Qfornell Ittioeratta ICibrarH 
 
 3tl;aca. Nent ^arlt 
 
 ^ BOUGHT WITH TH£ INQOME OF THE 
 
 SAGE ENDOWMENT FUND 
 
 THE GIFT OF 
 
 HENRY W. SAGE 
 
 1891 
 
Cornell University Library 
 arV19122 
 
 Rules for recovery from pulmonary tuberc 
 
 3 1924 031 238 276 
 olin.anx 
 
The original of tliis book is in 
 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924031238276 
 
RULES FOR RECOYERY 
 
 FROM 
 
 Pulmonary Tuberculosis 
 
 A LAYMAN'S HANDBOOK OF TREATMENT 
 
 BY 
 
 LAWRASON BROWN, M.D. 
 
 THIRD EDITION, THOROUGHLY REVISED 
 
 LEA & FEBIGER 
 
 PHILADELPHIA AND NEW YORK 
 
 L 
 
Copyright 
 
 LEA & j?EBIGER 
 
 1919 
 
PREFACE 
 
 The appearance of the third edition of this 
 little book is perhaps an indication that it has 
 proved itself useful now and again to some 
 patient. If it has helped the conscientious patient 
 to avoid blunders, so easily made at first through 
 ignorance, but so apparent to any patient who 
 knows the game, it has served its purpose. It 
 was written primarily for the author's patients, 
 for the mild and pleasurable excitement of human 
 intercourse deflects at a thousand angles the train 
 of thought, and many important details may not 
 be sufficiently emphasized or may be overlooked 
 entirely. It is not the author's intention that the 
 book should be hastily read and laid aside, like 
 the modem novel, but he believes that it should 
 be read slowly, chapter by chapter, day by day. 
 When it has been carefully read in this manner, 
 he hopes it will be used as a book of reference, 
 a hand-book, so to speak, of the fundamental 
 principles of the cure. He has attempted to 
 make clear the whys and wherefores of many 
 rules ordinarily given to patients in an oracular 
 manner, for he believes that the day has come 
 when the physician should look upon the patient, 
 
 (iii) 
 
Iv PREFACE 
 
 not as an ignorant child, but as a human being 
 endowed with more or less mature intelligence; 
 as one, in fact, who has a right to demand an 
 explanation of the way certain effects follow cer- 
 tain causes. The physician of today must teach 
 as well as serve ; or better, he must teach in order 
 to serve most intelligently. There may be a few 
 patients who are willing to do what they are 
 told without thinking about the matter, and for 
 these, explanations may povSsibly for a time be 
 unnecessary. 
 
 It has seemed wise to add some details about 
 the values of actual foodstuffs in a separate 
 chapter and to outline a liquid diet, which is so 
 often necessary, when the appetite fails. Many 
 other changes have been made here and there 
 throughout the book to keep it abreast of the 
 times. 
 
 The writer owes much to his colleagues in 
 Saranac Lake and elsewhere, from whom he has 
 borrowed expressions, similes and ideas. No 
 words can adequately express his indebtedness 
 and his affectionate gratitude to Dr. Trudeau, 
 the pioneer in the art of imparting advice to 
 tuberculous patients. Without his aid and 
 stimulus and that of his associates this little 
 book of rules could never have been written. 
 
 L. B. 
 
 Saranac Lake, 
 1919. 
 
CONTENTS 
 
 I. 
 
 II. 
 
 III. 
 
 IV. 
 
 V. 
 
 VI. 
 
 VII. 
 
 VIII. 
 
 IX. 
 
 X. 
 
 XI. 
 
 XII. 
 
 XIII. 
 
 XIV. 
 
 XV. 
 
 XVI. 
 
 XVII. 
 
 XVIII. 
 
 XIX. 
 
 XX. 
 
 XXI. 
 
 XXII. 
 
 XXIII. 
 
 XXIV. 
 
 XXV. 
 
 XXVI. 
 
 Preface ... . . 
 
 Introduction and Summary 
 
 On Rest 
 
 On Food ... 
 On Alcohol and Tobacco 
 On Fresh Air ... 
 On a Patient's Day .' . 
 On Sitting Out . . . . 
 
 3 
 
 7 
 
 20 
 
 .... 33 
 
 49 
 
 55 
 
 . . 66 
 
 ... .68 
 
 On Preparations for Sitting Out 70 
 
 On the Porch ... ... 75 
 
 On Sleeping Out ... .... 80 
 
 On the Patient's Room- . ... 89 
 
 On Exercise . . . . 92 
 
 On Cultivating an Outdoor Hobby and on 
 
 Recreation ... . . 102 
 
 On the Temperature of the Body ... . 107 
 
 On Controlling a Cough without Drugs . . . 117 
 
 On the Body Weight . . . . . 123 
 
 On Patient and Physician . . ... 129 
 
 On Climate .... ... 135 
 
 On How and When We Contract Tuberculosis . 139 
 On the Care of Children in the Homes of the 
 
 Tuberculous 149 
 
 On Tuberculin ... 155 
 
 On the Disease Tuberculosis ... . . 158 
 On Definitions of "Cure" and "Arrest" as Used 
 
 in the Treatment of Tuberculosis ... 162 
 
 On the Hygienic Care of the Patient . . . . 165 
 
 On the Care of the Mouth ... ... 171 
 
 On Suggestions for Patients 175 
 
 On Food Values 178 
 
 Bibliography 182 
 
 (v) 
 
mXRODUCTION AND SUMMARY 
 
 "The physician must not only be prepared to do what is right 
 himself but also to make the patient, the attendants and exter- 
 nals cooperate." 
 
 It is well for every patient to understand the 
 nature of this disease, and what his problem is. 
 It is no easy problem and a large percentage of 
 patients fail in the attempt to solve it. 
 
 The disease, tuberculosis, is the most wide- 
 spread in the world; it occurs everywhere, you 
 might say, that man lives, from the north polar 
 regions to the equator and south to the south 
 pole. It is more prevalent, however, in certain 
 regions than in others. All races are prone to 
 it. Some of them, especially those that live out 
 of doors, do not have it until they begin to live 
 indoors. The American Indian, for instance, is 
 more susceptible to it since he has begun to adopt 
 the ways of civilization. The Arabs and Bed- 
 ouins and some of the African tribes do not get 
 it until they begin to live in houses and towns. 
 
 The disease is caused by a tiny, microscopic 
 plant. It is called, as you know, the tubercle 
 bacillus. It is not green, like the fern iri the win- 
 dow, but is very much the color of a wall (buff), 
 and is shaped just like a lead-pencil. It is so 
 small that through the hole made by a pin in a 
 sheet of paper a thousand of these little germs 
 
 (7) 
 
8 RULES FOR RECOVERY 
 
 could pass, side by side, without touching each 
 other and without touching the sides of the hole. 
 Consequently, on a particle of dust, such as we 
 see floating in a ray of sunshine, many of these 
 little germs can easily ride as in a chariot, and 
 thus we may breathe them into our lungs. 
 
 A curious thing about this little plant is that 
 it differs from most other plants in two very 
 important particulars, which everyone ought to 
 remember. All ordinary plants, geraniums, for 
 instance, need sunshine and fresh air. This plant, 
 this tubercle bacillus, cannot live in sunshine and 
 it cannot live in fresh air. Give it either all the 
 fresh air that it can get (for example, place it in 
 a room with the windows open), or put it in the 
 sunshine, and it will die. Sunshine will kill the 
 tubercle bacillus, if not in a thick mass of sputum, 
 in four or five hours, and possibly in less time. 
 Of course, in a dark corner of the room, where 
 direct sunlight never penetrates, an exposure for 
 two or three days to the indirect sunlight may 
 be required to kill it, but such light will kill it 
 eventually. In other words, light is one of the 
 best germicides, and it will surely kill these 
 germs. If, on the other hand, the tubercle bacil- 
 lus is put in a dark place, but given plenty of 
 fresh air, it will also die. It cannot stand either 
 air or light. Thus, in a well-lighted and ventilated 
 room the tubercle bacillus is very speedily killed. 
 
 This leads me to say that tuberculosis is a 
 house disease. This means that it is practically 
 
FROM PULMONARY TUBERCULOSIS 9 
 
 never contracted out of doors but always in the 
 house. The tubercle bacillus can live out of 
 doors only a short time and practically never 
 infects anybody out of doors. For instance, if a 
 person expectorates on the pavement and some- 
 one walks in it and takes it into the house on 
 his shoes, or brings it in on her skirts, it gets on 
 the carpet and dries. The maid then sweeps the 
 carpet with a broom, breaking up the sputum 
 into fine dust, which settles on the window sills, 
 furniture, etc. The tubercle germ has no power 
 of locomotion. It can no more move from place 
 to place than a geranium or a tree. It depends on 
 many outside agencies mentioned in this chapter 
 to get from one place to another. A further 
 curious thing is, that as long as it is moist, it can 
 never get into the air except when subjected to 
 a violent blast of air, as we shall see later. The 
 great object, then, is to keep this germ moist. 
 For this reason, "moist" sweeping should always 
 be employed; that is, moist tea leaves or moist 
 sawdust should be sprinkled on the floor, or a 
 moist bag placed over the broom. This collects 
 the dust so that it can be burned and does not 
 allow it to fall upon the furniture, where the usual 
 practice is to stir it up once more with a dry 
 duster. This gives the germs one more chance._ 
 Here, too, "moist" methods should be employed 
 and the duster moistened with oil for furniture, 
 with water for paint. The duster should then be 
 boiled. By far the best cleaning method is the 
 
10 RULES FOR RECOVERY 
 
 vacuum system, which I hope and believe will be, 
 at some time, universally used. 
 
 Tuberculosis is almost always contracted by 
 means of these particles of dust. We may 
 breathe^them in or they may be swallowed, but 
 eventually they go to our lungs. They get into 
 our bodies practically always by these routes. 
 Usually they come from someone who has been 
 careless with his sputum. All adults have con- 
 tracted this disease from somebody who has been 
 ignorant or careless. The chances are. not one 
 in ten thousand that an adult has gotten it from 
 milk or from food or, in fact, in any other way 
 than from a person who has tuberculosis. If 
 there is a tuberculous patient in the house, and 
 he or she is careless about the disposal of sputum, 
 it is easily seen how the infection comes about. 
 If patients are careless about spitting on the 
 streets of the cities, others may walk in it and 
 track it into their houses. 
 
 Another method by which tuberculosis can be 
 contracted is a way that a great many people do 
 not realize. If a person coughs in front of a pane 
 of glass or in front of a looking-glass, one will 
 find that the glass is covered with fine spray or 
 droplets of sputum, and if he coughs in his hand, 
 .it is immediately sprayed with these fine par- 
 ticles of sputum. These droplets may contain 
 tubercle germs. They will carry for a distance 
 of about four feet from a patient and may remain 
 suspended in the air sometimes for as long as an 
 
FROM PULMONARY TUBERCULOSIS 11 
 
 hour. So it is easily seen that if a person who 
 is in a poorly ventilated room coughs and moves 
 about without covering his mouth, he could in 
 time infect the whole room. He will be sur- 
 rounded by a halo of these droplets, each of 
 which may contain tubercle bacilli. Patients do 
 not realize this. All a patient has to do to elimi- 
 nate this danger is to hold a cloth or a piece of 
 tissue paper in front of his mouth to catch the 
 spray. The tubercle bacillus cannot get through 
 the cloth or paper and he is no source of danger 
 to anybody else. He must cover his mouth when 
 he coughs. 
 
 Another lesson that he can draw from this fact 
 is that if anybody else coughs without covering 
 his mouth, he should not go near him. One can 
 catch pneumonia, grippe, bronchitis, colds and a 
 number of other diseases of the respiratory tract 
 by this means. It is a simple thing to cover one's 
 mouth, and it is not asking too much of patients 
 to request them to cover their mouths when they 
 cough. Sometimes patients cannot cover their 
 mouths in time; they cough occeisionally when 
 they do not know it is coming; but if a man does 
 not meike an honest, conscientious effort to cover 
 his mouth when he coughs, he should be avoided 
 and ostracized. Covering the mouth with the 
 hand alone is a lazy, dirty and dangerous prac- 
 tice. A piece of cheese-cloth or tissue paper as 
 stated above should be used and in any case the 
 hands washed frequently. The only proper way 
 
12 RULES FOR RECOVERY 
 
 to take care of sputum is to burn it, and for that 
 reason no one should expectorate into the bowls 
 or sinks, but always into sputum boxes which can 
 be burned. 
 
 Adults may get tuberculosis from food, but 
 they very, very rarely contract it from milk. 
 Children, on the other hand, do get it from milk. 
 We have heard that the cattle germs (bovine 
 tuberculosis germs) do not cause tuberculosis in 
 man, which, in a broad sense, is true, but chil- 
 dren are prone to the disease from this and other 
 sources. It has been estimated that 130,000 per- 
 sons die annually from tuberculosis in the United 
 States, and that 8 per cent., or 10,400 of these, 
 are children who die from the tuberculosis germ 
 found in cattle. These facts are serious enough 
 to make us all realize that cattle tuberculosis 
 must be stamped out. 
 
 The question of heredity is one that concerns 
 all of us more or less, but tuberculosis in man, 
 we may say, for practical, working purposes, is 
 unknown as an hereditary disease. It occurs 
 so rarely that we can disregard it, as when a 
 child is born with the disease it quickly suc- 
 cumbs to it. What does happen, though, is that 
 a predisposition to the disease may be inherited. 
 The children of tuberculous parents may, in fact, 
 have less resistance to all diseases. Consequently 
 these children should be protected more carefully 
 than other children. This simply means that 
 rules such as these I have mentioned and others 
 
FROM PULMONARY TUBERCULOSIS 13 
 
 must be carried out. The house must be well 
 lighted and ventilated; the floors well cleaned; 
 and care must be taken to see that the food supply 
 is of good quality and adequate. A person can- 
 not get the disease unless he gets the tubercle 
 bacillus into his body. 
 
 There are two forms of tuberculosis: the one 
 that patients have, which is developed tubercu- 
 losis, which we call clinical tuberculosis, and the 
 other a form that 75 per cent, of the people liv- 
 ing, for example, in New York City have, non- 
 clinical or undeveloped tuberculosis. They have 
 the tubercle bacillus in their bodies, they might 
 react to some of the tests for tuberculosis, but 
 they will never know that they have tubercu- 
 losis if they take care of themselves. Just as a 
 man should take care of himself to keep from 
 developing it, avoiding overwork, worry, disease, 
 and a great many other things which will bring 
 it on, so, when he gets well, these same things 
 will bring on fresh activity of the disease if he 
 does not avoid them. These are vitally impor- 
 tant facts for everyone to know. 
 
 The cure of tuberculosis is the point in which 
 we are now chiefly interested. Most patients 
 think they can leave work for two or three months 
 and get perfectly well. That is entirely wrong, 
 A patient may leave home or quit work for five 
 or six months, which is a very short time, and he 
 simply gets on the road to recovery. He has to 
 go home and finish it up by living carefully for 
 
14 RULES FOR RECOVERY 
 
 three or four years. I am firmly convinced that 
 tuberculosis is not cured for three or four years, 
 and that the reason so many people die is because 
 they do not realize that fact. They think that 
 after two or three months, because they feel bet- 
 ter and look better and have gained a great deal 
 of weight, they can go home or return to their old 
 ways of living ; but they cannot do it, and sooner 
 or later, if they do return to the same life with 
 its numerous and hard duties, they are going to 
 relapse, and the second attack is harder to treat 
 than the first. For this reason one must not get 
 the idea that tuberculosis is an easy thing to get 
 rid of. Thirty-eight per cent, of all patients who 
 have been treated at theTrudeau Sanatorium have 
 died, and at least 90 per cent, of these from tuber- 
 culosis. I speak of these things because a great 
 many people have the idea that the cure of tuber- 
 culosis is child's play, when really it is one of the 
 most difficult problems that anyone has ever had 
 to face. To get well from tuberculosis means 
 that a patient must pay attention to every little 
 detail. He must watch and make no mistakes, 
 for these often prove fatal. Many small things 
 may not seem essential to him, but they are, and 
 recovery really depends upon paying attention 
 to little details. A person who is careless and 
 slack about details will be slack about great 
 things. It was unnecessary for many of the 
 patients mentioned to have died, and it is for 
 this reason that we are endeavoring to teach the 
 
FROM PULMONARY TUBERCULOSIS 15 
 
 dangers that beset patients early and late, so that 
 they may plan wisely to avoid them. 
 
 Regarding the question of food, I am not quite 
 in accord with some other men. I do not believe 
 that the main thing for a patient to do is to get 
 to be such a mass of fat that he can hardly walk 
 around, with little or no strength and loss of 
 breath every time he walks up hill. I want my 
 patients to gain up to their normal weight and 
 to go a little beyond, but I want them to gain 
 proportionately in strength. An important thing 
 today is to realize that overeating is just as 
 dangerous as undereating, that the proper way is 
 to eat as little as a patient can to maintain his 
 strength. The less he can eat and continue to 
 gain, the better. Put too much into his body 
 and it will ferment and decompose and thus lower 
 the body's resisting powers. Many patients suf- 
 fering from tuberculosis are affected by overeat- 
 ing. The medical profession in general has real- 
 ized the importance of air, of good food, but not 
 many physicians have given attention to the 
 danger of overeating, which only clogs the sys- 
 tem and prevents the best results. Give an auto- 
 mobile too much gas, and the engine is choked; 
 or overstoke a steam engine, and its efficiency is 
 diminished. So find out the best amount to eat 
 to get the best work from the body. Large gains 
 are not necessary. To eat as little as will enable 
 him to hold his weight and strength is the 
 important thing. 
 
16 RULES FOR RECOVERY 
 
 We have come to believe that the general 
 public knows how important good food is, 
 realizes that fresh air is a necessity, but is_ still 
 wholly at sea in regard to the danger and value 
 of rest and exercise. Strychnine and arsenic 
 are valuable drugs, but not many would care 
 to experiment upon themselves to find out the 
 proper dose. In pulmonary tuberculosis it re- 
 quires far more experience to decide the "dose" 
 of exercise than is necessary in the use of arsenic 
 or strychnine. More patients fail to recover 
 their health from failure to appreciate the danger 
 that lurks even in gentle exercise than from any 
 other cause. 
 
 All patients will fall into one of three classes: 
 First, those who will never again be able to do 
 much work. Second, those who will be able to 
 do nothing for months or even years. The third 
 group includes those patients who, at the end of 
 six or more months, are going to be able to return 
 to work, many of them to their former occupa- 
 tions. For them an endeavor should be made 
 to supply exercise approximating more or less 
 nearly what they must do on their return to work. 
 This enables them to get their muscles in train- 
 ing for their work. We believe that no man or 
 woman should return to his or her work who 
 cannot take a great deal more exercise while 
 still under treatment than will be required at 
 work. 
 
 Some patients pass unexpectedly and at times 
 
FROM PULMONARY TUBERCULOSIS 17 
 
 quickly from one class to the other, for recovery 
 from tuberculosis does not follow a gentle ascent 
 toward complete arrest, but leaps from one level 
 which has been maintained for possibly some 
 months to another in a few weeks. 
 
 The only way we can attack tuberculosis is 
 by raising the body's powers of resistance to the 
 highest point and then letting it fight against 
 the disease. That is what I mean when I say 
 it takes four years to get over tuberculosis. We 
 cannot cure a patient in six months, but we can 
 get him in such shape that when he returns 
 home he will know how to take the right care 
 of himself and to keep his body in such shape 
 that it cannot only hold its own against the 
 tubercle germ, but also fight against it and in 
 three or four years overcome it. It does take 
 that length of time and it does require that kind 
 of treatment. 
 
 The treatment can be divided into two parts. 
 The first I like to consider as similar to a college 
 course. Now a college is a place where men 
 and women go and have set out for them each 
 day certain tasks which they must do. They 
 must come every day to the class-room for a 
 certain number of hours or recite upon, for 
 instance, so much history, philosophy, Greek or 
 biology. My duty to my patients in this part 
 of their "course" is to teach them all I can, all 
 that I know, about what they should do and 
 why. When they have learned this, when they 
 2 
 
18 RULES FOR RECOVERY 
 
 have corrected their mistakes and realize the 
 problem they have to face, I feel they can pass 
 into the second part of the treatment, which I 
 like to compare to a university. A university is 
 conducted very differently from a college. A 
 university is a place where a man can pursue 
 original work, where he has a certain problem 
 given him to work out, which he can do with 
 the assistance of the professors. If a difficulty 
 arises he consults them, and they give him help 
 and aid in solving his problem. So it is with 
 patients. They will have to solve this problem 
 for themselves. We cannot make them get well ; 
 all we can do is to give them help. We want 
 them to think over the whole thing seriously and 
 earnestly, and if anything comes up which they 
 do not understand, to come and talk it over. 
 We want them to realize that the matter is largely 
 in their own hands. We can watch them for six 
 months and send them to work; and then, in a 
 week, a day, an hour, they can upset all we have 
 done. It is a mere waste of time to try to make 
 a man take care of himself. You can lead a horse 
 to water but you cannot make him drink, nor 
 can you make a person get well. You can give 
 him every chance, but beyond that there is little 
 to be done. Constant care, day in and day out, 
 must be the watchword for the next four or five 
 years for all of them, and if they do that, we 
 think the vast majority of them will be in excel- 
 lent shape at the end of that time. 
 
FROM PULMONARY TUBERCULOSIS 19 
 
 In every community, in every village, city, or 
 State, it is necessary to have certain rules to 
 govern the inhabitants of these places in their 
 conduct toward one another. Every institution 
 needs to have a few simple rules. The patient 
 must carry on the spirit of the place and hand it 
 down to others that come after him. If he does 
 not, he fails to get the best out of his stay. 
 Every time he does not understand some rule, 
 if he will talk the matter over with some one in 
 authority it will be explained. These rules must 
 be carried out, not only in the letter, but in the 
 spirit. 
 
 After all, the most important thing is to be 
 able to control one's self. If a man does not 
 develop self-control while he is "curing," so that 
 when he is asked to do things he knows he should 
 not, and to which he cannot sa.y no, then his 
 time has been lost. Unless a patient can say no 
 when the occasion arises, his chances for getting 
 well are very slight. He can tear down in one 
 day or in an hour what it has taken him many 
 months to build up. 
 
20 RULES FOR RECOVERY 
 
 ON REST 
 
 " Repair is but the repetition of growth. The same elements, 
 the same kindred conditions, are necessary to the same results. 
 Rest is the necessary antecedent to the healthy accomplishment 
 of both repair and growth. " 
 
 There are three great medicines in the treat- 
 ment of tuberculosis; medicines which when 
 rightly used are far superior to those found in 
 any pharmacopoeia: Rest, food and fresh air. 
 Formerly this order of their importance was 
 reversed and the value of fresh air and food so 
 emphasized that rest was placed last, hyphenated 
 often to exercise and modified by "properly 
 regulated." Thus the great profit that accrues 
 from rest at the beginning of treatment was 
 often slurred over or, indeed, entirely escaped 
 attention. The value of rest at the outset of 
 treatment cannot be overemphasized, and for 
 that reason is discussed first, because to give a 
 patient with pulmonary tuberculosis and fever 
 good food and insufficient rest is like attempting , 
 to fill with water a barrel full of holes. 
 
 The importance of exercise to the healthy 
 body has been dwelt upon from time immemo- 
 rial, and while the idea of exercise for health's 
 sake will never exert upon Americans so much 
 
FROM PULMONARY TUBERCULOSIS 21 
 
 influence as, for example, it does upon the 
 English, nevertheless it is rare for any patient 
 to undergo the rest treatment without protest; 
 his organs, he states, will not perform properly 
 their functions. He has never tried resting out 
 of doors, yet hundreds of patients can testify 
 that such rest when the body is weakened begets, 
 not further weakness, . sluggish digestion and 
 elimination, but greatly increased strength. 
 
 Few realize how important a place rest occupies 
 in the life of the healthy man. The experienced 
 ditch-digger pauses before lifting each shovelful 
 of earth, while the beginner throws out three 
 times as much for the first few minutes and is 
 then exhausted and requires, according to some 
 experiments, two hours for complete recovery. 
 Any attempt to use muscles so fatigued greatly 
 prolongs "this period of complete recovery — a 
 fact that demonstrates the injurious effect of 
 straining a fatigued muscle." (Howell.) When 
 the nutrition of the body is poor, whether brought 
 about by disease, poor or too little blood, loss of 
 sleep or. mental activity, the muscular power is 
 lessened. It is interesting to note that continued 
 use of one set of muscles {e. g., those in walking) 
 decreases the work obtainable from other sets 
 (e. g., the arm). The heart, which is a muscular 
 bag, contracts so rapidly that few of us realize 
 that between beats it rests at least twelve hours 
 in twenty-four. Everyone has noticed that exer- 
 cise produces deeper and more rapid breathing, 
 
22 RULES FOR RECOVERY 
 
 due no doubt to the fact that the used muscles 
 require more oxygen. 
 
 To understand fully, however, the value of 
 rest and exercise for the body, in either health 
 or disease, it is necessary to become acquainted 
 with a few physiological facts. The amount of 
 work performed by any animal is the product 
 of the units of weight by the units of distance 
 they are lifted perpendicularly. For man these 
 units are the pound and the foot, and the unit of 
 work is the foot-pound, i. e., the energy required 
 to lift one pound one foot. A normal heart does 
 four foot-pounds of work at each contraction. 
 If, as is often the case, the pulse is quickened, 
 during exercise, twenty beats per minute, it is 
 evident that exercise for one hour would cause 
 the following increase of work for the heart: 
 20 beats x 60 minutes x 4 foot-pounds equals 
 4800 foot-pounds of work, equal in amount to 
 that required to carry two scuttles of coal up to 
 the third or fourth floor. Rest prevents this expen- 
 diture of energy. In a similar manner the number 
 of respirations may be increased four or more per 
 minute or two hundred and forty in an hour. 
 
 Every living thing seems to require rest, or 
 at least goes through periods of rest and of 
 activity. Sleep for many men is the only time 
 given to rest. During sleep the heart, lungs and 
 kidneys continue to function but become less 
 active. The muscles, however, relax completely 
 and loss of consciousness occurs, due probably 
 
FROM PULMONARY TUBERCULOSIS 23 
 
 to lack of blodd in the brain, brought about by 
 the fatigue of the small muscles that keep the 
 bloodvessels of the skin and abdomen contracted. 
 The average healthy man spends about one- 
 third of his life in bed — if not in sleep. 
 
 Injury demands rest for repair. Pain in many 
 cases is thought by some to be the gift of a kind 
 Providence to enforce rest of an injured part. 
 Pain has been called the monitor, and rest the 
 cure. "In every movement of the body when- 
 ever one begins to endure pain it will be relieved 
 by rest." No one attempts to walk on a broken 
 leg or to wiggle a finger with a skinned knuckle 
 in order to hasten recovery. When the pleura 
 (the covering of the lung) is inflamed it tries to 
 protect itself by the secretion of substances 
 designed to guard it against direct friction. When 
 such inflammation of the pleura (pleurisy) occurs, 
 whether from, pneumonia, a broken rib or tuber- 
 culosis, recovery is quickest wrought when rest 
 is most vigorously applied. The pain of pleurisy 
 causes the ribs and the diaphragm to move less, 
 in order to protect the lung and pleura against 
 injury from respiratory exercise. Even the deeper 
 breathing caused by talking may irritate such a 
 pleura. The fixation of inflamed joints by con- 
 traction of the muscle about the joint is known. 
 A boil or an abscess is opened to give its internal 
 surfaces rest. It has long been known that rest 
 in bed aids wonderfully a heart weakened by 
 disease. Exercise may, on the other hand, help 
 
24 RULES FOR RECOVERY 
 
 some individuals; but when fatigue quickly sets 
 in following exercise, and loss of appetite, of 
 weight, of strength or weakened digestion, fever, 
 night-sweats, increased cough and expectoration 
 occur or increase, are we to believe that exercise 
 is of value? Exercise demands increased nutri- 
 tive aid, while in this state of ill-health it is 
 lessened, and, before the loss can be repaired, a 
 new demand with added loss follows. "Every 
 motion costs the body fat or protein; climbing 
 more than walking, walking more than sitting 
 and sitting more than lying. The more quietly 
 the body lies, the less the muscles are called into 
 use, the less is the body substance used." (Cor- 
 net.) It is of interest to note that a semi-reclin- 
 ing position (three or four pillows if in bed, an 
 angle of thirty degrees in a chair) is believed to 
 be the best position for the majority of cases. 
 Such a position aids in resisting cold, as the heart 
 has less work to do against gravity. The exces- 
 sive demands upon the body in tuberculosis have 
 led to excessive waste of body substance and 
 ; given rise to the popular name "consumption." 
 The conservation of body substance is obtained 
 through rest. The expenditure must be reduced 
 while the receipts are increased. 
 
 Many patients argue that as they have no 
 appetite they must exercise in order to regain 
 it. Unfortunately, in pulmonary tuberculosis 
 this quickens the circulation, forces more poison 
 into the blood, weakens the digestive organs, 
 
FROM PULMONARY TUBERCULOSIS 25 
 
 brings about less appetite still and loss of strength 
 and weight. It produces what is known as a 
 vicious circle. Prolonged rest and its dangers 
 have been studied very carefully in patients who 
 have diseases of the joints. One observer states 
 that he has never seen a patient with severe hip 
 disease whose general health was not improved 
 by rest in bed. Curiously enough, rest of the 
 knee which is necessitated by proper treatment 
 of the hip does not injure the knee. The enforced 
 rest necessary to enable the lungs to wall off the 
 spots of disease and to dam up their poisons need 
 cause no uneasiness in regard to the other organs. 
 A thesis might be successfully defended which 
 states that in proportion as any part of the body 
 afflicted with tuberculosis can obtain functional 
 rest, so it can be cured speedily and surely. 
 Tuberculosis of the knee, on the one hand, is, 
 when taken in time, very curable, for it can be 
 given I GO per cent, of functional rest. Tuber- 
 culosis of the kidney, on the other hand, is much 
 more difficult to cure, for it performs its duties 
 day and night and can be given no functional 
 rest. The lungs occupy an intermediate position, 
 and while they must function to maintain life 
 they can be spared very greatly. One observer 
 has limited the pulmonary movement of one lung 
 of some rabbits, and then infected them with 
 tuberculous germs. The disease in the quieted 
 lung was far less acute than in the other more 
 active lung. It is unquestionably dangerous to 
 
26 RULES FOR RECOVERY 
 
 stretch tuberculous disease areas, and experience 
 with cattle shows that pulmonary rest is of value. 
 The amount of lymph (the tissue juice) that 
 flows through the diseased area supplies food to 
 the tubercle germs and washes away their waste 
 products which may tend to stop their growth. 
 Rest limits the flow of lymph and so aids in cer- 
 tain stages in healing. 
 
 It is of some interest at this time to consider 
 briefly in a broad way how recovery from pul- 
 monary tuberculosis takes place. The minute 
 dots of disease in the beginning are scattered 
 through a small part of the lung much as specks 
 occur in an unsound apple. In those minute 
 dots lie the germs which give off poisons to 
 weaken the body. On the other hand, the body 
 is trying to wall off, to imprison, the germs by 
 forming scar tissue about them. At first this 
 scar tissue is very, very delicate, possibly not 
 stronger than spider web. A deep breath, a 
 sudden exertion which causes us to shut our 
 windpipe and contract our chest muscles, may 
 readily stretch or break this delicate scar tissue 
 and so allow the germs to escape. These escaped 
 germs may form new dots of disease, and the 
 walling-off process must begin anew. Recovery 
 from tuberculosis then consists, first, in walling 
 off the diseased areas and, second, in maintain- 
 ing the wall in such a state of perfection and 
 strength that no germs can escape, so that even 
 their poisons are dammed up and that finally 
 
FROM PULMONARY TUBERCULOSIS 27 
 
 the resistance of the body becoming so strong 
 the germs are starved to death. That this 
 requires much time can be readily understood. 
 
 The time that should be devoted to rest and 
 the degree of rest varies, of course, with each 
 individual and must be prescribed by his physi- 
 cian. In early stages when the disease has just 
 been discovered the best treatment is without 
 doubt rest in bed. When high fever is present 
 the patient should be allowed for a time to move 
 neither hand nor foot, writing must be forbidden 
 and reading greatly curtailed, if permitted. It 
 may even be advisable for a time to feed the 
 patient. All excitement must be absolutely 
 avoided, for anything that quickens the pulse 
 and accelerates the circulation may flush out 
 of the poorly walled-off diseased areas poisons 
 which cause fever, loss of appetite, loss of weight 
 and strength, night-sweats, indigestion, and pos- 
 sibly constipation. Bathing should be performed 
 so as to avoid tiring the patient. A garrulous 
 nurse who relates all the fatalities and sad 
 experiences that have fallen within her notice, 
 should be discharged at once, for harrowing 
 stories have no place in a sick-room. 
 
 In any case, however, whether or not there is 
 fever, a patient is never injured by a six weeks' 
 rest in bed, but often so greatly benefited that 
 he feels profoundly grateful for the advice which 
 brought it about. The time of greatest improve- 
 ment in many cases occurs during the period 
 
28 RULES FOR RECOVERY 
 
 when the patient, having lost his fever, still re- 
 mains in bed. The idea that some patients have, 
 that should they "give up" and go to bed, they 
 would rapidly lose what little strength they have, 
 is wrong. Many patients can testify that such is 
 not the case, but that they get up feeling stronger 
 in every way. Few people go to bed without 
 being sick, and it is in nearly every case the 
 disease and the fever which cause the weakness 
 and not the rest in bed. Were it not for this 
 rest in bed, many patients would die from such 
 acute diseases as typhoid fever and pneumonia. 
 Many instances could be quoted, showing the 
 great improvement that occurs from resting in 
 bed. One patient, a man of forty, active and 
 athletic, was put to bed after a rather strenuous 
 journey. At the end of several weeks he had 
 made such improvement that he elected to 
 remain in bed eleven weeks and got up without 
 a symptom and has remained so for over four 
 years. Another patient rebelled on the day of 
 his arrival against going to bed. The following 
 day he spat blood, ran fever and was in bed 
 for nearly three months. He arose practically 
 symptomless and has remained so for many 
 years. Another patient never improved until 
 he broke his leg and was forced to remain in bed 
 for many weeks. The enforced quiet effected 
 an excellent arrest of the disease. It might be 
 noted here that for many patients the most 
 effectual treatment of cough is rest in bed. 
 
FROM PULMONARY TUBERCULOSIS 29 
 
 While the writer is firmly convinced that a 
 preliminary rest in bed will more quickly and 
 more surely wall off the disease and so arrest it, 
 he also recognizes that the vast majority of 
 patients who do arrest their disease, do so by 
 remaining in their "cure-chairs" until put upon 
 exercise. The object of this chapter, however, 
 is not to tell how most patients who arrest their 
 disease do so, but to guide patients along lines 
 that will bring about the best results in the 
 greatest number. That tuberculosis can be 
 "cured" without any interruption of business 
 or work cannot be denied, but that the vast 
 majority of patients who attempt to attain arrest 
 in this way fail to do so cannot be gainsaid. 
 
 When a patient decides that he will risk remain- 
 ing up at the beginning of treatment, he should 
 avoid for at least two months all unnecessary 
 movements, such as packing up to go to a health 
 resort, climbing stairs except when absolutely 
 necessary for the cure, all games like pool, 
 billiards, cards, or any games of chance, all 
 sports, and only such walking as is absolutely 
 necessary should be indulged in. The risk 
 should be fully realized, and the responsibility 
 assumed by the patient who, if the plan fails, 
 must pay the penalty. 
 
 How long a patient should remain in bed 
 depends entirely upon his condition and symp- 
 toms, points which only his physician can decide. 
 It might be of interest to the patient to have it 
 
30 RULES FOR RECOVERY 
 
 suggested that in most cases it is easier for the 
 physician to have the patient come to his office 
 than for the physician to visit the patient. The 
 physician experiences little pleasure from keep- 
 ing his patients in bed but he realizes that in this 
 disease the bed is a great medicine, which can 
 heal by itself alone many attacks of illness. If 
 by remaining in bed a few weeks a patient can 
 shorten his time of treatment by several months 
 it is time well spent. He should remember that 
 a cut in diseased skin will not heal as readily as 
 a cut in healthy skin. If patients could only 
 see the disease in their lungs, the slow progress 
 that is often made toward healing, it would be 
 difficult to persuade many of them to take any 
 exercise for a long, long time. 
 
 A further argument for rest in bed at the onset 
 of treatment is that at first sortie patients make 
 grievous mistakes through sheer ignorance, but 
 protected from such mistakes by rest in bed they 
 acquire such knowledge of the disease during this 
 period that when they get up the danger through 
 ignorance is passed. 
 
 In this connection it is of some interest to 
 consider two methods of treatment formerly 
 much used: horseback riding and sea voyages. 
 Of all former modes of locomotion, moderate in 
 expense, these entailed upon the traveler the 
 least exercise and afforded him the greatest 
 amount of fresh air. The small size of the ships, 
 the length and monotony of the voyage, forced 
 
FROM PULMONARY TUBERCULOSIS 31 
 
 unconsciously upon many a patient more pul- 
 monary rest than he had ever before experienced. 
 So, too, with horseback riding. It spelled out 
 of doors, and when taken moderately afforded 
 far less pulmonary exercise than walking, which 
 has led many a patient to sure destruction. 
 
 Few realize the amount of energy expended 
 in coughing. Fortunately for most patients the 
 muscles used in coughing are well developed. 
 Some years ago an enterprising observer esti- 
 mated that a patient who coughs hard all day 
 does as much work as a man who climbs a moun- 
 tain. However accurate this may be, the work 
 done by many patients in coughing is so severe 
 and exhausting that every means must be taken 
 to check it. That all coughing, whenever pos- 
 sible, should be controlled, on account of possible 
 pulmonary injury, is apparent to everyone. 
 
 Eight hours of sleep are said by many to be 
 sufficient for a man in health. It has already 
 been pointed out that during sleep the muscles 
 relax completely, and such a state of relaxation 
 is during waking hours only approximated by 
 rest in a chair. We hear much today of conser- 
 vation of natural resources, but few realize how 
 important in disease and even in health the con- 
 servation of energy is. Many men with arrested 
 or even only quiescent disease in their lungs are 
 enabled by a study of the conservation of their 
 efforts to work and live for years in comfort, 
 though dubbed no doubt by their fellows as 
 
32 RULES FOR RECOVERY 
 
 "cranks on rest." The eight hours in bed for 
 many men with arrested disease, who must work, 
 should be stretched to ten or eleven, and rest in 
 bed from Saturday night to Monday morning 
 enables many to return to work with a vigor that 
 is surprising. Rest for a half-hour before each 
 meal is helpful to many patients, and for some 
 with weak digestion a rest for a half-hour after 
 meals is remarkable in its results. During the 
 "cure" period a rest of two hours following 
 luncheon should be rigidly adhered to and every 
 effort made to sleep. When this is not possible 
 a light, non-exciting book or periodical can be 
 read, but all games and conversation should be 
 avoided. 
 
 The tuberculous patient is in most cases a 
 nervous patient as well, for the poisons of the 
 disease show a peculiar characteristic of attack- 
 ing the nervous system. Dr. S. Weir Mitchell 
 was the first to prove the great value of rest for 
 nervous patients and in many instances it is 
 remarkable to see how relaxation from nervous 
 tension follows rest, while recuperation treads 
 close upon its heels. 
 
FROM PULMONARY TUBERCULOSIS 33 
 
 II 
 
 ON FOOD 
 
 "Good food, spiced with laughter, eaten with contentment, 
 digested at ease, turns sour visages into sweet, bad health into 
 good." 
 
 Food Is said to stand In more or less the same 
 relation to the body that fuel (coal or oil) does 
 to the steam engine or gasolene to the motor, i. e., 
 it supplies the engine with power. However, 
 food does more than this for the body. It not 
 only supplies fuel and oil, but repairs the parts 
 injured in the wear and tear of life. The engine 
 bums the coal and, If It is good coal, few clinkers 
 clog the grates. We can vary our food at will, 
 but seldom do we consider the final purpose of 
 food, and think only of how It suits our palate. 
 Few of us live only to eat; but, until we fall 111, 
 still fewer have ever eaten to live. This is the 
 problem that we must now face and solve as 
 quickly as possible. 
 
 Two questions present themselves at once: 
 First, what shall we eat and, second, how much 
 shall we eat? 
 
 Some of the brightest Intellects of our time 
 have studied this problem very carefully. They 
 have noted the amount of food necessary for 
 3 
 
34 
 
 RULES FOR RECOVERY 
 
 men undergoing hard, moderate, and light labor 
 as well as for those engaged in sedentary work. 
 The result is what we would suppose — the neces- 
 sity for food increases with activity. 
 
 All foodstuffs may be divided into six great 
 classes: Water, inorganic salts, protein, albumi- 
 noids, carbohydrates, and fats. A few examples 
 of some of these foods will illustrate them better 
 than many pages of description. 
 
 NUTRITIVE INGREDIENTS OF FOODS (ATWATER) 
 
 Water 
 
 Food 
 as pur- 
 chased 
 contains 
 
 Edible 
 
 portion 
 
 e. g., flesh of 
 
 meat, yolk and 
 
 white of eggs, 
 
 wheat, flour, 
 
 Protein 
 
 Fats 
 
 Nutrients • 
 
 etc. 
 
 bones, 
 shells, 
 
 Refuse 
 
 e. g;, 
 
 entrails, 
 bran, etc. 
 
 Forms tissue . 
 , white (albumen) of 
 curd (casein) of milk, 
 lean meat, gluten of wheat, 
 etc. 
 
 Protein 
 Fats 
 
 Carbohydrates 
 Mineral matters 
 
 . Are stored as fat 
 e. g., fat of meat, butter, olive 
 oil, oils of corn and wheat, 
 etc. 
 Carbohydrates are transformed into fat, 
 e. g., sugar, starch, etc. 
 
 Mineral matters (ash) Share in forming bone, assist in 
 
 digestion, etc. 
 e. g., phosphates of lime, potash, 
 soda, etc. 
 
 All serve as fue.I 
 to yield energy 
 in the forms of 
 heat and muscular 
 power. 
 
FROM PULMONARY TUBERCULOSIS 35 
 
 Nature's call for water is usually^ early and 
 imperative, and no one doubts its great value. 
 The amount of water necessary for different 
 individuals varies greatly, but many, especially 
 women, drink too sparingly. The practice of 
 taking water at meals has long been frowned 
 upon, and on account of the weak stomach 
 muscles in many patients it should not be over- 
 done in those suffering from pulmonary tuber- 
 culosis. If, however, the stomach is not dis- 
 placed and the muscles strong, water at meals 
 is excellent. One rule, however, should be abso- 
 lutely followed if water is taken at meals. It 
 should be drunk only after the food is swallowed 
 and not used to wash down food incompletely 
 mixed with saliva. Water is of great help in 
 many instances of constipation. Pure spring or 
 tap water is just as valuable for this purpose 
 as many of the bottled waters on the market. 
 There is, however, one great difference. Tap 
 water is free; we all have an unlimited supply 
 of it. For this reason we regard it as of little 
 value. Bottle it, give it a fancy name and charge 
 for it by the gallon and we drink it with marked 
 benefit. Great is the power of suggestion ! 
 
 Inorganic salts comprise combinations of 
 sodium, potassium, calcium, magnesium, iron, 
 iodin and probably others in combination with 
 chlorine, phosphorus, sulphur, carbon and other 
 elements. The most familiar of these is sodium 
 chloride," or common table salt. The larger the 
 
36 RULES FOR RECOVERY 
 
 part vegetables play In the diet the more salt is 
 necessary. Iron is contained in comparatively 
 large quantities in spinach, yolk of eggs, aspara- 
 gus, beef, cabbage (green leaves) and apples, 
 and it is well known that anemic persons should 
 take iron. Many today are aware of the value 
 of lime salts (calcium) in the coagulation of the 
 blood and the curdling of milk, but that animals 
 fed on a liberal diet free from these compounds 
 die more quickly than those without any food 
 is not so fully known. These salts then are very 
 important, but luckily we usually find most of 
 what we need in our ordinary diet. 
 
 Anybody can tell that a cow is an animal, and 
 a cabbage a plant, but when both animal and 
 plant have such simple structures that they 
 strongly resemble one another the problem is 
 different. Now one of the fundamental differ- 
 ences between an animal and a plant is the fact 
 that the plant can lise nitrogen in the form of a 
 simple chemical compound to build up its cells, 
 whereas the animal requires the nitrogen to be 
 in a very complex state or, in fact, in the final 
 stage in which it is found in the plant. These 
 highly complex bodies are called "proteins," and 
 occur in considerable amounts in lean meats, 
 eggs and milk, and in smaller quantities in cer- 
 tain vegetables, such as peas, beans, rice, pota- 
 toes, wheat and corn, and in gelatin. These 
 protein substances are absolutely necessary for 
 life and can be replaced by no others. Recent 
 
FROM PULMONARY TUBERCULOSIS 37 
 
 studies have shown that they fall into three or 
 four classes, according to their ability to main- 
 tain life for a time or continuously, to maintain 
 weight or to aid in growth. It is only necessary 
 to add that the proteins in meat, milk, rice and 
 potato belong to the last or the highest and most 
 important group. 
 
 The group of albuminoids is best represented 
 by gelatin which is good food in that it spares 
 or saves the proteins for other uses. By itself 
 it cannot form any new body substances which 
 contain nitrogen. 
 
 The carbohydrates are represented in our food 
 chiefly by the starches (bread, rice, potatoes, 
 etc.), and to a certain extent by the sugars. 
 Most of these are changed to grape-sugar by 
 digestion and as such are absorbed into our 
 bodies. We have seen that food might be looked 
 upon as fuel for the human machine and have 
 learned that the protein food is necessary for 
 the repair and growth of the body. These carbo- 
 hydrates really carry out much more closely the 
 analogy of fuel. In the body they (as sugars) 
 are burnt (oxidized) in the muscles during work 
 (muscular contraction) and probably even during 
 rest, for the muscles are rarely, if ever, abso- 
 lutely relaxed. In this way they supply a large 
 part of the heat of the body. It can easily be 
 inferred from what has been said that the carbo- 
 hydrates also supply a large amount of the energy 
 of the body, possibly all the energy of the muscles. 
 
38 RULES FOR RECOVERY 
 
 These are the main uses of this class of food- 
 stuffs, but like the albuminoids they can also 
 "spare" the proteins, i. e., when the supply of 
 starch and sugar is abundant less protein food 
 is required. If this supply is in excess of the 
 needs of the body it may be changed into fat 
 and stored up as such. 
 
 The fats of the food really require no defini- 
 tion. Fat is found not only in meat, but also 
 in the many oils found in fish and in vegetables 
 (cod-liver oil, olive oil, cottonseed oil, peanut 
 oil, etc.). The fats also furnish energy to the 
 body, and, weight for weight, much more energy 
 than the carbohydrates. We store fat in many 
 nooks and crannies of the body, which when we 
 fall ill and cannot eat, we draw upon to supply 
 the energy to keep the necessary physiologic 
 activities in action (the beat of the heart, the 
 movements of breathing, etc.). So whenever 
 our intake falls below our daily requirement of 
 food we use or consume more and more of our 
 body fat. When this has reached an advanced 
 stage in tuberculosis, the disease is popularly 
 called "consumption." 
 
 This brings us to consider briefly the fuel value 
 of the foodstuffs. This has been studied outside 
 and inside the body and the results expressed in 
 heat units called calories, one of which repre- 
 sents heat enough to raise 1.056 quarts of water 
 from 32° F. to 33.8° F. The fuel value of fat is 
 greater than that of carbohydrates or of protein 
 
FROM PULMONARY TUBERCULOSIS 39 
 
 as ordinarily used in the body. For this reason 
 fat and carbohydrates might be called the "fuel- 
 foods." It is impossible for the body to make 
 use of as much fat as carbohydrates, and conse- 
 quently, as has been stated, the carbohydrates 
 (starches and sugars) are the chief heat- and 
 energy-producing foodstuffs. The body of an 
 adult man produces and gives off to the surround- 
 ing air about 2400 calories of heat in twenty- 
 four hours. Now when the various foods are 
 analyzed in regard to the various foodstuffs they 
 contain, it is not difficult to determine how many 
 calories or how much heat they are capable of 
 supplying to the body. Many tables have been 
 compiled, and it is of interest to note a few facts 
 regarding them. One glass of milk contains twice 
 as many heat units (150) as one raw egg. A 
 tablespoonful of fairly thick cream or a butter 
 ball is equivalent to an egg, or to a cubic inch 
 of many cheeses. Skimmed milk or buttermilk 
 has half the caloric value of whole milk, whey 
 about one-third. Twenty ounces (forty table- 
 spoonfuls, about three tumblers) of beef-juice 
 equal one glass of milk. A good slice of roast 
 beef equals four and one-half to five raw eggs, if 
 the fat and all are eaten ; if the roast is very lean, 
 it is equivalent to only one and one-half eggs. 
 Lamb chops, turkey and roast ham have a higher 
 value than chicken, while veal is much lower. 
 Two heaping tablespoonfuls of calf's-foot jelly 
 equal about one egg. 
 
40 RULES FOR RECOVERY 
 
 A portion of salmon or roast ham is about 
 equal to two and one-half eggs, but snielts and 
 brook trout are very low in value. Raw oysters 
 and clams are about equal, and twelve oysters 
 contain the same number of calories as one 
 egg. Soups, unless creamed, have a fairly low 
 value and ten tablespoonfuls about equal one 
 egg. Creamed soups are two or three times as 
 valuable. Potatoes, white or sweet, green peas, 
 mushrooms, corn, macaroni, boiled rice, oatmeal, 
 are all valuable. Beets, cabbage, cauliflower, 
 celery, cucumbers, parsnips and turnips have 
 very much lower heat values. Bananas, grape- 
 fruit and grapes are high among the fresh fruits, 
 and figs, prunes, dates and apricots among the 
 dried. Whole- wheat bread is but little more 
 valuable than white bread and less so than brown 
 bread, gingerbread, frosted or layer cake. All 
 pies have a high value, as well as bread and 
 custard puddings. French dressing is one-half 
 as valuable as mayonnaise or hoUandaise. Nuts 
 contain many heat units. Most drinks, such as 
 tea, coffee, cocoa and lemonade, are valuable on 
 account of their added ingredients. 
 
 We have now seen that the relative heat values 
 of food vary between wide limits, but we must 
 not forget that many other factors enter into 
 diet. Protein, we have seen, is necessary for 
 growth and repair. Inorganic salts, which are 
 vital for life processes, occur in vegetables with 
 slight heat value. Other compounds, some already 
 
FROM PULMONARY TUBERCULOSIS 41 
 
 described ( vitamines) , and probably others as yet 
 undescribed, play an important role in nutrition. 
 Lastly, in the choice of a diet, individual taste 
 must often be the deciding factor, and foodstuffs 
 of low heat value are often digested and assimi- 
 lated by patients far better than others appar- 
 ently more appropriate for their needs. Nor 
 must it be forgotten that the diet must be well 
 balanced, and only the patient's physician can 
 do this skilfully. 
 
 In health the appetite is a safe guidp to follow, 
 but in disease, when the body needs food most, 
 the stomach craves it least. It is an old adage 
 among patients with tuberculosis that they should 
 eat once for themselves, once for the germs and 
 once to gain weight. They meant by this that 
 the diet should be greatly increased, and not only 
 must three good meals but six glasses of milk and 
 six raw eggs be swallowed every day. For many 
 years it was thought that however well the 
 patient might be eating at his meals, the milk 
 and eggs must also be taken. Looked at from an 
 economic standpoint, in many instances, this was 
 a woeful waste. Let us see what the patient 
 i wishes to do! He has, for example, lost weight 
 and his usual weight is about ten pounds below 
 what a man of his height and age should weigh. 
 His first object is to regain his lost weight, and 
 his second to approximate or slightly exceed his 
 normal weight. To do this he must eat, and the 
 scales tell the story. The tendency is to overeat 
 
42 RULES FOR RECOVERY 
 
 and the desire to gain weight quickly is strong, 
 but the struggle is to be a long one and no organ 
 must be impaired. Everyone who knows any- 
 thing about a motor knows that too much gaso- 
 lene decreases the efficiency of the engine and 
 clogs it with unbumt carbon. A certain quantity 
 of gasolene enables the engine to do its greatest 
 amount of work; more gasolene decreases the 
 amount of work. So it is within limits in the 
 body. When more food is eaten than can be 
 assimilated' the excess may undergo putrefactive 
 changes in the intestines, and far from helping, 
 hinder the body in its struggle against disease. 
 
 The rule for the man under weight should be 
 to eat as little food as he can in order to gain 
 weight. 
 
 Three good meals a day, two or three glasses 
 of milk (with or between meals), one or two 
 eggs a day, cooked or raw, are often sufficient 
 to add enough to his weight to bring him the 
 gain wished for. As soon as this is brought 
 about he should consider his stomach and dis- 
 pense with eggs and milk. Sooner or later he 
 will fall ill with a cold or acute bronchitis, lose 
 a few pounds in weight, and can then, by adding 
 milk and eggs to his diet, quickly regain his lost 
 weight. Such a method will reduce gastric and 
 intestinal disturbances to a minimum. There 
 are no more difficult problems in the treatment 
 of pulmonary tuberculosis than to make some 
 patients gain weight and to help others to avoid 
 
FROM PULMONARY TUBERCULOSIS 43 
 
 digestive disturbances. Such subjects, of course, 
 cannot be discussed here and must be taken up 
 with the patient's physician. 
 
 During the course of treatment, it is not at all 
 unusual for a patient to lose his appetite, and, in 
 fact, to have such a distaste for food that it 
 becomes at times almost impossible to swallow 
 anything that requires chewing. It might be 
 stated, however, as Hippocrates has said, that it 
 is easier to fill up with drink than with food; 
 which means, in other words, that when a patient 
 has completely lost his appetite and cannot eat, 
 he can often take, and take easily, liquid food 
 which he can drink without chewing. Such a 
 diet without even a cracker to chew often restores 
 a lost appetite. 
 
 In the first place, a liquid diet in the vast 
 majority of such cases gives the patient many 
 times as much nourishment as he has been able 
 to take in solid form. So liquid diet does not 
 lessen but increases the amount of food eaten. 
 
 When milk and eggs can be partaken of freely, 
 the problem is simple. Four quarts of milk (about 
 sixteen glasses) a day contain about 2300 to 2400 
 calories, but few could ever drink so much milk, 
 and it is questionable whether it would' be advis- 
 able to do so if anyone could. We must seek 
 some substitutes for much of this milk. One 
 glass of milk contains 150 calories, and one egg 
 75 calories. For a time at least, when no solid 
 food is eaten, it is not difficult to replace three 
 
44 RULES FOR RECOVERY 
 
 glasses of milk by six eggs, preferably boiled one 
 minute (they can be swallowed cold and whole). 
 A cup of coffee or tea with sugar and cream con^ 
 tains about the same number of calories (156) 
 as a glass of milk, and two such cups could replace 
 two glasses of milk. A similar sized cup of cocoa 
 could replace nearly two more glasses of milk 
 (279 calories). A plate of creamed soup (250 
 calories) would more than replace a glass of milk. 
 This suggests how a liquid diet may be arranged 
 when milk and eggs are readily taken. When 
 such is not the case, a physician will have to 
 prepare a suitable liquid diet, but the problem 
 is not an easy one. 
 
 Students of diet have used the term "balanced 
 ration" to indicate that certain proportions of 
 protein, fat and carbohydrate should be eaten. 
 It is ordinarily said that 100 grams (6 to 7 ounces) 
 of protein are necessary for a man every twenty- 
 four hours, but many patients apparently do well 
 on less, even on 80 grams. Protein is necessary, 
 because new cells cannot be formed without it, 
 though from fat and carbohydrate body fat can 
 be formed. Fats and carbohydrates can be within 
 broad limits freely replaced one by another. To 
 outline a well-balanced diet with free use of milk 
 and eggs is an easy task but to do so without 
 milk and eggs is very difficult. Many patients 
 have lived so long on large quantities of milk and 
 eggs that even the sight of them may not only 
 bring about loss of appetite but nausea too. For 
 
FROM PULMONARY TUBERCULOSIS 45 
 
 these reasons it is well, if possible, to have a 
 dietary that precludes milk and eggs or depends 
 upon them for only a small and concealed portion 
 of the diet. It is no easy task and it is to be hoped 
 that this attempt may help others over some of 
 the rough roads that the author has tried to 
 follow. 
 
 When repugnance to food is marked, the diet 
 must be not only liquid but as concentrated as 
 possible. Hence the addition to the diet of sugar 
 of milk (which is not very sweet) is very impor- 
 tant and greatly increases the food values. Sugar 
 of milk and ordinary sugar (cane) contain 120 
 calories in one ounce, while many of the prepared 
 carbohydrate foods, such as malted milk, Mellin's 
 Food, Fairchild's Imperial Granum, Benger's, 
 Eskay's, Carnick's, Nestl6's, Allenbury's Foods, 
 Maltico, etc., which can be taken in fluids, vary 
 from 100 to 120 or more calories per ounce. These 
 substances will afford ample liquid carbohydrate 
 food. 
 
 The fats are less easily supplied and often far 
 less easily taken. Cocoa for many patients is 
 the most palatable form in which to eat fats, for 
 a large cup (8 ounces) contains 144 calories in 
 the form of fats and totals in all about 280 calo- 
 ries. If sugar of milk be added to cocoa, it is 
 readily seen that it forms a most valuable and 
 concentrated food. Phillips' cocoa can be taken 
 by some patients who can digest.no other. Other 
 forms in which the supply of fats may be taken 
 
46 RULES FOR RECOVERY 
 
 are cod-liver oil, either pure or as an emulsion 
 (Scott's), olive oil, cottonseed oil, the prepared 
 foods, Sevetol and Russell's Emulsion of Mixed 
 Fats, etc. Olive oil and pure cod-liver oil contain 
 about I20 calories to the tablespoonful. 
 
 To increase the supply of protein in the diet, 
 the prepared foods, tropon and plasmon, may be 
 used in liquid form. It must not be overlooked 
 that many of the other prepared foods contain a 
 certain quantity of protein. Again, while it can- 
 not replace the protein, gelatin, which can be 
 prepared in liquid form, flavored with meat or 
 fruit juices, and containing sugar of milk, spares 
 the body protein and is most valuable. Many 
 patients who cannot chew can swallow rare steak 
 scraped and made into small balls the size of a 
 marble which can, if desired, be rolled in powdered 
 chocolate. Beef juice squeezed in a press from 
 meat "grayed" in a dry skillet contains about 
 three-quarters of a gram of protein in one table- 
 spoonful. 
 
 Soups form a most valuable addition to the 
 liquid diet. The clear soups, naturally, are less 
 nourishing than the thicker soups. Bouillon and 
 consomm6 contain very little nourishment and 
 the bouillon cubes, as purchased, are said to be 
 composed chiefly of common table salt. The 
 thicker soups are much more valuable and when 
 creamed (asparagus, celery, corn, pea, potato, 
 tomato) contain, in eight ounces, from 235 to 
 300 calories, as well as a fair proportion of protein. 
 
FROM PULMONARY TUBERCULOSIS 47 
 
 A chocolate milk shake, containing four ounces 
 (eight tablespoonfuls) of milk, two ounces of 
 cream, two teaspoonfuls of powdered chocolate, 
 one and one-half teaspoonfuls of sugar and one 
 egg, contains over 400 calories and had best be 
 given only once or possibly twice in twenty-four 
 hours. 
 
 The following liquid menus are merely sugges- 
 tions, which the patient's physician must modify 
 or approve. 
 
 Breakfast (730 Calories) 
 
 Cafe-au-lait or coffee or, better, cocoa (8 ounces) 
 
 (with or without sugar of milk) 
 Two glasses of whole milk (1 pint) 
 
 (with or without Mellin's Food, etc.) 
 Two eggs (in the milk or separate) 
 
 Dinner (770-880 Calories) 
 
 Thick soup (8 ounces) 
 
 Beef juice (2 ounces) 
 
 Ice cream (2 large tablespoonfuls) or chocolate milk shake 
 
 Gelatin (4 ounces) (with meat juice) 
 
 Two eggs 
 
 Supper (840 Calories) 
 
 Junket (4 ounces) 
 
 Two eggs 
 
 Two glasses of milk, buttermilk 
 
 Thin gruel (to be drunk) (4 ounces) 
 
 Tablespoonful of olive oil (or other fatty food) 
 
 Lunch at Bedtime (225 Calories) 
 Glass of milk with one egg 
 
48 RULES FOR RECOVERY 
 
 When milk and eggs cannot be freely taken, 
 the following may be tried: 
 
 Breakfast (SOO Calories) 
 
 Thin gruel (to be drunk) (6 ounces) 
 
 (arrowroot, barley, oatmeal, etc.) 
 Coffee (with sugar and cream) or cafe-au-lait 
 
 (with milk-sugar) 
 OUve oil or Sevetol (| ounce) 
 
 Dinner (750 Calories) 
 
 Thick soup (8 ounces) 
 
 Gelatin (thin, to be drunk) (4 ounces) 
 
 (with beef juice) 
 Scraped beef 
 Apple sauce (6 ounces) 
 
 (with sugar of milk or Mellin's Food) 
 
 Supper (750 Calories) 
 
 Thin gruel (another flavor) (6 ounces) 
 Thin jellied chicken soup 
 Russell's Emulsion (J ounce) 
 Tea (8 ounces) with sugar of milk 
 
 (See page 178 for Food Values.) 
 
 The pernicious habit of eating candy at all 
 hours, without regard to the meals, needs only 
 to be mentioned to be condemned. A little candy 
 after meals or even at bedtime is, however, well 
 borne by many patients. 
 
FROM PULMONARY TUBERCULOSIS 49 
 
 III 
 
 ON ALCOHOL AND TOBACCO 
 
 "Abstinence is as easy to me as temperance would be difficult.'' 
 
 ON ALCOHOL 
 
 The value of alcohol in the treatment of tuber- 
 culosis is very slight, if any, and the danger from 
 its use is very great. Its use in the treatment of 
 pulmonary tuberculosis dates back many years. 
 In 1680 Richard Morton advised such a patient 
 to "forbear wine and other spirituous liquors, 
 but especially a debauch and a surfeit proceed- 
 ing from overcharging the stomach with them." 
 Nearly one hundred years later, Reid absolutely 
 forbade them, and this at a time when drinking, 
 was very common. Brehmer, the founder of the 
 sanatorium idea, advised the systematic use of 
 alcohol, and his pupil, Dettweiler, also used it in 
 limited quantities. Curiously enough, alcohol is 
 used in the treatment of pulmonary tuberculosis 
 in' the private sanatoria in Europe today more 
 freely than in any other part of the world. Since 
 the death of the late Dr. Austin Flint, of New 
 York, who advised for a time the free use of 
 whisky in pulmonary tuberculosis, no great stu- 
 dent of tuberculosis in America has advocated 
 its use. 
 
 4 
 
50 RULES FOR RECOVERY 
 
 Alcohol has been said to warm a man in cold 
 weather, but alcohol causes a dilatation of the 
 bloodvessels of the skin which, as we know, is 
 an important means of cooling off the body; and 
 so in healthy men the skin is chilled. Those, 
 however, who are subjected to great cold recog- 
 nize the danger of this fact, and Arctic explorers 
 absolutely prohibit its use. On the other hand, 
 those who live in the tropics indulge in its use. 
 
 Its action upon the body has been carefully 
 studied. Small doses (one and one-half ounces 
 of pure alcohol) may be burnt up in the body 
 and so possibly replace some of the fats and car- 
 bohydrates, but larger doses are not so disposed 
 of, and act in the body as poisons. In small 
 quantities it does not seem to increase the rapidity 
 of the heart-beat nor its force, while it may accel- 
 erate digestion in the stomach, though its action 
 • is not always uniform. These facts relate to pure 
 alcohol and not to much of the cheap whisky that 
 is sold, which contains poisons even more deadly 
 than too much pure alcohol. 
 
 The action of alcohol upon the tuberculous 
 patient has been referred to, and its advocates 
 base many of their arguments for its use upon 
 the fact that it produces scar tissues in the liver, 
 kidneys and bloodvessels. However, no conclu- 
 sive proof has been adduced to show that the 
 scar tissue in tuberculosis is not due to the tuber- 
 culous poison rather than to the alcohol. The 
 study of alcohol as a causative factor in tuber- 
 
FROM PULMONARY TUBERCULOSIS 51 
 
 culosis has been carefully investigated and many 
 believe that it predisposes to the disease. How- 
 ever this may be, alcoholism and poverty are 
 closely associated and the latter is also of prime 
 importance. Whether or not tuberculosis runs 
 an acute course in an alcoholic depends largely 
 upon how much the alcohol has already affected 
 him. Alcohol, even when not linked with pov- 
 erty, fosters late hours, careless and irregular 
 habits, for alcohol lessens the activities of the 
 brain by affecting the most recently acquired 
 faculties of self-control, repression and the sense 
 of responsibility. 
 
 Alcohol as a food is eight times dearer than 
 our ordinary foods and withal is of such slight 
 value that we can disregard it in the treatment 
 of pulmonary tuberculosis. "Drinking strong 
 wine," says the Father ot Medicine, "'cures,|^ 
 hunger." It has been s^id that when no wine 
 is served at a banquet 50 per cent, more food 
 must be provided. Hence, alcohol is not only 
 itself a poor food but may prevent the proper 
 consumption of food. It remains then to con- 
 sider it as a stimulant and as a drug. Is it a 
 useful stimulant? Some of the great railway 
 corporations have stated that they will employ 
 no man who uses alcohol. Some prominent stu- 
 dents of foods believe that the great majority 
 of the human race at any age or of either sex will 
 enjoy better health and will live longer without 
 any alcoholic drinks. The experience of Ameri- 
 
52 RULES FOR RECOVERY 
 
 can sanatoriums, where almost without exception 
 alcohol is prohibited under penalty of expulsion, 
 bears ample evidence that it is not necessary as 
 a stimulant and rarely as a drug. It has been 
 often stated that no drug should be taken without 
 a doctor's orders and this is especially true in 
 pulmonary tuberculosis. Great danger lies in the 
 fact that a man with nothing to do but to take 
 "the cure," is very likely to go to excess when 
 once he begins to use alcohol. If it gains hold 
 upon him his only course is to cut loose from his 
 boon companions and change his residence. 
 
 ON TOBACCO 
 
 Little did Sir Water Raleigh realize what he 
 did when he introduced smoking to the white 
 man. From that day to this praise and abuse 
 have flowed and ebbed about the practice, and 
 sad pictures of crime due to excessive use of 
 cigarettes, or exultant chronicles of how their age 
 of over one hundred years was attained in spite 
 of tobacco, have been drawn. As a matter of 
 fact tobacco injures fewer men than excess in 
 eating. On the other hand, the nicotine, the 
 active principle of tobacco, is very poisonous 
 when taken pure. One-tenth of a grain of nico- 
 tine will kill a dog in a few minutes and a cigar 
 contains enough of the poison to kill two men. 
 The odor and flavor ("bouquet") and probably 
 the strength of tobacco depend in part upon the 
 quantity and quality of this oil and in part also 
 
FROM PULMONARY TUBERCULOSIS 53 
 
 upon the products of decomposition of the nico- 
 tine. Nicotine acts chiefly upon the nerves and 
 can be absorbed by smoking, snuffing or chewing 
 the tobacco leaf. A large proportion of the nico- 
 tine in the tobacco passes over into the smoke, 
 while the amount in the smoke depends upon the 
 kind of tobacco, and the amount absorbed upon 
 the way it is inhaled. Curiously enough, the cause 
 of the pleasure of smoking has not been deter- 
 rnined and seems not to have been proved to be 
 due to the nicotine. It may possibly be due to 
 the action of the smoke on the mouth, nose and 
 throat. That it soothes and quiets some men 
 cannot be denied, but that mental work and 
 imaginative powers are increased or decreased is 
 still an open question. For many it apparently 
 has no harmful effect when used in moderation, 
 but in excessive quantities it produces in some 
 trivial, in others serious changes. The effect of 
 the first smoke is usually marked by nausea and 
 often by vomiting. 
 
 Tobacco rarely affects two smokers exactly 
 alike. In some it produces a chronic irritation 
 of the throat and a hacking cough which leads 
 some patients to overlook the tuberculosis in 
 their lungs. In others, through the free secretion 
 of the saliva, which dissolves the nicotine, and 
 its subsequent irritative action upon the stomach, 
 it may produce loss of weight or indeed prevent 
 gain. Palpitation and irregularity of the heart, 
 depression arid muscular weakness are all pro- 
 duced by too much tobacco. Like any other fixed 
 
54 RULES FOR RECOVERY 
 
 habit, it is very difficult to stop. The man who 
 ceases to use it becomes restless and ill at ease. 
 In a few cessation of smoking brings about gain 
 in weight. 
 
 Knowledge of its action upon a diseased lung 
 is of considerable importance. Unfortunately 
 little is known, though there is some evidence 
 to show that rabbits when treated with small 
 doses of nicotine combat disease less vigorously. 
 Smoky atmospheres are held to be injurious for 
 patients with pulmonary tuberculosis, as they 
 irritate the throat and pulmonary membranes. 
 Tobacco smoke when inhaled may have a some- 
 what similar action, and recently it has been sug- 
 gested that this irritation may aid in bringing 
 about the formation of scar tissue, but this is 
 still unproved. When a patient smokes fifty 
 cigarettes a day it is easy to picture what the 
 "atmosphere" in his lungs is. A pipe or cigar, 
 when the smoke is not inhaled, is far better. 
 
 Moderate smoking, then, for a healthy adult, 
 who tolerates well the nicotine, seems to exert 
 little harm, but for growing boys evidence has 
 been gathered to show that it tends to prevent 
 the normal development. The inhalation of the 
 smoke is where the danger lies, and hence usually 
 cigars or pipes are safer than cigarettes. As irri- 
 tation of the throat is made worse in all conditions 
 of acute or chronic throat disease, smoking should 
 be absolutely avoided. Finally it is far better for 
 every patient to stop, for a time, all use of tobacco 
 if he possibly can. 
 
FROM PULMONARY TUBERCULOSIS 55 
 
 IV 
 
 ON FRESH AIR 
 
 "The best medicine! Two miles of oxygen three times a 
 day. This is not only the best, but cheap and pleasant to take. 
 It suits all ages and constitutions. It is patented by Infinite 
 Wisdom; sealed with a signet divine. It cures cold feet, hot 
 heads, pale faces, feeble lungs and bad tempers. It has often 
 been known to reconcile enemies, settle matrimonial quarrels, 
 and bring reluctant parties to the state of double-blessedness. 
 This medicine never fails. Spurious compounds are found in 
 large towns; but get into the country lanes, among green fields, 
 or on the mountain top, and you have it in perfection as prepared 
 in the great laboratory of Nature." 
 
 "Fresh air, good food, and regulated rest and 
 exercise" is so familiar to most patients that 
 they seldom pause to think what it all means. 
 They have always heard "fresh air" put first. 
 Indeed so deeply has this been stamped upon 
 the mind of the average man that, if there is 
 any one thing he connects with the treatment 
 of pulmonary tuberculosis, it is fresh air. The 
 value of food and exercise has been spoken of 
 and it remains now for us to study the need and 
 uses of fresh air during the "cure." 
 
 We have seen that food supplies energy and 
 repairs the wastes of the body. Further, we 
 have noted that in doing this the food is burnt 
 up or, as the chemists say, "oxidized," for all 
 
56 RULES FOR RECOVERY 
 
 burning is a combination of the burned matter 
 with oxygen. Plunge a burning match into 
 nitrogen gas and it goes out at once, for it needs 
 oxygen to burn. The burning of food in our 
 bodies is no exception to this universal rule. 
 The air in which we live and breathe is a mixture 
 of about twenty parts of. oxygen and eighty parts 
 of nitrogen. Most food substances when they 
 are burned combine with oxygen to form among 
 other things a new compound, carbonic acid gas, 
 which must be gotten out of the body. This is 
 brought about by an exchange of gases, which 
 takes place in the blood as it passes through the 
 lungs. Carbonic acid gas is given off to the air 
 and oxygen absorbed from it. For this reason 
 we would suppose that the air which we breathe 
 out would contain more carbonic acid gas and 
 less oxygen. This is found to be true. Besides 
 this gas the lungs give off several others as well 
 as considerable water vapor. The respired air 
 is also heated and in this way some body heat is 
 lost. It can be readily seen that exercise causes 
 more food to be burned than when the body is 
 at rest, and, consequently, more oxygen must 
 be absorbed and more carbonic acid gas gotten 
 rid of. This produces more rapid and usually 
 deeper breathing movements, whose danger has 
 been discussed. High barometric pressure, such 
 as occurs in caisson or submarine work, is danger- 
 ous for patients with pulmonary disease. Low 
 atmospheric pressure occurs in high altitudes 
 
FROM "PULMONARY TUBERCULOSIS 57 
 
 (usually over 3500 feet elevation) and is marked 
 at 10,000 feet (Pike's Peak), Mountain sickness 
 rarely occurs at 5000 to 6000 feet, at which 
 elevation most patients who go to high altitudes 
 live. 
 
 The last half of the nineteenth century saw 
 the institution of the fresh-air treatment of pul- 
 monary tuberculosis, which in the first decades 
 of this century has been extended to the treat- 
 ment of many other diseases, including nervous 
 and mental disorders, pneumonia and certain 
 digestive disturbances. We know that fresh air 
 is of great benefit in pulmonary tuberculosis, 
 but even yet some of us have not fully realized 
 that fresh air benefits patients with other forms 
 of tuberculosis as much as it does those with the 
 respiratory type. It is, then, safe to say that 
 fresh air exerts no more influence on the lungs 
 than on the rest of the body. A further fact bear- 
 ing on this point is the unpleasant • symptoms 
 that many persons experience when confined in a 
 close or stuffy atmosphere and forced to breathe 
 "ruminated" air. It ' is almost needless to 
 enumerate these symptoms — at first headache, 
 drowsiness, lassitude, malaise, nausea, faintness, 
 vertigo ; later digestive and nervous disturbances, 
 followed by malnutrition, secondary anemia and 
 lessened resistance to infectious diseases. It is 
 of considerable interest to recall the symptoms 
 of mountain sickness experienced in very high 
 altitudes (15,000 feet): headache, intense drow- 
 
58 RULES FOR RECOVERY 
 
 siness, lassitude, nausea' or even vomiting, faint- 
 ing, vertigo, and further palpitation of the heart, 
 throbbing of the arteries and shortness of breath. 
 
 It would seem very reasonable, therefore, to 
 infer that lack of oxygen in the latter case was 
 the cause of the disturbance, and arguing by 
 analogy, it would appear most probable that lack 
 of oxygen was the disturbing factor in the former. 
 Such certainly was long a current belief. The 
 increased percentage of the carbonic acid gas has 
 been held by some to be the chief cause, while 
 others have believed that "crowd-poison" was 
 the essential factor. The existence of "crowd- 
 poison" has been questioned, and none has 
 beyond all doubt proved its existence. 
 
 Are these, then, the deleterious substances 
 that weaken resistance to and lessen chances of 
 recovery from pulmonary tuberculosis when the 
 patient fails to get fresh air? Ingenious experi- 
 ments have been devised to help answer this 
 question. Several healthy men have been con- 
 fined in small cabinets and made to rebreathe a 
 small amount of air. The percentage of oxygen 
 quickly fell and that of carbonic acid gas rose 
 greatly. The organic matter, which apparently 
 bears some relation to the percentage of carbonic 
 acid gas, must also have risen. The individuals 
 all became very uncomfortable and finally ceased 
 to talk. An electric fan inside the cabinet was 
 then set in motion, and great relief was experi- 
 enced, even though the composition of the air 
 
FROM PULMONARY TUBERCULOSIS 59 
 
 remained unaltered. In another experiment, the 
 individual within the cabinet was allowed to 
 breathe fresh air, without, however, experien- 
 cing any relief. Still again, a person outside the 
 cabinet was permitted to breathe only the air 
 within the cabinet and suffered no ill effects. 
 These and other careful observations have led 
 to the conclusions that coolness, dryness and 
 active motion of the air are factors to be sought 
 after, and further, as James puts it, that "many 
 atmospheres are good enough to be breathed 
 which are not good enough to be lived in." 
 
 The temperature of the air plays an important 
 role in health and disease. Recent inquiries con- 
 cerning certain mill operatives in Connecticut 
 have shown that men working on piece work 
 accomplished more when there was a marked 
 change in the atmospheric temperature, even 
 from cooler to warmer conditions. As a rule the 
 more vigorous races' live in climates where the 
 cold, though pronounced, is not severe enough 
 to limit the production of good crops. The 
 custom of sending young and vigorous patients 
 to climates with equable temperature has long 
 since been abandoned. An average daily varia- 
 tion of at least 20° F. is one requisite of a good 
 health resort for tuberculous patients. Sudden 
 changes for vigorous patients act like a tonic 
 and are to be desired when intelligently met. 
 This is a feature of the winter climate in Arizona, 
 where a marked change occurs each night at 
 
60 RULES FOR RECOVERY 
 
 sunset. The weight curve of healthy and tuber- 
 culous individuals bears this out. In 1200 
 patients at the Trudeau Sanatorium we found 
 that the weight began to increase in August and 
 continued to do so until Christmas. It then 
 remained stationary or decreased slightly to 
 Easter, after which it fell steadily to August. A 
 marked change of temperature is usually noticed 
 in the Adirondacks in August and early Septem- 
 ber, and the diurnal variations are great. I 
 might add that this is probably the normal 
 weight curve. Nearly every tuberculous patient 
 has a more or less deranged nervous system. 
 Like cold tubs in typhoid, cold air in pulmonary 
 tuberculosis is a great nervous sedative, for it 
 abstracts heat, especially when in motion. Too 
 intense or too prolonged cold, however, over- 
 stimulates some. It has long been a current 
 popular belief in Saranac Lake that one hour 
 of driving is worth two of sitting on the porch. 
 Who can say that, besides the psychic influence, 
 the rapid change of air about the body may 
 not be greatly beneficial? Unquestionably the 
 exhilaration of coasting and of automobiling may 
 in part at least be explained in this way. In any 
 case, to active motion of the air with the atten- 
 dant evaporation of moisture from the surfaces 
 of the body is to be ascribed much of the sensa- 
 tion of well-being experienced with good ventila- 
 tion. It requires only slight movement of the 
 air to increase markedly the loss of heat from 
 
FROM PULMONARY TUBERCULOSIS 61 
 
 the body. In cold climates this must be met 
 by heat production, by muscular contractions, 
 which, when the patient is at rest, are involun- 
 tary, but raise greatly the muscular tone. 
 
 The dryness of the atmosphere, that is, the 
 degree of humidity, relative and absolute, plays 
 an important part, but can be largely offset by 
 motion of the atmosphere. Mere dryness is of 
 little avail, for nearly every home in America, 
 especially in winter, has an atmosphere contain- 
 ing far too little moisture — in fact, far less than 
 is to be found in the deserts of Egypt or Arizona. 
 The really important point is the amount of 
 moisture that can be absorbed by the atmosphere 
 from the surface of our bodies, and, this depends 
 on the humidity of the air, on its temperature, 
 and most of all on its movement. 
 
 This brings us to the consideration of a few 
 practical points in the fresh-air treatment of 
 pulmonary tuberculosis. It might seem wholly 
 insufficient, from what I havQ said, for a patient 
 to be in bed with his head out of a window. In 
 reality it may not be so, but, in my opinion, it is 
 far less effective than the full air bath. Spraying 
 the upper part of the trunk with cold water in 
 typhoid fever is certainly not so efficient as a 
 complete sponge, but does some good. So with 
 the window tent. It must not be lost sight of, 
 however, that the room in which the body 
 remains needs very careful ventilation. 
 
 A question that must be decided frequently is 
 
62 RULES FOR RECOVERY 
 
 whether the roof or the back yard Is the best 
 place in which to take the fresh-air treatment. 
 I do not hesitate to say that the roof should be 
 used in every instance, where possible, for several 
 important reasons. The number of germs, the 
 quantity of dust and the temperature of the air 
 decrease directly with the elevation above the 
 street, while the movement of the air increases. 
 This leads to fewer secondary infections and to 
 less irritation of the respiratory tract, and sub- 
 jects the body to a far better hygienic environ- 
 ment. In summer, however, the roof may be 
 too warm. 
 
 These newer ideas about fresh air throw grave 
 doubts on the efificacy of "air carriers" and 
 emphasize the necessity of life in the open 
 "living" air. My impressions, after observing 
 patients for many years, do not lead me to 
 believe that sleeping out of doors materially 
 hastens recovery, provided eight to ten hours a 
 day are spent in the open air and the night passed 
 in a well- ventilated room. When, on the other 
 hand, the patient returns to his indoor work, 
 then sleeping out is very necessary. Ozone is 
 said never to occur in rooms, however well venti- 
 lated, but it is of no value to man except as an 
 indicator of the purity of atmosphere, though 
 this has recently been questioned. 
 
 A man out of doors is said to be exposed to loo 
 times more fresh air than he could get in the 
 best ventilated room in any given period of time. 
 
FROM PULMONARY TUBERCULOSIS 63 
 
 In any room germs are partially protected, while 
 in the open they quickly die. 
 
 What is the best dose of fresh air and how 
 should it be given to the patient? (This implies 
 that the patient has not had as much fresh air 
 as he should.) This question needs a serious 
 answer only during the colder months of the year. 
 During the summer the house is kept open, fresh 
 air is everywhere and the patient does well. 
 When the chill of autumn comes, however, the 
 house is shut up, except for a brief daily airing. 
 The stimulation of the change of temperature and 
 the bracing air usually buoy up the patient until 
 Christmas. Then the confinement indoors begins 
 to tell. He droops a little, and in early spring he 
 fails somewhat or has a breakdown. This is 
 unfortunately a common story. As soon as a 
 patient knows he has tuberculosis he should begin 
 to plan his life to live out of doors as much as 
 possible. In the summer it is possible to spend 
 twenty-three out of twenty-four hours out of 
 doors, but in the colder weather it is irksome. 
 
 Dr. Brehmer, who founded the first sanatorium, 
 had his patients walk out of doors to get the 
 fresh air. Among them was a young physician. 
 Dr. Dettweiler, who found he had not strength 
 enough to walk in the open air as much as he 
 thought he should. He devised a long chair, a 
 "cure" chair, a combination of bed and chair, 
 which makes sitting out for patients without 
 much strength a pleasure. The back was mov- 
 
64 RULES FOR RECOVERY 
 
 able and with cushions it was far superior to 
 the ordinary steamer chair. Dr. Dettweiier's 
 chair was taken as a model when the author 
 devised the Adirondack Recliner. 
 
 It remained for America to introduce verandas 
 or porches upon which the patient's bed, pro- 
 vided with large castors, could be rolled when 
 for any reason he should not leave it. Such pro- 
 visions enable a patient to remain so long out 
 of doors in suitable weather that it has been 
 called the " twenty-' hree-hour treatment." A 
 patient who has just begun the treatment seldom 
 objects to life in the open air provided he is 
 comfortably prepared for it. 
 
 In some instances it is impossible to move the 
 patient from his room, and equally impossible 
 to open the windows without subjecting his 
 head to a strong draught. In such cases a frame 
 covered with ordinary cheese-cloth should be 
 placed in the open part of the windows. This 
 permits free circulation of air without strong 
 draughts. When sitting out a patient should 
 be protected against strong winds by some form 
 of wind-shield. 
 
 A tent as ordinarily constructed is very poorly 
 ventilated, but when put up on a frame with 
 sides that can be pulled or rolled up it is trans- 
 formed into an open veranda and is excellent. 
 
 (Those who are interested in providing a suit- 
 able sitting-out shelter for themselves should 
 consult "Sleeping and Sitting in the Open Air," 
 
FROM PULMONARY TUBERCULOSIS 65 
 
 by P. P. Jacobs, published 191 7 by the National 
 Tuberculosis Association, 381 Fourth Avenue, 
 New York City.) 
 
 It might be advisable to add a word about 
 taking cold while living suitably protected in the 
 open air. It is true that some patients are more 
 susceptible than others to slight atmospheric 
 changes. These patients must be trained or 
 hardened to live in the open. This mode of 
 living often brings about an entire readjustment, 
 and the patient loses his susceptibility to colds. 
 
66 RULES FOR RECOVERY 
 
 V 
 
 ON A PATIENT'S DAY 
 
 "The deficiencies of the present day will be supplied by the 
 morrow." 
 
 It may seem unnecessary to many to enter 
 into such specific details as are mentioned in this 
 chapter, but odd things occur. Some years ago 
 a patient was told he could walk ten minutes a 
 day. He was very conscientious and strove to 
 obey orders, but wishing to go to a certain place 
 which required a walk of sixty minutes there and 
 back, he saved up his exercise for a week and 
 went! As the path to cure is steep and is paved 
 with the stones of small details, it must be closely 
 watched, as he who walks carelessly soon finds 
 himself astray. The daily routine below is not 
 to be blindly followed, but must serve as a basis 
 for a talk with the patient's physician who alone 
 is in a position to order most successfully bis 
 time. This program has been found to be the 
 best for the great majority of patients; 
 
 7.30 Awake. Take temperature 
 
 Milk (hot if desired) if necessary 
 Warm water for washing. Cold sponge 
 
 8.00 Breakfast 
 
 8.30 Out of dQors in chair or on bed 
 
FROM PULMONARY TUBERCULOSIS 67 
 
 10.30 Lunch when ordered 
 11-1 Exercise or rest as ordered 
 1-2 Dinner. Indoors not over one hour, less if possible 
 2-4 Rest in reclining position. Reading, but no talking 
 allowed 
 Take temperature 
 3.30 Lunch when ordered 
 4.00 Exercise in prescribed amount 
 6.00 Supper 
 7.00 Out on good nights 
 8.00 Take temperature 
 9.00 Lunch and bed 
 
 Once or twice a week a hot bath, followed by cold 
 sponge. 
 
68 RULES FOR RECOVERY 
 
 VI 
 
 ON SITTING OUT 
 
 They also serve who only sit and wait. 
 
 Leading an outdoor life in summer is a simple 
 enough matter, more enjoyable than otherwise, 
 but during the winter, especially in a cold climate 
 and when one is not exercising, as is usually the 
 case at first with those taking the open-air treat- 
 ment for tuberculosis, some hardships may be 
 expected. These hardships are magnified, how- 
 ever, by those who have never "taken the cure" 
 and therefore know little or nothing about the 
 matter. 
 
 If he be properly clad and sheltered from wind, 
 rain and snow a person may be quite comfort- 
 able sitting outdoors even when the temperature 
 is twenty to thirty degrees below zero. It is the 
 aim of this chapter to be helpful to those "sitting 
 out" for the cure of tuberculosis. In offering 
 suggestions the conditions which prevail in a cold 
 climate are considered, but there are hints appli- 
 cable to all climates. 
 
 While the patient must be outdoors in all kinds 
 of weather for at least eight hours daily, it should 
 be borne in mind that open air does not mean 
 exposure, and that]to subject one's self to unneces- 
 
FROM PULMONARY TUBERCULOSIS 69 
 
 sary hardships is not only foolish, but dangerous. 
 A person should gradually accustom himself to 
 the outdoor life, and should not stay out when 
 chilled. "Chilled," however, does not mean that 
 he merely prefers sitting indoors beside a fire. 
 In being "unfaithful to the cure" — that is, in 
 staying in when he should be out — he is retarding 
 his recovery and inviting more serious illness. 
 
 One should be so "faithful to the cure" that 
 his conscience will trouble him when he remains 
 inside; in other words, he should develop an 
 "outdoor conscience." Some may laugh at this, 
 but it is when such a feeling asserts itself that 
 the patient's chances of recovery are greatest. 
 
 If any encouragement be needed to brave the 
 severe cold, it can be found in statistics, show- 
 ing that patients improve more rapidly with the 
 onset of winter than in summer. In fact it has 
 come to be said that "one winter is worth two 
 summers." 
 
 In the following pages will be found men- 
 tioned a great many articles that have proved 
 of service to the "sitter-out." Of course, each 
 patient will not require all of these articles, but 
 what are absolute necessities at the start, besides 
 warm clothing, are a comfortable chair, two g;ood 
 rugs or horse blankets, a small table, and a shel- 
 tered spot on a porch or in a shack. The various 
 articles of clothing suggested may be acquired 
 as necessity arises. 
 
70 RULES FOR RECOVERY 
 
 VII 
 
 ON PREPARATIONS FOR SITTING OUT 
 
 "For every season she has dressings fit, 
 For Winter, Spring or Summer. " 
 
 CLOTHES 
 
 Much depends upon suitable preparations for 
 living out of doors. The high temperature at 
 which many homes and ofhce buildings are kept 
 enables many persons to wear in winter clothes 
 varying little in weight from those worn in 
 summer. These individuals are usually robust 
 and accustomed to active exercise. When they 
 fall ill and must perforce spend many hours of 
 enforced inactivity out of doors, they find such 
 clothes very unsuitable. This is often more true 
 of women than of men. Few hard-and-fast rules 
 can be laid down, however, but it must be 
 realized at once that chilling is very dangerous 
 and may be followed by disagreeable and even 
 dangerous complications. In other words, a safe 
 plan is to dress in such a way that you will 
 always be comfortable. The main requirement 
 of all warm clothes should be that they are non- 
 conductors of heat, or, in other words, they should 
 prevent as much as possible the loss of the natural 
 
FROM PULMONARY TUBERCULOSIS 71 
 
 body heat. Probably the best material for under- 
 wear is wool with a little cotton in it, as it is 
 usually cheaper than pure wool and gives suffi- 
 cient warmth. 
 
 It is unwise to bundle up the neck and chest, 
 and chest protectors and other swaddling clothes 
 should be abandoned. A chamois vest that can 
 be easily removed is permissible in some cases, 
 but as a rule it is best to get along without it. 
 The best sweaters are the "coat-sweaters" that 
 can be easily removed indoors or laid aside should 
 the temperature rise considerably during the day. 
 
 In regard to clothes, some knowledge of the 
 temperature of the house or building in which 
 the patient is to live is necessary. He must 
 dress for this temperature, for it is easy to put 
 on wraps when he goes out. Very heavy under- 
 wear in a warm house tends to produce a state 
 of relaxed skin, constantly bathed in perspira- 
 tion, and makes a patient much more subject 
 to colds. He should dress to be comfortable 
 indoors and add more overclothes for his out- 
 door life. In cold weather only the bathroom 
 should have a temperature over 6o°-64°. 
 
 Irritation of the skin by woolens can be avoided 
 by the use of cotton gauze garments under the 
 wool. Some prefer linen mesh to wool, and by 
 its use avoid colds, while others find it gives too 
 little protection. 
 
 For sitting out when one does not use a bed 
 or couch a good chair, provided with a comfort- 
 
72 RULES FOR RECOVERY 
 
 able mattress and two large (5x6 ft.) steamer 
 rugs or blankets are absolutely necessary in cold 
 weather. Horse blankets are cheaper than 
 steamer rugs and two are warmer than one rug. 
 Ordinary blankets, padded quilts, comfortables, 
 paper blankets and other devices can all be used 
 for this purpose. Woolen sleeping bags which 
 unbutton down the front, fur rugs, which afford 
 the best protection, a plush-lined rubber blanket, 
 are all of value in different instances. 
 
 In cold weather a fur coat is necessary for 
 sitting out. This may be obtained for any price 
 from $12 up. Sheepskin, dogskin, raccoon, cow- 
 skin, and many other furs are suitable and make 
 warm coats. The sleeves should be provided 
 with wind-guards, the collar should cover the 
 ears', the pockets should be wide and the coat 
 long and roomy, so that a sweater may be worn 
 under it if desired. This coat should not be worn 
 while walking, but a mackinaw or short leather 
 jacket lined with wool should be used. A sash 
 tied snugly about the waist adds greatly to the 
 warmth of the coat or jacket. 
 
 The feet and hands of many patients suffer 
 from the cold. It must not be overlooked that 
 chilly arms or legs produce cold hands and feet. 
 These must be warmly clad. All shoes should 
 be loose fitting. Two pairs of socks or stock- 
 ings, high arctics, moccasins lined with sheep- 
 skin for drawing over the ordinary shoes, foot 
 muffs, all-felt shoes, pontiacs (long felt boots 
 
FROM PULMONARY TUBERCULOSIS 73 
 
 worn by lumbermen), equestrian tights for 
 women, give comfort to different individuals. 
 Leather or woolen leggings, spats and thick golf 
 stockings are also useful. Any footwear that 
 constricts the ankles tends to produce cold feet. 
 Some must use artificial heat, and for them 
 "soapstones," hot- water bottles, electric heaters 
 or pads, stoneware "pigs," are useful, but a few 
 believe they increase the tendency to chilblains. 
 
 Cold hands are often a problem. Gloves of 
 many sorts can be had. They should always fit 
 loosely. Fur-lined gloves (lambskin, not squirrel) 
 are excellent. Dogskin or kid gloves under 
 woolen are often successful. The author has 
 tried while driving every form of glove and has 
 been led to the conclusion that a pair of loose 
 woolen mittens in a pair of leather mittens, lined 
 with lambs' wool, is the warmest combination 
 possible. For writing, reading or playing games, 
 an excellent combination is to wear first, thin, 
 easily fitting cotton gloves which allow perfectly 
 free movement of the fingers and over them a 
 pair of warm woolen mitts, fingerless and thumb- 
 less gloves (not mittens), which leave the fingers 
 free. A long woolen wristlet is used with advan- 
 tage by many. 
 
 There are many other accessories, such as caps 
 of various designs, of wool or fur, which should 
 be large enough to cover the ears when desired. 
 The fur coat collar should cover the ears as well. 
 The many designs of caps render it impossible 
 
74 RULES FOR RECOVERY 
 
 to describe them. For some patients a visor on 
 the cap is most important as it protects the eyes 
 from the glare of the sun. An ordinary eye-shade 
 helps some who read facing the sky, but many 
 will do better on bright days to sit with the back 
 to the light. 
 
FROM PULMONARY TUBERCULOSIS 75 
 
 VIII 
 
 ON THE PORCH 
 
 "The porch is the haven of rest for the patient, where, 
 anchored in the ebb and flow of invigorating air, he escapes the 
 jetsam and flotsam of the air of the house. " 
 
 Persons living in a health resort are often 
 struck with the inconsistencies of the new arrivals. 
 Every attention is paid to the selection of a room. 
 It must be comfortable, well heated, and fur- 
 nished with several easy chairs. For patients, 
 however, who have to sit out, the porch is the 
 most important part of the house, and too often 
 the porch-space and its provisions for comfort 
 receive scant, if any, attention. The foolishness 
 of neglecting to select a comfortable porch where 
 one is to spend eight to ten hours every day 
 needs only to be mentioned to be recognized. 
 The patient will use his room to dress and prob- 
 ably to sleep in, but the greatest part of his 
 waking hours will be spent on the porch out of 
 doors, and it is here that he needs the most 
 comfort. 
 
 There is a growing tendency today to enclose 
 the porch almost entirely with glass sashes which 
 make ventilation very difificult. As a matter of 
 fact some porches are colder and less well venti- 
 lated than many rooms with cross-corner venti- 
 
76 RULES FOR RECOVERY 
 
 lation. Coldness is no index of good ventilation. 
 Porches with deep recesses are a great mistake. 
 A simple rule in ventilation is to compare the 
 air currents with those in water. A long inlet 
 from a river has little circulation of water, and 
 the same is true either in rooms or on porches. 
 When two sides of a porch are well protected 
 it is wisest to leave the others open unless the 
 prevailing winds come from those sides. Where 
 many patients occupy one porch the problem 
 is more difficult but can be solved. A chair 
 placed deep in a recess should always be avoided. 
 If both ends are open, the draughts in such an 
 outside corridor are very unpleasant, for wind 
 has a greater cooling effect on the body than 
 a still atmosphere many degrees lower. The 
 depth of the porch should never be more than 
 one and one-half times its front opening. Fixed 
 or movable canvas or wooden screens can be 
 used, but glass is to be preferred, as it admits 
 light and sunshine. The porch should be so 
 arranged as to get sunshine throughout the 
 greater part of the short winter days, but this, 
 while pleasant, is not absolutely necessary. The 
 chairs should always be placed at least four 
 feet apart, and patients with weak eyes often 
 do well to wear eye-shades or turn their backs 
 upon the light. An attractive view is of consider- 
 able value, but many patients are willing to 
 exchange it for one which presents the activities 
 of life as shown by the passing crowd. 
 
FROM PULMONARY TUBERCULOSIS 77 
 
 It was once firmly believed that the ground 
 water and moisture played an important part in 
 the occurrence of pulmonary tuberculosis, and 
 it was predicted that when the great cities were 
 drained the number of deaths would greatly 
 decrease. While this has not taken place, porches 
 on the second story, apart from the more extended 
 view, have much to recommend them, insuring 
 as they do greater removal from any soil moisture, 
 less dust, more privacy. The porch should face 
 south by southwest in winter and north in sum- 
 mer, but a southern porch shaded well in summer 
 by deciduous trees is usually very habitable. 
 
 The porch is where the patient is to spend the 
 greater part of his time during the first few 
 months of treatment, and it should be made as 
 comfortable as possible. A table, a small book 
 case, a book rack to hold open his book while 
 he reads in cold weather, and in fact anything 
 that would tempt him to be out of doors is of 
 importance. For the dark afternoons in late 
 autumn and early winter a good reading light 'is 
 essential. 
 
 Porches should be provided for those who are 
 not able to be out of bed, and even many patients 
 who spend most of their time up and about find 
 such a "sleeping" porch very desirable if they 
 suffer a temporary relapse. Such a porch should 
 fulfil all the requirements noted for a sitting-out 
 porch, and should be connected with the sleeping 
 room by a door wide enough to enable the bed 
 
78 RULES FOR RECOVERY 
 
 to be rolled in and out. Proper shelter from the 
 rain and snow as well as from wind is very impor- 
 tant. An ideal sleeping porch is one sufficiently 
 wide for turning the bed, built out from the 
 second story^ with two sides that can be fully 
 opened. (See page 64 for porches of cheap con- 
 struction.) The sides should be provided with 
 dark curtains, but, better still, a " Black Knight," 
 a small stockinette covering for the eyes, can 
 be worn. 
 
 SITTING-OUT CHAIR 
 
 The chair in which the patient sits out should 
 be the most comfortable in the house. No 
 expense should be spared upon it, for here the 
 patient must sit many hours a day. A good 
 chair should elevate the feet from the floor, have 
 a movable back, move easily on castors from 
 place to place, be strongly constructed and be 
 provided with a good cushion, useful alike for 
 comfort and warmth. Many types of chair can 
 be bought. Personal experience has convinced 
 me that none I have tried is more suitable than 
 the latest models of the "Adirondack Recliner." 
 A chair of canvas and wood can be had for much 
 less but is not so satisfactory, as it often cramps 
 the shoulders and lungs. It is of interest to note 
 that as time passes more and more patients prefer 
 to use their beds as a lounge or couch and use 
 their chairs less and less. 
 
FROM PULMONARY TUBERCULOSIS 79 
 
 HOW TO WRAP UP 
 
 How to wrap up in a chair may seem an 
 unnecessary detail into which to go, but comfort 
 cannot be divorced from contentment. Many 
 ways have been devised and each patient has 
 his favorite. The following is a way which has 
 proved on extended trial to be of value, and it is 
 offered for what it is worth. Place the rug, 
 which should be large in size, fully extended on 
 the chair. After sitting down grasp the part of 
 the rug lying on the right of the chair and with 
 a quick motion throw it over the feet and knees 
 and tuck it well under the legs. Then do the 
 same with the part of the rug on the other side 
 of the chair but leave the edge free. Now grasp 
 the free edge of the rug lying on the left hand 
 side and pull it up hand over hand until the end 
 which was lying free beyond the feet is reached. 
 Then pull up the far end of the rug, taking care 
 to uncover as little as possible of the legs, and 
 tuck both sides under the knees. This will give 
 three or four layers of rug over most of the legs, 
 but only one over the feet. It forms, however, 
 a bag out of the rug and no air can enter. A 
 second rug folded and thrown over the first 
 makes a covering that defies the coldest weather. 
 
80 RULES FOR RECOVERY 
 
 IX 
 
 ON SLEEPING OUT 
 
 "Now blessings alight on him that first invented this same 
 sleep. It covers a man all over, thoughts and all, like a cloak; 
 it is meat for the hungry, drink for the thirsty, heat for the cold 
 and cold for the hot. It is the current coin that purchases all 
 the pleasures of the world cheap, and the balance that sets the 
 king and the shepherd, the fool and the wise man, even. " 
 
 Sleeping out as an aid in the treatment of 
 pulmonary tuberculosis may have been first put 
 into practice in the Rocky Mountains, but its 
 spread over America is due largely to the pioneer 
 work of Millet. The exhilarating effect of life 
 in the open has long been dwelt upon by sports- 
 men, and these two factors have influenced many 
 persons in apparently perfect health to take it 
 up. In fact today a considerable percentage of 
 suburban houses are provided with sleeping-out 
 porches. As a means of raising the resistance of 
 an individual to tuberculosis it is very valuable. 
 Many and varied devices for pursuing this have 
 been put upon the market and have been referred 
 to previously (page 63). Beds which can be 
 pushed partly out of the window and window 
 tents are far less valuable than a good porch. 
 The advantages of sleeping out have been empha- 
 
FROM PULMONARY TUBERCULOSIS 81 
 
 sized, if not overemphasized. For the invalid it 
 has been pointed out that he is out of doors 
 twenty to twenty-four hours a day, where usually 
 the ventilation is perfect. On the other hand, as 
 many conditions arise which render sleeping out 
 inadvisable, a physician should be consulted about 
 it by every patient. Some patients cannot sleep 
 out of doors, and sleep must be had. The early 
 morning light, the noises, the wind, the rise of 
 temperature on some nights, all disturb sleep. Still 
 in most cases such disturbances can be prevented. 
 A few suffer from catarrh, and have difficulty in 
 breathing through the nose. For these sleeping 
 out should be postponed. Some patients have 
 occasionally to arise at night; for these the danger 
 of exposure and chilling is considerable. There is 
 also an objection which may be theoretical. Cool, 
 fresh air acts like a tonic upon relaxed muscles 
 and quiets often an overwrought nervous sys- 
 tem. The loss of heat in the cold, fresh air is 
 much greater than in a room. The loss of heat 
 must be provided for, and to produce more heat 
 the muscles remain in a state of prolonged slight 
 contraction known as "tone." That this might 
 be too prolonged in a weak patient is easily con- 
 ceivable, and the ten to twelve hours indoors at 
 night in a cool, fresh room certainly works no 
 harm. In my experience I have seen many 
 patients sleep out and many sleep in. I have 
 tried to observe if any difference in the rapidity 
 of healing occurred, but have not been able to do 
 
 6 
 
82 RULES FOR RECOVERY 
 
 so, provided, of course, that the patients sleeping 
 indoors spent eight to ten hours a day in the 
 open and slept in well-ventilated rooms. 
 
 The great advantage of sleeping out is obtained 
 no^ by the patient who has all day to be out of 
 doors, but by him who through lack of funds or 
 through other unfortunate circumstances must 
 be indoors nearly the whole day and often in a 
 crowded store or office. He gets no fresh air 
 and has no time to get it except at night. Here 
 sleeping out or in may decide whether or not he 
 remains well. For such a patient sleeping out 
 if at all possible should be pursued. For another 
 man who works, say, indoors and out, and at 
 night must sleep either indoors in a poorly ven- 
 tilated or overcrowded room or outdoors, the 
 question can be easily decided. The establish- 
 ment of "sleeping-out" sanatoriums or "night" 
 sanatoriums has been begun and should be 
 pushed. Patients who cannot afford to sleep 
 out after working indoors would here have an 
 opportunity. 
 
 NIGHT AIR 
 
 Night air has long been avoided as dangerous. 
 Why it should be so considered is not difficult 
 to discover. On the Roman Campagna it means 
 or meant malarial fever to spend a night or many 
 hours in the open. Today it is recognized that 
 this has nothing to do with the quality of the 
 night air, but to the fact that at dusk the malaria- 
 
FROM PULMONARY TUBERCULOSIS 83 
 
 bearing mosquitoes leave their hiding or resting 
 places and begin to bite. As a matter of fact 
 the night air is often purer than the day air. As 
 traffic lessens the production of dust is less, and 
 the factories and foundries frequently bank their 
 fires at night, and hence the night air contains 
 usually far less dust and less smoke and gas. 
 So, fortunately for us, when we must choose 
 between pure night air outdoors or impure night 
 air indoors, the choice is easy. 
 
 DRESSING FOR SLEEPING OUT 
 
 In making these or other suggestions for sleep- 
 ing or sitting out, a climate where the mercury 
 drops often in winter to zero is considered. For 
 those who reside in a less rigorous climate this 
 fact must be taken into consideration. Indi- 
 viduals vary greatly in their sensitiveness to 
 cold and again some are warm during the day 
 and cold at night, or conversely, which makes it 
 clear that no hard-and-fast rules in regard to 
 clothing, etc., for night (or even day) can be made. 
 Each person sleeping out must be guided more or 
 less by his own comfort, facilities and resources. 
 While I have seen patients who in zero weather 
 could sleep out in a thin cotton nightgown 
 between cotton sheets and be comfortable, the 
 majority cannot keep warm in bed in cold 
 weather unless warmly dressed. In fact, many 
 have to dress especially for such a life, though 
 each person is a law unto himself. Some must 
 
84 RULES FOR RECOVERY 
 
 wear woolen underwear, woolen socks, stockings 
 or bed slippers, outing flannel or flannel pyjamas, 
 the legs of which are tucked into the socks, a 
 woolen sweater, and a sleeping hood or helmet 
 with a long neck-piece or cape which falls down 
 over the shoulders and fits under the collar of 
 the sweater. To protect the nose, some like a 
 domino mask lined with flannel. Eiderdown 
 leggings or boots which reach to the hips are 
 convenient to wear between the room and the 
 bed, or even on very cold nights in bed. Some 
 patients prefer a woolen bathrobe to some of 
 the garments mentioned. A knitted combination 
 suit with feet, gloves and hood attached (llama 
 wool garments), or Faultless Pyjamas, with hood, 
 boots and coat of two thicknesses, can be pur- 
 chased, and for very cold weather may be desir- 
 able. These are only a few of a thousand and 
 one devices for being comfortable in bed out of 
 doors. A "Black Knight" to keep the early 
 morning light from awaking the patient is often 
 useful and has been mentioned. An application 
 of cold cream to the face some find helpful. 
 
 THE BED 
 
 When a patient is up and about, the bed is of 
 far less importance than when he must spend 
 twenty-four hours a day in it. For invalids con- 
 fined to bed the best is none too good. The hos- 
 pital bed is of great advantage as it adds much to 
 the ease with which the patient can be cared for. 
 
FROM PULMONARY TUBERCULOSIS 85 
 
 Good springs which do not sag in the middle 
 are very important and box-springs when posr 
 sible should be used. The mattress should be of 
 hair and very heavy. To be comfortable while 
 lying in bed out of doors, it is necessary to 
 remember that cold can come through the 
 mattress. To prevent this, stiff building paper 
 which will not rustle can be placed between the 
 mattress and the springs, or between two mat- 
 tresses, if two are used. One or more blankets 
 can be placed under the patient, who, if cold- 
 blooded, should sleep between flannel or outing 
 flannel sheets. The number of blankets sufficient 
 to keep some patients warm weigh so much 
 that they should be replaced by comfortables of 
 eiderdown or lamb's wool. "Feather beds" as 
 coverings are used extensively in some Swiss 
 health resorts. Four double blankets (eight 
 folds) are usually sufhcient to keep the patient 
 warm when sleeping out in zero weather. Over 
 all can be thrown a large horse blanket, to pro- 
 tect the bed from rain or snow. The head of 
 the bed should have over it a blanket or shawl 
 to ward off the wind. Do not forget that too 
 heavy coverings prevent sleep and produce a 
 tired feeling the next morning. If possible the 
 sleeper-out should go to bed in a warm room and 
 have someone roll him out. If this cannot be 
 arranged for, he should have a warm dressing 
 room and put on the eiderdown bootlets, men- 
 tioned previously, when going out to bed. If 
 
86 RULES FOR RECOVERY 
 
 the bed must remain out of doors all day, a 
 heated brick, soapstone, hot "pig," hot- water 
 bottle, or electric pad should be used to warm 
 the bed before retiring. 
 
 KLONDIKE BED 
 
 The warmest bed is that known as the 
 "Klondike" bed. Place on top of the mattress 
 a horse blanket large enough to hang well over 
 the sides and foot. On this lay the ordinary 
 blankets, and finally upon these a single sheet. 
 Then fold back the portion of the bedding 
 hanging over the foot of the bed until the fold 
 is even with the mattress. The two sides are 
 folded over until just enough space is left for the 
 body to. slip in from the open top. This insures 
 a large overlap of the bedding. Large safety 
 pins may be used to fasten the laps. Over the 
 whole throw the counterpane and tuck it well 
 under the mattress at the foot and sides. The 
 pillows are placed in the form of an inverted V. 
 
 THE PILLOWS 
 
 When sleeping in an ordinary bed in a cold 
 room or out of doors, much cold air finds its way 
 under the covers through the space which unfor- 
 tunately is always ready to open up between 
 one's head, the pillow, and the mattress. To 
 provide against this the pillows may be arranged 
 in the form of an inverted V and the head placed 
 
FROM PULMONARY TUBERCULOSIS 87 
 
 in the apex. The shoulders should not rest upon 
 any part of the pillows. This method is employed 
 in the Klondike bed. Later a second method 
 occurred to the author. One pillow is placed 
 in the ordinary way at the head of the bed and 
 two others, at right angles to the first, but 
 under the covers. It is extraordinary what an 
 amount of heat seems to be generated or retained 
 in the pillow at one's back. 
 
 DANGER OF DAMPNESS 
 
 Few hesitate to affirm that a damp bed is 
 dangerous, but not many have reasoned out why 
 it should be so. Some indeed have stated that 
 when a hot-water bottle has leaked in their beds 
 they had no bad effects from ignoring it. What 
 physical difference is there between a dry and 
 a damp bed? Why is moist or damp air colder 
 than dry air at the same temperature? The 
 explanation is found in the fact that damp air 
 or damp cloth dissipates much more readily the 
 heat of the body. For a damp bed to do this 
 it is necessary for it to be wet through and 
 through. A damp sheet or a damp gown may 
 have little effect when surrounded by many dry 
 covers, for the dry covers prevent the loss of 
 heat. This fact is made use of in treatment, and 
 the patient may be wrapped in a cold, wet sheet 
 not only without harm but often with great 
 benefit. From what has been said it can be 
 readily seen that damp clothes or a damp bed 
 
88 RULES FOR RECOVERY 
 
 that leads to loss of the body heat is very dan- 
 gerous and should be carefully avoided. Some 
 patients who sleep out prefer to keep their beds 
 indoors and roll them out only when going to 
 bed. The large number of patients living in 
 climates far from dry, who are not able to do 
 this and still suffer no harm, proves that such a 
 step is rarely necessary. 
 
FROM PULMONARY TUBERCULOSIS 89 
 
 X 
 
 ON THE PATIENT'S ROOM 
 
 "What room suffices him who knows a porch?" 
 
 For many reasons already mentioned the sick 
 room is of secondary importance to the porch. 
 In some instances, however, when a man sud- 
 denly becomes ill of pulmonary tuberculosis at 
 his home and cannot be moved, and must occupy 
 some room indoors, it is very important to have 
 some knowledge of the requirements of a good 
 room. In the first place the room should be well 
 ventilated. This requires two openings to the 
 outside air, for no air flows out of a room unless 
 it can be replaced by air from without the room. 
 It is much like the flow of water or oil from a 
 barrel. A vent is necessary for the continuous 
 flow of the fluid. A match or a candle held in 
 front of a window quickly tells the direction of 
 the flow of the air. All communications with the 
 rest of the house should be closed in cold weather, 
 for the heated air from the lower floors quickly 
 rises through the halls to pass out of the open 
 windows, and if only one opening exists, the 
 invalid breathes the air from the house and not 
 the live air outside. Every room, therefore, 
 should have two windows or a window and a 
 
90 RULES FOR RECOVERY 
 
 door leading into the open air. These, if at all 
 possible, should be placed so that cross-corner 
 ventilation may be had. It is very undesirable 
 to have only one opening, which is usually a 
 window, to the outside. If this must be the case 
 for a time, see that the window is always open 
 at the top and bottom. It has been previously 
 stated that air, like water, flows straight away 
 whenever possible. A bed in a corner is therefore 
 in the worst possible place in regard to the amount 
 of fresh air that passes over it. It should really 
 be in the middle of the room, or at least in the 
 middle of a wall, to get the freshest air. Draughts 
 across the foot of the bed are of no moment, and 
 some patients even sleep with a strong movement 
 of air upon their faces without harm. The danger 
 of draughts in a room is that the stream of air 
 is usually small and plays upon a localized part 
 of the body, while adjoining parts are subjected 
 to much warmer air and less evaporation. This 
 is the difference between draughts indoors and 
 movements of air outdoors. Draught screens for 
 the windows have been mentioned. 
 
 What has been said here relates to the house 
 in winter, for, when all windows and doors are 
 open, excellent ventilation can be had through 
 the rest of the house. 
 
 The room should, of course, be as large as 
 possible and removed from the rest of the house 
 to isolate it, as far as possible, from the neces- 
 sary household noises and the odor of cooking. 
 
FROM PULMONARY TUBERCULOSIS 91 
 
 Only when very ill should the patient share his 
 room with a nurse. It should, of course, be 
 bright and well lighted at night. 
 
 The color of the walls should be a warm neutral 
 tint and of such a texture that they can be easily 
 cleaned. There is no objection to a few pictures, 
 and a few rugs on the floor. It must never be 
 lost sight of that pulmonary tuberculosis is not 
 an acute disease like typhoid fever or pneu- 
 monia, and what could be endured for a few 
 weeks cannot be borne for many months. The 
 room must be as cosy as is consistent with good 
 hygiene. A fireplace adds much to the ventilation. 
 
 The room should, of course, be kept scrupu- 
 lously clean, and only a damp cloth or dustless 
 duster used for cleaning, or indeed a vacuum 
 cleaner. 
 
92 RULES FOR RECOVERY 
 
 XI 
 ON EXERCISE 
 
 "Those who are accustomed to endure habitual labor, although 
 they be weak or old, bear it better than strong and young persons 
 who have not been so accustomed." 
 
 Exercise is as important as rest in the treat- 
 ment of pulmonary tuberculosis but vastly more 
 dangerous. We are all so accustomed to regu- 
 lating our own exercise that it seems the height 
 of folly to listen to anyone who allots to us only 
 a few minutes a day for such a mild form of exer- 
 cise as walking and then only upon the level. 
 When exercise should be begun depends entirely 
 upon the progress the walUng-oif process has 
 made. When the dots of disease (called "tuber- 
 cles") are so firmly and solidly walled off that 
 exercise with its attendant increase of the cir- 
 culation produces no evil effects, washes out no 
 more poison than the body can take care of, 
 then the time for leaving bed or beginning to 
 walk has arrived. It is readily seen, however, 
 that the onset of evil days may be so gradual, 
 so stealthy, that even the trained observer may 
 be puzzled to say whether or not they approach. 
 If this be so, as it is, then it must be the height 
 of folly for an untrained observer, whose mental 
 
FROM PULMONARY TUBERCULOSIS 93 
 
 powers and judgment have been weakened by 
 the disease-poisons, to attempt intelligently and 
 cautiously to dole out his medicine, for in these 
 cases exercise is medicine and dangerous medi- 
 cine. It has been stated that few would care to 
 dose themselves with arsenic or strychnine, when 
 an unlimited quantity was placed before them, 
 and they were told that one-fiftieth of a grain 
 would benefit them, while one grain would pro- 
 duce serious symptoms of poisoning. They 
 would no doubt hesitate long and decide finally 
 in all probability that they would take their 
 chances without depending upon the tonic effects 
 of either drug. 
 
 Now. exercise for the average patient with 
 pulmonary tuberculosis works far more harm, 
 poisons vastly more people, than either strych- 
 nine or arsenic ever does. But, like food and 
 air and rest, exercise is at the beck and call of 
 everyone, and most of us foolishly imagine we 
 can employ it in our own case cautiously, skil- 
 fully and helpfully. We argue thus from the 
 fact that, since in health we have found that 
 exercise benefits us, it should do so now. But 
 we reckon without the tiny dots of disease and 
 the poison they contain. There is no danger for 
 the patient with pulmonary tuberculosis so great 
 as that contained in exercise. His desire should 
 be to obtain the most expert medical advice he 
 can and then faithfully and trustingly to follow 
 it. The advice of the family, given in ignorance, 
 
94 RULES FOR RECOVERY 
 
 to do more than the physician says is fraught 
 with great danger. They only too often and too 
 late recognize that the physician must have 
 possessed some knowledge of which they were 
 ignorant. So, too, with the advice of patients 
 who have taken the "cure" for years, who long 
 since have given up hope of arresting their dis- 
 ease, and live long in chronic invalidism. They 
 advise early and recent cases to take more exer- 
 cise than their doctors prescribe, calling attention 
 to the fact that they in their much worse condi- 
 tion can do so, and thus often work irretrievable 
 harm to the beginner if he listens to their dan- 
 gerous wheedling. 
 
 As soon as a patient leaves his bed he begins 
 to exercise. It has been found that simply getting 
 out of bed and standing on one's feet raises the 
 temperature, for many large and powerful mus- 
 cles are called into play to keep the body erect. 
 Even sitting in a chair requires more food to 
 prevent loss of body substance than lying in bed. 
 Walking increases the amount of food needed 
 very considerably. If a man weighing 132 
 pounds walks two and one-half miles an hour, 
 he requires 132 calories of food over and above 
 what he needs while resting. Such facts must be 
 borne in mind constantly. The question of when 
 to get up must be decided by the physician, but 
 how to get up may be discussed in detail here. 
 The effects of overexercise are not immediately 
 apparent. The rise of temperature produced by 
 
FROM PULMONARY TUBERCULOSIS 95 
 
 the poisons flushed from the diseased areas into 
 the circulation may not occur until the following 
 day. Hence the rule, when beginning any form 
 of exercise, try it at first on alternate days. 
 Only on the day following the exercise can its 
 effect be observed. Sitting up in bed, seeing 
 visitors, reading, and particularly writing and 
 games, are all forms of physical and mental 
 exercise and must be carefully regulated. For 
 some patients, writing and all games should be 
 avoided for many weeks after physical exercise 
 has been begun, for mental excitement is very 
 injurious to some. The daily trip to the toilet 
 is the first out-of-bed exercise permitted. It 
 should be made every other day at first, but 
 the physician's explicit permission must be 
 obtained before this is begun. When this is well 
 borne — all must depend upon the doctor's advice 
 — sitting up iji a reclining chair for one hour 
 every other day may be begun. Dressing entails 
 considerable exercise and should follow only 
 when sitting up in the chair for two or more 
 hours a day produces no ill effect. How quickly 
 all this may be accomplished depends in part 
 upon how long the patient has been in bed and 
 how much his general health has suffered. It is 
 wiser to go slow than to have to begin afresh. 
 Walking comes next, walking at two to two and 
 one-half miles an hour on the level. He should 
 cultivate the " t. b. tread." Remember that deep 
 or rapid breathing may even now stretch the 
 
96 RULES FOR RECOVERY 
 
 scar tissue, and allow the escape of germs or 
 poisons. Never move so fast that you must 
 pant, and remember that walking in snow is 
 much more fatiguing than walking on dirt or 
 on a pavement. Even before walking, driving 
 for an hour in an easy carriage may be advisable. 
 Driving one's self may be indulged in later, but 
 more than one relapse has come from attempting 
 to hold a horse, frightened by a break in the 
 harness or carriage, or by an automobile or other 
 moving object. 
 
 Let us take for granted that the earlier stages 
 of exercise are successfully passed through and 
 all is apparently going well. What are some of 
 the danger signs of renewed activity of disease? 
 The disease is treacherous and the germ slumbers 
 not nor sleeps, but lies in wait for a false move 
 to extend its field of operation. The first symp- 
 toms are so indefinite that it is often impossible 
 to say that they are symptoms of the disease, 
 and not due, for example, to a disordered stomach 
 or intestine. A slight feeling of lassitude, slight 
 loss of strength, a sense of fatigue from the 
 accustomed exercise ("lack of ginger" some 
 would call it), loss of keenness of appetite, a 
 disinclination to get up after ten hours in bed, a 
 slight headache, one or many of these may indi- 
 cate that the "cloven hoof" will soon be seen. 
 
 Attention was called to the fact that a rapid 
 pulse may be a sign of nervousness, or of a heart 
 temporarily weakened through disease. The 
 
FROM PULMONARY TUBERCULOSIS 97 
 
 heart is a muscular bag and has as its task to 
 pump out a certain quantity of blood in a given 
 time. If the muscular wall is weak and the bag 
 cannot fully empty itself, it can be readily seen 
 that to force out the same amount of blood in 
 the same time the bag must contract more 
 rapidly. The pulse is the guide to the rapidity 
 of the contractions of the heart. When the pulse 
 is fast, and nervousness not a factor, it is prob- 
 able that the heart is a trifle weakened from the 
 effect of the poison from the area of disease. 
 This means that the dots of disease are not fully 
 enough walled off, and hence exercise, when the 
 pulse is fast, may prove to be dangerous. 
 
 The pulse varies with age and in some indi- 
 viduals. Napoleon's pulse was said to be 40 per 
 minute. As a fair average the normal pulse may 
 be said to fall between 70 and 80 beats in a 
 minute. A person usually increases the rapidity 
 of his pulse by attempting to count it. Excitable 
 individuals often for longer or shorter periods 
 have a more rapid pulse. When, however, the 
 pulse runs from 90 to 100 or more, it is inadvis- 
 able to exercise without the permission of a 
 physician. 
 
 Exercise entails the burning up of more food 
 than is used when the body is at rest. Loss of 
 weight means that the loss of body substance 
 exceeds the gain from body repair. The bank 
 account is overdrawn and the business must 
 pass into the hands of receivers, unless the profit 
 7 
 
98 RULES FOR RECOVERY 
 
 quickly equals or exceeds the loss. The bank 
 account of body substance cannot be overdrawn 
 any length of time without danger of failure. 
 The patient must retrench and cut down the 
 excessive expenditure. Now if exercise (expendi- 
 ture) produces continued loss of weight, it must 
 be replaced by a period of retrenchment (in- 
 creased rest). In other words, continued loss 
 of weight demands an increased amount of rest 
 or possibly total rest. 
 
 Of course, when a patient weighs much more 
 than his height, age and build indicate as normal 
 (see page 124), he must expect to lose some 
 weight when he begins active exercise or returns 
 to work. As long as his muscles harden and his 
 weight remains equal to or above his normal, 
 exercise should be taken. Here, too, the advice 
 of a wise physician is very necessary. Another 
 point of interest is the seasonal fluctuation of 
 the body weight. Late iri the summer or early 
 in the fall, as the nights cool off and the days 
 grow less warm, the body in most people slowly 
 gains weight. This gain continues until about 
 Christmas, when the body weight begins to 
 fluctuate with a slight loss, which continues 
 until Easter, when the loss of weight is more pro- 
 nounced until it again begins to rise in August 
 or September. Of course, climatic conditions 
 modify this. 
 
 It is, of course, needless to add that temporary 
 complications, such as blood-spitting, rapidly oc- 
 
FROM PULMONARY TUBERCULOSIS 99 
 
 curring shortness of breath, night-sweats, severe 
 pain in the chest, and many others, all demand 
 cessation of all and every form of exercise until 
 a physician is consulted. In fact, a wise patient 
 when in doubt about the advisability of certain 
 exercise at a certain time, will refuse to engage 
 in it without special permission from his phy- 
 sician. 
 
 Much has been written in the past few years 
 about the "auto-inoculation" or work treat- 
 .ment. The word inoculation means, as here 
 used, that the patient uses his muscles until his 
 heart and muscles of breathiiig are quickened into 
 such rapidity, or so forcibly used, that poisons, 
 lurking in the dots of disease in the lungs, are 
 washed out by the more rapid and forceful cir- 
 culation of the blood. The dose of this poison, 
 or the "auto-inoculation," may be so severe that 
 fever and prostration ensue, or so light that its 
 only manifestation is increased sputum. When 
 properly employed this method has yielded 
 wonderful results, but few physicians can watch 
 the patients closely enough to use the method 
 properly, and wrongly used, it may quickly 
 result in disaster. Certainly no one can use it 
 without much study. 
 
 Pulmonary gymnastics or respiratory exercises 
 occur to the mind of every patient who falls ill of 
 lung tuberculosis. They argue that patients are 
 sent away from home for the "air." The air, 
 therefore, must be the important factor. The 
 
100 RULES FOR RECOVERY 
 
 air enters the body through the lungs, and the 
 more deeply they breathe the more quickly will 
 they recover. For this reason respiratory exer- 
 cises are an important means toward recovery. 
 It is curious, however, that the invigorating 
 effect of air or change of air is not due to its 
 effect upon the lungs, and through them to the 
 rest pf the body, but to the effect upon the body 
 and through it to the lungs. Many arguments 
 have been advanced for and against pulmonary 
 gymnastics and inasmuch as the same object is 
 attained by walking on the level and uphill, it 
 is wisest probably to avoid such exercises unless 
 especially ordered by the physician. Muscular 
 exercise increases the rate (number per minute) 
 and depth of the respiratory movements. Now 
 through the lungs the carbonic acid gas, a waste 
 product of muscular activity, is gotten rid of 
 and oxygen absorbed. During muscular activity 
 more carbonic acid gas must be set free and 
 more oxygen absorbed than when at rest. But 
 not enough oxygen is absorbed to oxidize all 
 the waste products of the muscles when exercise 
 is taken, and these substances irritate or stimu- 
 late certain parts of the brain, and more frequent 
 and deeper breaths are taken. This holds true 
 no matter what set of muscles are exercised, 
 provided only that they are of sufficient size. 
 Walking, for example, on the level and up grades 
 would suffice to exercise fully the respiratory 
 muscles of a patient, who by this means of exer- 
 
FROM PULMONARY TUBERCULOSIS 101 
 
 cise takes three times as much air into his lungs 
 as a patient who remains still. 
 
 It may be of assistance to some to have these 
 rules boiled down, compressed into small space, 
 for ready reference. 
 
 RULES FOR EXERCISE 
 
 (Exercise means walking. Special permission 
 must be obtained before indulging in other forms 
 of exercise.) 
 
 None if feverish 
 
 None if blood in sputum 
 
 None if loss of weight 
 
 None if fast pulse 
 
 Never get out of breath 
 
 Never get tired 
 
 Never run 
 
 Never lift heavy' weights 
 
 No mountain climbing 
 
 Go slow 
 
 Exercise regularly and systematically whether 
 rain or shine 
 
 Walk uphill at start so as to come downhill on 
 return 
 
 Remember always that you will have to return 
 
 Rest one-half hour before and after meals 
 
102 RULES FOR RECOVERY 
 
 XII 
 
 ON CULTIVATING AN OUTDOOR HOBBY AND 
 ON RECREATION 
 
 " Better to hunt the fields for health unbought, than fee the 
 doctor for a nauseous draught." 
 
 The mad rush of life in America means many 
 different things to many people. To the English- 
 man, accustomed for years to a leisure class 
 who devote themselves to sport, art or travel, 
 the man of affairs in America seems to have but 
 one goal, riches. To them "trade" as a pro- 
 fession is incomprehensible and playing such a 
 game inconceivable. The association of America 
 with gold has been so pronounced since the dis- 
 covery of Columbus to the present day, that to 
 the majority of Europeans we seem to be engaged 
 in a life-long struggle for the root of all evil or 
 else in watering the plant. In other words, we 
 spend our lives in preparing to live and never 
 find time to live. There is, however, a growing 
 tendency for a man to retire from business at an 
 earlier age, but unfortunately for many, such 
 retirement is often associated with a relaxation 
 of mental as well as of bodily effort, which leads 
 in some cases to a rapid deterioration of all the 
 better qualities that made the man Successful. 
 
FROM PULMONARY TUBERCULOSIS 103 
 
 He has developed no tastes, no pursuits apart 
 from his business, which, he must follow to escape 
 boredom. This unfortunate state of affairs is 
 true also when the business or professional man 
 falls ill of tuberculosis. Apart from his calling 
 he has little or no resources and, unable to follow 
 his calling, he wanders about like a lost soul. 
 The advantages of resources within himself have 
 never before occurred to him and the therapeutic 
 value of a hobby, an out-of-doors hobby, is an 
 unknown thing. 
 
 It is a curious thing, but play brings relapse 
 more often than work. The writer frequently 
 tells patients that how they will do depends 
 more upon what they do after working hours 
 than upon their work. Put in another way it may 
 be stated that they can play and get well, or 
 work and get well, but they cannot play and 
 work and get well. This means that recreation 
 which entails exercise may add the proverbial 
 straw. A patient who must return to work at 
 the end of six months or a year must clearly 
 realize that he must take much of his recreation 
 while resting. 
 
 In discussing recreations it may be well to 
 generalize a little at first. A tuberculosis patient 
 should cultivate outdoor pleasures whenever 
 possible and, as soon as his condition permits 
 him to move about, a wide field is open to him. 
 On the porch, however, many take up bird study 
 and with the aid of opera or field glasses it is 
 
104 RULES FOR RECOVERY 
 
 remarkable how many birds a patient can come 
 to linow even while in bed. Botany, too, may 
 be begun in a similar way, for many patients or 
 friends willingly bring strange or common wild 
 flowers to anyone whose field of action is strictly 
 limited. It must be fully appreciated, however, 
 that the bird life and plants of any locality are 
 so great in number that at first the bewilder- 
 ment of riches seems overwhelming. In a short 
 time, however, the patient becomes orientated, 
 and his pleasure and delight in the subject grow 
 every day. Some, again, prefer geology, and 
 glacial deposits and erosions have for them great 
 interest. Photography is now made so easy 
 that little experience is needed to take a fairly 
 good photograph, but much study and interest 
 can be aroused by pursuing such a hobby further, 
 and for these color photography has perennial 
 charms. 
 
 After the patient has taken sufficient exercise, 
 driving, gentle horseback riding and automobil- 
 ing may be indulged in, but — the amount must 
 be prescribed by the physician. Croquet may be 
 played, and later on under his physician's direc- 
 tion a little putting, followed later by a few holes 
 of golf. The full swing in golf, however, cannot 
 be recommended. Fishing from a boat entails 
 little exercise when the patient does not row and 
 prefers trolling. Later, rowing a light boat in 
 calm weather or shooting, when it does not 
 involve too much exercise, is permissible. Hunt- 
 
FROM PULMONARY TUBERCULOSIS 105 
 
 ing, polo, mountain climbing, tennis, and base- 
 ball involve at times sudden and excessive strain, 
 and a wise patient will turn elsewhere for amuse- 
 ment. After the disease has been arrested for 
 several years a little swimming may be indulged 
 in. 
 
 Indoor games and amusements are never as 
 good for anyone as outdoor. The excitement 
 caused by playing games for stakes is harmful 
 to some patients and for many months should 
 be avoided except under medical direction. In- 
 deed, some patients for many months cannot 
 indulge in any competitive amusements without 
 harmful effects. The strain of playing upon the 
 piano or other musical instruments is not well 
 borne by a number of patients. Pool and 
 billiards entail much exercise and a1 times stretch- 
 ing, and only when the tables are in a well- 
 ventilated room and the patient has consider- 
 able exercise should they be played. Sewing, 
 knitting or crocheting for pleasure or to p^ass 
 the time are permitted, but those who feel that 
 they must finish so much every day should 
 avoid them. Solitaire may speed along many 
 lagging hours. 
 
 The respiratory exercise induced by singing, 
 especially solo singing, should be postponed as 
 long as possible. Gymnastic work, except the use 
 of weights and pulleys, had better be omitted. 
 Hanging by. the arms has led to more than one 
 fatal result. Boxing has, in the author's experi- 
 
106 RULES FOR RECOVERY 
 
 ence, at least twice led to hemorrhage of the 
 lungs. After long arrest of the disease, bowling 
 with light balls may be cautiously undertaken, 
 but the ventilation is often bad and other forms 
 of recreation are to be preferred. 
 
FROM PULMONARY TUBERCULOSIS 107 
 
 XIII 
 
 ON THE TEMPERATURE OF THE BODY 
 
 "Oh friend! have you not felt the wild desire 
 To call your mouth-thermometer a liar? 
 Would we could shatter it to bits — and, then, 
 Remould it so it never could go higher. '' 
 
 Inasmuch as it is expedient for all patients for 
 a time at least to take their temperatures, they 
 should know a few fundamental facts about the 
 body temperature and about the thermometer. 
 
 The association of increased body tempera- 
 ture or heat and disease was noted in the fifth 
 century before Christ by Hippocrates, the Father 
 of Medicine. As time passed by, however, less 
 attention was paid to it, and when Galen lived 
 in the first century after Christ little thought 
 was bestowed upon the body heat and the vari- 
 ations in the pulse were considered all important. 
 No protest was uttered until Sanctorius, an 
 Italian of Padua, in 1638, published a study of 
 the temperature in health and disease. It was 
 still, however, apparently considered an academic 
 question and only about 1750 was temperature- 
 taking in the hospital made practical by De Haen, 
 who lived in Vienna. The question of what was 
 the normal body temperature was still unsettled, 
 
108 RULES FOR RECOVERY 
 
 and some held it to be io8° F. It remained for a 
 Frenchman, Becquerel, in 1835, to establish the 
 normal body temperature at 98.6°. The study 
 of the temperature in disease then proceeded 
 along an orderly line, and in 1851 Wunderlich, 
 stimulated by Traube, both Germans, published 
 a study of the temperature in 25,000 persons, 
 having taken some million observations of 
 temperature. 
 
 The first thermometer was the hand of the 
 observer, often placed in or near the armpit, but 
 this was very crude and liable to many errors. 
 The earliest attempt at an accurate measurement 
 of temperature was probably that devised by 
 Galileo in 1597. A glass tube was inserted in a 
 closed glass vessel partly filled with colored 
 water. As the air in the vessel expanded by 
 heat or contracted by cold, the fluid rose or fell 
 in the glass tube, upon which was placed a scale. 
 In 1714 Fahrenheit, a mechanician of Dantzig, 
 made a thermometer, whose zero was at the 
 lowest temperature obtainable at that time, 
 namely, that of a mixture of salt and snow. 
 According to his scale, water froze at 32'^ and 
 boiled at 212°. A few years later Celsius, of 
 Upsala, devised a new scale, where the freezing- 
 point of water was zero and the boiling-point 
 100°. This method of dividing the scale between 
 the freezing- and boiling-points of water into 
 100 degrees is now known as the centigrade or 
 hundred-scale. It is used the world over in 
 
FROM PULMONARY TUBERCULOSIS 109 
 
 scientific work and everywhere in the study of 
 the body temperature, except in the United 
 States and England, where the Fahrenheit scale 
 is employed. It should be noted,- however, 
 that the Rdaumur scale (o° at the freezing- and 
 80° at the boiling-point) is used for household 
 purposes in Germany. 
 
 A comparison of the two scales (centigrade 
 and Fahrenheit) may be of interest and of value 
 to those who may go abroad. 
 
 ° Centigrade 
 
 
 " Fahrenheit 
 
 35.0 
 
 = 
 
 95.0 
 
 35.55 
 
 = 
 
 96.0 
 
 36.0 
 
 = 
 
 96.8 
 
 36.11 
 
 = 
 
 97.0 
 
 36.66 
 
 = 
 
 98.0 
 
 37.0 
 
 = 
 
 98.6 
 
 37.22 
 
 = 
 
 99.0 
 
 37.77 
 
 = 
 
 100.0 
 
 38.0 
 
 = 
 
 100.4 
 
 38.33 
 
 = 
 
 101.0 
 
 38.61 
 
 = 
 
 101.5 
 
 38.88 
 
 = 
 
 102.0 
 
 39.0 
 
 = 
 
 102.2 
 
 39.44 
 
 = 
 
 103.0 
 
 39.5 
 
 = 
 
 103.1 
 
 40.0 
 
 = 
 
 104.0 
 
 40.5 
 
 == 
 
 104.9 
 
 40.55 
 
 = 
 
 105.0 
 
 The little clinical thermometers, which we now 
 use so freely and break so easily, have come down 
 to us through modifications at many hands. At 
 first the thermometer had to be read while still 
 
110 RULES FOR RECOVERY 
 
 in contact with the body, for the mercury quickly 
 retracted and the reading was inaccurate. James 
 Currie, an Englishman, whose work on the body 
 temperature is a classic, introduced a tiny bit of 
 iron which held the mercury at its highest point, 
 but today a slight constriction in the diameter 
 of the glass tube acts in the same way. The mer- 
 cury rises above it when the bulb of the ther- 
 mometer is warmed by the body but cannot fall 
 below it until shaken down. The clinical ther- 
 mometer is therefore a maximum thermometer; 
 it registers the highest temperature. The many 
 steps necessary for its construction emphasize 
 the fact that accuracy and care in construction 
 must be sacrificed when it is made to sell at 
 retail for much less than one dollar. Only a 
 special sort of hard glass is suitable for the bulb 
 which holds the mercury. It must be heated to 
 blow it and for months afterward it shrinks. 
 Thermometers made from such "unripe" glass 
 are consequently inaccurate and read in a short 
 time often too high. It takes many months to 
 ripen the glass. Many manufacturers agree 
 to retest their thermometers after they have 
 been in use a year. Few are returned! Now 
 the very fine bore of the hair-like tube, through 
 which the mercury rises, may not be absolutely 
 uniform and hence the division of the scale 
 may not correspond exactly to the temperature 
 recorded upon the tube. Certificates indicating 
 such corrections accompany many thermometers. 
 
FROM PULMONARY TUBERCULOSIS 111 
 
 The dislike of the patient to make such correc- 
 tions may lead unscrupulous manufacturers to 
 state that all their thermometers need no cor- 
 rections. As corrections of a tenth or fifth of a 
 degree are of no practical importance, it is better 
 to buy thermometers from a firm that indicates 
 occasionally a correction than from one which 
 states that all their thermometers are absolutely 
 accurate. In any case absolute accuracy of 
 observation is unattainable, and generally speak- 
 ing errors of two or three-tenths of a degree do 
 not matter greatly. The scale of a good ther- 
 mometer (92°-iio°) should be about two and 
 one-quarter inches long, otherwise it is difficult 
 to read. It should not be difficult to shake down, 
 but many patent appliances now overcome this 
 difficulty. 
 
 A good thermometer, when much distress of 
 mind is occasioned by a rise of one or two-tenths 
 of a degree, is of great importance to every 
 patient. Price is not always a guarantee of 
 excellence, but the cost of production of an 
 accurate instrument far exceeds that of an 
 unreliable one. A good thermometer must 
 register accurately under all circumstances. If 
 the scale is put on incorrectly the thermometer 
 will, of course, be inaccurate, but if the bore of 
 the tube is not uniform or if the mercury "jumps" 
 or "retreats" it is unreliable, for the reading 
 for these or other causes is not always the 
 same at the same temperature. The clinical 
 
112 RULES FOR RECOVERY 
 
 thermometer is a maximum thermometer, and 
 registers only the highest temperature, for in 
 the mercury column is a "trap" or constriction, 
 so made that while the mercury can be forced 
 by this point when it expands, on contracting 
 that part which passed the constriction cannot 
 again fall below it. This can be made so tight 
 that the mercury cannot be shaken down, and 
 to make it just snug enough is not easy. The 
 importance of "aging" the thermometer has been 
 mentioned. It should be done after the ther- 
 mometer is finished and before the scale is etched 
 upon it. It has been pointed out that a certi- 
 ficate is of value only when it is known by whom 
 it is given. The National Bureau of Standards 
 in Washington will test or retest any thermometer 
 and it is to be hoped that before long the govern- 
 ment will supervise the manufacture of all clinical 
 thermometers. 
 
 Before taking the temperature the lips should 
 be kept closed ten to fifteen minutes and the 
 thermometer inserted under and near the middle 
 of the tongue for at least five minutes. It is not 
 wise to leave it there longer. Hot or cold drink 
 or food materially affects the mouth tempera- 
 ture for some minutes. Cold air also affects it 
 slightly when the temperature is below ioo°, 
 but above that point hardly at all. Many 
 advocate taking the temperature in the rectum, 
 which for children and patients confined to bed 
 is preferable. Standing on the feet, walking, 
 
FROM PULMONARY TUBERCULOSIS 113 
 
 horseback riding and nervousness in a patient 
 raise more or less the rectal temperature. A 
 healthy runner who won a long-distance race 
 had a rectal temperature of 105°, which did not 
 fall to normal for twelve hours. Hence rectal 
 temperature should be taken only after rest of 
 one-half to one hour. 
 
 The normal mouth temperature may be said 
 to be about 98.5°, though it may vary in different 
 individuals from 97° to 99°. The rectal tem- 
 perature varies from 0.5° to 1° higher. (All 
 the temperatures referred to are measured on 
 the Fahrenheit scale.) A subnormal tempera- 
 ture when the patient feels well need not be 
 regarded. The important temperature is the 
 highest temperature for the twenty-four hours. 
 It is an interesting fact that the effect of exercise 
 upon the temperature may not be noted until 
 the following day. What probably happens is 
 that the patient by exercise increases the number 
 of the heart-beats and respirations, which help 
 to pump out from the areas of disease poisons, 
 which in turn affect that part of the brain regu- 
 lating the heat of the body. When this is irri- 
 tated, more heat is produced or less lost, or both, 
 and hence the patient has a rise of temperature. 
 It may require twenty-four hours for the effect 
 to be noted (see page 95). 
 
 The temperature should be taken on awaken- 
 ing, at four and at eight p.m. It may be wise 
 to take it every two hours for several days at 
 8 
 
114 RULES FOR RECOVERY 
 
 first to find out when it is highest, and then to 
 take it at that time instead of at four or eight 
 P.M. Some patients become slaves to their 
 thermometers, "trouble sticks," as some term 
 them. The thermometer must be used as an 
 aid, not as a hindrance to recovery, and when 
 such a state of affairs arises the thermometer 
 should be put away and used only when the 
 patient feels upset or ill. When the patient is 
 not nervous he should record his temperature 
 at the times mentioned and note the date and 
 show it to his physician at regular intervals. 
 
 A little cold, constipation, an attack of diar- 
 rhea, tonsillitis and many other minor ailments 
 may cause a rather sharp rise of temperature. 
 When, however, without any special symptoms 
 but increase of cough and expectoration the 
 temperature rises slowly above 99.5° when pre- 
 viously it had been normal, the physician should 
 be notified and the patient should remain quietly 
 in his chair or if i t reaches 100° he should go to bed. 
 
 Here it is important to remember that the 
 temperature of yesterday decides what the 
 patient must do today. If he has had elevated 
 temperature for several days and it was 100° 
 yesterday, he often feels that because this morning 
 it is normal he can get up. The body temperature 
 is usually lowest in the morning and gradually 
 rises to a maximum in the afternoon or evening. 
 Hence the error of using the morning tempera- 
 ture as a guide to increasing the exercise. A 
 temperature of 100° yesterday usually means 
 
FROM PULMONARY TUBERCULOSIS 115 
 
 stay in bed today, but here again the physician 
 must be consulted if grave mistakes are to be 
 avoided. From what has been said it is easy 
 to see that a temperature above the usual morn- 
 ing temperature, although normal, may indicate 
 that the temperature will rise above normal 
 during the day. In this case it is wisest to 
 remain in bed until noon, and only then, if the 
 temperature is normal, should the patient get 
 up. This holds true even if the increase of 
 temperature is only from 97.5° to 98.5". 
 
 It may be of interest to patients to know that 
 temperatures ranging from 75.2° to 114.8° have 
 been recorded in patients who have recovered. 
 The temperatures of animals are usually higher 
 than that for man: The horse, 99.5°; the cow, 
 101.5°; the sheep, 104.5°; the pig, 102°; the dog, 
 101°; the rabbit, 102.5°; the guinea-pig, 102°; 
 the common fowl, 106.9°; the perch, 52°. 
 
 The temperature of the body is kept constant 
 by the circulation of the blood. When the heat 
 of the body rises too high more blood flows to 
 the skin, the sweat glands are stimulated and the 
 evaporation of the moisture (of the skin) cools 
 the skin, the blood and hence the body. When 
 the body is exposed to cold and the bloodvessels 
 of the skin contract, the blood is driven into. the 
 internal parts of the body and the cooling of the 
 body lessened. All of this, as has been stated, is 
 under the control of a part of the brain. Exposure 
 of the skin first to hot and then to cold water 
 causes these little bloodvessels of the skin to 
 
116 RULES FOR RECOVERY 
 
 dilate and contract, keeping them in "condition, " 
 and so aids in preventing chilling when exposed 
 to cold or dampness. 
 
 It must be borne clearly in mind that the tem- 
 perature of patients with pulmonary tuberculosis 
 varies from slight causes. Slight excitement, an 
 interesting story, a game of cards, can all raise 
 the temperature. Some patients have a normal 
 temperature until they come into a warm room, 
 when the temperature rises above normal. 
 
 Here the explanation lies in the fact that that 
 part of the brain which controls the temperature 
 is hypersensitive and cannot regulate the body 
 temperature as readily as it does in health. 
 
 'It has been mentioned that cold fresh air 
 stimulates the body of a patient vigorous enough 
 to bear it. All the processes of nutrition are 
 whipped up by such treatment better than by any 
 drug. More carbonic acid gas is given off, more 
 oxygen absorbed, more food required, and all the 
 processes of the body quickened. The old idea 
 that life in a room with a temperature that does 
 not vary two or three degrees a day is good for 
 patients with pulmonary tuberculosis has long 
 since been discarded. The equable temperature 
 of the tropics is also" bad for most patients. 
 Today we know that a daily change of at least 
 20° a day is important for tuberculous patients. 
 Greater changes even are good, and some have 
 attributed the activity of Americans to the sudden 
 climatic changes to which they are subjected. 
 
FROM PULMONARY TUBERCULOSIS 117 
 
 XIV 
 
 ON CONTROLLING A COUGH WITHOUT DRUGS 
 
 " Be not discontented, be not disheartened, be not out of hope 
 if often it succeed not." 
 
 The best advice that can be given about a 
 cough is that offered by Punch to those about 
 to marry: "Don't!" 
 
 To the average patient who is suffering from 
 pulmonary tuberculosis there are two points 
 which are far above all others in importance. 
 The first is the question of cough and the second 
 is a question of whether or not he has developed 
 a cavity in his lungs. Undoubtedly, to the lay 
 mind, the cough is the main characteristic of 
 pulmonary tuberculosis, and, for this reason, 
 it is undoubtedly true that many patients will 
 take any medicine, patent or otherwise, that is 
 suggested to them by their friends or by adver- 
 tisements. The object of this chapter is to 
 suggest other means than drugs for the treat- 
 ment of the cough. 
 
 The dangers of excessive coughing are many 
 but chief among them is the fact that the lungs 
 can get no rest. It has been estimated that a 
 man who coughs hard all day takes as much 
 exercise as another who climbs a mountain. 
 
118 RULES FOR RECOVERY 
 
 When the vast amount of literature that has 
 been written on coughing is consulted, it is seen 
 that the cause of a cough has been at one time 
 or another attributed to an affection of nearly 
 every part or organ of the body. The act of 
 coughing is explained by the physiologists to be 
 a preliminary inspiration followed by an expira- 
 tion which is frequently interrupted, the glottis, 
 or upper part of the windpipe, being partially 
 closed at the time of occurrence of each inter- 
 ruption, so that a series of characteristic sounds 
 is produced. The air is forcibly ejected through 
 the mouth and thus foreign particles, such as 
 mucus in the respiratory passages, may be 
 expelled. Hawking, which is very similar to 
 coughing in its effects, is a voluntary act entirely, 
 while coughing may be involuntary or reflex in 
 origin. In hawking the glottis is open during 
 the respiratory act and the expiration is con- 
 tinuous. The current of air is forced through 
 the contracted passages between the root of the 
 tongue and the soft palate. 
 
 Coughing, in the vast majority of cases, is 
 undoubtedly due to an abnormal condition of 
 the lungs, windpipe or larjoax (upper end of the 
 windpipe where the voice is produced). How- 
 ever, it is said that it may indicate irritation in 
 even remote and entirely unassociated parts — 
 irritation in the nose, ear, pharynx, stomach, 
 liver, spleen, intestines, etc. Such coughs are 
 called "sympathetic" or "reflex" coughs. 
 
FROM PULMONARY TUBERCULOSIS 119 
 
 Among the various causes of cough, other than 
 that caused directly by tuberculosis, may be 
 mentioned smoking, chilling of cold sheets at 
 night, exposure to sudden differences of tempera- 
 ture, wind, dust, exertion — such as rapid walk- 
 ing, talking, laughing — pleurisy and majny other 
 things. Unquestionably, the first remedy to be 
 tried for a cough should be the open-air cure. 
 It is astonishing to observe how quickly many 
 patients lose their cough when they "take the 
 cure" faithfully. In others, however, the cough 
 may be so severe that the mere fact that they 
 lead an open-air life may not be sufficient to 
 enable them to control their cough. 
 
 At this point it may be well to recall the fact 
 that in some instances the cough is undoubtedly 
 due in part to nervousness and can be largely 
 controlled. An instance of this was observed a 
 year or two ago, when a young girl, leaving home 
 to go to a health resort, suffered severely from a 
 cough which her physician thought was due in 
 part to nervousness. On the trip she had a 
 sudden scare and from that time on the cough 
 disappeared. This cough was undoubtedly due 
 to nervousness. It is for patients of this class 
 that Dr. Dettweiler's advice has most weight. 
 He said coughing was merely scratching the 
 throat, and that it was as impolite to scratch 
 the throat as to scratch the back in public. 
 
 There are many simple devices which one can 
 follow for controlling the cough. Probably the 
 best of all is rest in a semi-reclining position, or 
 
120 RULES FOR RECOVERY 
 
 indeed for several days in bed, avoiding talking 
 and especially hearty laughing. Prolonged rest 
 in bed may be required to cure a persistent and 
 otherwise uncontrollable cough. Coughing dur- 
 ing the day can frequently be controlled by sips 
 of cold water, tablets of Iceland moss, . slippery 
 elm or glycerine; cold water with a little lemon 
 juice or orange juice; very slow, full breaths, 
 holding the breath, and many other such devices. 
 Many of the widely advertised cough remedies, 
 either in tablet or liquid form, may have a delete- 
 rious effect on the stomach and should not be 
 taken without medical advice. This is true also 
 of the glycerine tablets mentioned on the preced- 
 ing page. 
 
 Patients with tuberculosis cough most fre- 
 quently in the morning either before or just after 
 rising. This cough is usually caused by some 
 secretion which has to be gotten rid of. The 
 cough which is productive, in other words, which 
 is accompanied by expectoration, is to be sepa- 
 rated in its treatment from a dry, hacking, unpro- 
 ductive cough. The mucus which accumulates 
 in the lungs during the day and especially during 
 the night has to be gotten rid of, as was stated at 
 first, and the cough is the best means of freeing 
 the air passages of the accumulated mucus. In 
 a few patients the mucus can be expectorated 
 without coughing. Such are indeed fortunate. 
 When, however, a patient has great difificulty 
 in rising in the morning and is troubled with 
 severe coughing, a cup of hot milk, a cup of 
 
FROM PULMONARY TUBERCULOSIS 121 
 
 coffee, or of caf6-au-lait or a glass of hot water 
 with a few drops of aromatic spirits of ammonia 
 (id to 15) or with lemon juice very often gives 
 relief. This should be taken, if possible, before 
 the patient rises. Coughing is then made much 
 easier. This, too, is an excellent means of pre- 
 venting that dry, hacking, obstinate cough which 
 is often followed by vomiting. 
 
 When a patient coughs after meals an excellent 
 thing is to take a glass of very hot water, as 
 was just suggested, half an hour before meals, 
 endeavoring from that time to the beginning of 
 the meal to cough as much as possible. If 
 change of position does not bring on coughing 
 it may be well for these patients to lie down 
 immediately after meals for an hour or more. 
 This, of course, should be done out of doors. A 
 further point of considerable benefit to patients 
 who cough until they vomit after meals is to take 
 all of their fluids an hour before meals and none 
 with the meal. This will frequently stop the 
 vomiting. A tight cough at night is often helped 
 by a cold pack on the chest and neck. How- 
 ever, before attempting this, one should get full 
 details from his physician, how to apply it and 
 whether or not it should be used in his case. It 
 is usually applied as follows: Strips of cotton 
 cloth of three or four thicknesses and four or 
 five inches wide should be placed over each 
 shoulder and a wide binder about the chest from 
 the armpits to the lower part of the chest. This 
 should then be covered with oiled silk or muslin 
 
122 RULES FOR RECOVERY 
 
 and a broad flannel bandage applied closely over 
 the chest. In the morning on rising a cold sponge 
 at least to the waist should be taken at once. 
 
 Some coughs are undoubtedly due to pleurisy, 
 and in these cases counter-irritation by applica- 
 tion of some liniment may prove of benefit. 
 
 It is needless to say that coughing is exceed- 
 ingly disagreeable to everyone, including the 
 cougher, and for this reason as well as others it 
 should be controlled whenever possible. Further- 
 more, no one has any more right to cough with- 
 out covering the mouth than he has to expectorate 
 without taking care of the sputum. 
 
 Before taking any cough tablets or remedies 
 other than the very simple ones mentioned 
 above, anyone troubled with a cough should 
 consult a physician. The doctor may be able to 
 help him with some simple remedy that may 
 prove superior to anything referred to in this 
 chapter. In any event a patient should never 
 take any remedy without notifying his physician. 
 
 Strange as it may seem few persons know how 
 properly to blow the nose. The usual way is to 
 close one nostril and to blow as hard as possible. 
 This may blow sputum or secretions into the tube 
 leading to the middle ear and bring about inflam- 
 mation. Neither nostril should be completely 
 closed, but the egress of air from one side partly 
 blocked by holding the thumb or finger covered 
 with the handkerchief over one nostril at a time 
 and blowing carefully. 
 
FROM PULMONARY TUBERCULOSIS 123 
 
 XV 
 
 ON THE BODY WEIGHT 
 
 "Success lies not in acliieving what you aim at but in aiming 
 at what you ought to achieve." 
 
 The weight of the body varies with sex, age 
 and height. Some divide all persons into three 
 classes. The first is the normal type, which the 
 painter and sculptor delight in portraying and 
 the anatomist in describing. The other types 
 are common; one is tall, thin, lithe, like the 
 panther, quick of action but of very low weight 
 for his height; the other, short, stocky, beefy 
 like the ox, slow of action but steady of purpose 
 and inclines to weigh more than his height and 
 age would indicate. While any of these three 
 types may fall ill of tuberculosis, it selects most 
 often the thin type. The writer's experience 
 leads him to believe that the usual weight of 
 persons who develop tuberculosis is on an average 
 ten pounds below the normal weight for their 
 height, age and sex. It is readily seen that 
 individuals belonging to this class should lead 
 carefully regulated lives. 
 
 The loss of weight which occurs in some 
 patients has given to the later stages of pul- 
 monary tuberculosis the name phthisis (Greek) 
 
124 
 
 RULES FOR RECOVERY 
 
 or consumption (Latin). The cause of this loss 
 of weight is most often failure to follow some of 
 the suggestions set forth in previous chapters. 
 The patients may, e. g., continue to exercise not- 
 withstanding high fever and lack of appetite. 
 The engine runs at high speed and must have 
 fuel. 
 
 WEIGHT TABLE (MALES) 
 
 Showing Average Weight for Each Height and Age 
 
 (Constructed from "Nylio Graphic Table." Correct to one Pound) 
 
 Inches 
 Age 
 
 Inches 
 
 67 58 59 60 61 62 63 64 65 
 
 57 58 59 60 61 62 63 64 66 
 
 67 68 
 
 140 
 141 
 142 
 143 
 144 
 141^ 
 145 
 146 
 147 
 148 
 148 
 149 
 150 
 150 
 151 
 152 
 152 
 153 
 153 
 154 
 164 
 154 
 166 
 155 
 155 
 166 
 156 
 167 
 157 
 157 
 157 
 158 
 158 
 158 
 168 
 158 
 
 144 
 146 
 146 
 147 
 148 
 149 
 150 
 150 
 151 
 152 
 152 
 153 
 154 
 155 
 156 
 166 
 156 
 167 
 158 
 158 
 158 
 159 
 159 
 160 
 160 
 161 
 161 
 161 
 161 
 162 
 162 
 162 
 162 
 163 
 163 
 163 
 
 70 71 72 73 
 
 67 68 69 70 71 72 73 
 
 167 
 168 
 169 
 170 
 171 
 172 
 173 
 174 
 176 
 176 
 177 
 178 
 179 
 179 
 180 
 181 
 181 
 182 
 183 
 183 
 184 
 184 
 185 
 185 
 186 
 186 
 186 
 187 
 187 
 187 
 188 
 188 
 188 
 188 
 188 
 188 
 
FROM PULMONARY TUBERCULOSIS 125 
 
 The study of the weight in pulmonary tuber- 
 culosis is of much interest and importance. The 
 weights should be accurately taken. They 
 should be noted at the same time of day, in 
 the same clothes, and on the same scales. What 
 is more important is not the absolute but the 
 relative weights from week to week. The charts 
 
 WEIGHT TABLE (FEMALES) 
 
 Showing Average Weight for Bach Height and Age 
 
 (Based on "Nylic Graphic Table") 
 
 Inches 
 
 Age 
 
 Inches 
 
 57 58 59 60 61 62 63 64 65 66 67 68 
 
 113 116 
 
 114 117 
 
 114 118 
 
 115 118 
 
 115 119 
 
 116 119 
 117il20 
 117,121 
 118 121 
 
 57 58 59 60 61 62 63 64 65 
 
 67 68 69 70 
 
 70 71 72 73 
 
 71 72 73 
 
 161 
 162 
 162 
 163 
 164 
 165 
 166 
 166 
 167 
 168 
 169 
 170 
 170 
 171 
 172 
 173 
 174 
 175 
 175 
 176 
 177 
 178 
 179 
 179 
 180 
 181 
 182 
 182 
 183 
 184 
 185 
 186 
 186 
 187 
 188 
 188 
 
126 RULES FOR RECOVERY 
 
 shown are arranged for age, height and sex and 
 are for individuals dressed and measured in their 
 shoes. Most persons weigh two or three pounds 
 more at night than in the morning. 
 
 It has been stated (page 42) that it matters 
 not how Httle a person eats provided he gains 
 weight. "Sufficient weight" varies, of course, for 
 different patients. For those greatly under their 
 normal weight it must be more than for those 
 who have lost less. In general it may be said that 
 a patient should regain his usual weight and if 
 possible should exceed it by ten to fifteen pounds. 
 If this can be done only by overcrowding the 
 stomach, great care should be exercised, and at 
 the slightest sign of any digestive disturbance 
 it should be abandoned. Some patients burn or 
 oxidize very little of their food while others 
 burn large quantities and remain thin. Patients 
 with fever require more food than those with a 
 normal temperature but often can digest it less 
 readily. They should take the greatest part of 
 their food when their temperature is lowest. 
 Persistent loss of weight when the weight is not 
 above normal must be combated by many means 
 to be advised only by the patient's physician. 
 
 Some patients who have ceased to gain begin 
 again when they commence to exercise. Weight 
 gained while exercising is often more lasting 
 than that gained at rest. The writer's impres- 
 sion is that weight gained on a good general diet 
 including only a glass or two of milk and one 
 
FROM PULMONARY TUBERCULOSIS 127 
 
 or two eggs is more likely to be of permanent 
 benefit than that put on from taking excessive 
 quantities of milk and eggs. 
 
 Change of environment, even from one place 
 to another in the same climate, is often of help. 
 Change to more congenial companions, change 
 of cooks, even changing one's place at the table 
 may prove of benefit. Change of climate from 
 the sea level to the mountains, or vice versa, is 
 universally recognized as beneficial, and few- 
 choose to spend their vacations at home. Such 
 changes stimulate the nutrition of many patients. 
 In fact, the gist of the matter is that we all 
 need some of the spice of life. 
 
 Warmth and sunshine are not necessary factors 
 for gain in weight; indeed, many patients do 
 better in winter. Cold weather stimulates the 
 patients' much more than warm. Some patients, 
 however, have an antipathy to cold, and these 
 are frequently found to gain more in a warm, 
 equable climate. Great dryness is not always 
 conducive to gain in weight. Patients gain even 
 when there is little sunshine. 
 
 A study of the records of the Trudeau Sana- 
 torium will show that more patients gain and that 
 the gain is larger from August to January. This 
 is the period when the temperature begins to fall, 
 but it also includes the greatest number of 
 cloudy days. The precipitation departs slightly 
 from the average during this period. Patients 
 who have held their own or lost slightly during 
 
128 RULES FOR RECOVERY 
 
 the early summer often begin to gain in August. 
 This period of gaining extends to Christmas, 
 when often the patient has surpassed his normal 
 weight. During January, February and March 
 the weight fluctuates and gradually begins to 
 lessen. It is at this time that a radical change 
 in the life of the patient, a change of environment 
 and later of climate for a few months, proves 
 of great benefit. From March to August there 
 is usually a loss of weight. It might be added, 
 however, that the weight of the body in health 
 follows this course. 
 
FROM PULMONARY TUBERCULOSIS 129 
 
 XVI 
 
 ON PATIENT AND PHYSICIAN 
 
 "To be trusted is a greater compliment than to be loved." 
 
 The relation, that should exist between physi- 
 cian and patient is peculiar and very difficult to 
 define. Until recently every physician did and 
 even at the present time many physicians still 
 subscribe to the Hippocratic oath: "I will fol- 
 low the system of regimen which according to my 
 ability and judgment I consider for the benefit 
 of my patients and abstain from whatever is 
 deleterious and mischievous. I will give no 
 deadly medicines to anyone nor suggest any 
 such counsel . . . with purity and holi- 
 ness I will pass my life and practice my art. 
 . . . Into whatever houses I enter I will go 
 into them for the benefit of the sick and will 
 abstain from every voluntary act of mischief 
 and corruption. . . . Whatever in connec- 
 tion with my professional practice or not in 
 connection with it I see or hear in the life of 
 men which ought not to be spoken of abroad 
 I will not divulge as reckoning that all such should 
 be kept secret." The word physician, some 
 believe, is derived from an ancient word which 
 means to serve, and a physician is therefore one 
 9 
 
130 RULES FOR RECOVERY 
 
 who serves. Now while this service is often- 
 times as indefinable as the relation between 
 patient and physician, still it is clearly recog- 
 nized by law that when a patient employs a 
 physician he enters into a contract with the 
 physician. The physician must use a reasonable 
 amount of skill and knowledge or else he is held 
 accountable by the courts. A patient is held 
 liable by the courts for the bills that he contracts 
 with the physician and is forced by law to 
 pay such bills. The law also recognizes a more 
 sulDtle relationship, one comparable to that which 
 exists between penitent and priest. Knowledge 
 gained in such a way is held to be sacred and 
 inviolate. 
 
 It will soon become evident to anyone who 
 looks at the matter at all thoughtfully that a 
 physician stands in much the same relation to 
 his patient that a builder does to his employer. 
 Few would be so foolish as to ask a builder to 
 construct a house for them and then either 
 refuse to give him true information about the 
 foundation on which he was to build or later 
 make misleading and at times erroneous if not 
 false replies to questions which related to the 
 perfecting of the construction. Nor would they 
 when the building was three-fourths completed 
 try to see if it could stand all the strain that 
 would be expected of it when finished. It would 
 indeed be foolish if during the night they should 
 knock down a number of bricks from the walls 
 
FROM PULMONARY TUBERCULOSIS 131 
 
 while the builder was not there or injure the 
 property in any of a hundred ways that could be 
 suggested. Some of these may seem possibly 
 to have little bearing upon the relation of physi- 
 cian and patient, but let us see. 
 
 When a patient consults a physician the physi- 
 cian supposes that the patient has put himself 
 entirely in his hands to be guided in the matter 
 of his health by the physician's knowledge and 
 skill, whatever they may be. They enter, as it 
 were, into a partnership which has as its aim 
 the recovery of the patient's health. The physi- 
 cian should bring expert knowledge and the 
 patient willingness and ability to carry out his 
 physician's orders. In any business perfect 
 frankness and honesty must exist between the 
 partners. Any patient who does not tell his 
 physician everything related to his health in the 
 past, or who by his misstatements leads him to 
 believe that something is the case which is riot, 
 is certainly giving the physician false informa- 
 tion about the foundation on which he hopes to 
 upbuild his health. Such false information may 
 mislead the physician but works harm only to 
 the patient. 
 
 Patients who think when they are given cer- 
 tain instructions that it is not necessary to carry 
 them out, assume that they know more than 
 the physician. Possibly this may be so. If a 
 patient feels confident that it is so, he should at 
 once discharge the physician and seek advice 
 
132 RULES FOR RECOVERY 
 
 from another. Physicians are human and some- 
 times err, but wide experience teaches that their 
 mistakes can be numbered in the units, while 
 patients' mistakes run into the thousands. In 
 no disease is absolute confidence so important 
 as in pulmonary tuberculosis — confidence of the 
 patient in the physician, confidence of the 
 physician in the patient. Each must look upon 
 the other not as a master at a boarding-school, 
 nor as a proctor at a university, nor again as a 
 policeman in a large city, but each should con- 
 sider the other as his personal friend, a friend to 
 whom all his troubles can be imparted and halved, 
 a friend with whom his joys can be shared 
 and doubled. Such should be the relations, 
 certainly so far as matters of health are con- 
 cerned, between physician and patient. No 
 patient can expect the best results until such 
 relations exist. The physician must be his con- 
 fidant. The physician knows only too well 
 that his patient will err at times, will wander 
 from the straight and often difficult path that 
 leads to health. He expects it, but he also expects 
 that his patient will be frank and will tell him. 
 An honest confession disarms criticism and 
 engenders a feeling of confidence and respect 
 which is worth more to physician and patient 
 than any pecuniary or other reward. A patient 
 can in many ways easily deceive his physician, 
 for the latter may have no opportunity to verify 
 statements nor have any desire to do so. But in 
 
FROM PULMONARY TUBERCULOSIS 133 
 
 so doing the patient really deceives himself and 
 often brings about conditions which greatly 
 prolong his illness. 
 
 Therefore, when you go to your physician, go 
 to hira in the same spirit in which one should 
 approach a confessor. You may be certain he 
 will divulge nothing that you tell him. You may 
 rest assured that his advice, based upon a full 
 knowledge of your case and condition and upon 
 what you have done and will do, will be thou- 
 sands of times more valuable to you than advice 
 based upon insuflticient knowledge of the past 
 history of yotir case or upon insufficient knowl- 
 edge of your temperament. 
 
 Few persons realize how expensive cheap 
 advice may prove to be. No one would take an 
 important case to a lawyer of whom he knows 
 nothing and follow blindly his advice; neither 
 would he consult a business acquaintance at 
 lunch in regard to a legal matter of some impor- 
 tance and try to see if his advice would solve the 
 problem. Such an individual would be extremely 
 foolish. On the other hand, the majority of 
 mankind exhibit a gr^at distaste for consulting a 
 physician of prominence often on account of the 
 fee he charges. Their fortunes must be protected 
 by the best legal advice possible, but their health 
 may be entrusted to the mercy of friends who, 
 while chary about advice as to how to invest 
 $1,000.00, feel fully competent to give numerous 
 suggestions about health. The money may be 
 
134 RULES FOR RECOVERY 
 
 replaced, but health once lost is often irrecover- 
 able. When, however, they have followed this 
 well-intentioned but ignorant advice and find too 
 late that they are incapacitated for further work 
 they seek skilled medical advice and then berate 
 the doctors who tell them how long it will take 
 to get back to the place where they were when 
 they first sought advice of any sort. 
 
 I often ask patients if when they form a part- 
 nership in business they go about asking their 
 friends who are ignorant of the business what 
 they should do. Then why, I ask again, do they 
 often seek and at times follow medical advice 
 from laymen who may be and usually are totally 
 ignorant of the condition of their various organs? 
 Does such blind advice help either him who 
 proffers or him who follows? ; 
 
FROM PULMONARY TUBERCULOSIS 135 
 
 XVII 
 
 ON CLIMATE 
 
 "Of natures or temperaments some are well- or ill-adapted for 
 summer and some for winter. '' 
 
 Tuberculosis is found from pole to pole. No 
 people, no land, no climate is free from the 
 disease, though in some lands it is more common 
 than in others. The Indians about Hudson Bay, 
 the Eskimos of Greenland, the African in his 
 native land, all suffer severely; while in the 
 temperate zone it is a scourge. Tuberculosis is 
 found in every climate and at every altitude, 
 though less frequently in arid or semi-arid lands, 
 on mountains and in the higher altitudes. 
 Brehmer, the founder of the sanatorium treat- 
 ment of pulmonary tuberculosis, believed in 
 immune zones, districts where tuberculosis was 
 very infrequent or did not occur. Today, how- 
 ever, it is recognized that it is not climate but 
 sparseness of population and difficulty of fre- 
 quent communication with the outlying world 
 that produces such zones, while density of popu-, 
 lation with the accompanying overcrowding 
 under itisanitary and poor economic conditions 
 plays a far more important part in reducing 
 the individual resistance to the disease than any 
 
136 RULES FOR RECOVERY 
 
 possible climatic condition in the temperate 
 zone. 
 
 The relation of climate to health is very com- 
 plex, but a few facts do stand out. Warm or hot 
 moist climates depress many of the bodily func- 
 tions, the stomach and the intestines are less 
 active, evaporation from the lungs is slight, per- 
 spiration is profuse, the kidneys overexcited, all 
 of which produce at times torpor of body and 
 mind. That such a climate is bad for patients 
 with pulmonary tuberculosis is very evident. 
 The severe cold within the Arctic Circle with the 
 many unpleasant symptoms produced, render 
 it a climate to be avoided except in summer. 
 The temperate zones again have marked changes 
 of temperature, which today are looked upon 
 as beneficial to patients who can stand them 
 and meet them intelligently. Strange as it may 
 seem, more severe changes are of daily occurrence 
 in the deserts of Arizona and of Sahara at sunset 
 than occur in colder climates. The most vigorous 
 race of men, some hold, is that which lives far 
 enough north to have to combat a vigorous winter 
 and yet not far enough north to experience 
 scarcity of food. Such cold acts like a healthy 
 stimulant upon body and mind, and the feverish 
 activity of the American people has been attrib- 
 uted to our variable climate. 
 
 The value of climate in the treatment of pul- 
 monary tuberculosis rests today largely upon 
 personal belief and experience, for much has 
 
FROM PULMONARY TUBERCULOSIS 137 
 
 been stated and little proved. Such widely 
 divergent climates as the desert, the mountain- 
 top or the mid-ocean are all good climates, and 
 certain patients thrive wonderfully well under 
 their influence. But it is now clearly recognized 
 that proper treatment is more important than 
 climate and, further, that there is no specific 
 climate. Rainy winds or bad weather may 
 exert some influence upon the onset of tuber- 
 culosis, but it is an open question whether by 
 preventing an outdoor life they do not reduce 
 the individual's resistance and so bring about the 
 disease. 
 
 Change of climate when it involves change of 
 residence, food, habits, freedom from care and 
 worry, accompanied by properly regulated rest 
 and exercise, is of influence as a preventive or 
 restorative, but such action must not be attrib- 
 uted solely or even largely to change in atmos- 
 pheric conditions. That climate is best which 
 tempts us most to be outdoors, especially when 
 we expect to reside in it permanently, but to 
 return from a lovely, warm, exhilarating sunny 
 climate where one has spent many hours out of 
 doors to one which is bleak, dreary and sunless 
 is depressing and makes an outdoor existence 
 more difficult. 
 
 There are certain localities in all climates 
 which by experience many individuals have 
 found to be stimulating. Such localities are 
 frequented by numbers of people and become 
 
138 RULES FOR RECOVERY 
 
 known as summer, winter or health resorts. 
 The benefit derived from these places is to be 
 attributed largely to change of environment and 
 in some instances to a more properly regulated 
 life. Even change from a "good" to a "bad" 
 climate may produce this benefit, and a sojourn 
 in any climate for more than eight or nine 
 months without change is often inadvisable. 
 But here again many factors enter which only 
 the physician can pass upon. 
 
 Any patient who seeks a change of climate 
 should make inquiries about the place he selects 
 and obtain a letter, if possible, from his physi- 
 cian to some medical man located there. On 
 arrival he is often stimulated, and for this reason 
 should remain quiet for some time until his 
 physician permits him to walk. He must not 
 expect to alight upon the platform of a health 
 resort and to have a "package" of good health 
 handed him with an insurance against relapse 
 attached to it. There, as at home, the rules 
 mentioned elsewhere in this book and his physi- 
 cian's advice must be conscientiously followed. 
 
FROM PULMONARY TUBERCULOSIS 139 
 
 XVIII 
 
 ON HOW AND WHEN WE CONTRACT 
 TUBERCULOSIS 
 
 "Knowledge comes but wisdom lingers." 
 
 When through knowledge the time comes 
 that we fear not for the pestilence that walketh 
 in darkness, nor for the sickness that destroyeth 
 in the noonday, then the need for sanatoriums 
 and for such books as this will be done away 
 with. Until that time, however, we must cease- 
 lessly strive to increase our meagre knowledge 
 of the spread of disease, and having acquired a 
 little mpre, must put it as soon as possible into 
 practical use. 
 
 The idea of contagion is centuries old, and 
 100 B.C. we find it suggested that animalculse, 
 invisible to the naked eye, may bring about dis- 
 ease. Everyone has no doubt heard many times 
 of infectious and of contagious diseases. An 
 infectious disease is one in which the cause of 
 the disease gains entrance into the body and 
 multiplies there, giving off poisons. Contagion 
 relates to the method of transmission of the 
 disease from the infected person to the well. 
 From this it can be readily seen that a contagious 
 disease is a communicable disease. While I 
 
140 RULES FOR RECOVERY 
 
 have not time to discuss it, it may be said that 
 not all infectious diseases are communicable. 
 
 What concerns us now are the methods of 
 transmission of disease in general and of tubercu- 
 losis in particular. First, a number of diseases, 
 and among them tuberculosis, may be trans- 
 mitted through the air. Second, some diseases 
 require a peculiar form of direct personal contact 
 for transmission. Third, a few diseases are con- 
 veyed from one person to another through food 
 or water, very rarely by personal contact or by 
 air: for instance, typhoid. Fourth, many dis- 
 eases, such as malaria and yellow fever, are 
 transmitted by insects. Fifth, some diseases 
 can be acquired only by an injury of the body, 
 never by contact without injury. Here are 
 lockjaw and hydrophobia. 
 
 We must next consider how these germs (for 
 I shall limit this chapter to diseases caused by 
 germs) gain entrance into the body. The most 
 common entrances are through the skin, the 
 membranes of the eye, nose, mouth, tonsils, 
 lungs, stomach and intestines. When the disease 
 is air borne it can enter through any of the 
 sources, but in the case of tuberculosis most 
 usually through the respiratory tract or lungs, or 
 when through food, through the mouth, tonsils 
 or intestines. I refer especially to milk from 
 tuberculous cows. 
 
 If we devote our attention more particularly 
 to tuberculosis we see that there are two great 
 
FROM PULMONARY TUBERCULOSIS 141 
 
 sources of infection: first, man, and second, 
 cattle. While the tubercle germs from cattle 
 affect chiefly children and cause only 8 per cent, 
 of the deaths from tuberculosis, nevertheless they 
 kill 10,400 persons in the United States each 
 year. The germs enter the body practically 
 always in the milk drawn from a tuberculous 
 cow. It would seem to be a simple matter to 
 rid our cattle of tuberculosis, but the cost would 
 be so great that it appears impracticable to 
 attempt it today. Man, however, is the source 
 of infection of man in 92 per cent, of all cases, 
 and it is necessary that we should study h-ow this 
 takes place. While some of the secretions of the 
 body do contain some tubercle germs, it has 
 not yet been shown that any of them plays an 
 important part in comparison with the sputum. 
 The sputum is unquestionably the source of 
 infection in almost all of the 92 per cent, which 
 I have mentioned. Sputum is usually coughed 
 up, and in the course of twenty-four hours a 
 patient may expectorate billions of tubercle 
 germs. During this act of coughing a fine spray 
 is emitted from the mouth, and may go for a 
 distance of four or five feet from the cougher. 
 This spray may contain tubercle germs, and 
 anyone coming within this radius may inhale 
 them. Most of these droplets, however, must 
 fall to the floor, where they quickly dry. The 
 sputum contains mucus, which when dry is 
 very tough, and it requires considerable force 
 
142 RULES FOR RECOVERY 
 
 to dislodge dried sputum from even a smooth 
 surface. Many men are careless about spitting 
 upon the floors of cars, of public buildings or 
 upon the sidewalks. In the last case, fortunately, 
 the tubercle germs are quickly killed by the light 
 and air, but before that has come about we may 
 contaminate our shoes and skirts and so carry the 
 germs into our homes. Here by one process and 
 another the sputum is finally reduced to dust, and 
 thanks to our darkened houses the tubercle germs 
 may escape death from light. Being incapable 
 of motion they lie in some dark comer for the 
 mistress of the house or for the maid to stir them 
 into the air by dry sweeping. If perchance they 
 fall upon some piece of furniture they are again 
 given a chance, as Dr. Osier says, by that per- 
 nicious process aptly termed dusting. When 
 each tiny particle of dust can carry a dozen or 
 more of these germs we see how readily they 
 can be breathed in, for it requires from one to 
 eight hours for the dust to settle completely, a 
 strong argument in favor of the vacuum cleaner. 
 From what I have said it can readily be seen 
 that tubercle germs need protection from light 
 and air, which will kill them, and this they gain 
 in the house. For this reason tuberculosis has 
 been well called a house disease. I do not believe 
 it is ever acquired in the open air. So much then 
 for the tubercle germ. 
 
 We must now turn our attention to the 
 persons who become infected and attempt to see 
 
FROM PULMONARY TUBERCULOSIS 143 
 
 how and when this may occur. It might be 
 stated at the outset that no person is so resistant 
 to the disease that he cannot acquire it if he 
 gets into his body a sufhcient number of the 
 germs. Again, it is readily seen that when this 
 person's powers of resistance are weakened, 
 fewer germs are needed to infect him. There 
 is much evidence to show that young animals 
 and children have less powers of resistance to 
 the tubercle germs than adults. Many reasons, 
 which we cannot enter into, have been advanced 
 to explain this. The child lives, however, nearer 
 the earth and the dust than his elders. He 
 creeps on the floor and mouths all objects that 
 he can get into or near his mouth. Dirt has no 
 terror for him and he no repugnance for it. They 
 are often constant companions, and if perchance 
 he lives with infected dirt his chances of infec- 
 tion are nearly loo per cent. Figures have been 
 published to show that in some large European 
 cities in nearly every child before the age of four- 
 teen tubercle germs have found a lodgment. In 
 infants, when they cause tuberculosis which is 
 discoverable, the outlook is gloomy. It has 
 been estimated that 80 per cent, of infants 
 infected in the first year die from tuberculosis, 
 while death occurs in only 20 to 30 per cent, of 
 those so infected in the second year of life. In 
 the later years of childhood, the outlook for 
 discoverable disease is brighter. But as I said 
 before, from 50 per cent, to 100 per cent, of all 
 
144 RULES FOR RECOVERY 
 
 children who have reached their fifteenth year 
 have gotten tubercle germs into their bodies. 
 These children are infected, as we say. As only 
 one in seven to one in ten of all persons die of 
 tuberculosis, many of these must recover from the 
 infection, or holding it in check, finally succumb 
 to other diseases. This lodgment of tubercle 
 germs, this infection, must have some effect upon 
 the person, and it is interesting to try to find 
 out what it is. It is well known what tuberculin 
 is, the poison of the tubercle germ, and that when 
 it is injected in moderate amount into the body 
 of a healthy person it produces no results. This 
 is also true of children. The first effect of the 
 tubercle germs when once in the body is to change 
 it so that it reacts, as we say, to tuberculin. 
 Remember that it is impossible to make a man 
 or baby or animal without tubercle germs react 
 to tuberculin. This, then, is the first effect. 
 
 The next question is: What becomes of the 
 tubercle germs? We know that in the vast 
 majority of cases they produce no discoverable 
 disease. Do they die or do they smoulder along 
 like fire in cotton, waiting for a suitable moment 
 to burst out? It has gradually been proved that 
 to make an animal resistant, or immune, as we call 
 it, to tuberculosis, we must inject living. tubercle 
 germs. If this is so, these infected children may 
 be more or less immune so long as the tubercle 
 germs remain alive. This means that they can 
 resist fresh doses of new tubercle germs, pro- 
 
FROM PULMONARY TUBERCULOSIS 145 
 
 vided the doses are not too large. The children 
 grow up and possibly for one reason or another, 
 such as overstudy, too little sleep, poor food, 
 stale air or what not, become run down. Their 
 immunity or resistance is greatly lessened and 
 they become liable to fall a prey to their own 
 tubercle germs which they have housed for years, 
 or to the germs of another, which some believe 
 is less likely to occur. This unfortunate accident 
 occurs most frequently between the eighteenth 
 and thirtieth years. Symptoms develop and 
 attention is drawn, say, to the lungs where is 
 found a deposit of germs which came from the 
 original point of infection, usually a (lymph) 
 gland. The older a person becomes after twenty^ 
 five, the less likely is he to develop tuberculosis. 
 After adult life is reached the number of germs 
 necessary to produce an infection is very much 
 larger, and, furthermore, it seems often neces- 
 sary that the resistance of the person so exposed 
 must be reduced for an infection to take place. 
 The resistance can be reduced by overwork, 
 great mental anxiety, worry, nursing some 
 member of the family, poor food, poor air and 
 a thousand and one other things. For years I 
 have felt that we do not know all there is to 
 be known about contagion and tuberculosis. 
 Many thought and some still think heredity 
 might play a part. By this I mean not the 
 inheritance of the tubercle germ, but of lessened 
 resistance to it. It may play some part and 
 
 10 
 
146 RULES FOR RECOVERY 
 
 should make us more careful about exposure of 
 such children. Picture a child born into a family 
 where the father is ill with pulmonary tubercu- 
 losis. He cannot work and sits about the house 
 and spits, not always into the stove or cuspidor. 
 The dirt on the floor becomes infected with 
 tubercle germs. The baby, with lessened resist- 
 ance through poor inheritance, poor air, poor 
 food, creeps in this infected air on the infected 
 floor and the result is quickly manifested. The 
 older children develop bone or gland tuberculosis 
 and later possibly- pulmonary tuberculosis. 
 
 It might be asked on what evidence much of 
 this is based. It has been slowly accumulating 
 for years, and today we have a large amount 
 of experimental work on animals that goes to 
 prove what I have said. That infection in 
 adults is rare is proved by the number of nose 
 and throat specialists who after years of work 
 with tuberculous patients, escape discoverable 
 tuberculosis. In Brompton Hospital in London, 
 where a large number of doctors have for years 
 cared for tuberculous patients, the number of 
 doctors who developed pulmonary tuberculosis 
 is astonishingly small. Of 376 internes in the 
 City Hospital in Chicago (Cook County), where 
 tuberculous patients were in all the wards, only 
 one in twenty developed pulmonary tuberculosis, 
 whereas in the general population one in ten 
 dies from it. These persons were especially 
 exposed to tuberculosis. Some years ago we 
 
FROM PULMONARY TUBERCULOSIS 147 
 
 attempted to prove that adults could be infected. 
 We wanted to find two closely associated but 
 unrelated adults and chose to study man and 
 wife, one of whom was tuberculous. We collected 
 over 40,000 couples, one partner of each couple 
 being tuberculous, and Mr. Pope, a statistician, 
 studied them. Allowing for the one in ten who 
 becomes tuberculous under any conditions, we 
 had very great difficulty in proving infection for 
 the small remainder. On the other hand, I do 
 believe there is some though not great danger for 
 adults. This is suggested by the fact that when 
 healthy milch cows are associated in a barn with 
 tuberculous cows, sooner or later most of them 
 become infected. 
 
 Now to recapitulate: We have seen that, 
 roughly speaking, tuberculosis is spread from 
 cattle to man in 8 per cent., but from man to man 
 in 92 per cent. Sputum in the form of dust or 
 droplet is the chief source of infection. We must 
 not relax in the slightest our efforts to destroy 
 all germs as they leave the body. We have 
 learned that young animals and children are 
 many, many times more prone to tuberculous 
 infection than adults. We must redouble our 
 efforts to protect infants and children, and what 
 is not less important, we must see that the 
 resisting powers of adults are not lowered by 
 circumstances over which they have no control, 
 such as long hours of work, working under poor 
 hygienic conditions, and the many other factors 
 
148 RULES FOR RECOVERY 
 
 that I have mentioned. In fact, it is likely that 
 adults must have a very large dose of germs or 
 have lessened resistance to become infected at all. 
 In conclusion I would say that I believe the 
 most efficient methods of combating tubercu- 
 losis now at our disposal are: the greatest pro- 
 tection of children during the first few years of 
 life, and the maintenance, especially from the 
 fifteenth to the thirtieth year, of the individual's 
 resistance to disease. 
 
FROM PULMONARY TUBERCULOSIS 149 
 
 XIX 
 
 ON THE CARE OF CHILDREN IN THE HOMES 
 OF THE TUBERCULOUS 
 
 "Forethought will often save much afterthought." 
 
 The Jaelief that tuberculosis is acquired nearly 
 always in childhood and that after lying dor- 
 mant for many years it breaks out again as 
 tuberculosis of the lungs, most often between the 
 eighteenth and thirtieth years, has been accepted 
 by many prominent students of the disease. 
 Whether tuberculosis is due to an outcropping 
 of the early infection or to a fresh implantation 
 of germs, we know that tuberculosis is a very 
 deadly disease among infants. Some have 
 claimed that 70 to 80 per cent, of infants under 
 one year of age who contract tuberculosis die 
 from it. The disease is very much less fatal 
 in the second year of life and from this time on 
 becomes less dangerous and even runs a more 
 favorable course than in adults. 
 
 Some investigators have stated that in some 
 large European cities among the poorer people 
 nearly every child (95 per cent.) by the age of 
 fourteen or fifteen years has gotten the tubercle 
 germ into its body, but in the vast majority it is 
 dormant. In one of the large American cities 
 
150 RULES FOR RECOVERY 
 
 only one-third of such children were found to 
 harbor this germ. 
 
 On the basis of such statements, it is easy to 
 outline what we should do theoretically but 
 difficult to carry it out practically. It might be 
 well, however, to state the ideal conditions and 
 from them draw what practical help we can. 
 
 From what has been said it readily follows 
 that the greatest effort to protect the infant, 
 baby and child from the tuberculosis germ should 
 be exerted during the first four years of life and 
 particularly during the first year. During this 
 first year of life the baby possesses no power of 
 locomotion and the problem is far simpler then 
 than later when he begins to walk and play about. 
 Thereafter it appears that sooner or later he 
 comes in contact with the tuberculosis germ. If 
 he be protected carefully during the first two or 
 three years it is probable that he will develop 
 normally if his inheritance be good. Some have 
 suggested that the long, narrow chest is due to 
 infection (implantation with the tubercle germ) 
 before the third year. In any case we know 
 that it makes a great difference whether the 
 child gets its first tubercle germs in its first or 
 seventh year. 
 
 In the first place, we can learn from the 
 handling of calves born of tuberculous cows that 
 when they remain with their mothers even a 
 very short time the tubercle germ gets into their 
 bodies. If, on the other hand, they are removed 
 
FROM PULMONARY TUBERCULOSIS 151 
 
 at birth from their tuberculous mothers and 
 brought up so that they do not come in contact 
 with the tubercle germ they become healthy 
 cattle. Theoretically this should be done for one 
 and one-half years with infants whose mothers 
 are tuberculous, but practically it is generally 
 impossible to bring this about. However, for 
 the sake of the mother as well as for the child 
 she should not nurse her infant. It should be 
 brought up in a room apart from hers ; she should 
 not kiss it nor cough near it, nor should she 
 allow it upon her bed even for a short time. In 
 fact, it should be with her as little as possible until 
 her disease is arrested and the tubercle germs 
 disappear from her sputum. The use of her 
 handkerchief or of eating utensils which she 
 has used should be absolutely forbidden. These 
 rules, of course, apply to a tuberculous father, 
 who should not be set to care for the baby. 
 
 The domestics, and particularly the nurse, 
 should be healthy. The nursery should be invio- 
 late, and visitors or the family with dirty or dusty 
 skirts and shoes should be kept out. The 
 baby may be taken to the parlor to see visitors. 
 The floor of the nursery should be kept scrupu- 
 lously clean, for soon the baby creeps and crawls 
 everywhere upon it. What is on the floor is 
 quickly on his hands and under his nails, and 
 what is on his hands is shortly in his mouth. 
 Again, very little draught stirs up the dust on 
 the floor just high enough to enable the youngster 
 
152 RULES FOR RECOVERY 
 
 to inhale it. Where there are cracks there is 
 dust, and tiles (a heated tile floor) make the 
 ideal thing for a nursery. 
 
 These conditions are ideal and can be pro- 
 vided in few homes. In faot, in many there can 
 be no nursery and under such conditions a 
 blanket, so marked that one side is always placed 
 upon the floor, makes a good place for the baby 
 to crawl upon. Dry sweeping or dry dusting 
 should not be used where there is a baby. 
 
 The time, however, soon comes when the 
 child begins to walk and to play out of doors, and 
 then it is impossible to prevent sooner or later 
 his coming in contact with the tubercle germ. 
 Fortunately every year he is better able to 
 resist it. 
 
 Another important source of danger to babies 
 is the milk which cpmes from tuberculous cows. 
 No price is too great to pay for pure milk, and 
 in milk, as in other things, we get just what we 
 pay for. A large amount of the tuberculosis in 
 children has been found to come from milk from 
 tuberculous cows. The cows should all fail to 
 react to tuberculin and the milk should fall in 
 Grade A, that is, have relatively few other and 
 no tuberculosis germs. When such ideal con- 
 ditions cannot be fulfilled, the milk should be 
 properly pasteurized and very carefully kept, for 
 germs grow as rapidly in pasteurized as in raw 
 milk. 
 
 We have seen now what a great struggle should 
 
FROM PULMONARY TUBERCULOSIS 153 
 
 be made to keep the infant and the young child 
 and the tuberculosis germ apart, and we have 
 seen that it is exceedingly difficult. As they 
 grow older we must take it for granted that from 
 one-third to nineteen-twentieths of all children 
 get these germs into their bodies. Now our 
 problem changes, and added to the struggle 
 to keep out the tuberculosis germs must be 
 added the fight to keep those which have gained 
 entrance from multiplying and producing dis- 
 ease as we recognize it in everyday life. This 
 is accomplished by raising the resistance of the 
 child to all diseases. Good air and good food are 
 prime essentials. The effects of the good hous- 
 ing laws and of the model tenements are now well 
 established, but the work of the open-air schools 
 and medical inspection of school children have 
 not yet been fully felt. Both are powerful fac- 
 tors in increasing the child's resistance to the 
 advance and multiplication of the tuberculosis 
 germ already within it, as well as to the implan- 
 tation of these germs. For predisposed children 
 hyperventilation is necessary and school should 
 not be begun too early. Care of the mouth, 
 throat and nose is important, but for a child 
 which harbors the tuberculosis germs the most 
 strenuous efforts should be taken to avoid measles 
 and whooping-cough — especially must this be 
 done when the child is still under three or four 
 years of age. If unfortunately they occur in 
 such children, the children should be treated 
 
154 RULES FOR RECOVERY 
 
 for some time as if they already had tuberculosis 
 as a disease. An important point is to teach 
 early to these young people the value of self- 
 restraint and unselfish and self-denying habits. 
 An outdoor life at all times should be encouraged, 
 but indulgence in sport be kept within their 
 strength, and the danger of injuries not over- 
 looked as a predisposing factor. Fresh air should 
 be supplied to these children in large quantities 
 day and night. 
 
FROM PULMONARY TUBERCULOSIS 155 
 
 XX 
 
 ON TUBERCULIN 
 
 Science is a river with two sources: the practical source and 
 the theoretical source." 
 
 The extensive use of tuberculin both in diag- 
 nosis and treatment of tuberculosis has aroused 
 much interest among patients who have fallen 
 ill of tuberculosis. Naturally their first inquiry 
 is: What is tuberculin? This is best answered by 
 describing its preparation. The tuberculin first 
 discovered by Koch is still so widely used that 
 its preparation will be described. Tubercle 
 bacilli are allowed to grow on beef broth for five 
 or six weeks. The fully developed growth is then 
 boiled for an hour, evaporated down to one- 
 tenth of its original volume and filtered through 
 porcelain. This clear brown fluid contains no 
 tubercle germs but only the substance extracted 
 from their bodies through boiling and possibly 
 the product secreted by the germs in their 
 growth. There are many other tuberculins in 
 use, but it will be of no help to us here to discuss 
 in endless detail slight variations. 
 
 This form of tuberculin, then, is an extract of 
 the tubercle germs. It is not a serum which 
 comes from the blood, not an antitoxin. To pre- 
 
156 RULES FOR RECOVERY 
 
 pare diphtheria antitoxin, the diphtheria toxin 
 (a name for a variety of poison) obtained from 
 diphtheria germs is injected into the horse. 
 The horse's body is stimulated then to form 
 substances which combat the toxin. These sub- 
 stances are contained in the blood serum and are 
 called antitoxins. When injected into the body 
 of a child ill with diphtheria, they neutralize the 
 diphtheria poison, and the child is enabled to 
 recover. While many attempts have been made 
 to obtain such an antitoxin in tuberculosis they 
 have all failed. From what has been said about 
 the effect of antitoxin in the child, it is clearly 
 seen that the child's body is not called upon to 
 form any new substances but is merely passive; 
 this form of immunity {i. e., the ability to 
 resist disease) is called passive immunity. The 
 horse which formed the antitoxin, on the other 
 hand, had active immunity, for its body created 
 or formed immune bodies. The child could be 
 desperately ill and the antitoxin would save its 
 life, but only when the horse is in good condition 
 can its body form much antitoxin. 
 
 Now tuberculin is a poison, and only when the 
 body is in fairly good condition can it respond 
 favorably to tuberculin, which must be given 
 very carefully. To obtain the best results neces- 
 sitates considerable study and experience and 
 great frankness on the part of the patient with 
 his physician. No matter how little his symp- 
 toms or feelings deviate from their usual course 
 
FROM PULMONARY TUBERCULOSIS 157 
 
 they should be recorded and reported. Just how 
 tubercuHn acts is not fully understood, but a safe 
 method of giving it has been devised. In a small 
 number of patients the results from the use of 
 tuberculin have been remarkable; another small 
 group cannot tolerate it, but the vast majority 
 take it well, although they experience apparently 
 little benefit from its use. When given carefully 
 it may help the patient and will do him no harm. 
 
158 RULES FOR RECOVERY 
 
 XXI 
 
 ON THE DISEASE TUBERCULOSIS 
 
 "When a man's knowledge is not in order, the more of it he 
 has the greater will be his confusion." 
 
 Curiosity, termed at times, more politely, a 
 spirit of investigation, activates or lies dormant 
 in most of us. It is, therefore, natural that 
 patients who for months live in the open, sitting 
 much on porches, conversing on many subjects, 
 should dwell occasionally on what is uppermost 
 in their minds, tuberculosis. What is it? What 
 causes it? Why is it so called? These and a 
 thousand other questions arise in those with 
 active minds, and some attempt will be made 
 here to answer a few of them. It must be remem- 
 bered, however, that it takes a good preliminary 
 education, four years in a medical school and 
 a year or two in a hospital, before a physician 
 is in any position to comprehend all these prob- 
 lems and answers. Indeed, some patients seem 
 to think that even after many years some phy- 
 sicians fail utterly to understand the disease and 
 that their own knowledge of it is far superior. 
 The fallacy in this lies in the fact that the physi- 
 cian has many diseases to think of, the patient 
 but one, and he attributes the symptoms of many 
 other diseases to this. But however this may be, 
 the fact remains that many years are required 
 
FROM PULMONARY TUBERCULOSIS 159 
 
 before the disease in all its bearings is fully 
 understood by those who have already studied 
 medicine. It seems needless then to add that it 
 is impossible to impart to any patient without 
 this preliminary study in a few minutes or a few 
 hours what others with such study often fail 
 to grasp. The conclusion from all this is the fact 
 that the patient must not expect that his knowl- 
 edge of these facts will become in a short time so 
 accurate that he can base his course of action 
 upon them. Of course, many empirical rules are 
 laid down in the other chapters of this book, 
 but what is said here relates to the underlying 
 pathological and anatomical changes in the body 
 brought about by the tuberculosis. 
 
 The name "tuberculosis" or "tubercle" is 
 the diminutive form of "tuber," a swelling or 
 knot, and hence tubercle means a little swelling. 
 We speak of potatoes as tubers because they are 
 swellings upon the roots of the potato plant. 
 The cause of this swelling in the lung is the 
 "tubercle " germ, and without this germ there can 
 be no tuberculosis. When the tubercle germ is 
 inhaled or swallowed and reaches in some way 
 the lung, it poisons the lungs and they react 
 against it and try to wall it off. In this process 
 a little swelling is formed, and this swelling is 
 called a tubercle. After a little while the body 
 attempts to inclose this within a scar. The scar 
 tissue at first is very delicate, almost like a spider 
 web, but later gets stronger and stronger and 
 avails off the tubercle germ, which has by this 
 
160 RULES FOR RECOVERY 
 
 time multiplied into a number of tubercle germs. 
 Many of these germs lie in cells which attempt 
 to wander through the scar wall, carrying the 
 germs with them. Now when the body is over- 
 coming the disease the scar is so strong that the 
 germs cannot escape through the wall, but if 
 the germs can so poison the body that the scar 
 wall dies before a larger wall can form without 
 the first, then the disease advances and spreads. 
 When the latter takes place the former process 
 also often occurs. When the body is gaining the 
 ascendency lime salts (calcium) are deposited in 
 the tubercle and form, so to speak, its gravestone. 
 This is the history of the single swelling or 
 tubercle, but many occur in the lung before we 
 can detect the evidences of disease. The lung 
 then looks like an apple which has scattered in 
 a small part of it little yellow spots of decay. No 
 part or only a microscopic part of the lung is lost, 
 and all about the swellings there lies good lung 
 which we use. If the disease advances and the 
 swellings become so numerous that a part of the 
 lung is so destroyed that it can never again be of 
 use to us Nature steps in and cuts it out. If the 
 very end of one's finger had become so full of 
 tubercle germs that the bone was destroyed and 
 it could not be used, but remained a source of 
 danger, the natural decision would be to have 
 it amputated. When Nature or the body's 
 forces cut off a bit of the lung they are acting 
 in the same way. The result of such a process is 
 a hole or a cavity which we can readily see is^ 
 
FROM PULMONARY TUBERCULOSIS 161 
 
 after the disease has reached a- certain stage, the 
 first step toward healing. This hole is surrounded 
 by a scar which gradually shrinks and contracts 
 the cavity. 
 
 In some patients more scars form than in 
 others, and as these scars shrink the lung cannot 
 expand so freely, nor can it take in as much air 
 as formerly. The result is the patient is some- 
 what short of breath, due to the healing process. 
 
 It may not be amiss to speak in a few words 
 of the physiology of the lungs. The body is 
 composed of millions of tiny units called cells 
 which, highly specialized, carry on the various 
 works of the body. In each of these cells 
 combustion of the food products is carried on. 
 Waste consequently accumulates and must be 
 removed. This is done by the blood which car- 
 ries it to the kidneys, where part is thrown out of 
 the body, and to the lungs, where carbonic acid 
 gas is given off in the exhaled air. Now for 
 combustion oxygen is necessary and the cells 
 must be supplied with it. The blood absorbs it 
 from the air in the lungs and carries it to the 
 cells which need it. Fresh air perhaps makes the 
 work of the lungs easier and possibly reduces 
 the number of breaths necessary, but when no 
 irritating substances are present fresh air acts 
 no more upon the lungs than upon the liver or 
 muscles of the leg. While this is so it must be 
 remembered that fresh air is essential for the well- 
 being of all parts of the body in good health, and 
 vitally so during disease. 
 11 
 
162 RULES FOR RECOVERY 
 
 XXII 
 
 ON DEFINITION OF "CURE" AND "ARREST" 
 
 AS USED IN THE TREATMENT OF 
 
 TUBERCULOSIS 
 
 "Call things by their right names." 
 
 The following medical terms are used in a 
 meaningless way by many laymen. It is always 
 a doubtful procedure to attempt to instruct 
 patients in their use, but as it is impossible to 
 prevent their use a few words about them may 
 in a way clear the situation. From the earliest 
 times to the present, physicians have attempted 
 to classify all patients with pulmonary tuber- 
 culosis into three classes or stages: The first 
 class includes patients in the very earliest or 
 incipient stage (which term relates less to the 
 time the patient has had the disease than to its 
 extent and its ravages), the third class contains 
 the patients in the later or far-advanced stages, 
 and the second, by far the largest class, embraces 
 those in the middle or moderately advanced 
 stage. 
 
 Twenty-five years ago it was difficult for any- 
 one, even a physician, to believe that a patient 
 ill of pulmonary tuberculosis ever recovered. 
 When the treatment of the disease, described 
 
FROM PULMONARY TUBERCULOSIS 163 
 
 in other chapters, was inaugurated it became 
 necessary to convince the public that many 
 patients did recover, for to extend the struggle 
 against tuberculosis it was necessary to build 
 many sanatoriums, and their construction 
 depended upon the generosity of the public. 
 For this reason, even against the better judg- 
 ment of some medical men, the term "cured" 
 was used in connection with patients who had 
 apparently recovered. It was true that for a 
 time the modifying word "apparently" was 
 used, "apparently cured." Soon, however, it 
 was realized both by physicians and laymen that 
 "cure" in tuberculosis meant something far 
 different from what is meant in measles, small- 
 pox, pneumonia or any one of a dozen other 
 diseases. The "cures" or "apparent cures" 
 returned home or to work, and, alas, a certain 
 number of them fell again into their hygienic- 
 ally evil ways and met shortly the fate of such 
 transgressors. This led to many articles upon 
 such topics as: "Is Such Treatment of Tubercu- 
 losis Worth While?" The outcome of it all was 
 that a strong opposition arose to the terms 
 "cured" and "apparently cured," for the oppo- 
 nents said they created an erroneous impression 
 upon the public and lulled the patients into a 
 false sense of security. The ultimate result in 
 both instances was deplorable, for the public 
 said: "The physicians call these patients 'cures,' 
 and see how quickly they relapse;" and the 
 
164 RULES FOR RECOVERY 
 
 patients said: "Why did they lead us to believe 
 we were 'cured' when they knew we might not 
 be?" The final outcome of the matter was that 
 the term "apparently cured" is now applied 
 only to patients who have been at home working 
 under ordinary conditions of life for two years, 
 and even then stress, much stress, must be laid 
 upon "apparently." Today patients are said 
 to have their disease "apparently arrested" or 
 "arrested," for that is all that a physician can 
 honestly say. If a patient keeps well indefi- 
 nitely, he is cured; if he relapses after one, two, 
 or three months of strenuous life, or even after a 
 year or two, he belonged to the vast multitude 
 of those with their disease arrested. Today as 
 many, and in all probability more, patients are 
 "cured" than ever before, but the writer wishes 
 to emphasize the fact that no one can say when 
 a patient passes from a condition of arrest into 
 that of cure. 
 
FROM PULMONARY TUBERCULOSIS 165 
 
 XXIII 
 
 ON THE HYGIENIC CARE OF THE PATIENT 
 
 "I am a man: I hold that nothing which concerns mankind 
 can be of indifference to me." 
 
 Every patient with tuberculosis has certain 
 duties and obligations that he should perform 
 to protect his family, his friends and all those 
 with whom he comes in contact. On the other 
 hand, these persons have certain obligations to 
 such a patient, not least among which is the dis- 
 sipation of foolish fear about contagion from a 
 careful patient. He who collects and destroys his 
 sputum, who covers his mouth when coughing, 
 can be of no source of danger to anyone. 
 
 Many laws have been passed prohibiting 
 spitting wherever anyone must tread. It is 
 not sufficient, however, to pass such laws; an 
 intelligent sympathetic public opinion should be 
 created to enforce them. The "arrested" patient 
 should heartily uphold all such measures, for 
 his training has taught him that many appar- 
 ently well persons who spit have tuberculosis, 
 and a belief that one is well affords no excuse 
 for breaking such laws. If one must spit he 
 should always spit in some receptacle provided 
 for the purpose or in running water. Moist 
 tuberculosis germs cannot leave the moist sur- 
 
166 RULES FOR RECOVERY 
 
 face except under peculiar conditions, i. e., 
 coughing, which will be mentioned later. 
 
 Every patient should know about the disposal 
 of sputum. In the first place, it is necessary for 
 a patient who expectorates to have with him 
 constantly some sort of receptacle to hold the 
 sputum until it can be destroyed. While in bed 
 or on the porch nothing is better than the ordi- 
 nary individual sanitary cuspidor, constructed 
 of a tinned iron frame, holding a thick water- 
 proofed paper cup, folded in such manner that 
 flanges prevent spilling if accidentally overturned. 
 Each day, or oftener if necessary, the filler is 
 removed, filled with sawdust, wrapped in paper 
 and burned in the furnace or stove. The metal 
 frame should be washed with a 5 per cent, solu- 
 tion of carbolic acid. Several types of .good 
 waterproof paper pocket cups have been devised, 
 and a patient should never be without one. 
 These, too, should be wrapped up and burned. 
 The use of small pieces of cheesecloth or paper 
 napkins is not so cleanly but is permissible when 
 a patient is confined to bed. Each piece of 
 cloth or napkin should be used but once, then 
 folded and placed in an ordinary paper bag 
 (obtained at the grocery), pinned on the side of 
 the bed or mattress. This should be removed 
 daily and burned. Such a method eliminates 
 all handling of infected material by anyone but 
 the patient. Much needless fear prevails among 
 the laity about getting a little sputum upon the 
 hand. It can be of no possible source of danger 
 
FROM PULMONARY TUBERCULOSIS 167 
 
 (provided it does not get into a scratch or wound) 
 if the hands are carefully washed with soap and 
 water. 
 
 To make a practice of expectorating into a 
 handkerchief is inexcusable and dangerous. It 
 has been said that the only dangerous germ is 
 the dry germ, for only the dry germ can get into 
 the air. Sputum in handkerchiefs quickly dries 
 on account of the heat of the body, and if the 
 handkerchief is used again some of the sputum 
 becomes in part pulverized, and when shaken in 
 the air tends to disseminate as dust. When this 
 soiled handkerchief is used to blow the nose 
 upon the dried sputum may gain entrance into 
 the lungs through the deep breath that usually 
 precedes such an act. The Chautauqua Salute 
 (the waving of handkerchiefs) should be abol- 
 ished. If at any time the handkerchief must be 
 used to receive sputum it should be burned. 
 
 The writer believes that colds may be dissemi- 
 nated by the careless use of handkerchiefs, and 
 even by the prolonged use of a handkerchief 
 an individual may possibly reinfect himself. 
 Colds, grip and influenza are all contagious, and 
 a person suffering from one of them should not 
 be allowed to come near a patient. 
 
 The only dangerous germ is the dry germ, but 
 there is one exception. When a patient coughs 
 or sneezes he may cough or sneeze out a spray 
 and the spray may contain the germs which 
 have brought about the cough. This is true 
 for grips, colds, bronchitis, influenza, diphtheria, 
 
168 RULES FOR RECOVERY 
 
 pneumonia or tuberculosis. The little germ- 
 laden droplets may go for a distance of three or 
 four feet from the cougher and may remain sus- 
 pended in the air for one-half to one or more 
 hours. Anyone who inhales these droplets would 
 inhale any germs they contain. Fortunately the 
 effect of light and air is such that the germs are 
 quickly weakened and destroyed. But it is not 
 necessary that the germs should escape into the 
 air. A piece of cheesecloth of two or three 
 thicknesses held over the mouth will filter out 
 and catch all these droplets and germs. At the 
 end of the day or oftener the cloth may be burned. 
 It should never be shaken, and it is advisable to 
 have a second piece to use as a handkerchief. 
 Another practical point is that patients' chairs 
 or beds should be at least four feet distant one 
 from another. 
 
 The patient should, of course, exercise scru- 
 pulous cleanliness about his person, linen and 
 clothes. As soon as a diagnosis is made it may 
 be of value to disinfect the patient's clothes and 
 his room, for previous to the diagnosis he may 
 not have used sufficient care. If a patient wears 
 a mustache or beard it should be closely cropped, 
 for sputum may get on it, dry, and so be a source 
 of danger to himself and others. Kissing must 
 be given up. He should wash his hands fre- 
 quently. He should have whenever possible 
 and feasible a room to himself, but separate 
 dishes and silver are not necessary if they are 
 washed carefully and scalded and polished. The 
 
FROM PULMONARY TUBERCULOSIS 169 
 
 room may contain a few pictures and rugs. 
 Washable curtains are permissible. Dry dusting 
 or dry sweeping is inexcusable. 
 
 The skin is crowded with tiny bloodvessels 
 in whose walls are still smaller muscles which 
 narrow or dilate the bloodvessels. Through the 
 contact of the blood in these tiny vessels and in 
 lungs with the air the body loses heat. In 
 colder air the skin blanches through the contrac- 
 tion and in hot air it becomes reddened through 
 dilatation of these bloodvessels. To meet sudden 
 changes of temperature these tiny vessels must be 
 quickly contracted or dilated, or otherwise we 
 become chilled or overheated and catch cold. We 
 must strive to keep the muscles of these blood- 
 vessels in good condition to avoid these mishaps. 
 We can best do this by washing with hot water 
 and quickly sponging off with cold. The neck, 
 arms, chest and back should be treated in this 
 way every day, but the room must be at least 60°. 
 Twice every week a hot bath, using plenty of 
 soap, should be taken, followed by a cold sponge, 
 performed in cold weather while still standing 
 in the hot water. Every patient should begin 
 to sponge himself as soon as possible, but his 
 physician must decide when he should begin. 
 
 We have spoken of many facts the individual 
 patient should know; of many things he should 
 do to protect others, and yet there remains one 
 more duty that he should not neglect. He can 
 no doubt recall how little real knowledge he had 
 about the spread of the disease when he fell ill 
 
170 RULES FOR RECOVERY 
 
 and possibly what a difficult time he had to 
 acquire it. These facts should impress upon him 
 the necessity of enlightening others along these 
 lines, and he may welcome a word or two about 
 how this can be accomplished. The workers 
 against tuberculosis, physicians as well as lay- 
 men, some years ago banded together to do more 
 effective work, forming the National Tubercu- 
 losis Association. This society meets once a year, 
 usually in Washington in May, and publishes in 
 its Transactions papers and reports on all phases 
 of the struggle against tuberculosis. Every 
 patient who can do so should send $5 to the 
 Association, at 381 Fourth Avenue, New York 
 City, and become a supporter of this important 
 work. Having thus made a good beginning he 
 should endeavor to find out about the antituber- 
 culosis campaign in his community and join what- 
 ever organizations there are fighting against the 
 disease or strive to awaken interest in such a 
 fight. He should always bear clearly in mind 
 that while the physician may lead or at least 
 direct the way, the real work must be done by 
 laymen. He should further back up the Board of 
 Health, for whatever improves the general health 
 of the public reduces the amount of tuberculosis. 
 For the same reason, better housing, better 
 working conditions, better conditions in schools, 
 open-air schools for children threatened with 
 decline, and many others are among the agencies 
 which should enlist his support. 
 
FROM PULMONARY TUBERCULOSIS 171 
 
 XXIV 
 
 ON THE CARE OF THE MOUTH 
 
 "Out of thine own mouth will I judge thee." 
 
 The stomach has been described as the bul- 
 wark in the individual's fight against tubercu- 
 losis. If this be true, and it is in part at least, 
 should we not look to our first and second lines 
 of defense, the gums and teeth? More than 80 
 per cent, among civilized races are said to suffer 
 from dental caries (decayed teeth). Sound teeth 
 and a healthy mouth are necessary to maintain 
 health, and are of much more importance in 
 tuberculosis patients. Decayed teeth prevent 
 perfect mastication and may lead to aches and 
 abscesses that greatly upset the even tenor of a 
 patient's way. 
 
 The mouth harbors constantly germs of many 
 sorts, and at times those that produce pus and 
 are capable of producing blood poisoning, as 
 well as the diphtheria germ and the pneumonia 
 germ. These germs are found in greater numbers 
 in patients with uncleanly mouths, proof that 
 cleansing the mouth reduces greatly the number 
 of its germs. It has long been recognized that 
 it is impossible to render the mouth sterile for 
 any period of time, but it is well known that 
 wounds of the mouth heal very quickly, and our 
 
172 RUL'ES FOR RECOVERY 
 
 aim should be to keep the number of harmful 
 germs in the mouth so reduced that they can 
 produce no injurious effect. If this be not 
 done decay of the teeth may set in or progress 
 more rapidly, the gum may become affected with 
 Rigg's disease (pyorrhea alveolaris), and. at 
 times the germ may gain access through these 
 places of entry to the heart, kidney or joints and 
 cause serious disease. A tooth with an abscess 
 on its root (an ulcerated tooth) may cause this 
 trouble, and unclean false teeth and plates may 
 also bring about disease. 
 
 Again, the author has known patients who, 
 suffering for years from diarrhea and other 
 digestive disturbances, were cured by having 
 their mouths put in good condition. Every 
 patient whose mouth and teeth are not in perfect 
 order should have them attended to as soon as 
 his physician thinks it advisable. 
 
 Once in order the teeth should be inspected 
 at least every six months by a competent den- 
 tist, and the patient should be scrupulous in his 
 care of them. It is said that "a clean tooth 
 never decays" and "a lazy tooth in time becomes 
 a rotten one." From this the importance of 
 suitable food and a proper tooth toilet can 
 readily be seen. 
 
 Foods which necessitate considerable chewing 
 are of much benefit to the teeth and should be 
 eaten, as such mastication would in itself help 
 cleanse and so greatly preserve the teeth. 
 
FROM PULMONARY TUBERCULOSIS 173 
 
 But for most of us this is not or cannot be 
 followed out so completely as to do away with 
 other methods of cleansing. Simple rinsing 
 of the mouth with water is not sufficient, and a 
 tooth-brush, with bristles as stiff as the indi- 
 vidual can stand, and shaped after the form of 
 the so-called prophylactic brush, should be used 
 at least twice a day (night and morning),. and if 
 possible after each meal. The brush should be 
 placed against the teeth and gums with the 
 bristles resting on the gums, and then turned 
 in a rotatory manner so that the bristles pass 
 lightly over the edges of the gums, enter into 
 the" spaces between the teeth, cover the surface 
 of the teeth and so clean parts that the bristles 
 do not reach in the ordinary methods. This 
 procedure must, of course, be modified to cleanse 
 the inner surface of the teeth. Warm water 
 should then be forced between the teeth and 
 dental floss passed gently between them. The 
 tooth-brush should always be dry when put in 
 use, and it is often advisable to use several 
 brushes in rotation. They should hang in the 
 sunlight when not in use. The advice given to 
 patients to keep their tooth-brushes in a weak 
 germicidal solution may help to destroy the teeth 
 as well as the germs upon the bristles. Immersion 
 in such a solution may be carried out when three 
 or four brushes are kept in use and dried before 
 using. 
 
 The question of a good mouth-wash has long 
 
174 RULES FOR RECOVERY 
 
 been discussed, and experts have said a good 
 mouth-wash should be non-poisonous, neutral 
 (in reaction), non-corrosive, germicidal, pleasant 
 to taste and smell and refreshing. Patients, 
 however, should not get the idea that any mouth- 
 wash can kill the tubercle germs in the mouth. 
 It has been held, and many still hold, that an 
 alkaline alcoholic solution is excellent for the 
 mouth and teeth, but recent work has cast some 
 doubt upon this. In fact. Prof. Gies advocates 
 the use of fruit juices or vinegar diluted with 
 2 or 3 parts of water (to suit the individual taste), 
 instead of alkaline dentifrices or mouth-washes, 
 and in some patients they may be useful. The 
 problem is still, like many others in medicine, 
 unsettled, and the patient should seek the advice 
 of his dentist or physician for a suitable formula. 
 As a rule the formula prepared by the author 
 and druggists at the Trudeau Sanatorium is good 
 but not suitable for everyone. It follows: 
 
 Ol. eucalypti 
 
 . m 30 
 
 01. gaultherise . . . . 
 
 m 36 
 
 Mentholis . 
 
 . grs. 20 
 
 Thymolis . .... 
 
 . drs. 1 
 
 Extract! baptisiae fluidi 
 
 . drs. 3 
 
 Acid benzoic 
 
 oz. ^ 
 
 Sodii bicarbonatis 
 
 . oz. 1 
 
 Alcohol 
 
 . oz. 48 
 
 AquK 
 
 oz. 80 
 
 Only a part of this should be made up. For 
 use it should be diluted freely. Too free use of 
 tooth powders should not be made. 
 
FROM PULMONARY TUBERCULOSIS 175 
 
 XXV 
 
 ON SUGGESTIONS FOR PATIENTS 
 
 " In pulmonary tuberculosis the notes of personal experience 
 mature too late and cannot be discounted. " 
 
 It has been thought wise to reprint the 
 following summary of suggestions for patients. 
 The explanations of these suggestions have been 
 given elsewhere. 
 
 Food 
 
 Eggs — 2 to 6 a day 
 
 Milk — 2 to 6 glasses 
 
 Meat (at 1 or 2 meals) 
 
 Lunches — 10:30, 3:30, 9, when ordered 
 
 No alcohol 
 
 Baths 
 
 Warm, at least one a week 
 
 Cold sponge to the waist at least every morning 
 
 Air 
 
 8 to 10 hours outside 
 Windows open at night 
 Avoid draughts 
 Avoid crowded rooms 
 
 Ezpectoration 
 
 Use sputum box 
 
 Cloths not to be used, except as directed 
 
 Bed 
 
 9 to 10 hours in bed 
 
 Sleep out of doors or in tent, except in winter 
 No draughts on head 
 
176 RULES FOR RECOVERY 
 
 Sun 
 
 Head out of it on warm days 
 
 Cough 
 
 Control 
 
 Hold cheesecloth in front of mouth 
 
 Use second cheesecloth as handkerchief 
 
 Clothes 
 
 Not too much 
 Use wraps 
 
 Never get overheated 
 Never get chilly 
 
 Colds 
 
 Stay in bed. Report 
 
 Dally Routine 
 
 7.30 Awake. Take temperature 
 
 Milk (hot if desired) if necessary 
 Warm water for washing. Cold sponge 
 8.00 Breakfast 
 
 8.30 Out of doors in chair or on bed 
 10.30 . Lunch when ordered 
 11-1 Exercise or rest as ordered 
 1-2 Dinner. Indoors not over one hour, less if possible 
 2-4 Rest in reclining position. Reading, but no talking 
 
 allowed. Take temperature 
 3.30 Lunch when ordered 
 4.00 Exercise when ordered 
 6.00 Supper 
 7.00 Out on good nights 
 8.00 Take temperature 
 9.00 Lunch and bed 
 
 Once or twice a week a hot bath, followed by cold 
 sponge 
 
FROM PULMONARY TUBERCULOSIS 177 
 
 Always stop any medicine that upsets stomach. 
 
 A hemorrhage does not mean that you are 
 hopelessly worse or cannot be cured. 
 
 Remember that the porch is the most essen- 
 tial feature of the house. 
 
 12 
 
178 RULES FOR RECOVERY 
 
 XXVI 
 
 ON FOOD VALUES 
 
 The following table indicates roughly the 
 amount of protein and the calories in some of the 
 foods most frequently eaten by patients with- 
 tuberculosis. 
 
 Protein 
 
 in grams. Calories. 
 
 Soups — clear 
 
 Beef broth, 4 ounces S.O 32 
 
 Bouillon, 4 ounces 2.6 13 
 
 Consomme, 4 ounces 3.0 14 
 
 Chicken, 4 ounces 13.0 72 
 
 Soups — creamed 
 
 Asparagus, 4 ounces 3.0 114 
 
 Celery, 4 ounces 3.0 116 
 
 Corn, 4 ounces 4.0 140 
 
 Pea, 4 ounces 6.0 162 
 
 Potato, 4 ounces 3.0 135 
 
 Tomato, 4 ounces 3.0 ' 126 
 
 Gruels . 
 
 Arrowroot, 6 ounces 8.0 225 
 
 Barley, 6 ounces 6.0 140 
 
 Cornmeal, 6 ounces 4.0 90 
 
 Oatmeal, 6 ounces 9.0 .200 
 
 Cracker, 6 ounces . .- 11.0 290 
 
FROM PULMONARY TUBERCULOSIS 179 
 
 Protein 
 in grams. 
 
 Beverages 
 
 Whole milk, 8 ounces . . ... 7.2 
 
 Skimmed milk, 8 ounces 7.5 
 
 Beef juice, 4 ounces 6.0 
 
 Cream, J ounce .74 
 
 Tea, 8 ounces 3.0 
 
 Coflfee, 8 ounces 3.0 
 
 Cocoa, 8 ounces 9.0 
 
 Lemonade, 8 ounces 0.1 
 
 Grape juice, 1 ounce 0.1 
 
 Buttermilk, natural, 8 ounces . 6.0 
 
 Buttermilk, artificial . . 7.0 
 
 Chocolate milk shake 13.0 
 
 Whey, 4 ounces 1.0 
 
 Koumiss, 4 ounces 3.6 
 
 Egg white, 1 4.0 
 
 Gelatin, 1 ounce 27.0 
 
 Apple sauce, 3 ounces .25 
 
 Honey, J ounce 0.1 
 
 Orange juice, 1 ounce 0.0 
 
 Prepared Foods and Oils: 
 
 Olive oil, 2 ounce 0.0 
 
 Cod-liver oil, 5 ounce 0.0 
 
 Mellin's Food, 1 ounce 2.0 
 
 Eskay's Food, i ounce 1.5 
 
 Nestle's Food, 1 ounce . . . . 3.0 
 
 Fairchild's Food, 1 ounce ... . .34 
 
 Condensed milk (sweetened), J ounce . 1.0 
 
 Calories. 
 
 150 
 
 84 
 
 30 
 
 50 
 150 
 150 
 280 
 174 
 
 20 
 
 80 
 110 
 400 
 
 28 
 
 70 
 
 17 
 
 ■ 110 
 
 200 
 
 100 
 
 13 
 
 120 
 120 
 108 
 110 
 110 
 105 
 19 
 
 Meats, Fish, etc. : 
 
 Roast beef, fat, 1 slice 
 Roast beef, lean, 1 slice 
 Lamp chop, 1 . . . 
 Turkey, 1 slice . . 
 Ham, roast, 1 slice 
 
 22.0 
 23.0 
 22.0 
 28.0 
 28.0 
 
 357 
 110 
 367 
 285 
 210 
 
180 
 
 RULES FOR RECOVERY 
 
 Protein 
 
 in grams. Calories. 
 
 Meats, Fish, etc.: 
 
 Veal, roast, 1 slice 21.0 97 
 
 Salmon (a helping) 20.0 198 
 
 Smelts 2.0 28 
 
 Brook trout (a helping) 11.0 57 
 
 Oysters, 6 raw S.O 44 
 
 Clams, 6 7.0 47 
 
 Bacon, 1 slice 3.0 190 
 
 Vegetables: 
 
 Potatoes, white, boiled, medium size . 4.0 140 
 
 Green peas, 3 large tablespoonfuls 6.0 150 
 
 Mushrooms (boiled), 2 large on toast 4.0 150 
 
 Corn (canned), 2 large tablespoonfuls 3.0 100 
 Macaroni, baked with cheese, 2 large 
 
 tablespoonfuls . . 19.0 450 
 
 Rice (boiled), 1 large tablespoonful . 3.0 112 
 
 Beets, 2 large tablespoonfuls .... 1.6 30 
 
 Cabbage, 3 large tablespoonfuls . . .6 5 
 
 Cauliflower, 2 large tablespoonfuls ..1.0 8 
 
 Celery (raw), 3 small stalks .... .5 8 
 
 Cucumbers (raw), 8 thin slices . .4 9 
 
 Parsnips, 4 slices .22 10 
 
 Turnips, 2 large tablespoonfuls ... .45 6 
 
 Salad Dressings: 
 
 French dressing, J ounce . 
 Mayonnaise, 1 tablespoonful . 
 HoUandaise, 2 tablespoonfuls 
 
 0.0 
 
 .26 
 1.80 
 
 74 
 187 
 170 
 
 Bread, Cake, Pies, etc.: 
 Bread, white, 1 slice . 
 
 whole wheat, 1 slice 
 Graham, 1 slice 
 Cake, frosted, 1 slice . 
 layer, 1 slice 
 
 2.0 
 4.0 
 
 90 
 106 
 100 
 150 
 250 
 
FROM PULMONARY TUBERCULOSIS 181 
 
 
 
 
 Protein 
 
 
 
 in grams. 
 
 Calorij 
 
 Bread, Cake, Pies, etc.: 
 
 
 
 Gingerbread, 1 slice 
 
 3.0 
 
 220 
 
 Pies, i piece 
 
 4.S 
 
 250 
 
 Bread pudding, 2 large tablespoonfuls 
 
 6.0 
 
 225 
 
 Custard pudding, 2 large tablespoonfuls 
 
 7.0 
 
 180 
 
 Fruits: 
 
 
 
 Bananas ... .... 
 
 1.5 
 
 127 
 
 Grapefruit, J large 
 
 
 2.0 
 
 139 
 
 Grapes 
 
 
 1.5 
 
 112 
 
 Oranges, 1 
 
 
 
 1.5 
 
 96 
 
 Figs, 10 large 
 
 
 
 8.0 
 
 633 
 
 Prunes, 10 large 
 
 
 
 4.0 
 
 525 
 
 Dates, 10 large . 
 
 
 
 2.0 
 
 266 
 
 Apricots, 10 large . 
 
 
 
 4.0 
 
 228 
 
 Aoole .... 
 
 
 .45 
 
 72 
 
 * fr'"' ...... 
 
 Miscellaneous: 
 
 
 
 Nuts, 10 large .... 
 
 4.0 
 
 200 
 
 Eggs, 1, boiled one minute 
 
 6.7 
 
 75 
 
 Butter, i ounce 
 
 0.0 
 
 120 
 
 Cheese (American), 1 cubic inch 
 
 5.7 
 
 91 
 
 Sugar of milk, 1 teaspoonful . 
 
 0.0 
 
 15 
 
 Sugar (J ounce), 1 teaspoonful . 
 
 0.0 
 
 15 
 
 Junket, 4 ounces 
 
 4.0 
 
 75 
 
 Oatmeal (boiled), 2 large tablespoonfuls 
 
 3.0 
 
 63 
 
 Calf 's-foot jelly, 1 ounce . . 
 
 2.2 
 
 45 
 
 Ice-cream, 2 large tabU 
 
 ;spoonl 
 
 uls 
 
 5.0 
 
 190 
 
182 BIBLIOGRAPHY 
 
 BIBLIOGRAPHY 
 
 " My never-failing friends are they with whom I converse day 
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 Allen (William H.) Civics and Health 
 
 New York, 1909, Ginn & Company 
 
 Ayres (Leonard P.) . . . . . . Open-air Schools 
 
 New York, 1910, Doubleday, Page & Company 
 
 Bardswell (Noel D.) .... Advice to Consumptives 
 London, 1910, Adam & Charles Black 
 
 Bates (Stanley H.) .... Open-air Treatment at Home 
 Bristol, 1910, John Wright & Sons, Ltd. 
 
 Collins (Joseph) Sleep and the Sleepless 
 
 New York, 1912, Sturgis & Walton 
 
 Collins (Joseph) . . The Way with the Nerves 
 
 New York, 1911, G. P. Putnam's Sons 
 
 De Forest (Chas. M.). 
 
 Daily Health Guide Chart for Boys and Girls 
 National Tuberculosis Assn., 381 Fourth Ave., N. Y. 
 
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 New York, 1910, B. W. Huebsch 
 
 Flick (Lawrence F.) Consumption: A Curable and Prevent- 
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BIBLIOGRAPHY 183 
 
 Galbreath (Thomas Crawford) Chasing the Cure in Colorado 
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 Galbreath (Thomas Crawford) T. B. Playing the Lone 
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 1915, Journal of the Outdoor Life Publishing Company 
 
 Gardner (Charles F.) . . The Care of the Consumptive 
 New York, 1900, G. P. Putnam's Sons 
 
 GiBBS (Winifred F.) Lessons in Proper Feeding of the Family 
 New York, 1909, Association for Improving the Con- 
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 GuLicK (L. H.) Emergencies 
 
 New York, 1909, Ginn & Company 
 
 GuLiCK (L. H.) Good Health 
 
 New York, 1906, Ginn & Company 
 
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 GuLicK (L. H.) The Body at Work 
 
 New York, 1909, Ginn & Company 
 
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 New York, 1908, Ginn & Company 
 
 Hawes (John B., 2d) Consumption: What It Is and What to 
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 Hutchinson (Woods) . The Conquest of Consumption 
 
 New York, 1910, Houghton, MifHin & Company 
 
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184 BIBLIOGRAPHY 
 
 Knopf (S. A.) Tuberculosis as a Disease of the Masses and How 
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 Latham (Arthur) 
 Garland (G. 
 
 London, 1910, Fisher Unwin 
 
 „ , [ . . . The Conquest of Consumption 
 
 LusK (Graham) . . . The Fundamental Basis of Nutrition 
 New Haven, 1914, Yale University Press 
 
 Maxwell (William H.) . Ventilation, Heating and Lighting 
 London, 1907, The Sanitary Publishing Company 
 
 Minor (Chas. L.) Hiiits and Helps 
 
 Pamphlet. Asheville, N. C. 
 
 Mitchell (John K.) Self-help for Nervous Women 
 
 Philadelphia, 1909, J. B. Lippincott Company 
 
 Otis (Edward O.) The Great White Plague 
 
 New York, 1917, Thomas Y. Crowell & Company 
 
 Powell (Lyman) . The Art of Natural Sleep 
 
 New York, 1908, G. P. Putnam's Sons 
 
 Thomas (J. W.) Ventilation, Heating and Lighting of Dwellings 
 New York, 1906, Longmans, Green & Company 
 
 Walton (George L.) . . . . Why Worry 
 
 Philadelphia, 1910, J. B. Lippincott Company 
 
 Ward (Robert de C.) . . Climate 
 
 New York, 1908, G. P. Putnam's Sons 
 
 Journal of the Outdoor Life, 381 Fourth Avenue, New York 
 City, monthly, $1.50 a year 
 
INDEX 
 
 Adirondack recliner, 64, 78 
 Adults, infection in, 146 
 Advice, blind, 134 
 
 cheap, 133 
 
 of old patients, 94 
 
 skilled medical, 134 
 Age of infection, 149 
 Air, 175 
 
 "carriers," 62 
 Albuminoids, 37 
 Alcohol, 49 
 
 amount, 50 
 
 and cold, 50 
 
 as drug, 50 
 
 effect on eating, 51 
 
 and health resorts, 52 
 
 as stimulant, 51 
 
 and tuberculosis, 49, SO 
 Altitudes, high, 56 
 Antitoxin, 155 
 Apparently arrested, 164 
 Appetite, 41, 43 
 
 and exercise, 24 
 
 loss of, 43 
 Arctic Circle, 136 
 Arizona, 61, 136 
 Arrested, 164 
 Arsenic, 93 
 Atmosphere, stuffy, 57 
 
 atmospheric pressure, low, 56 
 Auto-inoculation, 99 
 Automobiling, 60, 104 
 
 B 
 
 Bag, moist, 9 
 
 paper, 166 
 
 sleeping-out, 72 
 Baseball, 105 
 Bathroom, 71 
 Baths, 165, 171 
 
 hot, 165 
 Beard, 168 
 Bed, 84, 86 
 
 cold, 87 
 
 damp, 87 
 
 hours in, 31 
 
 Klondyke, 86 
 
 pillows, 86 
 
 window, 80 
 Bedding, 85 
 Bibliography, 182 
 Billiards, 105 
 Bird study, 103 
 Blanket, floor, 152 
 Blood; 161 
 
 spitting, 98, 177 
 Body heat, 39 
 Botany, 104 
 Bowling, 106 
 Boxing, 105 
 Bread, 37 
 
 Breath, shortness of, 99 
 Brehmer, 63, 135 
 Brompton Hospital, 146 
 Bronchitis, 168 
 
 (185) 
 
186 
 
 INDEX 
 
 Caisson, 56 
 
 Calcium salts, 36, 160 
 
 Calory, 38 
 
 Candy, 48 
 
 Caps, 73 
 
 Carbohydrates, 37 
 
 Carbolic acid, 156 
 
 Carbonic acid gas, 56, 58, 
 
 161 
 " Carriers, " air, 62 
 Cattle, 12 
 Cavity, 161 
 Cells, 161 
 
 Certificates, thermometer, 1 10 
 Chair, "cure," 63, 76, 168 
 Change of climate, 137 
 Chautauqua salute, 167 
 Cheesecloth, 166, 168 
 Chest protectors, 71 
 Children, 12 
 
 care of, 148 
 
 predisposed, 153 
 Cigarettes, S3 
 City Hospital (Cook County) 
 
 in Chicago, 146 
 Classes of patients, 16 
 Climate, 135 
 
 and activity, 116 
 
 Arctic Circle, 136 
 
 change of, 137 
 
 health resorts, 138 
 
 high altitudes, 56, 57 
 
 specific, 137 
 
 stimulating (localities), 137 
 
 sudden change in, 59 
 
 and treatment, 138 
 value of, 136 
 
 temperate zone, 136 
 
 warm moist, 136 
 
 and weight, 126 
 Clinical tuberculosis, 13 
 Clothes, 70, 168 
 Coasting, 60 
 Coat, fur, 72 
 Cold, 59, 60, 136 
 
 Cold, alcohol and, 50 
 
 bed, 87 
 
 hands, 73 
 
 severe, 136 
 
 as stimulant, 136 
 
 value of, 69 
 
 and weight, 127 
 Colds, 167 
 
 taking cold, 65, 176 
 College, 17 
 Combating tuberculosis, 
 
 methods of, 143 
 Communicable disease, 139 
 Comparison of scales, 109 
 Composition of food, 34 
 "Conscience, Outdoor," 69 
 Consumption, 124 
 Contagion, 139 
 Cough, 176 
 
 after meals, 121 
 
 air and, 118 
 
 cause of, 117, 118 
 
 and change of position, 121 
 
 cold pack for, 121 
 
 covering' the mouth, 11, 
 122 
 
 danger of, 117 
 
 nervous, 119 
 
 physiology of, 117 
 
 production of, 120 
 
 rest and, 28, 119 
 
 simple remedies for, 119 
 
 treatment of, 117, 119 
 
 vomiting and, 121 
 Coughing, 141, 165 
 Cows, tuberculous, 152 
 Crocheting, lOS 
 Croquet, 104 
 "Crowd poison," 58 
 Cups, pocket, 166 
 Cure, 163 
 
 apparent, 163 
 
 chair, 64, 76, 168 
 
 details of, 14 
 Curing, position while, 24 
 Curtains, 169 
 Cuspidor, 166 
 
INDEX 
 
 187 
 
 D 
 
 Damp bed, 87 
 Dampness, 87 
 Danger of exercise, 16, 24 
 
 of expectorating in handker- 
 chief, 167 
 
 of ignorance, 30 
 
 of rest, 25 
 
 of tobacco, 52, 53 
 Deaths from tuberculosis, 14 
 Definition of "cure" and 
 
 "arrest," 162 
 Details essential to cure, 14 
 Dettweiler, 63 
 Diet, liquid, 47 
 Digestive disturbance, 125 
 Diphtheria, 168 
 Disease, house, 9, 142 
 
 transmission of, 140 
 Dishes, sterilization of, 169 
 Disinfecting, 8 
 
 Distribution of tuberculosis, 7 
 Domestics, 151 
 Draught, 64 
 Dressing, 95 
 
 for sleeping out, 83 
 Driving, 60, 96, 104 
 Droplets, 10, 11, 141 
 Dryness, 61 
 Dust, 62, 142 
 Dusting, 142, 169 
 
 moist duster, 9 
 
 E 
 
 Early life, infection in, 149 
 
 tuberculosis in, 143 
 Eating, effect of alcohol on, 51 
 
 overeating, 15, 41, 42 
 
 purpose of, 41 
 Eggs, 42 
 Egypt, 61 
 Entrance of germs, common, 
 
 140 
 Exercise, 92 
 
 Exercise, advice in, 93 
 
 appetite and, 24 
 
 contra-indications, 96 
 
 danger of, 24, 93, 94 
 
 family and, 93 
 
 fatigue, 21, 96 
 
 healthy organs and, 2 1 
 
 medicine as, 93 
 
 at onset, 29 
 
 respiratory, 99 
 
 rules for, 101 
 
 and temperature, 113 
 
 and weight, 126 
 
 what is, 94 
 
 when to, 92 
 Expectoration, 175 
 
 danger of, in handkerchief, 
 167 
 Experimental work, 146 
 Exposure, 68 
 Eye-shade, 74 
 Eyes, weak, 76 
 
 Family and exercise, 93 
 Fat, 38, 45 
 Fatigue, 21, 96 
 Fever and food, 126 
 Fireplace, 91 
 Fishing, 104 
 Floor, tile, 152 
 Fluid food, 43 
 Food, 13, 33, 175 
 
 composition of, 34 
 
 eggs, 42 
 
 fat, 38 
 
 fever and, 126 
 
 fluid, 43 
 
 fuel value of, 38, 39 
 
 heat value of, 39 
 
 individual taste, 41 
 
 purposes of, 34 
 
 rule of, 42 
 Foodstuffs, 34 
 Food values, 178 
 
188 
 
 INDEX 
 
 Foot-pound, 22 
 Footwear, 72 
 Fresh air, 156 
 
 dose of, 63 
 
 experiments on, 58 
 
 value of, 57 
 Fuel value of food, 38, 39 
 
 Gain in weight, IS 
 
 Games, 95 
 
 Geology, 104 
 
 Germicides, 8 
 
 Germs, 62 
 moist, 9 
 number of, 142 
 tuberculosis, 12 
 
 Get up, when to, 29 
 
 Gloves, 73 
 
 Golf, 104 
 
 Grip, 168 
 
 Gymnastic work, 105 
 
 Habits, unselfish, 154 
 Hands, cold, 73 
 
 to be washed, 12, 168 
 Headache, 96 
 Heal, how the lungs, 26 
 Health resorts and alcohol, 52 
 Healthy, place of rest in life of, 
 
 21 
 Heart, work of, 22 
 Heat, artificial, 73 
 
 body, 39 
 
 value of foods, 39 
 Hemorrhage, 177 
 Heredity, 12, 145, 150 
 Hippocratic oath, 129 
 History of body temperature, 
 
 107 
 Home of the tuberculous, 149 
 
 Honesty and frankness, value 
 
 of, 132 
 Hood, sleepin^-out, 84 
 Horseback riding, 30, 104 
 Hot bath, 165, 175 
 Hours in bed, 31 
 House disease, 9, 142 
 Hunting, 99, 100 
 Hygienic care of patient, 165 
 Hyperventilation, 153 
 
 Immunity, 156 
 
 active, 156 
 
 passive, 156 
 Infants, 149 
 
 tuberculosis in, 143 
 Infection, 146 
 
 in adults, 146, 147 
 
 age of, 145 
 
 blanket, floor, 152 
 
 danger in early life, 150 
 
 domestics, 151 
 
 infants, 149 
 
 inheritance, 145 
 
 injuries, 154 
 
 man, 141 
 
 man and wife, 147 
 
 .medical inspection, 153 
 
 nurse, 151 
 
 nursery, 151 
 
 separation of mother and 
 child, 151 
 
 sources of, 140 
 
 susceptibility to, 143 
 
 tile floor, 152 
 
 tuberculous cows, 140 
 
 visitors, 151 
 Infectious disease, 139 
 Influenza, 167 
 Inheritance, 145 
 Injuries, 154 
 
 and rest, 23 
 Iron, 36 
 
INDEX 
 
 189 
 
 Kidneys, 161 
 Kissing, 151, 168 
 Klondyke bed, 86 
 Knitting, lOS 
 Koch, 155 
 
 Lassitude, 96 
 Leggings, 73 
 Life, outdoor, 154 
 Lime salts, 36, 160 
 Liquid diet, 43 
 Locomotion, power of, 9 
 Loss of weight, 97, 123 
 Lungs heal, how the, 26 
 
 M 
 
 Man and wife, 147 
 
 Measles, 153 
 
 Medical advice in exercise, 93 
 
 inspection, 153 
 Medicine, 177 
 
 exercise as, 93 
 Milk, 42 
 
 danger of, 12 
 
 grade of, 152 
 
 pasteurized, 152 
 
 price of, 152 
 
 pure, 152 
 Mill operatives, 59 
 Minor ailments and tempera- 
 ture, 114 
 Moist germ, 9 
 Mountain climbing, 105 
 
 sickness, 57 
 Mouth coverings, 11, 122 
 
 germs of, 172 
 
 normal temperature of, 113 
 
 wash, 174 
 Musical instruments, 105 
 Mustache, 168 
 
 N 
 
 Napkins, paper, 166 
 National bureau of standards, 
 
 112 
 Nerves, 32 
 Night-sweats, 99 
 Non-clinical tuberculosis, 13 
 Nose, how to blow, 122 
 Nurse, 151 
 Nursery, 151 
 
 Oath, hippocratic, 129 
 
 Oils, 38 
 
 "Old" patients, advice of, 94 
 
 Onset, gentle exerise at, 29 
 
 Open-air schools, 153 
 
 Organs, effect of rest on healthy, 
 
 21 
 Outdoor hobby, 103 
 
 life, 154 
 Overeating, IS, 42, 43 
 Oxygen, 56, 58, 161 
 Ozone, 62 
 
 Pain in the chest, 99 
 Paper bags, 166 
 
 napkins, 166 
 Partnership, health, 134 
 Patient, hygienic care of, 165 
 
 and physician, 129 
 Photography, 104 
 Phthisis, 123 
 
 Physician, confidence in, 132, 
 133 
 
 meaning of, 129 
 
 relation between patient and, 
 129 
 Piano, 105 
 Pictures, 91, 169 
 Pillow, 86 
 
 Play, danger of, 103 
 Pneumonia, 168 
 
190 
 
 INDEX 
 
 "Poison, crowd," 58 
 Polo, 105 
 Pool, 105 
 Pope, E. G., 147 
 Porch, 75, 177 
 
 accessories, 77 
 
 coldness and ventilation, 76 
 
 depth of, 76 
 
 door, 77 
 
 facing of, 77 
 
 shut-in, 75 
 
 ventilation, 75, 76 
 Position while curing, 24 
 Potatoes, 37 
 Pound, foot-, 22 
 Predisposed children, 153 
 Pressure, high barometric, 56 
 
 low barometric, 56 
 Protein, 36 
 
 Pulmonary gymnastics, 99 
 Pulse, 96 
 
 normal, 97 
 
 rapid, 96 
 Pyorrhea alveolaris, 172 
 
 Reading, 95 
 
 Recovery depends on patient, 
 
 18 
 Rectal temperature, 113 
 Relapse, signs of, 96 
 Relation between physician and 
 
 patient, 129 
 Resistance, 12, 17, 144, 145 
 
 of child, 143 
 
 raising, 153 
 
 youth and, 143 
 Resorts, health, 137 
 Respiration, 56 
 Respiratory exercises, 99 
 Rest, 20 
 
 cough and, 28, 119 
 
 danger of, 25 
 
 enforced, 28 
 
 Rest, functional rest and tuber- 
 culosis, 25 
 
 hours in bed, 31 
 
 injury and, 23 
 
 mid-day, 32 
 
 place in life of healthy, 21 
 
 preliminary, 29 
 
 recliner, Adirondack, 64, 78 
 
 sleep and, 22 
 
 value, in disease, 30 
 
 when to get up, 29 
 Restraint, self-, 154 
 Rice, 37 
 
 Riding, horseback, 30, 104 
 Rigg's disease, 172 
 Roof, 62 
 Room, 75 
 
 patient's, 89, 90 
 Routine, daily, 66 
 Rowing, 104 
 Rugs, 72, 91, 169 
 Rules, 19 
 
 for exercise, 101 
 
 of food, 42 
 
 S 
 
 Sahara, 136 
 
 Salt, table, 35 
 
 Salts, inorganic, 35 
 
 Sanatorium, sleeping out, 82 
 
 Sawdust, 9 
 
 Scars, 161 
 
 Screens, 76 
 
 Seasonal fluctuations of weight, 
 
 60, 98, 127 
 Sea voyage, 30 
 Second story, 77 
 Self-control, 19 
 Separation of mother and child, 
 
 151 
 Serum, 155 
 Sewing, 105 
 Shooting, 104 
 
 Shortness of breath, 99, 161 
 Signs of relapse, 96 
 Silver, 169 
 
INDEX 
 
 191 
 
 Singing, 105 
 Sitting-out chair, 78 
 
 articles for, 72 
 Size of tubercle germs, 7 
 Sleep and rest, 22 
 Sleeping out, 62, 80 
 
 advantages, 80, 81, 82 
 
 bags for, 72 
 
 "Black Knight," 84 
 
 contra-indications, 81 
 
 dressing for, 83 
 
 eye covering, 84 
 
 hood for, 84 
 
 night air, 82 
 
 results of, 81 
 
 sanatoriums for, 82 
 
 wrapping up, 84 
 Smoking, effect of, S3 
 Solitaire, 105 
 Sources of infection, 140 
 Spitting, 141 
 
 blood, 98, 177 
 Sponge, cold, 169, 175 
 Sports, 154 
 Spray, 141 
 
 Spread of tuberculosis, 9 
 Sputum, 147, 165, 166 
 burning of, 166 
 disposal of, 166, 167 
 droplets, 10, 11, 141 
 number of germs in, 142 
 Stages, three classes or, 162 
 Starch, 37 
 
 Stimulant, alcohol as, 50 
 Strength, 96 
 Strychnine, 93 
 Submarine work, 56 
 Subnormal temperature, 1 13 
 Suggestions for patients, 175 
 Sun, 176 
 
 Sunlight, power of, 8 
 Sunshine and weight, 127 
 Susceptibility to infection, 143 
 Sweaters, 71 
 Sweeping, 9 
 
 dry, 142, 169 
 Swimming, 105 
 
 Table, weight (males), 124 
 
 (females), 125 
 Taste, individual, 41 
 Tea leaves, 9 
 Teeth, 171 
 
 care of, 171 
 
 decayed, 171 
 Temperature of animals, 115 
 
 atmospheric, 59 
 
 daily change of, 116 
 
 effects of food on temperature 
 of mouth, 112 
 
 high, 114 
 
 history of body, 107 
 
 importance of rise of, 1 14 
 
 instability of, 115 
 
 minor ailments and, 114 
 
 normal mouth, 113 
 
 rectal, 113 
 
 regulation of, 115 
 
 skin and, 115 
 
 subnormal, 113 
 
 when not to take, 114 
 to take, 113 
 Tenements, model, 153 
 Tennis, 105 
 Tent, 64 
 
 window, 61, 80 
 Thermometer certificate, 110 
 
 clinical, 109 
 
 correction of, 110 
 
 maximum, 110 
 
 price of, 110 
 
 "trouble stick," 114 
 Tights, equestrian, 73 
 Time necessary for recovery, 13, 
 
 17 
 Tobacco, 52 
 
 danger of, 52, 53 
 
 effect of, 53 
 on diseased lung, 54 
 Tooth brush, 173 
 
 how to use, 173 
 Training, 16 
 Transmission of disease, 140 
 
192 
 
 INDEX 
 
 Treatment — ^two parts, 17 
 
 climate and, 137 
 
 "twenty-three-hour," 64 
 Tubercle bacilli, 155 
 
 germs, 7, 159 
 
 size of, 7 
 Tuberculin, 144, 155 
 
 effect of, 156 
 
 treatment, 155, 156 
 
 what is, 155, 156 
 Tuberculosis, 158 
 
 alcohol and, 49, SO 
 
 clinical and non-clinical, 13 
 
 •distribution of, 7 
 
 in early life, 143 
 
 efficient methods of combat- 
 ing, 148 
 
 how and when we contract, 
 139 
 
 in infants, 143 
 
 sunshine and fresh air and, 8 
 
 word, 1S9 
 Tuberculous cow, 141 
 
 infection, 142 
 
 man, 141 
 "Twenty-three-hour" treat- 
 ment, 64 
 
 Underwear, 71 
 University, 17 
 
 Vacuum cleaning system, 10, 
 
 91, 142 
 Value of foods, heat, 38 
 Ventilation, hyperventilation, 
 153 
 
 of room, 89 
 
 Vest, chamois, 71 
 Visitors, 95, 151 
 
 W 
 
 Walking, 95 
 
 Warmth and weight, 127 
 
 Water, 35 
 
 running, 165 
 Weak eyes, 76 
 Weight, 60, 123 
 
 change and, 126 
 
 cold weather and, 127 
 
 exercise and, 126 
 
 great dryness and, 127 
 
 in health, 128 
 
 loss of, 97, 126 
 
 relative, 98, 124, 125 
 
 seasonal fluctuations of, 60, 
 98, 127 
 
 sufficient, 126 
 
 sunshine and, 127 
 
 tables (females), 125 
 (males), 124 
 
 of tuberculous, 123 
 
 warmth and, 127 
 Whooping-cough, 153 
 Window beds, 80 
 Windows, number of, 89 
 Winter, danger of, 63 
 Work, 22 
 
 of heart, 22 
 
 treatment, 99 
 Writing, 95 
 
 Yard, back, 62 
 
 Zones, immune, 135