to return, it is best to flush those parts which the animals 
 may reach with their tongues, to remove any remaining poison. 
 
 " (>) Chloride of lime, five ounces to a gallon of water (four per 
 cent.). This should be applied in the same way. 
 
 "(c) The following disinfectant is very serviceable. It is not 
 so dangerous as mercuric chloride, but is quite corrosive, and care 
 should be taken to protect the eyes and hands from accidental 
 splashing. 
 
 Gallon 
 
 Crude carbolic acid 
 
 Crude sulphuric acid 
 
 " These two substances should be mixed in tubs or glass vessels. 
 The sulphuric acid is very slowly added to the carbolic acid. Dur- 
 ing the mixing a large amount of heat is developed. The disin- 
 fecting power of the mixture is heightened, if the amount of heat is 
 kept down by placing the tub or glass demijohn containing the 
 carbolic acid in cold water while the sulphuric acid is being added. 
 The resulting mixture is added to water in the ratio of one to 
 twenty. One gallon of mixed acids will furnish twenty gallons of 
 a strongly disinfectant solution having a slightly milky appearance. 
 
 " (d) Whitewash is not in itself of sufficient strength to destroy 
 tubercle bacilli, but by imprisoning and incrusting them on the 
 walls of stables they are made harmless by prolonged drying. 
 Whitewashing should be preceded by thorough cleaning. 
 
 "Particular attention should be paid to the sides and ceilings of 
 stables. All dust and cobwebs should be periodically washed 
 down. Those parts coming in contact with the heads of cattle, Stables. 
 stanchions, halters, troughs, etc., should be frequently cleansed and 
 disinfected, even when they have not been used by diseased cattle. 
 
 " The removal of virus from the stables should, furthermore, be 
 promoted by the regular removal of manure and by abundant ven- 
 tilation. Good air has the effect of diluting infected air, and 
 thereby reducing the chance of inhaling dried, floating tubercle 
 bacilli, or at least of reducing the number inhaled. It likewise 
 improves the vigor of the confined animals, and hence increases 
 the resistance to infection.
 
 62 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 "Cattle should not be placed so that their heads are close to- 
 gether; each animal should have plenty of room (each cow should 
 have at last six hundred cubic feet of air space) and occupy the 
 same place in the stable at all times. These precautions will pre- 
 vent the nasal, lung, or vaginal discharges from one animal strik- 
 ing the head or soiling the feed of another. It is true that it is 
 impossible to prevent animals licking each other outside of the 
 stable, but it should be remembered that prevention must begin 
 with the removal of all cases which are suspected of discharging 
 tubercle bacilli. Stables should, furthermore, be carefully pro- 
 tected from the expectorations of human beings affected with tu- 
 berculosis of the lungs. 
 
 " Cattle should be housed as little as possible. The pasture has 
 the effect of greatly reducing the chances of infection by a more or 
 less rapid destruction of the virus, as well as by increasing the vigor 
 of the animals through muscular exertion in fresh air. To what 
 extent animals may pick up the virus on fields, it would be difficult 
 to estimate. That it is perfectly possible cannot be gainsaid. A 
 tuberculous animal may soil the ground over which it passes, and 
 other animals may take up the virus with the food soon after. 
 
 "It is not likely that the virus remains alive long enough on the 
 ground to become dried and ready for inhalation. The action of 
 sunlight, the alternate wetting and drying which goes on in nature, 
 may be looked upon as destructive agents. Even if the tubercle 
 bacilli became speedily dried, the great diluting effect of the open 
 air would reduce to a minimum the chances of inhaling the virus. 
 
 "Among the other dangers deserving attention is the infection 
 of food and water. Drinking troughs should be so arranged that 
 the surface water is constantly flowing away. Discharges from 
 the nose or mouth left floating on the surface may be drawn in by 
 healthy cattle while drinking. Each person must in such cases 
 use his own judgment and ingenuity to prevent infection, in ac- 
 cordance with the quantity of water at his disposal. 
 
 " To restrict the dissemination of the disease among young stock, 
 the safest plan is to bring skimmed milk and other dairy products 
 to the boiling point before feeding them. If the cows are posi- 
 tively known to be healthy, this may be unnecessary, but where
 
 AND HOW TO COMBAT IT. 53 
 
 any doubt exists the heating should be resorted to. Such a pre- 
 caution will, furthermore, reduce scouring among calves, which is 
 probably due in a great measure to bacteria in the food. 
 
 " In presenting the foregoing suggestions the writer has endeav- 
 ored to keep in view two conditions : (1) That in which tuberculin 
 is not within reach and only unusual watchfulness can be exer- 
 cised in separating suspected animals from the healthy, and (2) 
 that in which tuberculin is tried, but with a view that it is not 
 wholly infallible and requires to be seconded with other precau- 
 tionary measures. If tuberculin is infallible, most of the sugges- 
 tions made fall to the ground as unnecessary, unless the disease 
 can be readily introduced by man or diseased animals of other 
 species, a possibility of wholly unknown dimensions at present." 
 
 We will only add to these valuable instructions that tuberculin 
 is a substance invented by Prof. Robert Koch for the purpose of 
 diagnosing tuberculous diseases. It is a fluid made from cultures 
 of the germs of tuberculosis, but it does not contain either dead or 
 living germs of tuberculosis, because it has been sterilized by heat- 
 ing, thus killing the germs ; and filtered through porcelain, so that 
 after they are destroyed they are completely removed from the fluid. 
 
 By tuberculin test is understood the process by which tuberculin 
 is applied to an animal for the purpose of determining whether it Tuberculin 
 is free from, or afflicted with, tuberculosis. In making the test it Test, 
 is necessary to determine the normal temperature of the animal, 
 and then inject a small quantity of the tuberculin. If the animal 
 has tuberculosis, its temperature will rise within from eight to six- 
 teen hours after the injection, but if it does not suffer from tuber- 
 culosis, the temperature is not influenced. 
 
 The tuberculin test should always be applied by a competent 
 veterinarian, and no danger will arise to the animals, for, when 
 properly applied, the healthy animal is never affected thereby. 
 
 Of course, there are conditions in animals, as there are in man, 
 which predispose to the disease. The breed as well as the condi- 
 tions under which an animal is compelled to live determine its 
 susceptibility. We believe it to be perfectly safe to say that the 
 suggestions made regarding the prevention of tuberculosis in man 
 are also applicable to animals. Light, air, cleanliness, proper food,
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Predispos- 
 ing 
 
 Conditions 
 in Cattle. 
 
 Tuberculo- 
 sis in 
 Swine. 
 
 and sufficient exercise are essential in combating tuberculosis ifc 
 the bovine race. After a herd has been freed from its tuberculous 
 members and a strict hygiene has been instituted, with plenty of 
 room for every animal, there will be little danger of a new out- 
 break of the disease. 
 
 Of course, as already mentioned in Dr. Smith's instructions, it is 
 essential that no consumptive, no matter in what stage of the dis- 
 ease, should be permitted to enter these stables. To have cows 
 attended to by tuberculous help is absolutely dangerous. Ex- 
 pectorating en the floor of a stable should be as strictly prohibited 
 as in the dwelling of man. If there is any disease such as diar- 
 rhoea, fever, etc., about the dairy or farm the physician should be 
 called in. Medical advice should also be sought in cases of slowly 
 healing ulcers and sores. Scrupulous cleanliness in the handling 
 of milk and butter in dairies is, of course, essential and all the 
 vessels used should be thoroughly cleaned with hot water before 
 being used again. 
 
 Tuberculosis among swine is not so rare as is usually assumed. 
 While the disease among cows may not always be recognized by 
 the loss of fat and general bad appearance (for even tuberculous 
 cattle can be fatted), in swine tuberculosis manifests itself at a 
 very early date by a marked emaciation. Very often these swine 
 are then quickly slaughtered and the meat made into sausages. 
 That through such procedures the health of the consumers is en- 
 dangered is evident, especially when one considers that many 
 kinds of sausages are eaten without being cooked. Tuberculosis 
 among young swine manifests itself most frequently in the form 
 of intestinal troubles. The mam symptoms of the disease are the 
 loss of flesh and bad appearance already mentioned, a pale mucous 
 membrane that is to say, the inner lining of the mouth loses its 
 reddish color a marked diarrhoea, flatulency and discharge of 
 gases. If there is tuberculosis of the lungs, cough and vomit- 
 ing are additional symptoms. In both forms of tuberculosis a 
 swelling of the glands around the neck is often observed. When 
 these animals are slaughtered, one can see little tubercles or ele- 
 vations and ulcerations along the inner walls of the guts, and on 
 the surface of the lungs. As soon as the disease is discovered
 
 AND HOW TO COMBAT IT. 55 
 
 among the animals, the sick swine should be separated from the 
 healthy ones. A veterinarian should then be consulted, who will 
 give directions for the destruction of the tuberculous meat and the 
 disinfection of the sties. 
 
 The prevention of tuberculosis among swine is not so difficult 
 when one thinks of the causes of the disease. A sucking pig can 
 be infected by a tuberculous sow. The most frequent source of 
 tuberculosis among hogs, however, comes from feeding them on 
 skimmed milk and other dairy products from tuberculous cows. 
 A few cases are also known where hogs became tuberculous from 
 eating the expectoration of consumptives. 
 
 Tuberculosis of horses is rare and difficult for a layman to recog- 
 nize. When a horse with a seemingly good appetite has" a bad Tuberculo 
 appearance and loses flesh, tires easily, and is short of breath, one sis in 
 should think of tuberculosis. Much urinating ana a high tern- Horses and 
 perature (fever) are additional symptoms of tuberculosis in horses. . . * 
 When such conditions are discovered, it is, of course, self-evident 
 that the animal should be isolated until the veterinarian arrives. 
 
 Tuberculosis among goats is extremely rare. In the few cases 
 which have been recorded the origin of the disease could be traced 
 to the ingestion of milk from tuberculous cows. Dogs take the 
 disease when living with consumptive people, and the infection 
 probably takes place through ingesting and inhaling infectious 
 substances. 
 
 CHAPTER XVH. 
 
 WHAT ARE THE OCCUPATIONS IN WHICH TUBERCULOUS INVA- 
 LIDS, EVEN IN THE FIRST STAGES OF THE DISEASE, SHOULD 
 NOT BE EMPLOYED? 
 
 There are certain occupations, especially those that require a long 
 sojourn in the open air every day without too much bodily exertion, 
 which tuberculous invalids in the first stages of the disease may 
 be permitted to follow in their own interest as well as in that of 
 their fellow-men. There are, on the other hand, certain occupa- 
 tions which should never be permitted to consumptives. What 
 we have said in the preceding chapter concerning tuberculous 
 help about cow stables and the possibility of their propagating the
 
 56 
 
 TUBERCULOSIS AS A DISEASE OP THE MASSES 
 
 Handling 
 
 of 
 
 Food 
 
 Substances, 
 Bread, etc. 
 
 Tuberculo- 
 sis among 
 
 Caged 
 Animals. 
 
 disease, is, of course, also applicable to milk dealers, butchers, 
 cooks, bakers, confectioners, and all who have to do with the 
 preparation or sale of food substances. For bread to be handled 
 by tuberculous bakers or bread dealers is dangerous. The possi- 
 bility of infection is evident when one considers through how 
 many hands the bread passes before it enters the mouths of the 
 consumers, and that, probably, nobody ever thinks of cleaning the 
 bread before eating it. A very recommendable practice is now in 
 vogue in some of the large bakeries in connection with the hand- 
 ling and transporting of bread. The moment the bread comes out 
 of the oven, while it is still too hot to be handled, it is placed, by 
 the aid of a shovel, upon a piece of wrapping-paper large enough 
 to envelop the whole loaf. By twisting the two ends of the 
 wrapper the bread is completely enclosed. 
 
 The most scrupulous cleanliness should be practised wherever 
 articles of food are handled or exposed for sale. We have already 
 mentioned in Chapters XIII. and XIV. that certain occupations, 
 such as those of stone-cutters, printers, and cigar-makers, render 
 weak individuals particularly prone to consumption; therefore, any 
 one inclined to this disease should, in his own interest, never 
 pursue such an occupation. 
 
 Lastly, we must mention one more occupation in which tuber- 
 culous individuals should never engage, namely, that of keepers of 
 animals in menageries. Large animals, such as lions and tigers, 
 also the larger and smaller classes of apes, are subject to tubercu- 
 losis when in captivity. There is no doubt that an ape-house, 
 visited by thousands of people, old and young, every day, must be 
 considered dangerous and capable of propagating the germs of tu- 
 berculosis among the visitors if some of the animals should be 
 tuberculous. 
 
 CHAPTEE XVIII. 
 
 WHAT ARE THE MAIN SIGNS AND SYMPTOMS OF THE BEGINNING 
 OF TUBERCULOSIS OF THE LUNGS OR CONSUMPTION? 
 
 These symptoms are often so obscure and show themselves so 
 gradually that they are frequently overlooked by the patient as 
 well as by his friends. Since, however, the cure of the patient
 
 AND HOW TO COMBAT FT. 57 
 
 depends upon the early discovery of the disease and a timely treat- 
 ment, we will here describe such symptoms as may be recognized 
 by the layman. 
 
 The man, woman, or child with a hereditary predisposition to 
 consumption often has a narrow chest and stooping shoulders. 
 While a slow, gradual emaciation and loss of weight may at times 
 be observed, this is by no means a rule. One occasionally sees 
 tuberculous patients who present a relatively good appearance dur- 
 ing the first stage of the disease. Paleness of the skin, at times 
 with bright red cheeks, is, however, a rather common early sign. 
 A marked inclination to frequent catarrh is often present, and the 
 character and disposition of the individual may change when the Importance 
 disease comes to an outbreak. There is a dislike to work, also to f Early 
 the pleasures and occupations which the invalid formerly loved to ConsumD- 
 jursue. He will probably also complain of getting tired easily. tion. 
 In the afternoon hours he will have a light fever, and a hacking 
 cough in the morning or evening. Dyspepsia and loss of appetite, 
 palpitation of the heart and pains in the chest, are also symptoms 
 of importance. Of course, some or several of these signs and 
 symptoms may also be the indication of the approach of other dis- 
 eases than tuberculosis of the lungs. The presence of such symp- 
 toms should, however, serve to all, whether predisposed to tuber- 
 culosis or not, as a warning to seek medical advice. Especially 
 persons who cough more or less continually should submit them- 
 selves to a thorough examination. The science of medicine has 
 made such progress that the recognition of a beginning tuberculo- 
 sis of the lungs no longer presents any difficulty ; therefore, when- 
 ever there is a suspicion of the beginning of consumption, the call- 
 ing in of a physician may assure cure and restoration to health, 
 and if no tuberculosis is present the medical examination will quiet 
 unnecessary fears. 
 
 CHAPTER XIX. 
 
 WHAT ARE THE EARLY SYMPTOMS OF OTHER FORMS OF TU- 
 BERCULOSIS ? 
 
 In case of tuberculosis of the throat, the general symptoms are 
 about the same as those just described for the beginning of con-
 
 58 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Early 
 Symptoms 
 of Throat 
 Tuberculo- 
 sis. 
 
 Early Signs 
 
 of 
 Scrofula, 
 
 sumption of the lungs; but in addition there will be a certain 
 hoarseness and roughness of the voice. Pain in swallowing very 
 hot and cold liquids or hard food may also sometimes be observed 
 in the early stage of this disease. 
 
 The early symptoms of tuberculosis of the bones and joints 
 manifest themselves in lameness and easy tiring of the arm or leg 
 affected. A light pressure in the region of the joints causes a 
 sudden severe pain. If the spinal column is affected, the symp- 
 toms will depend upon the location of the vertebra which is 
 attacked by the disease. For example, if this should be in the re- 
 gion of the neck, there will be difficulty in swallowing, in breath- 
 ing, or a frequent dry cough. If any one of the vertebrae in the 
 region of the chest is affected, a feeling of constriction like a 
 tight band around the chest will be observed, accompanied often 
 by digestive troubles. If the seat of the disease is the lower por- 
 tion of the spinal column, there will be irritation of the bladder 
 and lower bowels, an inclination to much urinating, and radiating 
 pains toward the hips. 
 
 It is, of course, self-understood that when any of these symp- 
 toms are discovered the physician should be called in, for only 
 through the most careful treatment can a patient be saved from a 
 lasting deformity. 
 
 The bone-and-joint tuberculosis is most frequent during child- 
 hood. The same may be said of that form of tuberculosis which 
 is known as scrofula, and which might be considered almost ex- 
 clusively a disease of children. The scrofulous child is usually 
 pale with flabby skin and muscles. The glands around the neck 
 are swollen, and skin disease, sore eyes, and running ears are fre- 
 quent symptoms. The little patient usually manifests a phleg- 
 matic condition, but we may also find some that are nervous and 
 irritable. The latter often have a particularly white, delicate 
 skin, which makes the veins visible. Fever may be observed in 
 some children. In view of the happily very curable nature of 
 scrofulous affections, the importance of the early recognition and 
 of the timely and judicious treatment is, of course, self-evident.
 
 AND HOW TO COMBAT IT. 
 
 59 
 
 CHAPTER XX. 
 
 How CAN CHILDREN BE PROTECTED FROM SCROFULA AND OTHER 
 FORMS OF TUBERCULOSIS ? 
 
 Scrofula may be either hereditary or acquired. The hereditary 
 type comes from parents who are scrofulous, tuberculous, or syphi- 
 litic. It has also been proved that when one or both of the par- 
 ents were alcoholics, that is to say, addicted to the chronic use of 
 intoxicants, their offspring has become scrofulous. 
 
 All this shows how dangerous it is for weakly and sickly per- 
 sons, or those afflicted with any of the above enumerated diseases, 
 to marry and have children before being completely restored to 
 health. We wish to state again that all these diseases can be 
 cured by timely medical treatment. To be cured from alcoholism 
 the physician's help is not always necessary; inmost cases it 
 requires only the earnest and honest endeavor to abstain. 
 
 The causes of acquired scrofula in children are to be sought in 
 unhygienic environments and conditions, such as unhealthy dwell- 
 ings, damp, crowded, unclean, and badly ventilated rooms, much 
 indoor life, underfeeding, exposure, and colds brought about by 
 insufficient clothing and lack of care. In fact, one may say the 
 same conditions which produce favorable soil for the invasion of 
 the germs of consumption in the adult are conducive to the de- 
 velopment of scrofula in children. How these conditions are to 
 be overcome we have endeavored to explain in Chapters XII., XIV., 
 and XV., and we will speak of them in their sociological aspect in 
 Chapter XXVIII. 
 
 On page 41 we stated that it is extremely rare for tuberculosis to 
 be directly transmitted, and that in children the contagion nearly 
 always takes place while they are very young. We will now ex- 
 plain the various ways in which a healthy child may become 
 tuberculous, and learn therefrom how to protect it from the dan- 
 ger of getting the disease, either by inhalation, ingestion, or inoc- 
 ulation. 
 
 The most common modes of infection during early childhood 
 are perhaps the following: The consumptive mother caresses the 
 
 Hereditary 
 Causes of 
 Scrofula, 
 
 Acquired 
 Causes of 
 Scrofula.
 
 60 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Tubercu- 
 lous 
 
 Infection 
 
 During 
 
 Early 
 
 Childhood. 
 
 Kissing 
 Unsani- 
 tary. 
 
 Clean 
 Play- 
 grounds. 
 
 child and kisses it on the mouth; she prepares the food, tasting it 
 to judge its temperature and flavor through the same rubber nipple 
 or with the same spoon the child uses, and thus unconsciously 
 conveys the germs of her disease from her own mouth to that of 
 the child. Later on the child will play on the floor of the room, 
 and should there be a consumptive in the family who from care- 
 lessness or ignorance is not prudent in the disposal of his expec- 
 toration, the child is indeed likely to be infected. The little one, 
 while playing on the floor, may with great facility inhale the 
 bacilli floating with the dust in the air, and can thus acquire 
 tuberculosis by inhalation, the full development of which may 
 only take place in later years, when the origin will not be thought 
 of. Again, the little child touches everything it can take hold of, 
 infecting its fingers thoroughly, and by putting them in its mouth 
 tuberculosis by ingestion may result and gradually develop into 
 consumption of the bowels. Lastly, should the child's nails be 
 neglected, it may scratch itself with the infected fingers, and thus 
 inoculate its system with the disease. Tuberculosis of the skin, 
 or lupus, may result from such an unfortunate accident. 
 
 To prevent these infections during childhood is certainly pos- 
 sible by taking the following precautions : Not only should con- 
 sumptives be religiously careful with their expectoration, but they 
 should associate as little as possible with young children, and stay 
 away from playrooms and playgrounds. We repeat that to kiss 
 children on the mouth should never be allowed, and the little 
 ones should be taught never to kiss nor be kissed by strangers, 
 They should be kissed by their own friends and relatives as little 
 as possible, and then only on the cheeks. The floor on which the 
 child plays should be kept scrupulously clean. Carpets in such a 
 place are an abomination ; they only serve as dust and dirt collec- 
 tors, and not infrequently harbor the germs of contagious diseases. 
 The hands and nails of little children should be kept as clean as 
 possible. 
 
 Expectorating on playgrounds should be considered a grave 
 offence and should be punished accordingly. These playgrounds 
 should be kept clean, as free from dust as possible, and daily 
 strewn with clean sand or graveL
 
 AND HOW TO COMBAT IT. 
 
 61 
 
 CHAPTER XXI. 
 
 CAN TUBERCULOSIS, ESPECIALLY IN ITS PULMONARY FORM, OR 
 CONSUMPTION OF THE LUNGS, BE CURED ? 
 
 This question can be answered with a very decided Yes. Of 
 eminent men of the past and present, who in their youth or early 
 manhood were declared to be consumptive, but who attained, 
 nevertheless, a more or less advanced age, may be mentioned the 
 German poet Goethe, Napoleon the First, and our own Peter 
 Cooper. Dr. Hermann Brehmer, one of the foremost German 
 physicians, was a consumptive when he started the first sanato- 
 rium for tuberculous patients in 1859, over which he presided for 
 more than thirty years with great success. His most celebrated 
 pupil, Dr. Dettweiler, entered his sanatorium as a consumptive, 
 became Brehmer' s assistant, and has since been for twenty-five 
 years active as the medical director of the Falkenstein Sanatorium. 
 The late Dr. Pean, of Paris, who died at the age of sixty-five, was 
 declared phthisical when twenty. Francis Coppe"e, one of the 
 greatest poets of modern France, takes delight in telling that more 
 than twenty years ago a life insurance company refused to insure 
 him, because he was declared consumptive, and how badly the com- 
 pany ought to feel now, having lost his premiums for over 
 twenty years ! There are thousands of such cases where people, 
 once declared consumptive by competent physicians, have ulti- 
 mately recovered, and pursued their vocations in life with unim- 
 paired vigor for many years afterward. 
 
 The statistics from sanatoria for consumptives, where patients 
 in all stages of the disease are received, show that twenty-five 
 per cent, leave as absolutely cured, and forty to fifty per cent, 
 leave much improved, many of them being again capable of earn- 
 ing their living. In institutions where only patients in the 
 early stages of the disease are received, as many as seventy to 
 seventy-five per cent, have been cured. 
 
 Celebrated 
 
 Men Who 
 
 were Cured 
 
 of 
 
 Consump- 
 tion. 
 
 Results 
 
 Obtained in 
 
 Sanatoria.
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Reports 
 
 from 
 
 Dettweiler, 
 
 Wolff, 
 
 Hauffe, 
 
 Von Ruck, 
 
 and 
 Baldwin. 
 
 CHAPTER XXII. 
 
 HAVE THE FORMER PATIENTS WHO LEFT SANATORIA OR SPECIAL 
 INSTITUTIONS FOR THE TREATMENT OF CONSUMPTION AS CURED, 
 REMAINED LASTINGLY So? 
 
 That a lasting cure of consumption is possible we have shown 
 in the preceding chapter by enumerating the names of some 
 great men who were consumptive in their youth, but were cured 
 and lived a long and useful life, some even attaining a ripe old age. 
 
 Concerning the duration of cures accomplished in sanatoria and 
 special hospitals for consumptives, we will reproduce some of the 
 statistics published in recent years. Among 99 patients dis- 
 charged from the Falkenstein Sanatorium as cured, 72 were well 
 at the time the inquiry was made, which was three to nine years 
 after the patients had left the sanatorium. In 15 cases a re- 
 lapse had occurred, but 12 of these patients had improved again; 
 12 of the 99 had died. Dr. Wolffs inquiries concerning 95 pa- 
 tients discharged as cured from Brehmer's institution in Goerbers- 
 dorf , resulted in the following : 5 were alive and well after a period 
 of from 21 to 29 years; 52 were well after a period of from 12 to 
 21 years; and 38 were well after a period of from 7 to 12 years. 
 Dr. Hauffe, of the St. Blasien Sanatorium in Germany, wrote in 
 1891 to 324 former patients who had left the institution between 
 1879 and 1889. Forty-six did not reply, 5 were reported dead, 
 12 had grown worse, 201 thought themselves still relatively cured, 
 and 72 were absolutely cured. Dr. von Ruck, of Asheville, N. 
 C., reported to the author of this essay that he had written to 650 
 of his former patients who had left the sanatorium from one to 
 three years before; 457 responded, directly or through friends. 
 Of these, 67 felt absolutely cured; 70 felt relatively cured; 258 
 felt still improved ; 62 got worse or had died. Dr. E. R. Baldwin, 
 of Saranac Lake, N. Y., reported recently that at the Adirondack 
 Cottage Sanatorium they were in constant correspondence with 115 
 patients who had been discharged within the last ten or twelve years, 
 and while a few had relapsed slightly, the majority were well at
 
 AND HOW TO COMBAT IT. 
 
 63 
 
 their homes. Of course, these reports do not, and cannot, corre- 
 spond exactly. With the exception of the last-named institution 
 (Adirondack Cottage Sanatorium), which only takes patients in the 
 earlier stages, those sanatoria receive patients for treatment in all 
 stages of the disease. But, as a whole, these statistics are certainly 
 encouraging, and the question "Can consumption be lastingly 
 cured ? " may also be answered with a decided Yes. 
 
 Not only the living but even the dead give us absolute proof of 
 the curability of tuberculosis of the lungs. In the autopsies (post- 
 mortem examinations) of many individuals who have died of other 
 diseases than consumption, healed scars are found in the lungs, 
 giving the visible evidence of a healed tuberculosis. Statistics 
 concerning this occurrence show that the number of cases of 
 healed tuberculosis of the lungs, discovered at autopsies, is nearly 
 twenty-five per cent. 
 
 Other forms of tuberculosis are also curable, particularly the 
 forms which manifest themselves as scrofula, or diseases of the 
 bones or joints in children. The results which have been obtained 
 in sea-coast sanatoria and special hospitals, of which a number exist 
 in France, Germany, Holland, and Italy, are well-nigh surprising. 
 According to a recent report of the general secretary of the Society 
 for the Creation of Sea-Coast Sanatoria for Scrofulous and Tuber- 
 culous Children in Germany, no less than fifty per cent, of these 
 little ones leave those institutions perfectly cured. 
 
 We do not think it an exaggeration to say that of all chronic 
 diseases tuberculosis is the most curable, and of" late years the 
 most frequently cured. After these glad tidings concerning the 
 curability of tuberculosis in general, and particularly of the once 
 so very much feared tuberculosis of the lungs or consumption, let 
 us ask how consumption is treated and cured. 
 
 CHAPTEK XXIII. 
 
 WHAT AKE THE MODERN METHODS TO TEEAT AND CURE CON- 
 SUMPTION ? 
 
 It is not cured by quacks, by patent medicines, nostrums, or 
 other secret remedies, but solely and exclusively by scientific and 
 
 Pathologi- 
 cal Proofs 
 
 of the 
 Curability 
 
 of 
 
 Consump- 
 tion. 
 
 Other 
 Forms of 
 Tuberculo- 
 sis Also 
 Curable.
 
 64 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 judicious use of fresh air, sunshine, water, abundant and good food 
 (milk, eggs, meat, vegetables, fruit), and the help of certain medic- 
 inal substances when the just-mentioned hygienic and dietetic 
 means do not suffice in themselves to combat the disease. 
 
 The thorough and constant supervision of the pulmonary invalid, 
 the immediate intervention when new symptoms manifest them- 
 selves or old ones become aggravated or do not disappear rapidly 
 enough, the prescribing of proper food and drink, can only be done 
 by the thoroughly trained physician. Therefore, right here let us 
 sound a note of warning ; namely, that not the most beautiful cli- 
 mate nor the most delightful resort can cure the consumptive 
 patient if he is not wisely guided in his treatment. 
 
 Sometimes this class of patients think that they feel well enough 
 to no longer need to submit themselves to the control of their 
 physician. They think that they may safely pursue pleasures, 
 sometimes even excesses, or take up work just as well as healthy 
 people. Such carelessness on the part of a recovering consumptive 
 has many a time resulted in a serious relapse. 
 
 The thorough belief in the curability of pulmonary tuberculosis, 
 and the conviction that the hygienic and dietetic treatment under 
 constant medical supervision could be most successfully carried out 
 Medical ^ an ms ti tu ti n exclusively intended for that purpose, caused Her- 
 Supervision mann Brehmer, the German physician mentioned above among 
 Essential to the illustrious men cured of consumption, to establish the first sana- 
 CurCt torium for consumptives, at Goerbersdorf in Silesia (1859); al- 
 though it must be said, in justice to the English medical world, 
 that special hospitals for consumptives were erected in or near 
 large cities as far back as sixty years ago. These " special hospi- 
 tals " for consumptives in former years did not differ much from 
 general ones, while a sanatorium for consumptives has many fea- 
 tures by which it differs entirely from an hospital. Brehmer, in 
 his day, maintained that such institutions should have particular 
 
 Special climatic conditions, and should always be situated at a consider- 
 Chmatic 
 Advantages a ^ e e l evat ion above the sea in order to obtain satisfactory results. 
 
 Not The experience of more recent years, however, in Europe as well 
 Essential to as ^ the United States, has shown that properly conducted sana- 
 toria or modern special hospitals, erected in regions with no claims
 
 AND HOW TO COMBAT IT. 65 
 
 for special climatic advantages, obtained just as good results in the 
 end as institutions situated in typical climatic resorts. 
 
 To give the layman an idea of what is understood to-day by & 
 closed institution or sanatorium, exclusively intended for the treat- 
 ment of consumptives, we will answer the following questions : 
 
 CHAPTEE XXIV. 
 
 WHAT is A MODERN SANATORIUM FOR CONSUMPTIVES ? AND CAN 
 SUCH A SANATORIUM BECOME A DANGER TO THE NEIGH- 
 BORHOOD ? 
 
 A modern sanatorium * for the treatment of consumptives is an 
 institution usually situated in a healthy locality, somewhat elevated, 
 relatively free from dust and traffic. Only patients suffering from 
 tuberculosis are received. The greatest care is exercised every- 
 where, in buildings and surroundings, to avoid the possible trans- 
 mission of the disease to employees, visitors, or the neighbors of 
 the institution, and equally great care is exercised to prevent a 
 reinfection of the patients themselves. All the precautions enu- 
 merated in Chapters IV. and V. , which provide for the destruction 
 of the infectious expectoration, are carried out with the utmost 
 rigor in the sanatorium. A voluntary violation of rules, relating 
 to the disposal of the expectoration, is followed by immediate dis- 
 missal of the offender. 
 
 The hygienic and preventive measures in these modern sanatoria Hygiene in 
 are so thorough that it may be said one is in less danger of becoming the 
 infected with the germs of consumption there than anywhere else. k 
 It is of the rarest occurrence that any of the physicians, nurses, 
 or employees in such an institution contract tuberculosis. It 
 seems to us that this is a very good proof of how easily infection 
 
 *The word sanatorium is used in this essay in preference to the word 
 "sanitarium" for the following reasons: Brehmer, the founder of the first 
 institution of that kind, called it " Heilanstalt," which means a healing insti- 
 tution ; and the word "sanatorium," from the Latin sanare, to heal, gives cer- 
 tainly a better equivalent to the German word than the word "sanitarium." 
 This latter word is derived from the Latin sanitas, health, and is usually em- 
 ployed in this country to designate a place considered as especially healthy, a 
 favorite resort for convalescent patients, or an institution for the treatment of 
 mental or nervous diseases.
 
 66 
 
 TUBERCULOSIS AS A DISEASE OP THE MASSES 
 
 Mortality 
 
 can be avoided when physician and patient work together to com- 
 bat the tubercle bacillus, this great foe of mankind. 
 
 Another very interesting observation is that in localities where 
 sanatoria for consumptives are situated, the mortality from con- 
 sumption among the inhabitants of the respective villages has 
 
 Goerbers- 
 
 dorf and 
 
 Falken- 
 
 stein. 
 
 Statistics of markedly decreased since the establishment of the institution. 
 The splendid hygienic and preventive measures instituted in the 
 sanatoria have been voluntarily imitated by the villagers, and as a 
 result the mortality from pulmonary tuberculosis among the in- 
 habitants has gradually decreased. Thus we are glad to be able 
 to answer in the negative the question so important in the combat 
 of tuberculosis as a disease of the masses, " Are sanatoria for con- 
 sumptives a danger to the neighborhood ? " From well-conducted 
 sanatoria for consumptives no danger can arise to the surroundings. 
 To confirm this statement by exact statistics, we will reproduce 
 the data taken from the official documents of the two vilkges, 
 Goerbersdorf and Falkenstein, where five of the largest German 
 sanatoria have been located for many years. 
 
 In Goerbersdorf the deaths from consumption were : 
 
 1790-99 14 
 
 1800-09 5 
 
 1810-19 9 
 
 1820-29 9 
 
 1830-39 . . 8 
 
 1840-49 6 
 
 1850-59 7 
 
 1860-69 4 
 
 1870-79 5 
 
 1880-89.. . 5 
 
 The sanatorium in Goerbersdorf was established in 1859, and 
 since then the population of the village of Goerbersdorf has 
 doubled. 
 
 In the village of Falkenstein died from tuberculosis : 
 
 Before the Establishment of the Sanatorium. 
 
 1856-58 . 17.2 per 100 
 
 1859-61 7.7 
 
 1862-64 22.6 
 
 1865-67 14.0 
 
 1868-70 16.7 
 
 1871-73 21.0 
 
 1874-76.. . 33.3 
 
 After the Establishment of the Sanatorium. 
 
 1877-79 17.0 per 100 
 
 1880-82 14.6 " 
 
 1883-85 6.0 " 
 
 1886-88 5.0 " 
 
 1889-91 13.9 " 
 
 1892-94.. . 15.1 " 
 
 The patients in such a sanatorium live, so to speak, day and 
 
 Rest Cure n ^ fc m tne P en auv During the day they lie on lounging chairs 
 
 in the Open on the open verandas and take walking and breathing exercises, 
 
 Air. and at night they sleep, of course, with the windows open. It is
 
 AND HOW TO COMBAT IT. 
 
 67 
 
 surprising how easily consumptives get accustomed to the pro- 
 longed sojourn in the open air. Neither change of weather, cold, 
 rain, snow, nor even wind, providing it is not too strong, hinders
 
 68 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 the patients from spending most of their time on the piazza, porch, 
 or rest-cure gallery. Observations made by the house physicians 
 in sanatoria prove that the change of weather has little influence 
 on the trained consumptive patient, and that the rest cure on the 
 galleries of the sanatorium can be successfully carried out in win- 
 ter or summer, rain or shine. When it is very cold patients cover 
 themselves a little more with blankets or furs. Dr. Andvord, of 
 the Tonsaasen Sanatorium, reported that his patients remained in 
 the open air from five to nine hours a day at a temperature of 
 
 FIG. 20. A German Rest-Cure Gallery. 
 
 13 F. below zero, and felt very well. Similiar reports come to us 
 from that excellent American institution, the Adirondack Cottage 
 Sanatorium, under the direction of Dr. Edward L. Trudeau, the 
 pioneer of the sanatorium treatment in the United States. We 
 reproduce a photograph (Fig. 19) taken on a winter day at that 
 institution, showing how well and comfortable the patients are in 
 spite of the cold. We also give a typical German rest-cure gal- 
 lery or "Liegehalle " (Fig. 20), and finally a picture representing 
 the rest cure in summer in the woods at a sanatorium in the Black 
 Forest in Germany (Fig. 21). The latter shows how the patients 
 in a sanatorium know how 1 o have a good time. One must not
 
 AND HOW TO COMBAT IT. 
 
 69 
 
 think these institutions dreary and cheerless places. The major- 
 ity of the patients do well, as a rule, and progress favorably toward 
 recovery. As a consequence they feel happy and impart their joy
 
 70 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Discipline. 
 
 Relation 
 of Patient 
 
 and 
 Physician. 
 
 and good humor to the rest, thus helping to keep all the patients 
 in good cheer. 
 
 The discipline in these institutions deserves by no means to be 
 considered an objectionable feature. Discipline in a sanatorium 
 for consumptives is as essential in the interest of the patient as 
 for everybody else. The rules and regulations of the institution 
 are for the common good. The physicians and nurses have, 
 as a rule, the patience, forbearance, and devotion which their 
 calling requires; but when it is necessary in the interest of the 
 patients and then- environments, the physician must have the right 
 to make his authority felt. A sanatorium should not only be a place 
 where a patient becomes cured, but also a place where he should 
 learn some lessons for the future. All that he will have learned 
 from the rules and regulations, and the advice of the physician 
 concerning how to protect himself and others from contracting the 
 disease, how not to take cold, and how not to lose what he has 
 gained, are precious lessons which he will take home with him. 
 
 The physician of the consumptive, whether in a sanatorium or 
 at home, must be the friend of the patient, and have his unlimited 
 confidence. In all such questions as marriage, sexual relations, 
 and childbirth, the physician's advice should be sought. Much 
 unhappiness and family misfortune can often be avoided by asking 
 and conscientiously obeying the physician's advice. One of the 
 main features of sanatorium treatment is ample nutrition, one 
 might even say overfeeding. The principal meals are usually 
 taken in well- ventilated dining-rooms, the lunches on the piazzas 
 or on the rest-cure galleries. Many patients, in order that they 
 may gain more rapidly in weight and strength, receive an addi- 
 tional quantum of fresh milk daily. 
 
 On arriving at the institution every patient is carefully examined 
 and weighed by the physician, and this process is repeated at 
 regular intervals during the entire stay of the patient at the sana- 
 torium. The physician in charge or one of his assistants keeps 
 regular office hours for the convenience of the patients. Those 
 who are unable to be up are visited twice a day by one of the phy- 
 sicians of the institution. Specially constructed rooms for the ap- 
 plication of cold water, one of the means of treatment, are usually
 
 AND HOW TO COMBAT IT. 71 
 
 located in the basement, or the apparatus is installed in a neigh- 
 boring building. A pharmacy, a laboratory, and a room for the 
 treatment of throat diseases usually completes the equipment of a 
 large sanatorium. 
 
 To enable the poorer classes to avail themselves of the advan- 
 tages of institution treatment for consumptives, noble-minded 
 men and women, philanthropists, statesmen, and physicians have 
 in recent years been instrumental in creating in many parts of Eu- 
 rope and in some parts of the United States so-called State or peo- 
 ple's sanatoria (Volksheilanstalten). 
 
 CHAPTER XXV. 
 
 WHAT ARE STATE SANATORIA ? AND WHAT ARE "VOLKSHEIL- 
 ANSTALTEN " OR PEOPLE'S SANATORIA ? 
 
 A State sanatorium in the United States means an institution 
 for the exclusive treatment of patients suffering from pulmonary 
 tuberculosis, created by the funds of the State and supported en- 
 tirely or in part by the State. The first State sanatorium in 
 America was erected a few years ago near Rutland, Mass. In this 
 institution patients pay fifty cents per day. Recently other States, 
 New York, New Jersey, Iowa, Illinois, Maine, etc., have projected 
 the building of similar institutions. 
 
 People's sanatoria in the United States are institutions intended 
 for the poor and people in moderate circumstances, erected and 
 maintained by private philanthropy. While in some institutions 
 patients receive medical treatment and board gratuitously, in 
 others they are supposed to pay part of the expense. 
 
 People's sanatoria in Germany have a somewhat different mean- 
 ing. There, the moment an individual 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 in- 
 surance companies, have long since learned that by timely treat- 
 ment in a sanatorium the tuberculous individual is most speedily 
 and lastingly cured, and consequently with the least expense.
 
 72 
 
 TUBERCULOSIS AS A DISEASE OP THE MASSES 
 
 State 
 
 Insurance 
 of 
 
 Consump- 
 tives. 
 
 Urgent 
 Need of 
 
 State and 
 People's 
 
 Sanatoria. 
 
 Thirty-seven of these government insurance companies have, 
 according to their published figures for 1897, collectively assisted 
 4,480 consumptives, of whom 4,432 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 ad- 
 vantage 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 in 1898 a fund 
 of between three and four millions was destined for that purpose. 
 
 To discuss whether such state invalidity insurance companies 
 are practicable or feasible in this country does not come within the 
 scope of this work. Still less can we enter into a discussion of 
 why private life insurance companies will not insure persons among 
 whose near relatives consumption has occurred, in spite of the evi- 
 dent curability of the disease. While it is most gratifying to note 
 that some States have undertaken to care for their consumptive 
 poor, and while noble men and women have privately undertaken 
 to care for some of those unfortunate sufferers, there is yet a great 
 deal to be done. In view of the great number of consumptives 
 with little or no means in our thickly populated States, it is evi- 
 dent that the existing institutions are like a " drop of relief in an 
 ocean of woe." Thus let us hope that the good work will go on, 
 and that the new century will see the multiple creation of State 
 and people's sanatoria in the United States. 
 
 That such special institutions and thorough hygienic measures 
 are well calculated to combat tuberculosis as a disease of the 
 masses, we shall try to prove in the following chapter. 
 
 CHAPTEK XXVI. 
 
 WHAT EVIDENCE EXISTS THAT BY TAKING CAKE OF CONSUMP- 
 TIVES IN SPECIAL INSTITUTIONS AND BY HYGIENIC MEAS- 
 URES, TUBERCULOSIS AS A DISEASE OF THE MASSES CAN 
 REALLY BE SUCCESSFULLY COMBATED ? 
 
 In England there have existed special institutions for the treat- 
 ment of consumptives, that is to say, hospitals and sea-coast sana- 
 toria, in relatively large numbers, for over fifty years. As a result
 
 AND HOW TO COMBAT IT. 
 
 of the maintenance of these institutions and the enforcement of a 
 most excellent general public hygiene, it was possible to reduce 
 the mortality from tuberculosis during the last years in a most 
 surprising manner, and more rapidly than in any other country of 
 the world. According to the following statistics, compiled by Dr. 
 Tat ham, the statistical superintendent in the registrar-general's 
 office, the mortality from tuberculosis among the population of 
 England and Wales has been reduced to wellnigh half of that 
 which it was thirty years ago. 
 
 The death rate per million of the population of England and 
 Wales from pulmonary tuberculosis was in 
 
 1870 2,410 
 
 1875 2,202 
 
 1880 1,869 
 
 1885 1,770 
 
 1890 1,682 
 
 1893 
 1894 
 1895 
 1896 
 
 1,468 
 1,385 
 1,398 
 1,307 
 
 These figures are perhaps the best answer to the question asked 
 at the head of this chapter. 
 
 CHAPTER XXVII. 
 
 CAN THE TREATMENT OF CONSUMPTION BE CARRIED OUT WITH 
 SATISFACTORY RESULTS OUTSIDE OF AN INSTITUTION ? 
 
 This question, too, may be answered in the affirmative, for the 
 cure of a consumptive 7 patient is certainly also possible outside of 
 a sanatorium. The conditions essential to success in such a case 
 are that the social position of the patient and the general environ- 
 ments are such that all the hygienic and dietetic measures, so es- 
 sential in the modern treatment of consumption, are at the disposal 
 of the physician. The latter, however, though he may be well 
 trained and exceedingly skilful, cannot hope for success unless 
 the patient is obedient and willing to carry out every detail of the 
 treatment. 
 
 We give here an illustration (Fig. 22) of how the patient in his Sanatorium 
 own house may arrange for permanent open-air treatment by build- at Home. 
 ing a small addition with galleries and awnings where he can spend 
 the greater part of the day, and where in warmer weather he may 
 sleep at night. Another simple method for carrying out the rest
 
 14: 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 cure in the open air might be accomplished in the following man- 
 ner : A large beach chair of wicker-work, such as is seen at our 
 fashionable sea-side resorts, is procured. After the seat has been 
 removed the inner walls are lined with padding. A reclining 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 the 
 patient installs himself for the day, with his books and writ- 
 ing materials at his side placed on a little table, on which his 
 meals may also be served. Being light, the whole can be shifted 
 
 FIG. 23. Arrangement for Open- Air Treatment at Home. 
 
 whenever the wind changes and according to the different time of 
 day, so that the invalid's body may be bathed by the rays of the 
 sun, while his head remains in the shade (Fig. 23). 
 
 Poorer patients, who for financial reasons cannot have such con- 
 veniences and who cannot be received in a sanatorium, must be 
 advised to ask the help of a physician, and under his guidance imi- 
 tate as far as possible and practicable the sanatorium instalment 
 and treatment at 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 win-
 
 AND HOW TO COMBAT IT. 
 
 75 
 
 ter, the patient may be placed, warmly wrapped, on his 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 garden, a small plat- 
 form of boards may be arranged for the chair 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 
 
 FIG. 23. Rest Cure at Home. 
 
 chair. How to arrange for the. cold-water treatment at home, we 
 have already described on page 34. 
 
 The hygienic precautions concerning the expectoration must, of 
 course, be carried out in the private home as rigorously as in the 
 institution. Thus, if the patient has an earnest determination to 
 do his duty, confidence in his physician, and the good will of the 
 friends and relatives who live with him, it is possible to make even 
 a modest home temporarily suitable for the sanatorium treatment.
 
 76 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Need of 
 Sanatoria 
 
 for 
 Children. 
 
 CHAPTER XXVIII. 
 
 WHAT CAN PHILANTHROPISTS AND OTHER MEN AND WOMEN OF 
 GOOD WILL Do TO HELP COMBAT TUBERCULOSIS AS A DIS- 
 EASE OF THE MASSES ? 
 
 In Chapter XXV. we have spoken of the most urgent need of 
 sanatoria for the consumptive poor. These institutions are par- 
 ticularly wanted in large centres of population. In nearly all of 
 our large cities there are thousands of poor consumptives living 
 without care or treatment in their dark, filthy tenement-houses, 
 and spreading their disease to then- kin and neighbors. Perhaps 
 not one of all the great cities of the Union at the present time can 
 offer sufficient hospital facilities for the treatment or isolation of 
 these unfortunate people. A very large percentage of these pa- 
 tients could be cured or restored to health and made breadwinners 
 of their families if they were taken away from their unhygienic 
 surroundings in time and received proper treatment in a sana- 
 torium. 
 
 What great good wealth may do in this respect, how much mis- 
 ery and suffering it may alleviate, and how many lives it may thus 
 save, needs hardly any further demonstration. 
 
 But, besides the sufferers from pulmonary tuberculosis, there is a 
 large class of sufferers, especially among the children of the poorer 
 classes, who are afflicted with other forms of tuberculous disease, 
 particularly scrofula, and joint and bone tuberculosis. How very 
 prevalent these scrofulous and tuberculous diseases are among chil- 
 dren people in general have scarcely an idea. In Berlin, Ger- 
 many, careful statistics are kept concerning the daily attendance of 
 the children at the public schools. . In one of them it was found 
 that out of 125 boys and 132 girls who did not attend school 
 regularly, not less than 114 of the former and 115 of the latter 
 suffered from tuberculous or scrofulous troubles. 
 
 We have already spoken on page 63 of tb 3 excellent result ob- 
 tained in the treatment of tuberculous and scrofulous children in 
 the sea-coast sanatoria of France, Germany, Holland, and Italy. 
 The climate at the sea-shore, in addition to good nutrition and cold
 
 AND HOW TO COMBAT IT. 
 
 and warm sea-baths, seems to be particularly favorable for the 
 cure of scrofula and tuberculosis in. children. Institutions for this 
 treatment, like sanatoria for consumptive adults, are important 
 factors in combating tuberculosis as a disease of the masses. 
 The creation of such institutions in our own country cannot be 
 too warmly recommended to those who wish to help suffering little 
 children. 
 
 The cure of tuberculosis in its various forms can be accomplished 
 only by a thorough hygienic, and dietetic treatment under strict 
 medical supervision, in sanatoria, or, if circumstances permit, at 
 the home of the patient. 
 
 The prevention of tuberculosis as a disease of the masses, on the 
 other hand, especially in the form of pulmonary tuberculosis or 
 consumption, must be sought in combating the causes. In igno- 
 rance, lack of light, air, and sun, unhealthy tenements, unclean 
 linen, lack of proper or sufficient food, excesses of all kinds, and, 
 above all, in the abuse of alcoholic beverages, must we recognize 
 to-day the most important factors in the propagation of the disease. 
 
 To combat the ignorance in regard to hygienic modes of life in 
 general and the hygiene of tuberculosis in particular, among the 
 masses, must be the duty of the educated. Physicians, teachers, 
 employers, and all men and women who have time, means, talent, 
 and inclination, should unite to educate the masses by lectures and 
 the distribution of pamphlets concerning the nature of diseases, 
 particularly tuberculosis. The formation of societies for the pre- 
 vention of tuberculosis should be encouraged in every State of 
 the Union. The State and municipal governments, boards of 
 health, or other sanitary authorities should not only favor these 
 useful enterprises, but gladly co-operate in order to increase their 
 usefulness. 
 
 To give to the poor people of large cities more air, light, and 
 sun, it is essential not only to provide for good sanitary dwellings, 
 of which we shall speak in detail in the next chapter, but also 
 to create a number of parks and playgrounds, by public means or 
 private philanthropy, particularly in the more densely populated 
 districts. Such parks and breathing places are justly called the 
 lungs of a great city. 
 
 General 
 Causes of 
 Tubercu- 
 lous 
 Diseases.
 
 78 TUBERCULOSIS AS A DISEASE OP THE MASSES 
 
 Cleanliness and the beneficent influence of a bath must be prac- 
 tically taught to the ignorant. While it would be desirable that 
 every family should have its own bathroom, it will be some 
 time yet before this ideal condition will be obtained. In the 
 Public mean time the establishment of a number of public baths, of which 
 Baths. we made mention on page 43 in speaking of labor colonies, will be 
 one of the best means to improve the condition of the poor in this 
 respect and render them less liable to disease. As an example of 
 the excellent work of such public baths I give an extract from 
 the report of the New York People's Bath of last year. These 
 baths were erected and are maintained and managed by the Asso- 
 ciation for Improving the Condition of the Poor: "The People's 
 Baths are located at No. 9 Centre Market Place, New York. They 
 were opened in August, 1891. The building and its equipment 
 have cost about $28,000. It is situated on land for which no 
 ground rent is charged. The city furnishes the water free. The 
 building is constructed of enamelled brick and iron, and contains 
 twenty -six baths, twenty-three of which are spray baths (seventeen 
 for men and six for women). The other three baths are tubs for 
 old women and children. On the second floor are living quarters 
 for the superintendent, and in the basement the steam plant and 
 laundry. The cost of a bath is five cents, which includes a sepa- 
 rate piece of soap and a towel. Last year (1899) the baths sur- 
 passed all previous records, and have paid their operating expenses. 
 The result of the year's work shows a credit balance of 
 $137.01. The total number of bathers was 120,347, an increase 
 over the previous fiscal year of 4,662. All monthly and daily 
 records of number of bathers were also surpassed. In July there 
 were 17,452 bathers, and on July 22d the number was 1,175. 
 
 "The total operating expenses were $5,571.99, and the total re- 
 ceipts $5,709. No more interesting attempt to better the condi- 
 tions under which the tenement population live has ever been 
 made than the People's Baths. Their record for the past eight 
 years demonstrates that habits of cleanliness can be instilled into 
 those occupying the very worst quarters of the city. The success 
 of the baths is also largely due to the fact that they have been 
 conducted strictly on a business basis, the patrons feeling that they
 
 AND HOW TO COMBAT IT. 
 
 79 
 
 have given a reasonable equivalent for the services and accommo- 
 dations extended them." 
 
 Of course, these establishments, in order to be truly useful, 
 should be open all the year round, all day and in the evenings, 
 and to men, women, and children. 
 
 The causes of insufficient and bad nutrition, while they have 
 often to be sought in the economical and social condition of the 
 community, which we cannot discuss here, are just as, and per- 
 haps more, frequently to be found in ignorance and inexperience. 
 To make a good, plain, healthy, and tasty meal with relatively 
 little expense is an art which must be taught to the young wife, 
 leaving the factory or the position in the store to enter upon the 
 duties of a housewife. Here is a field for noble-minded and ex- 
 perienced women who have made the art of cooking & study. By 
 imparting their experience to their less fortunate sisters, they will 
 make a new household lastingly happy. 
 
 Of course, the establishment of public eating houses, where 
 especially the unmarried people of the working classes can obtain 
 good and plain meals for a nominal price, is also a necessity. In 
 connection with the subject of malnutrition, we wish to say one 
 more word concerning poor school-children, especially in large 
 cities. The majority of them very rarely go home for luncheon, 
 and the provisions they bring along from home are often of the 
 most meagre kind. In some cities of Germany the experiment 
 has been made to provide these poor children with a lunch of good 
 meat sandwiches and a glass of milk. The result of this most 
 praiseworthy work among children badly fed at home has been 
 simply surprising. Nearly every one of them gained in weight 
 within a month's time, and all of them were certainly made hap- 
 pier and capable of doing better work at school. 
 
 Now one more word concerning alcoholism or drunkenness. 
 There is no doubt that alcoholism must be considered the greatest 
 enemy of the welfare of a nation, the most frequent destroyer of 
 family happiness, the ruination of mind, body, and soul, and cer- 
 tainly the most active co-operator of the deadly tubercle bacillus or 
 germ of tuberculosis (consumption). 
 
 To combat alcoholism (drunkenness or intemperance) require? 
 
 Some 
 Causes of 
 
 Bad 
 Nutrition. 
 
 Alcoholism 
 and 
 
 Tuberculo- 
 sis.
 
 80 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 above all education. Extreme prosecution and fanatical laws will 
 do little good. From early childhood the dangers of intemperance 
 and its fearful consequences should be taught. In schools and at 
 home the drunkard should be pictured as the most unhappy of all 
 mortals. While the very moderate use of feebly alcoholic drinks, 
 such as light beers, may be considered as harmless to adults when 
 taken with their meals, alcohol should never be given to children 
 even in the smallest quantities. 
 
 In families in which there is a fear of hereditary transmission 
 of the desire for strong drink, even the mildest alcoholic drinks 
 should be absolutely avoided. It would also be best if all people 
 so predisposed, or who may have acquired only the occasional de- 
 sire for drink, would never smoke, for experience has taught that 
 attacks of dipsomania (periodical sprees) are often caused by an 
 excessive use of tobacco. The young man starting out in life 
 should take with him the moral training which will enable him 
 to be a gentleman, and be considered a polite gentleman, though 
 he absolutely refuses ever to enter a liquor saloon in order to treat 
 or be treated to drink. It is this treating habit alas ! so prevalent 
 in our American society which has ruined many a young man 
 and made him a moral and physical wreck. The creation of tea 
 and coffee houses where warm, non-alcoholic drinks including 
 bouillon are sold in winter and cool ones in summer, are to be 
 encouraged. It would be of additional advantage if some of these 
 houses could also offer healthful amusements for old and young. 
 Temperance societies, which through intelligent propaganda help 
 to combat the fearful evil of alcoholism, should receive encourage- 
 ment from everybody. 
 
 CHAPTEE XXIX. 
 
 How MIGHT THE TUBERCULOSIS PROBLEM IN THE UNITED STATES 
 BE SOLVED BY JUDICIOUS LEGISLATION AND A COMBINATION 
 OF PUBLIC AND PRIVATE PHILANTHROPY? 
 
 Presuming that there were in all the States sufficient regulations 
 against the spread of tuberculosis from man to man, and that the 
 laws against the propagation of tuberculosis by animals were uni-
 
 AND HOW TO COMBAT IT. 81 
 
 form throughout the United States and enforced in the best pos- 
 sible manner, we would, for further work, suggest the following 
 plan, more particularly for the larger centres of population : 
 
 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 a proper subject for state care in an asylum for the 
 insane, so should there exist a commission for the determination 
 of admission to a municipal or state institution for consumptives. 
 Such a commission, composed of a certain number of general prac- 
 titioners and health officers, should be aided in its work by the 
 charity organizations. Each case should be investigated by a com- 
 bined committee of physicians and laymen, for the following pur- 
 poses : 
 
 1. To determine the applicant's condition by a medical exami- 
 nation. 
 
 2. To visit his home if he has been found tuberculous, and to 
 institute such hygienic measures as seem necessary (distribution of 
 pocket spittoons, disinfectants, etc., gratuitously if the patient is 
 poor). 
 
 3. To examine the other members of the family, in order to find 
 out if any of them have also contracted the disease, and, if so, to 
 counsel proper treatment. 
 
 4. To report in full to the sanitary authorities concerning the 
 condition of the patient's dwelling. Its renovation or even de- 
 struction may be imperative when it is evident that tuberculosis 
 has become " endemic " there, owing to the condition of the soil 
 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 be necessary for the 
 municipality to provide 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 ex- 
 amination, and every physician should be at liberty to recommend 
 any person for examination to the board of his precinct or district.
 
 82 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 The institutions needed to carry out this plan would be : 
 
 1. A centrally located reception hospital and dispensary. The 
 dispensary should treat the ambulant tuberculous patients, whose 
 admission into the sanatorium is impracticable or has to be delayed 
 for want of room. These dispensaries should also serve the pa- 
 tient discharged from the sanatorium as a pkce to seek counsel, 
 and thus aid in his continued improvement and guard against the 
 possibility of a relapse. 
 
 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. Here all 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 from three to five hours by rail, at an altitude, if 
 possible, of between one thousand and two thousand feet, on porous 
 ground, with southern exposure, as nearly as possible protected from 
 the coldest winds by higher mountains, and preferably surrounded 
 by a pine forest. A farm in the vicinity, where the thoroughly 
 convalescent patients could do light work, might make the institu- 
 tion in a measure self-supporting. To this place the selected in- 
 cipient and the improved cases from the city sanatorium should 
 be sent to complete their cure. To the mountain sanatorium 
 there should also be attached a department for children suffering 
 from pulmonary tuberculosis. 
 
 4. Several sea-side sanatoria for the treatment of children 
 afflicted with tuberculous diseases of the joints and other tubercu- 
 lous (scrofulous) manifestations. 
 
 5. A maternity sanatorium where tuberculous mothers should 
 be received a few months previous to their confinement, and sur- 
 rounded by the best hygienic and dietetic care. They should also 
 remain in the sanatorium for some time after childbirth. It is 
 only by taking away these mothers from their unsanitary tenement 
 homes, and placing them under constant medical supervision in 
 such an institution, some time before and after their confinement, 
 that the fearful mortality among tuberculous mothers after child- 
 birth can be reduced.
 
 AND HOW TO COMBAT IT. 
 
 83 
 
 The beneficial effect on the woman's and child's constitutions 
 through such an arrangement can hardly be over-estimated. Leav- 
 ing aside the physical well-being thus largely assured to mother 
 and child at a period when their organisms need the most tender 
 care, the hygienic training which the mother will have received in 
 such an institution will be of lasting utility to herself and child, 
 to the family, and to the community. 
 
 These maternity sanatoria need not be situated at a great dis- 
 stance from the city. All that would be essential is that they 
 should be erected on good, porous ground, preferably somewhat ele- 
 vated, and in a locality where the atmosphere is as pure as possi- 
 ble. The buildings should be constructed according to the re- 
 quirements of modern ways of treating 1 women in childbirth, and 
 with ample facilities for rest cures, sun baths, and the other equip- 
 ments of a sanatorium for tuberculous invalids. 
 
 Another important work toward the solution of the tuberculosis 
 problem which might be accomplished by a combination of public 
 and private philanthropy, in addition to legislative measures, is 
 the multiple creation of model tenement houses, particularly in 
 large centres of population. There should everywhere be legisla- 
 tion to make the erection of any but model tenement houses 
 impossible, and the law should at the same time empower the 
 sanitary authorites to inspect all existing tenements, and if there 
 are any which are unfit or unsafe for human habitation owing to 
 lack of air* light, or ventilation, they should be condemned. As 
 has been said before, if a thorough renovation will not make them 
 sanitary, to tear them down will be the only remedy. 
 
 Overcrowding in tenement houses should be considered a crime, 
 and the owner should be held responsible for it. A family of from 
 six to ten living in three rooms, of which perhaps only one receives 
 direct light and air, cannot possibly remain in a good state of health 
 for any length of time. It is the dreary and cheerless room of the 
 tenement dwelling which often drives the wage earner to the 
 saloon. He finds light and life in the saloon and becomes indiffer- 
 ent to home conditions. Give the workingman a pleasant, clean, 
 healthy, and comfortable home, and the rumshop will have less 
 attraction for him. He will be a better husband, father, and citi- 
 
 Maternity 
 Sanatoria. 
 
 Tenements 
 and 
 
 Tuberculo- 
 sis.
 
 84 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 zen. The money formerly spent for liquor will go to the butcher 
 and baker for the better nutrition of his family, and underfeeding 
 (another important agent in preparing the field for tuberculous dis- 
 eases) will be materially lessened. A very praiseworthy move- 
 ment in this direction was recently inaugurated in New York by 
 the creation of a tenement-house commission, which has for its 
 purpose the improvement of the housing of the poor by the crea- 
 tion and enforcement of better tenement laws. 
 
 Overcrowded prisons, asylums, almshouses, schools, barracks, 
 public homes, lodging houses, etc., must also receive the attention 
 
 Uver r o f t ne sanitary authorities. The often crowded and unclean sailors' 
 ing of 
 Prisons boarding houses must not be overlooked. Enough cubic space per 
 
 Asylums, individual, more systematic ventilation, and the isolation of tuber- 
 Lodging culous invalids are the remedies which must be applied. 
 
 Ship-builders, ship-owners, and captains should bear in mind 
 that the intensely crowded quarters to which the average sailor is 
 confined during his hours of rest and sleep are absolutely detri- 
 mental, and even the outdoor life during the hours of work cannot 
 counteract the deleterious influence which the vitiated air of the 
 forecastle exerts on the health of the seaman. Of course, we are 
 aware that the space given to each individual on board ship must 
 be, of necessity, limited; still there can be some improvement, 
 and the ventilation can be made more perfect. For the very rea- 
 son that sailors have to live in crowded quarters the danger 
 of infection on board ship is very great. A tuberculous sailor 
 still at work is almost certain to infect his comrades. But ship- 
 board is not the only place where sailors are exposed to the dis- 
 ease. When on shore they mostly frequent and sleep in houses 
 where the accommodations consist of bunks and straw, and where 
 sanitation is so neglected that they are in still greater danger of 
 contracting disease. To prevent the spread of infection among 
 sailors there is but one remedy, and that is the regular periodic 
 examination of every sailor on board ship and the exclusion from 
 service of individuals suffering from pulmonary tuberculosis. 
 
 Lastly, the physicians, statesmen, and philanthropists interested 
 in the solution of the tuberculosis problem have, besides working 
 for the better housing of the poor and the creation of special insti-
 
 AND HOW TO COMBAT IT. 85 
 
 tutions for the treatment of consumptives, an additional mission . 
 
 Emigration 
 to perform. The tide of emigration from village to city should be f,. om Qitj to 
 
 reversed. If tuberculosis has made its appearance in a family liv- Country. 
 ing in a large city, the physician should exert all his influence to 
 induce especially the younger members to migrate to the country 
 and seek outdoor occupations. Statesmen should protect the in- 
 terests of the farmer, so that farming will have more attraction to 
 the rising generation than it has had in the last few decades ; and 
 philanthropists should aid the statesmen by endowing institutions 
 for instruction in scientific and profitable agriculture, and also by 
 providing healthful amusements, good libraries, and other educa- 
 tional institutions in country districts, thus making living outside 
 of large cities more interesting and attractive to young people ; in 
 short, the love of nature and life in the open air should be more 
 cultivated. In the proportion in which this is done tuberculosis 
 will decrease. Life "* t . lie 
 
 The creation of schools of forestry in connection with the preser- 
 vation and cultivation of forests in many States where a wasteful 
 destruction of trees is now carried on, would give useful and 
 healthful employment to a number of people, as well as render the 
 region more healthful. It would offer attractive careers to young 
 men seeking to overcome hereditary or acquired tendencies to tu- 
 berculous diseases. 
 
 CHAPTER XXX. 
 
 CONCLUSIONS. 
 
 The author of this essay is aware that much that has been asked 
 in the preceding pages may appear at first too difficult to be realized ; 
 nevertheless, he is convinced that by the earnest co-operation of all 
 interested in the solution of the various problems, the task will 
 prove far easier than might be anticipated. In view of the great 
 mortality and fearful ravages of the disease in question, his hopes 
 for a more rigorous crusade against this common foe of all mankind 
 are justified. He is optimistic enough to believe even in an ulti- 
 mate eradication of the disease. 
 
 If any community is visited by an acute contagious disease,
 
 86 TUBERCULOSIS AS A DISEASE OF THE MASSES. 
 
 smallpox for example, of which a few people may die, everybody 
 is up in arms; while consumption, a far more prevalent disease, 
 demanding thousands of lives every year, is treated wellnigh with 
 indifference. Yet all who have made the disease a study have for 
 years come to the conclusion that tuberculosis, especially in its 
 pulmonary form, is not only a preventable disease, but one which 
 can in the majority of cases be completely and lastingly cured. It 
 is certainly within the power of man, living in a civilized country, 
 such as the United States, where so much intelligence, wealth, 
 prosperity, and philanthropy prevail, to combat tuberculosis as a 
 disease of the masses most successfully. 
 
 All that is required to attain this goal is the combined action 
 of a wise government, well-trained physicians, and an intelligent 
 people.
 
 SUPPLEMENT. 
 
 HOME HYGIENE TO PREVENT TUBERCULOSIS. 
 
 TUBERCULOSIS may be called a dust and indoor disease. The 
 less dust, the less tuberculosis. The less people live in an indoor at- 
 mosphere, the less are they liable to contract this disease. 
 
 How may the danger arising from dusting and sweeping be re- 
 duced to a minimum? To answer this question I cannot do better 
 than to reproduce the excellent rules which were suggested to our 
 New York Committee on the Prevention of Tuberculosis, by the 
 distinguished Prof. T. Mitchell Prudden, of Columbia University. 
 
 Tuberculo- 
 sis an In- 
 door 
 Disease. 
 
 SWEEPING AND DUSTING. 
 
 " When you sweep a room, raise as little dust as possible, because 
 this dust when breathed irritates the nose and throat and may set 
 up catarrh. Some of the dust breathed in dusty air reaches the 
 lungs, making parts of them black and hard and useless. 
 
 " If the dust in the air you breathe contains germs of consump- 
 tion (tubercle bacilli), which have come from consumptives spitting 
 on the floors, you run the risk of getting consumption yourself. If 
 consumptives use proper spit-cups and are careful in coughing or 
 sneezing to hold the hand or handkerchief over the nose and mouth 
 so as not to scatter spittle about in the air, the risk of getting the 
 disease by living in the same room is mostly removed." 
 
 " To prevent making a great dust in sweeping, use moist sawdust 
 on bare floors. When the room is carpeted, moisten a newspaper 
 and tear it into small scraps and scatter these over the carpet when 
 you begin sweeping. As you sweep, brush the papers along by the 
 broom and they will catch most of the dust and hold it fast, just 
 as the sawdust does on bare floors. Do not have either the paper 
 or the sawdust dripping wet, only moist. 
 
 "In dusting a room, do not use a feather duster, because thig 
 
 How to 
 
 Sweep 
 Without 
 Raising 
 
 Dust.
 
 88 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Dry or 
 
 Moist 
 Cloths in 
 Place of 
 Feather 
 Dusters. 
 
 Vacuum 
 Cleaning 
 the Most 
 Sanitary. 
 
 Possible 
 Results of 
 
 too Dry 
 and Over- 
 heated At- 
 mosphere. 
 
 does not remove the dust from the room, but only brushes it into 
 the air so that you breathe it in; or it settles down and then you 
 have to do the work over again. 
 
 " Use soft, dry cloths to dust with, and shake them frequently 
 out of the window; or use slightly moistened cloths, and rinse 
 them out in water when you have finished. In this way you get 
 the dust out of the room." 
 
 " In cleaning rooms you should remember that dust settles upon 
 the floors as well as on the furniture, and is stirred into the air we 
 breathe by walking over them. You can easily remove all this 
 dust in rooms which have bare floors, in houses, stores, shops, 
 schoolrooms, etc., after the dust has settled, by passing over the 
 floor a mop which has been wrung out so as to only be moist, but 
 not dripping wet." 
 
 Thus we should clean our homes until the time comes when not 
 only factories, public buildings, hotels, and schoolhouses, but also 
 the homes of ordinary citizens, including the tenement-houses, can 
 be cleaned by the hygienic pneumatic or vacuum cleaning process. 
 
 How may the air in our homes be rendered as fresh, pure, and 
 sanitary as possible? In summer this problem is relatively easy. 
 The windows and doors can be left open so as to make the air as 
 fresh as that outside. The greatest difficulty is experienced in 
 winter. The windows cannot be left open all the time then, but 
 the rooms should be thoroughly and frequently aired whether there 
 is sickness or not. I have already referred in Chapter XII., page 
 39, to the unwholesome custom of heating our American dwellings 
 altogether too much and producing thereby too dry an atmosphere. 
 
 Experience has proven that we can be perfectly comfortable in 
 a temperature of 65 F. and even a little lower, provided that the 
 relative percentage of moisture is 60. If this moisture falls to 30 
 or to 20 per cent, then the dry throat, dry nose, and dry skin are 
 in evidence. The explanation is simple. The dry air absorbs 
 the moisture from the body and causes discomfort. The drying 
 of mucous membrances in this way lays them open to the invasion 
 of the organisms causing colds, grippe, pneumonia, and tubercu- 
 losis. On page 39, Chapter XII., I have illustrated an apparatus 
 called a "humidifier," and suggested various other ways to render 
 the atmosphere moist enough to be sanitary. I reproduce here an 
 instrument which will be helpful in determining the relative humid-
 
 AND HOW TO COMBAT IT. 
 
 89 
 
 FIG. 24. Direct Reading Hair- 
 Hygrometer. 
 
 ity. It has been strongly recommended by the Indiana State 
 Board of Health, which published it with the following description 
 in its monthly bulletin under the name of Direct Reading Hair- 
 Hygrometer. Fig. 24 is a picture 
 of a direct reading hair-hygrometer. 
 Every household, every schoolroom, 
 and every workroom should have one 
 of these instruments, for it is a fact 
 that the humidity of the air is of more 
 importance than the temperature 
 This hygrometer is not absolutely ac- 
 curate, but is sufficiently so for practi- 
 cal purposes. Indeed, it is as accu- 
 rate as the ordinary thermometer. If 
 the matter of humidity was carefully 
 attended to by every one, there would 
 be a decided improvement in the 
 general health and a very great less- 
 ening of diseases of the air passages. 
 
 In Chapter IV., directions concerning the disinfection of rooms, 
 furniture, wearing apparel, etc., used by a consumptive have been 
 explicitly given. To secure absolute certainty we would add that 
 after every disinfection, be it for tuberculosis or for disease pre- 
 disposing to tuberculosis such as measles, scarlet fever, whooping 
 cough, epidemic grippe, diphtheria, smallpox, pneumonia or 
 typhoid fever, a thorough airing and scrubbing with soap and 
 water, of floor, walls, furniture, and wearing apparel are absolutely 
 essential. If the walls are papered and do not permit a thorough 
 washing they should be repapered. By thorough disinfection 
 followed by an equally thorough cleaning and airing home hygiene 
 can be made a real barrier to the spread of many infectious diseases. 
 Lastly filtering or boiling all ordinary drinking water will serve as 
 additional preventative. 
 
 SCHOOL HYGIENE AS A FACTOR IN THE PREVENTION 
 OF TUBERCULOSIS. 
 
 The school board, or board of education as it is called in some 
 localities, in choosing a site for a school should bear in mind that 
 the most suitable locality is a somewhat elevated region, where the 
 streets are wide and the surrounding houses not too high and not 
 
 Disinfec- 
 tion, Scrub- 
 bing, and 
 Airing. 
 Pure 
 Drinking 
 Water.
 
 90 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Law in the 
 
 State of 
 New York 
 Concerning 
 Construc- 
 tion of 
 School- 
 houses. 
 
 Play- 
 
 grounds 
 and Roof- 
 gardens. 
 
 too close together, and where the traffic is not too heavy. About 
 the construction of a modern and model schoolhouse much could 
 be said. The essentials of such construction are well known to all 
 sanitarians and up-to-date architects, still in the interest of the 
 cause I may be permitted to quote here a portion of a law which 
 has recently been enacted in the Legislature of New York in refer- 
 ence to sanitation of schoolhouses. " No schoolhouse shall here- 
 after be erected in any city of the third class or in any incorporate 
 village or school district of this State, and no addition to a school 
 building in any such place shall hereafter be erected, the cost of 
 which shall exceed five hundred dollars, until the plans and specifi- 
 cations for the same shall have been submitted to the commissioner 
 of education and his approval endorsed thereon. Such plans and 
 specifications shall show in detail the ventilation, heating, and 
 lighting of such buildings. Such commissioners of education shall 
 not approve any plans for the erection of any school building or 
 addition thereto unless the same shall provide at least fifteen 
 square feet of floor space and two hundred cubic feet of air space 
 for each pupil to be accommodated in each study or recitation room 
 therein, and no such plans shall be approved by him unless pro- 
 vision is made therein for assuring at least thirty cubic feet of 
 pure air every minute per pupil, and the facilities for exhaustion 
 of the foul or vitiated air therein shall be positive and independent 
 of atmospheric changes. ... All schoolhouses for which plans 
 and detailed statements shall be filed and approved, as required 
 by this act, shall have all halls, doors, stairways, seats, passageways, 
 and aisles, and all lighting and heating appliances and apparatus, 
 arranged to facilitate egress in case of fire or accident, and to afford 
 the requisite and proper accommodations for public protection in 
 such cases. All exit doors shall open outwardly and shall, if double 
 doors be used, be fastened with movable bolts operated simul- 
 taneously by one handle from the inner face of the door. No 
 staircase shall be constructed with winding steps in lieu of a plat- 
 form, but shall be constructed with straight runs, changes in direc- 
 tion being made by platforms. No door shall open immediately 
 upon a flight of stairs, but a landing at least the width of the door 
 shall be provided between such stairs and such doorways." 
 
 In relation to the prevention of tuberculosis I would suggest 
 only a few points. Where the site or locality does not permit of 
 having a large playground, a roof-garden which can be covered in
 
 AND HOW TO COMBAT IT. 
 
 91 
 
 winter is absolutely necessary. Instead of our American windows, 
 which can only be opened to one-half of their extent, I should 
 wish to see French or casement windows in every schoolhouse,or win- 
 dows sliding into the wall, or those that turn on a pivot, all of 
 which permit twice the amount of foul air to go out and of good air 
 to come in that our ordinary windows do. Heating and general ven- 
 tilation of schoolrooms should, of course, be of the most improved 
 kind. The walls and woodwork of schoolrooms should be plain, to 
 make the accumulation of dust virtually impossible and the cleaning 
 easy. All corners should be rounded off, and the walls painted 
 with oil paint. The interior equipment that is to say, the school 
 furniture, benches, and desks should be so arranged that they 
 can easily be moved or folded together, so that a thorough cleaning 
 of the floors is made possible after each daily session. It goes 
 without saying that the drinking-cup should be replaced by the 
 hygienic drinking-fountain, which makes the use of a cup unneces- 
 sary, and thus eliminates one method of transmission of microbic 
 disease. 
 
 Every public school should have a well-equipped gymnasium, 
 and a swimming-tank with constantly running fresh or salt water, 
 warmed to a suitable temperature in winter. Each pupil should 
 be given the opportunity to bathe several times during the week. 
 To learn to swim should be made obligatory, and every class should 
 be supervised by a competent swimming master. 
 
 I am convinced that the public school which has a well-equipped 
 swimming establishment and which makes regular bathing and in- 
 struction in swimming obligatory for every pupil will not only have 
 fewer cases of infectious and contagious diseases, particularly scrof- 
 ula and tuberculosis, but that the intellectual and moral status 
 of its pupils will be higher. 
 
 The duties of the superintendent of a public school in the pre- 
 vention of tuberculosis are manifold. In arranging the curriculum 
 he should bear in mind never to push the intellectual training to 
 the detriment of the bodily development or physical welfare of the 
 children in his school. There has been, and is yet, altogether too 
 much overtaxing of the brain and the nervous system of our boys 
 and girls in public and also in private schools. 
 
 The physician who has studied closely the beginning of tuber- 
 culous diseases knows that it is often at the period of entering 
 puberty that the predisposed individual becomes most susceptible 
 
 Internal 
 Equipment 
 of School- 
 rooms. 
 
 Sanitary 
 
 Drinking 
 
 Fountains. 
 
 Gymnasi- 
 um and 
 
 Swimming 
 Tank. 
 
 Curriculum 
 Should be 
 Suited to 
 Proper 
 Mental and 
 Physical 
 Develop- 
 ment.
 
 92 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 to the invasion of the bacillus, particularly when additional strain 
 is put upon the physical or mental system. This holds good of 
 both sexes. A judiciously divided curriculum, interspersed with 
 gymnastics, swimming, and as much outdoor instruction as possible, 
 would seem to me a most important factor in the prevention, not 
 only of tuberculosis, but of all indoor diseases and even nervous 
 troubles. 
 
 td ^ Olj tdoor instruction I mean not only botanizing tours and 
 
 Instruction, geological excursions, but also outdoor singing and outdoor recita- 
 tion. I am convinced that outdoor singing and recitation, when the 
 weather is neither too windy nor too cold, are most excellent means 
 to prevent the development of pulmonary diseases. Breathing 
 exercises, such as are described in ChapterJCII. of this book should 
 of course be instituted at least for a few minutes at a time every 
 hour or two. The lessons in physiology and hygiene at school 
 must be adapted to the age and understanding of the pupils. The 
 teacher should, of course, be familiar with all the practical - and 
 feasible methods in vogue in regard to the prevention of tubercu- 
 losis as an infectious and communicable disease. The source of 
 infection from indiscriminate expectoration, from coughing and 
 sneezing in people's faces, from kissing on the mouth, and other 
 unhygienic habits can be taught in simple words to the children 
 of even the primary classes. A good method to impress these 
 simple rules on school children, and thus prevent them from con- 
 tracting tuberculosis during school life, is to have a printed leaflet 
 given 'to each child. These leaflets should contain the do's and 
 don'ts which are the alphabet in the prevention of tuberculosis in 
 kindergartens, private and public schools, and colleges. For this 
 purpose I have compiled the following: 
 
 SIMPLE RULES FOR SCHOOL CHILDREN TO PREVENT TUBERCULOSIS. 
 
 Every child and adult can help to fight consumption. School 
 children can be helpful by complying with the following rules: 
 
 Do not spit except in a spittoon, a piece of cloth, or a handker- 
 chief used for that purpose alone. On your return home have the 
 cloth burned by your mother, or the handkerchief put in water 
 until ready for the wash. 
 
 Never spit on a slate, floor, playground, or sidewalk. 
 
 Do not put your fingers into your mouth.
 
 AND HOW TO COMBAT IT. 93 
 
 Do not pick your nose or wipe it on your hand or sleeve. 
 
 Do not wet your fingers in your mouth when turning the leaves rm, -o n 
 
 me A. D, L. 
 of books. for Chil . 
 
 Do not put pencils in your mouth or wet them with your lips. dren in the 
 
 Do not hold money in your mouth. Prevention 
 
 Do not put pins in your mouth. of Tubercu- 
 
 Do not put anything in your mouth except food and drink. 
 
 Do not swap apple cores, candy, chewing gum, half-eaten food, 
 whistles, bean-blowers, or anything that is put in the mouth. 
 
 Peel or wash your fruit before eating it. 
 
 Never sneeze or cough in a person's face. Turn your face to one 
 side or hold a handkerchief before your mouth. 
 
 Keep your face, hands and finger-nails clean. Wash your hands 
 with soap and water before each meal. 
 
 When you don't feel well, have cut yourself, or have been hurt 
 by others, do not be afraid to report to the teacher. 
 
 Keep yourself just as clean at home as you do at school. 
 
 Clean your teeth with toothbrush and water, if possible, after 
 each meal ; but at least on getting up in the morning and on going 
 to bed at night. 
 
 Do not kiss any one on the mouth or allow anybody to do so 
 to you. 
 
 Learn to love fresh air and learn to breathe deeply and do it often. 
 
 These leaflets should be read at regular periods, say once a month, 
 and explained and commented upon by the teacher. The children 
 should be allowed to keep the leaflets and take them home to their 
 parents. 
 
 In schools where slates and lead-pencils are given to the children 
 and collected after school hours, these articles should be disinfected 
 before they are again distributed to the pupils. Not only the 
 spread of tuberculosis, but far more contagious diseases, such as ,. 1 
 measles, diphtheria, and scarlet fever, may be prevented among Lead-pen- 
 school children by this simple precaution. The custom in vogue oils, etc. 
 in some schools of having every child use a suitable envelope, 
 so as always to have the same pencil, while preferable to no precau- 
 tion at all, is, in my opinion, not nearly so safe as a thorough 
 disinfection. 
 
 On playgrounds and in corridors, elevated spittoons with auto- 
 matic flushing devices and cover such as illustrated in Fig. 25,
 
 94 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 Child-labor 
 at Home is 
 as Perni- 
 cious as 
 that in 
 Factories. 
 
 should be placed here and there to remind the old and young 
 never to expectorate on the ground. 
 
 An important point in the prevention of the disease under con- 
 sideration among school children is that the school teacher should 
 be familiar with the objective signs and symp- 
 toms of tuberculosis and the characteristics of 
 a person predisposed to consumption. 
 
 The symptoms have been described at 
 length in the preceding chapters, XVIII. 
 and XIX. The duties of the school physi- 
 cian should be a daily inspection of the chil- 
 dren to avoid the propagation of acute 
 infectious diseases including bronchitis and 
 grippe; the constant supervision of the sani- 
 tary condition of the school buildings ; regular 
 visits to the gymnasium and the swimming- 
 school ; and, lastly, the most important func- 
 tion of all, the periodical examination of the 
 chests of all pupils, teachers, and employees of 
 the school. The weeding out of all individuals 
 that might constitute a source of infection, 
 or those whose treatment becomes an impera- 
 tive necessity, and the advice to be given to 
 the parents of a tuberculous child, will make 
 the school physician a most important factor 
 in the solution of the tuberculosis problem. 
 
 In the prevention of tuberculosis in child- 
 hood I have always looked upon the sup- 
 pression of child-labor as one of the prima-facie necessities. While 
 it is with a sense of deep humiliation that we must acknowledge 
 that this curse to childhood is not yet entirely done away with in 
 all our States, it is gratifying to note the ever-increasing progress 
 toward its suppression. 
 
 However, there is one kind of child labor which the law can only 
 reach with difficulty, except as it has the co-operation of the school 
 teacher and the school physician. I refer to those cases where 
 cruel or thoughtless parents impose upon their often delicate chil- 
 dren the fulfilment of household duties or the performance of manual 
 labor which would task the strength of a grown person. The timid 
 child will probably never complain ; but when the teacher or school 
 
 FIG. 25. Knopf-Thi- 
 bert Elevated Self-Flush- 
 ing Spittoon.
 
 AND HOW TO COMBAT IT. 
 
 95 
 
 physician suspects that the paleness, the stooping shoulders, and 
 the tired, sad look are the results of excessive manual labors im- 
 posed upon the child by parents or guardians, it is his duty to 
 investigate and interfere. 
 
 In schools located in the districts of the poor where under-feeding 
 of the pupils not only often hinders the child from doing good 
 school work, but actually predisposes to tuberculosis, I would 
 suggest to the board of education a philanthropical enterprise in 
 which the generous, good-hearted people of every community should 
 gladly join. This is to provide these half-starved little ones with 
 a luncheon of one or two meat sandwiches and one or two glasses 
 of good milk. I am convinced that fewer will develop tuberculosis 
 and scrofulosis and they will do better work at school and at 
 home. 
 
 To avoid a pauperizing tendency, a few pennies may be charged 
 for these lunches. 
 
 What shall be done with a tuberculous child whose presence in 
 the public school may be a danger to his comrades, besides making 
 his own recovery much more difficult? Municipalities and philan- 
 thropists should, after the example of the people in Europe, create 
 seaside or country sanatoria where the tuberculous children may 
 not only have the best possible chance of becoming cured, but 
 also receive the necessary education. 
 
 On pages 63, 76, and 77 of this volume I have spoken at length 
 of the prevalence of tuberculosis among school children and the 
 admirable work which is accomplished in seaside sanatoria. Grati- 
 fying results have also been attained in inland institutions de- 
 voted to the treatment of tuberculous and scrofulous diseases of 
 children. In such seaside or inland sanatoria for children the un- 
 fortunate teacher also, whether predisposed to tuberculosis or 
 already in the earlier stages of the disease, may find suitable em- 
 ployment with the best possible chance for recovery. 
 
 Luncheon 
 
 for Poor 
 
 School 
 
 Children. 
 
 Provision 
 
 for Tuber- 
 culous 
 School 
 
 Children 
 and 
 
 Teachers. 
 
 INSTALLATION FOR THE SANATORIUM TREATMENT OF CON- 
 SUMPTIVES AT HOME. 
 
 In Chapter XXVII. the question "Can the treatment of con- 
 sumption be carried out with satisfactory results outside of an institu- 
 tion?" has already been answered in the affirmative. On page 23, 
 Chapter V., we described how the consumptive's room should be
 
 96 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 arranged, and in this supplement it is our purpose to give additional 
 g , ,. - suggestions in case the home treatment becomes necessary or desirable 
 
 Room for 
 Tubercu- 
 lous 
 Patient. 
 
 and show how the sanatorium treatment can be imitated as nearly as 
 possible. First, one should bear in mind that the sunniest, best- 
 ventilated, and most comfortable room of the house, preferably 
 on a higher floor, is the best suited for that purpose. All super- 
 fluous furniture, dust-catching curtains, and fixed carpets should 
 be removed, but the room must not be made cheerless. A few rugs, 
 washable curtains, some cheerful pictures may well be allowed. 
 
 FIG. 26. Dr. S. A. Knopfs Window-tent in Position, with Patient in Bed Looking 
 through the celluloid window into the room, but breathing outdoor air only. 
 
 If the arrangements illustrated in Fig. 22 and Fig. 23 for outdoor 
 sleeping at night and the rest cure in the open air by day be added, 
 so much the better. This, however, will only be feasible in a few 
 
 Description instances, and is not at all practicable in large cities, particularly 
 of Window- . ^ 
 
 tent in our a P a rtment- and tenement-houses. To make the open-air 
 
 treatment feasible by day and night even in the homes of the poor 
 living in cities, I have devised what I call a "Window Tent." It 
 consists of an awning, which, instead of being placed outside of the 
 window, is attached on the inside of the room. It is so constructed 
 that the air from the room cannot enter or mix with the air in the
 
 AND HOW TO COMBAT IT. 97 
 
 tent. The patient lying in the bed, which is placed parallel with 
 the window, has his head and shoulders resting in the tent (Figs. 
 26, 27, 28). By folio whig the description (Fig. 29) closely it will 
 be seen that the ventilation is as nearly perfect as can be pro- 
 duced with so simple a device. The tent is attached to the 
 frame of an American window, but it does not quite fill the lower 
 half. A space of about three inches is left for the escape of the 
 warm air in the room. By lowering the window, this space can 
 
 FIG. 27. Dr. S. A. Knopf's Window-tent Raised when Not in Use. 
 
 be reduced to one inch or less , according to need. On extremely 
 cold and windy nights there need not be left any open space at 
 all above the tent frame. The patient's breath will rise to the top 
 of the tent, the form of which aids in the ventilation. The tent is 
 constructed of a series of four frames, made of Bessemer rod suitably 
 formed and furnished with hinged terminals; the hinges operating 
 on a stout hinge pin at each end with suitable circular washers 
 interposed to insure independent and easy action in folding the 
 same, the Bessemer rod being hardened to make a stiff, rigid frame 
 to insure its maintaining the original form.
 
 98 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 The frame is covered with extra thick yacht-sail twill, properly 
 fitted, and having elongated ends to admit of their being tucked 
 in under and around the bedding to prevent the cold air from enter- 
 ing the room. The patient enters the bed and then the tent is 
 lowered over him, or with the aid of a cord and a little pulley 
 attached to the upper portion of the window he can manipulate 
 the lowering and raising of the tent himself. Shutters or Venetian 
 blinds, whether they are attached on the inside or on the outside 
 of the window, can be utilized in conjunction with the window- 
 tent as a screen to intercept the gazes of the neighbors, and in stormy 
 weather as a protection. The bed can be placed by the window to 
 suit the patient's preference for sleeping on his left or right side, 
 so that he has the air most of the time in his face. Another advan- 
 tage of the window-tent is that it will not attract attention from 
 the outside. The bed being placed alongside of the window will 
 be convenient for a majority of the poor who have small rooms. 
 If, however, the bed must be placed at a right angle to the window, 
 
 this can be arranged as well. 
 A piece of transparent cellu- 
 loid is placed in the front of 
 the tent to serve as an obser- 
 vation window for the nurse 
 or members of the family to 
 watch the patient if this is 
 necessary. It also serves to 
 make the patient feel less out- 
 doors and more in contact 
 with his family, as he can, if 
 he desires to, see what is 
 going on in the room. If the 
 bed must be placed at a right 
 angle to the window, the ob- 
 servation glass can be put in 
 on either side. It goes with- 
 out saying that, as a rule, 
 patients should not smoke; 
 when, in exceptional cases, 
 
 this can be allowed, the danger of the celluloid window becoming 
 ignited must be impressed upon them and the greatest precau- 
 tion urged. I prefer celluloid to glass for this purpose, because 
 
 FIG. 28. View of Window-tent and Patient 
 taken from the outside.
 
 AND HOW TO COMBAT IT. 
 
 99 
 
 there is no danger of its breaking when the tent is raised and 
 lowered. 
 
 If it is necessary to raise the bed to the height of the window 
 sill, this can be done with little expense. If the bed is of iron, a 
 few additional inches of iron piping can be attached to 
 the legs by any plumber or one handy with tools; 
 raising a wooden bed can be accomplished with equal 
 facility. If the window-tent is to serve the patient only 
 during the night, the tent can be pulled up and the bed 
 moved a\vay from the window during the day, and the 
 window closed. Or the tent can be taken from the hooks 
 
 and put out of the way. 
 
 *"+*! The window-tent, of course, is of 
 
 the greatest service to the consump- 
 tive sufferer in winter. If he is 
 feverish, or his stay in bed is ad- 
 visable, he can spend his entire time 
 in the tent. If the people are poor, 
 and the room where the consumptive 
 sufferer lies serves as living-room for 
 the rest of the family, the fact that 
 the well members need not shiver 
 while the patient takes his open-air 
 treatment is of vital importance 
 in many respects. While the room 
 will not be quite as warm as if the 
 window was entirely closed, it will 
 be much warmer than if there was no tent in front of the win- 
 dow. Laying aside the economic advantages to a poor family 
 when not obliged to heat more than one room, the patient feels 
 that he does not deprive his loved ones of comfort and warmth 
 and that he is less a burden and hinderance to their happiness. 
 The other members of the family, on their side, feel that they can 
 give the patient all the air he needs and that he need not suffer for 
 their comfort. 
 
 In winter the patient's bed must be covered with a sufficient 
 number of blankets to assure his absolute comfort and warmth 
 throughout the night. Still, the coverings should not be so heavy 
 as to press down upon the body and make the patient feel uncom- 
 fortable or tire him. The tightly woven blanket is a better pro- 
 
 FIG. 29. Diagram Showing Ventila- 
 tion of Window-tent. 
 
 Adjust- 
 ment of 
 Bedstead 
 to Suitable 
 Height. 
 
 Advantages 
 
 of the 
 Window- 
 tent in 
 Winter. 
 
 Warm Cov- 
 ering But 
 not too 
 Heavy is 
 Essential.
 
 100 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 tection than the loosely woven one. To the poor, whose disposal 
 of blankets is, alas, often very limited, it may be good advice to 
 tell them to put several layers of newspapers between the coverings. 
 
 Outdoor Life of December, 1905, recom- 
 mends to sew half a dozen layers of paper 
 between two layers of flannel. This cer- 
 tainly will make a cheap, light, and 
 warm covering. In extremely cold 
 weather, the patient while sleeping in 
 the window- tent, should wear a sweater 
 and protect his head and ears with a 
 woollen cap, shawl, or woollen helmet, 
 such as is shown in Fig. 30. 
 
 Some patients will often complain that 
 FIG. so. Woollen Hood or Hei- the bright light awakens them too early 
 met for Out-Door Sleeping in m the morning, and that they have diffi- 
 
 Cold Weather. , 
 
 culty in going to sleep again. In such 
 
 instances I counsel the patient to have some light-weight but dark- 
 colored material (such as a black lisle-thread hose) to put over his 
 eyes. This usually suffices to obviate the inconvenience caused by 
 the bright light. 
 
 It will be observed that by merely closing the window and rais- 
 
 _ , ing the tent the patient finds himself in the warm room, ready for 
 
 Window- kis t^ e t> sponge-bath or massage as the case may be. 
 
 tent can When there is no garden, veranda, or roof, the window-tent 
 
 be Utilized can also be put into service for the rest cure during the day. The 
 
 for the bed j s m0 ved away, and the reclining-chair put in its place. The 
 
 Kest LUI latter can be raised to the necessary height by wooden blocks or a 
 
 Reclini platform, and with the aid of blankets and comforters the air from 
 
 Chair by the room can be excluded, and the patient, being in front of the 
 
 Day. open window, breathes only outdoor air. When beginning this 
 
 aerotherapy, it is of course essential that it must be done gradually 
 
 according to the susceptibility of the patient to the cold. It 
 
 should, however, be impressed upon him that night air is as pure 
 
 as day air. It is best to begin by placing him in the tent for a few 
 
 hours at night, and a few hours during the day in the chair. The 
 
 attending physician will regulate all this so as to get the patient 
 
 gradually accustomed to live in the pure cold air day and night. 
 
 A hot-water bottle for the feet either in bed or in the chair may 
 
 often be necessary in extreme cold weather. The patient's feet 
 
 must be kept warm if he is to benefit by the open-air treatment.
 
 AND HOW TO COMBAT IT. 
 
 101 
 
 HISTORICAL REVIEW OF THE ANTITTJBERCULOSIS MOVEMENT 
 IN THE UNITED STATES. 
 
 The first private sanatorium for tuberculous patients was es- 
 tablished by Dr. J. W. Gleitzmann some thirty years ago (1875). 
 It was followed some years later (1884) by the establishment of 
 the first sanatorium for the consumptive poor through the personal 
 efforts and devotion of Dr. E. L. Trudeau, of Saranac Lake. The 
 first sanatorium established near a large city and without regard 
 to any climatic ad vantages was the Sharon Sanatorium, near Boston. 
 It was opened in 1890. It owes its existence to the enthusiasm 
 and personal work of Dr. Vincent Y. Bowditch. The construction 
 of the first State sanatorium for consumptives was authorized by 
 an act of the Legislature of the State of Massachusetts in 1895. 
 It is situated at Rutland, Mass., and was opened for reception of 
 patients on Oct. 1, 1898. 
 
 Since then, and particularly during the past five years, private, 
 State, and municipal sanatoria have been established in many 
 of the States of the Union, or are at this moment projected or in 
 course of construction. 
 
 In 1903 there was established at Lake Kushaqua, N. Y., an in- 
 stitution called the Stony Wold Sanatorium, which is unique of its 
 kind. 
 
 It owes its inception to the thoughtful wives of two New York 
 physicians, Mrs. James E. Newcomb and Mrs. Geo. F. Shrady; 
 it is consecrated exclusively to the treatment of consumptive 
 workingwomen and children and maintained mainly by noble- 
 hearted women of wealth. 
 
 The first seaside sanatorium for tuberculous and scrofulous 
 children, called Sea Breeze, was established a few years ago (1904), 
 by the Society for the Improvement of the Condition of the Poor, 
 and is situated on Coney Island. 
 
 The first dispensary class in the United States, devoted exclu- 
 sively to the treatment of tuberculosis, was inaugurated in 1894 
 by Dr. Edward J. Bermingham of this City, at the New York 
 Throat and Nose Hospital. 
 
 The first municipal dispensary for the treatment of the con- 
 sumptive poor was established by the city of New York under the 
 name of Clinic for Pulmonary Diseases of the Health Department. 
 
 First Sana- 
 toria for 
 Consump- 
 tives in the 
 United 
 States. 
 
 First Sea- 
 side Sana- 
 torium for 
 
 Tubercu- 
 lous Chil- 
 dren. 
 
 First Spe- 
 cial Tuber- 
 culosis Dis- 
 pensaries.
 
 102 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES 
 
 First So- 
 ciety and 
 First Com- 
 mittee for 
 Prevention 
 of Tuber- 
 culosis. 
 
 Tuberculo- 
 sis Exhibi- 
 tions and 
 Their Edu- 
 cational 
 Influence. 
 
 It was started mainly through the initiative of Prof. Hermann M. 
 Biggs, the General Medical Officer of the city, and was opened March 
 1, 1904. Since then dispensaries for tuberculous patients have been 
 established in many of the larger cities of the United States. 
 
 The first society for the prevention of tuberculosis was the 
 Pennsylvania Society founded in 1892 by Dr. Lawrence F. Flick, 
 who was also its first president. This society was the only active 
 organization until five years ago. 
 
 The first Tuberculosis Committee of the Charity Organization 
 Society doing educational and relief work was founded in 1902, 
 largely through the efforts of Prof. Edward T. Devine, Ph.D., the 
 general secretary of the Charity Organization Society and the 
 Tuberculosis Committee's first secretary. 
 
 To-day there are at least 15 State organizations, and 60 city 
 societies or committees all devoted to spreading the gospel of the 
 preventability and curability of tuberculosis. 
 
 The first tuberculosis exhibition was held in Baltimore in Janu- 
 ary, 1904, under the joint auspices of the Tuberculosis Commission 
 of the Maryland State Board of Health and the Maryland Public 
 Health Association. This exhibition was an objective presenta- 
 tion of the history, distribution, varieties, causes, cost ; prevention, 
 and cure of tuberculosis. The next most important tuberculosis 
 exhibition was held in New York from November 27 to December 
 9, 1905, at the Natural History Museum. The exhibition was 
 organized under the auspices of the National Association for the 
 Study and Prevention of Tuberculosis and the Committee on the 
 Prevention of Tuberculosis of the Charity Organization Society 
 of New York. Like the Baltimore exhibition it was planned as an 
 educational measure in the wide-spread campaign against tuber- 
 culosis. It showed by means of models, photographs, charts, dia- 
 grams, etc., the main facts with regard to the disease and its pre- 
 vention and cure. Cooperation from all parts of the country had 
 been enlisted and a comprehensive demonstration of the facts had 
 been installed. On the opening evening, addresses were made by 
 the Mayor of the City of New York, the Hon. George B. McClellan; 
 by Dr. Thomas Darlington, the Commissioner of Health; and by 
 President Morris K. Jesup, of the American Museum of Natural 
 History. Since then the same exhibition has become a traveling 
 one, so that up to this date it has been shown in Boston, Philadel- 
 phia, Newark, Indianapolis, Chicago, Milwaukee, Grand Rapids,
 
 AND HOW TO COMBAT IT. 
 
 103 
 
 Manistee, Detroit, Toronto, Cleveland, Cincinnati, Mexico City, 
 San Antonio, Minneapolis, St. Paul and Providence. The attend- 
 ance at these exhibitions has been a total of nearly five hundred 
 thousand. Smaller exhibitions, organized by local committees, 
 have been held in various cities and towns and materially helped 
 in spreading the much needed information concerning the pre- 
 ventability and curability of tuberculosis. 
 
 Four journals published in the United States are largely devoted 
 to spreading information concerning the antituberculosis move- 
 ment and sanatorium matters. These are: first. Charities and the 
 Commons, published in New York under the auspices of the Charity 
 Organization Society; second, The Journal of the Outdoor Life, 
 published at Trudeau, N. Y., under the auspices of the Adirondack 
 Cottage Sanatorium; the Open Air Quarterly, published by The 
 Open Air Quarterly Company at the Pembroke Sanatorium, Con- 
 cord, N. H., and lastly The Vanguard, the monthly bulletin of the 
 Kentucky Anti-Tuberculosis Association. 
 
 As the culmination of the work done by many lay and medical 
 men and women devoted to the noble cause, the American National 
 Association for the Study and Prevention of Tuberculosis was estab- 
 lished at a meeting in Philadelphia in March, 1904, and the organ- 
 ization completed in June of that year at the time of the meeting 
 of the American Medical Association at Atlantic City. Dr. Edward 
 L. Trudeau was elected President; Drs. William Osier and 
 Hermann M. Biggs, Vice-Presidents; Dr. Henry Barton Jacobs, 
 Secretary; and Gen. George M. Sternberg, Treasurer of the asso- 
 ciation. Among the honorary vice-presidents the association has 
 the good fortune to count the Hon. Theodore Roosevelt, President 
 of the United States, and the Hon. Grover Cleveland, ex-President 
 of the United States. This society which welcomes as members 
 men and women from all ranks of life who are interested in the 
 solution of the tuberculosis problem, has its offices in New York 
 City in the United Charity Building, 105 East 22d Street. Its 
 present executive secretary is Prof. Livingston Farrand, M.D. 
 
 The first Institute for the study, treatment, and prevention of 
 tuberculosis was founded in Philadelphia-, Pa., in 1903. It owes 
 its existence to the sagacious munificence of the well-known philan- 
 thropist, Mr. Henry Phipps, formerly of Pittsburg, now of New 
 York. 
 
 A second Tuberculosis Institute with purposes similar to those 
 
 Journals 
 Devoted to 
 the Anti- 
 Tuberculo- 
 sis Move- 
 ment. 
 
 National 
 Association 
 
 for the 
 Study and 
 Prevention 
 of Tuber- 
 culosis. 
 
 Tubercu- 
 losis 
 Institutes.
 
 104 
 
 TUBERCULOSIS AS A DISEASE OF THE MASSES. 
 
 First 
 
 federal and 
 " Day Sana- 
 toria " and 
 " Tubercu- 
 losis 
 Classes." 
 
 First Anti- 
 tuberculosis 
 Work in 
 Factories. 
 
 Interna- 
 tional Tu- 
 berculosis 
 Congresses. 
 
 First 
 
 Federal 
 Antituber- 
 
 culosis 
 Executive 
 
 Order. 
 
 Federal 
 Tubercu- 
 losis Com- 
 mission. 
 
 of the Phipps Institute was established in Chicago in 1906 by such 
 men as Drs. Babcock, Davis, Favill, Hektoen, Klebs, Sachs, etc. 
 
 The first two Federal Sanatoria Avere established in the year 1899, 
 one at Fort Stanton, the other at Fort Bayard, N. M. The first 
 " Day Sanatorium," where patients are cared for from eight in the 
 morning until five in the evening, was established in Boston under 
 the auspices of the Association for the Control of Tuberculosis in 
 1905. The first Tuberculosis Class (treatment of poor patients by 
 modern sanatorium methods at their homes) was established in 
 1905, by Dr. J. N. Pratt under the auspices of Emanuel Church of 
 Boston. 
 
 The first systematic work to treat tuberculous factory employees 
 was inaugurated in 1906 by Dr. Frank T. Fulton of Providence, R. I. 
 
 Among those who represented the Medical Profession of the 
 United States at the British Congress on Tuberculosis in 1901 were 
 Frank Billings, W. J. Councilman, Charles Denison, George Dock, 
 W. A. Hare, Henry J. Hartz, A. Jacobi, E. G. Janeway, H. M. King, 
 H. P. Loomis, S. Weir Mitchell, J. H. Musser, Edw. 0. Otis, M. P. 
 Ravenel, Arthur R. Reynolds, F. C. Shattuck, G. B. Shattuck, 
 E. S. Solly, A. K. Stone, Arthur R. Thomas, J. Tyson, W. H. Welch, 
 J. C. Wilson. At the International Tuberculosis Congress which 
 convened in Paris in 1905, this country was represented by an 
 official delegation appointed by the President of the United States, 
 composed of Drs. Beyer, Flick, Jacobs and Knopf. Various medical 
 centers were represented by Brannan of New York, Lowman of 
 Cleveland, McCarthy and Walsh of Philadelphia, Pottenger of Los 
 Angeles, Evans of Chicago. At the closing session of this congress 
 an invitation was given to have the next Tuberculosis Congress 
 meet in Washington in the fall of 1908. This will be the first time 
 that this distinguished body will honor our country by its presence, 
 and the American Medical Profession as well as the Public at large 
 should rejoice in the distinction of having the greatest minds 
 engaged in the combat against the White Plague soon gathered 
 in our Capital. 
 
 The first executive order by a President of the United States 
 with a view to preventing the spread of tuberculosis among the 
 employees of the Government was issued by Theodore Roosevelt, 
 Feb. 28, 1906. 
 
 Finally, on Dec. 16, 1907, there was introduced in the House of 
 Representatives, by Mr. Smith of Iowa, a bill (H R 9123) to create 
 a Federal Tuberculosis Commission for the purpose of securing a 
 uniform system of the prevention of tuberculosis in the United 
 States.
 
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 1908 
 Knopf, Sigard Adolphus. 
 
 Tuberculosis as a disease of 
 
 the masses. . . 
 
 WF200 
 K?2t2 
 1908 
 Knopf, Sigard Adolphus. 
 
 Tuberculosis as a disease of the 
 
 masses. . . 
 
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