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TUBERCULOSIS 
 
 A PREVENTABLE AND CURABLE DISEASE 
 
IMPORTANT RECENT BOOKS AND MONOClRAPHS 
 KV THE SAME AUTHOR: 
 
 " Les Sanatoria." These pour le Doctorat en Medecine. Pre- 
 sentee et soutenue devant la Faculte de Medecine de Paris. 
 
 Paris, 1S95 
 
 " Les Sanatoria, Traitement et Prophylaxie de la Phtisie Pulnio- 
 naire." Paris, igoo 
 
 " Pulmonary Tuberculosis, Its Modern Prophylaxis and the Treat- 
 ment in Special Institutions and at Home." Alvarenga Prize 
 Essay. Philadelphia, iSt/j 
 
 "Die Tuberkulose als Volkskrankheit und deren P>ekampfung." 
 Kongress Preisschrift. Berlin, 1900 
 
 " Tuberculosis as a Disease of the Masses and How to Combat It." 
 Six editions from 1900 to iqog. New York 
 
 Translations of this have appeared as Arabic, Brazilian, Bulga- 
 rian, Chinese, Dutch, English, Finnish, French, Hebrew, 
 Hungarian, Icelandic, Italian, Japanese, Mexican, Norwe- 
 gian, Polish, Russian, Serbian, Siberian, Spanish, Swedish, 
 and Turkish editions between 1900 and u/x). 
 
 "Tuberculosis" in Twentieth Century Practice of Medicine. 
 
 New York, 1900 
 
 "A Few Thoughts on the Medical and Social Aspect of Tubercu- 
 losis at the P>eginning of the Twentieth Century." Contribu- 
 tion to Prof, von Leyden's Festschrift. Berlin, 1902 
 
 " Woman's Duty Towards the Health of the Nation." 
 
 Bostf»n, 1904 
 
 " Medicine and Eaw in Relation to the Alcohol, Venereal Disease 
 and Tuberculosis Problems." New York, 1906 
 
 " A Plea for Cremation." Chicago, 1907 
 
 "Tuberculosis" in Nelson's Encyclopedia. New York, 1907 
 
 " The Etiology, Prophylaxis and Treatment of the Social 111." 
 
 New York, 1908 
 
 " A Plea for More Sanatoria for the ConsumiHive Poor in all Stages 
 of the Disease." New York, k/jS 
 
 '• Sun, Air, and Water, Their Use in the Preservation of Health and 
 the Cure of Disease." Wa.shington, k/jS 
 
 "Public Measures in the Propliylaxis of Tuberculosis." Contri- 
 bution to tlie American Treatise on Tul)crculosis. 
 
 New York, n;ocj 
 
 " Tlie Hfjpeful Outlook of the Tuberculosis I'roblem in the United 
 States. ^t. Louis, i</>9 
 
Professor Robert Koch, Discoverer of the Tubercle Bacillus. 
 
TUBERCULOSIS 
 
 A PREVENTABLE AND 
 CURABLE DISEASE 
 
 MODERN METHODS FOR THE SOLUTION 
 ■ OF THE TUBERCULOSIS PROBLEM 
 
 BY 
 S. ADOLPHUS KNOPF, M.D. (New York and Paris) 
 
 Professor of Medicine, Department of Phthisiotherapy, at the New York Post- 
 
 Graduate Medical school and Hospital; Senior Attending Physician 
 
 to the Riverside Hospital — Sanatorium for Consumptives 
 
 of the City of New York, etc. 
 
 NEW EDITION 
 
 NEW YORK 
 
 MOFFAT, YARD AND COMPANY 
 
 1916 
 
a-, 
 
 Copyright 1909, by 
 MOFFAT, YARD AND COMPANY 
 
 New York 
 
 All Rights Reserved 
 
 PUBLISHED, JUNE, igCK) 
 
 1-' ! I 
 
 K 1 5 X \ 
 
Sto my MASTERS in MEDICINE in Amer- 
 ica, France, and Germany, by whose wisdom I am 
 guided, by whose experience I gain courage for 7ny 
 work, and whose lives are my constant inspiration. 
 
 ®:0 the NOBLE MEN and WOMEN inside 
 and outside oj the medical profession all over the 
 civilized world, whose unselfish labors have been so 
 helpftd to the anti-tuber cido sis cause. 
 
 Eo the STATESMEN and PHILANTHRO- 
 PISTS to whose wisdom and generosity we look for 
 help in the realization oj our utmost desires, the 
 eradication of the Great White Plague. 
 
MOTTO 
 
 To combat tuberculosis successfully, requires the 
 combined action of a wise government, well-trained 
 physicians, and an intelligent people. 
 
PREFACE TO SECOND EDITION 
 
 The first edition of this volume was more than 
 kindly received by the medical profession and the 
 general public. For the words of praise which were 
 bestowed upon it in numerous reviews and personal 
 letters I feel deeply grateful. The criticisms were 
 few, but for them also I wish to express my sincerest 
 thanks. Some referred to scientific points about 
 which none of us as yet are certain, others referred 
 to more or less serious typographical errors which 
 have now been corrected, and a few new phases in 
 the popular campaign have been described. 
 
 To one assertion, however, which appeared in 
 two or three of the criticisms I must reply in 
 detail, and leave the public to judge the right of 
 the case. It has been said that a number of my 
 statements regarding the prevention and cure of 
 tuberculosis, in its social as well as in its medical 
 aspect, were non-authoritative, and not based on 
 experience. My reply to this serious criticism is 
 merely to enumerate the opportunities which I 
 have had in the space of twenty-five years, for the 
 study and observation of this disease. 
 
 ix 
 
X PREFACE TO SECOND EDITION 
 
 I began my medical career as a student at the 
 ^ledical College of the University of Southern 
 California, in the early 'eighties. My first impor- 
 tant position was that of interne in the Los Angeles 
 County Hospital, where the majority of patients 
 consisted of consumptives, nearly all of them in 
 the more advanced stages. They had come 
 thither thinking that the glorious chmate alone 
 would suffice to cure them. Some had come with 
 little or no money, others had spent their all and 
 had not enough left to return to their Eastern 
 homes which, perhaps, all of them had left in the 
 hope that a few weeks in Southern California 
 would restore them to health and vigor when they 
 would find work and be able to support them- 
 selves. This delusion filled the Los Angeles 
 County Hospital, year in and year out, with hun- 
 dreds of poor, discouraged consumptives, many 
 of them hopelessly ill. They became a burden 
 to a strange community. It was this situation 
 which inspired me to devote my life to the anti- 
 tuberculosis cause, to seek out and to study the 
 means of curing tuberculosis as far as it was 
 practicable without regard to climate, and to labor 
 for the early recognition of the disease. 
 
 I came to New York to finish my studies in 
 the celebrated Bellevue Hospital Medical College, 
 where I also took my degree. In those days con- 
 
PREFACE TO SECOND EDITION xi 
 
 sumptives were treated in general hospitals. It 
 was nothing unusual for a consumptive to have 
 some one afflicted with malaria, pneumonia, or 
 heart disease as a neighbor in the ward. Under 
 these conditions consumption was propagated 
 among other patients, nor was the infection con- 
 fined to the patients alone. I sadly remember 
 that not a few of my colleagues, serving in the 
 hospitals, fell victims to the disease. 
 
 Subsequent to my graduation at Bellevue I 
 engaged in general practice in the tenement house 
 districts of New York. Here I learned much of 
 the social causes of tuberculosis, of the tenement 
 house problem, alcohoHsm, sweatshops, and child 
 labor, — all predisposing factors to tuberculosis. 
 Feeling that I had much more to learn regarding 
 tuberculosis science, I went abroad and devoted 
 six years to additional study. I remained several 
 years in Paris, matriculated as a regular medical 
 student, and served as assistant in the general and 
 special hospitals, which enabled me to take the 
 degree of Doctor of Medicine of that great fac- 
 ulty. Prior to presenting my thesis for this de- 
 gree, I visited all the leading European and 
 American sanatoria and health resorts conse- 
 crated to the treatment of tuberculosis. My 
 French doctor thesis had for its title "Les Sana- 
 toria, Traitement et Prophylaxie de la Phtisie 
 
xii PREFACE TO SECOND EDITION 
 
 Pulmonaire." Because of the above mentioned 
 criticisms I may be permitted to mention that this 
 thesis received the highest mark (extremement 
 satisfait) from the jury which presided over its 
 defense, and the French Academy of Medicine 
 and the Institute of France made the author of it 
 a laureate. The enlarged English translation of 
 this thesis was awarded with the Alvarenga prize by 
 the College of Physicians of Philadelphia in 1898. 
 
 My practical training as a sanatorium physician 
 I received after my graduation in Paris, by a 
 lengthy sojourn in the Falkenstein Sanatorium 
 as assistant to that great and immortal teacher 
 of modern phthisio-therapy, Geheimrath Professor 
 Dettweiler, then Director of that institution. 
 
 The two above mentioned volumes which passed 
 several editions were purely scientific treatises, 
 but it was also the author's good fortune to receive 
 recognition for his popular essay entitled ''Tuber- 
 culosis as a Disease of the Masses and How to 
 Combat it." The Tuberculosis Congress which 
 convened in Berlin in 1899 bestowed upon this 
 work the International Congress prize of 4000 
 Marks ($1000). This little essay has since been 
 translated into 25 different languages and largely 
 distributed throughout the civilized world. 
 
 Since my return to the United States in 1896, I 
 have had no lack of opportunities to study tuber- 
 
IPREFACE TO SECOND EDITION xiii 
 
 culosis in its sociological as well as in its medical 
 aspect. It is my privilege to have been one of the 
 founders of the New York Tuberculosis Committee, 
 and of our National Association for the Study and 
 Prevention of Tuberculosis. The admirable work 
 of these organizations, as far as the social combat 
 of tuberculosis is concerned, is too wtII known to 
 need mentioning here. Through the many years 
 of my connection with the New York Health 
 Department as Associate Director of its clinics 
 for pulmonary diseases and as senior attending 
 physician of the Riverside Hospital-Sanatorium 
 for the consumptive poor of this city, I believe 
 that my opportunities for observing and learning 
 have been and are still exceptional. It is on the 
 basis of these many years of experience that I 
 have laid down in this volume what I consider 
 not only my thoughts but those of the best among 
 our leading tuberculosis specialists. 
 
 In conclusion I should like to reproduce a few 
 of the opinions that have been expressed by leading 
 men on the appearance of the first edition of this 
 volume : 
 
 His Excellency, Real Privy Councillor, Pro 
 FESSOR Robert Koch, of Berlin. 
 "Such work as yours should be welcomed, as it is 
 destined to play an important part in the enlightenment 
 of the people and the American people seem to me 
 
xiv PREFACE TO SECOND EDITION 
 
 particularly susceptible to such education. Your 
 book is sure to meet with great success." 
 
 William Osler, M. D., LL. D., Regius Professor of 
 Medicine, Oxford University, England. 
 "I am greatly pleased with your new book. It is 
 admirable in every way — form and substance are 
 equally good. I am sure it must be having a great 
 success." 
 
 Mr. Ernest P. Bicknell, Director of the American 
 National Red Cross, Washington, D. C; Formerly 
 Superintendent Chicago Bureau of Charities. 
 "I have been testing the value of this book by sub- 
 mitting to it many of the questions and problems which 
 have been encountered in a somewhat extended and 
 varied relationship with persons afflicted by tuberculosis 
 in tenements, hovels, schools, shops, and public institu- 
 tions. And in every instance I have found the answer 
 concise, definite, positive." 
 
 Hermann M. Biggs, M. D., LL. D., Professor of 
 Medicine, New York University and Bellevue 
 Medical College; General Medical Officer, Depart- 
 ment of Health, New York. 
 "Like all of your publications, your recent book 
 entitled 'Tuberculosis A Preventable and Curable 
 Disease,' is notable because of its clearness, directness, 
 anfl simplicity of style. It seems to me excellent in 
 every respect and is an important and valuable contri- 
 bution to the propagandum for the treatment and pre- 
 vention of tuberculosis." 
 
PREFACE TO SECOND EDITION xv 
 
 Rev. John H. Holmes, Minister of the Unitarian 
 Church of the Messiah, New York. 
 "I do not know when I have read a volume of more 
 practical value and one destined to accomplish more 
 good. Packed from cover to cover, with the most 
 important kind of information, it ought to work a 
 miracle in the education of the public." 
 
 A. Jacobi, M. D., LL. D., Emeritus Professor of Diseases 
 of Children, Columbia University; Ex-president of 
 the N. Y. Academy of Medicine and of the Associa- 
 tion of American Physicians. 
 "Your new book contains whatever we now know of 
 tuberculosis, its nature, prevention and treatment, in 
 a lucid and popular style. By publishing it you have 
 rendered an important and pleasing service." 
 
 Theodore C. Janeway, Ph. B., M. D., Professor of 
 Medicine, Columbia University; Attending Physi- 
 cian, St. Luke's Hospital, New York. 
 "It seems to me you have put between the covers of 
 your book practically everything of importance for the 
 general practitioner and the intelligent layman, who 
 wishes to take his part in the anti-tuberculosis campaign. 
 For the former your pages — one might almost say 
 sermon — on the Physician's Duty ought to be of the 
 greatest value, if he has not given the subject much 
 thought, in setting before him clearly the great responsi- 
 bility to other individuals and the community, which 
 rests on everyone who undertakes the treatment of a 
 tuberculous invahd." 
 
xvi PREFACE TO SECOND EDITION 
 
 John H. Lowm.\x, ]M. D., Professor of Medicine at 
 the Western Reserve University, Cleveland, Ohio. 
 "The author of this book has the art of putting 
 plain questions plainly and of appealing to the practical 
 sense of a people. That Dr. Knopf has put his heart 
 as well as his mind in his work is shown by the evident 
 sincerity and purpose of his work. The book is an 
 appeal and it cannot fail of its object." 
 
 George M. Kober, M. D., Professor of Hygiene, 
 University of Georgetown, Washington, D. C. 
 "Professor Knopf has shown that tuberculosis is a 
 preventable and curable disease — we firmly believe 
 that if the measures recommended by him in his book 
 were generally adopted, the ' great white plague ' which 
 now carries off annually over 150,000 victims in the 
 United States alone would be eradicated within one 
 or two generations." 
 
 Edward O. Otis, A. B., M. D., Professor of Pulmon- 
 ary Diseases and Climatology, Tufts Medical 
 College, Boston, Mass.; Visiting Physician to the 
 Massachusetts State Hospital for Consumptives. 
 "You have not only discussed the whole subject of 
 tuberculosis, but have, as well, considered innumerable 
 social conditions which predispose to the disease as 
 well as their remedy; indeed the book can almost be 
 considered a treatise on healthy living." 
 
 W. S. Thayer, A. B., M. D., Professor of Medicine, 
 Johns Hopkins University; Physician to Johns 
 Hopkins Hospital, Baltimore, Md, 
 
PREFACE TO SECOND EDITION x\'ii 
 
 "Such a book as this is sure to be of real great value 
 to the public, medical and non-medical. One of its 
 great values, it seems to me, Kes in the fact that it is 
 not the compilation, but the authoritative statement 
 of one who has given his Hfe to the study of this 
 subject." 
 
 Edward L. Trudeau, A. M., M. D., Founder and 
 Physician of the Adirondack Cottage Sanatorium, 
 Trudeau, N. Y.; First President of the National 
 Association for the Study and Prevention of Tu- 
 berculosis. 
 ''This book has a great field of usefulness in the 
 education, specially of patients, of the public, and of 
 the general practitioner. As an educational factor 
 it will aid greatly the antituberculosis crusade in Amer- 
 ica, and I congratulate you on the accompKshment of 
 so thorough and useful a work." 
 
 I have all reason to believe and to hope that 
 this second edition will meet with the success equal 
 to that of the first and thus not fail to fulfil its mis- 
 sion in helping toward the goal which I inscribe in 
 my dedication, The Eradication of the Great 
 White Plague. 
 
 S. A. KNOPF. 
 
 New York, 
 April, 1910. 
 
PREFACE TO FIRST EDITION 
 
 In presenting this new volume to the English- 
 speaking public, and to the people of the United 
 States more especially, the author wishes to make 
 clear its objects and aims. The book is intended 
 to be helpful, first, to the patient afflicted with a 
 tuberculous disease, but not with a view of re- 
 placing the physician, the direct m.edical adviser; 
 for no book, not even a scientific treatise, can 
 replace for the patient the experience and judg- 
 ment of the skilled physician. But it will aid the 
 sufferer by giving him such insight into his afflic- 
 tion as will convince him of the curability of the 
 disease in the earlier stages and the great possibil- 
 ity of improving his condition in the latter stages, 
 providing he places himself under the careful 
 guidance of a physician in his own hygienically ar- 
 ranged home, in a health resort, or in a special in- 
 stitution (sanatorium or hospital). 
 
 To the patient and those living with him, the 
 book is intended to teach the most efficacious yet 
 most simple and practical means of preventing 
 the spread of the disease — in other words, to teach 
 
XX PREFACE 
 
 him and those with whom he comes in contact 
 how infecting others can be prevented and he 
 himself can be guarded against reinfection. 
 
 Again, to those living and associating with the 
 tuberculous, the book is intended to give the as- 
 surance that the clean, conscientious consumptive 
 who is careful in the disposal of his sputum and 
 the prevention of droplet infection, is as safe an 
 individual to associate with as anybody else, and 
 that phthisiophobia (exaggerated fear of the pres- 
 ence of a consumptive) is unjustified, cruel, and 
 inhumane. 
 
 To the physician, it is hoped, that the book may 
 be helpful by enabling him to give to his tuber- 
 culous patients in detail the necessary instructions 
 concerning their duties to themselves, to their 
 friends and families, to their medical advisers, and 
 to the community in which they may live. 
 
 To the physician, nurse, and family of the pa- 
 tient, the descriptions and illustrations of some 
 devices whereby the open air treatment and other 
 hygienic and sanitary installations in the home of 
 the patient can be easily arranged, it is hoped, 
 may likewise be helpful. 
 
 To the hygienist and sanitarian, the hints 
 which the book contains concerning the housing 
 problem in its relation to the prevention of tuber- 
 culosis may not be amiss. 
 
PREFACE 
 
 XXI 
 
 To municipal and health authorities of cities 
 and towns wherein the compulsory notification of 
 tuberculous cases and the proper control of tuber- 
 culosis is not yet inaugurated, a description of 
 such methods as have proved most efficacious will 
 surely be welcome. The book is designed to be 
 helpful to all those interested in this phase of anti- 
 tuberculosis work. 
 
 To the city fathers, legislators, and statesmen, it 
 is hoped this little work will show that the aboli- 
 tion of child and sweatshop labor, the regulation 
 of woman labor, proper labor and factory laws in 
 general, and the enactment and enforcement of 
 proper bovine laws are indispensable in the com- 
 bat of tuberculosis. It will also show that to take 
 care of the tuberculous poor at the right time and 
 right place is wiser than to keep them at the wrong 
 place when it is too late to do them any good ; and 
 that by pursuing the policy outlined herein, the 
 community will in the end be the financial gainer, 
 and the sanitary and moral conditions of its citizens 
 will be vastly improved. The author hopes to 
 convince the proper authorities that tuberculosis 
 in prisons, reformatories, and asylums should be 
 combated by the examination, segregation, and 
 treatment of those ill with the disease. 
 
 To the employer of men and women, the factory 
 owner, the farmer, and even to people employing 
 
xxii PREFACE 
 
 only servants, the book is intended to show that by 
 proper sanitation of workshops, stores, factories, 
 and sleeping quarters, and by looking after the 
 health of working people in general, a vast amount 
 of orood can be done and the solution of the tuber- 
 culosis problem greatly advanced. 
 
 To the public press, to professors of colleges, to 
 teachers of public and private schools, and educa- 
 tors in general, the book is intended to point out 
 the part they have to play in the combat of tuber- 
 culosis as a disease of the masses. 
 
 To the clergy, philanthropists, charitable indi- 
 viduals, and charity organizations, it is hoped to 
 give some valuable hints concerning the best way 
 to come to the aid of the consumptive poor without 
 pauperizing them. Philanthropists willing to aid 
 the anti-tuberculosis cause, will be shown many 
 ways in which they can serve their creator by 
 serving their fellow-men. 
 
 Even people of moderate means who are willing 
 to help in the cause of consumptives may learn how 
 they can be most useful. 
 
 The people living in neighborhoods where sana- 
 toria exist, or are projected, it is hoped will 
 be convinced by the carefully gathered statistics 
 that such institutions are not 'a sanitary or eco- 
 nomic danger to the neighborhood, but that on 
 the contrary the hygienic conditions of places 
 
PREFACE xxiii 
 
 where sanatoria are situated have usually improved 
 after the establishment of such institutions, and 
 the economic prosperity of the community has 
 correspondingly increased. To fraternal organiza- 
 tions, mutual benefit associations, and life insur- 
 ance companies, the author hopes to show the 
 great service such bodies can render in the solution 
 of the tuberculosis problem. 
 
 To the people at large, this volume is intended to 
 show that tuberculosis is a preventable and curable 
 disease, rarely directly hereditary; and that in chil- 
 dren of tuberculous parentage, the hereditary pre- 
 disposition can be overcome if they are properly 
 raised, and their physique, particularly the chest, 
 well developed. Even a predisposition acquired 
 after birth or later in adult life can be successfully 
 combated by similar means and by careful, sober, 
 and hygienic modes of life. 
 
 By reading the following pages, it is hoped the 
 layman may learn that a sober, proper, and regular 
 mode of living is all that is necessary to overcome a 
 hereditary predisposition or an acquired tendency 
 to the disease, and learn also what he is to do and 
 what not to do if he wishes never to fall a victim 
 to tuberculosis. By pointing out the early symp- 
 toms that may be easily recognized by a layman, it 
 is hoped to induce the individual having such 
 symptoms to place himself under the care of a 
 
xxiv PREFACE 
 
 physician immediately, while he is still in the most 
 curable stage of the disease, and thus be restored 
 promptly to health an^t^trength. In short, it is 
 hoped that the knowredge which this book is in- 
 tended to impart will help to solve the tuberculosis 
 problem and bring us nearer to the time when the 
 great white plague shall be forever eradicated from 
 
 our midst. 
 
 S. A. KNOPF. 
 
 New York, 
 May, 1909. 
 
TABLE OF CONTENTS 
 
 PAGE 
 
 Preface to Second Edition . . . . ix 
 Preface to First Edition .... xix 
 
 CHAPTER I 
 
 What a Tuberculous Patient Should Know 
 
 of His Disease 3 
 
 Professor Robert Koch. Definition of pulmonary 
 tuberculosis. Infectiousness of tuberculosis. Dis- 
 covery of the tubercle bacillus. Infection by inhala- 
 tion. Droplet infection. Infection from food sub- 
 stances. Infection by inoculation. Methods of pre- 
 venting the four sources of infection. Cuspidors and 
 sputum pocket flasks. Danger of infection by flies. 
 Useless cough. General personal hygiene. Rational 
 dress. Advantages of being acquainted with charac- 
 ter of the disease. Proofs of the curability of tuber- 
 culosis. The importance of medical guidance and 
 supervision of the tuberculous patient. 
 
 CHAPTER II 
 
 What Those Living with Patients Should 
 
 Know Concerning the Disease . . 16 
 How to deal with tuberculous patients. Natural 
 
 XXV 
 
xx\'i TABLE OF CONTEXTS 
 
 PAGE 
 
 sources of defense against tuberculosis. How to guard 
 against infection. Direct heredity. Hereditary pre- 
 disposition. Care of a child to prevent post-natal in- 
 fection. Prevention of tuberculosis from milk. Ster- 
 ilization and pasteurization of milk. Care of personal 
 and bed linen. Cleaning the rooms occupied by con- 
 sumptives. The sweeping by pneumatic, exhaustive, 
 or vacuum process. How to render the tuberculous 
 patient cheerful. Phthisiophobia. Opinions of lead- 
 ing medical authorities on the character of tuberculous 
 invalids. 
 
 CHAPTER III 
 
 The Duties of the Physician Towards His 
 Patient, the Family of the Patient, the 
 Community He Lives in, and Other Com- 
 munities 29 
 
 Individual instruction to the patient. Hope and 
 cheerfulness. Leaflets of instruction, Inauguration 
 of preventive measures. When to send the patient 
 away. Maxims in choice of cHmate. Examination 
 and periodical reexamination of all members of a 
 family. Selection of trade or profession for young man 
 or woman predisposed to tuberculosis. Com])ulsory 
 notification. Physician's duty toward the community 
 he lives in. Physician's duty toward other communi- 
 ties. Disinfection of sick room. Leaflet of general 
 advice to tuberculous patients. S])ccial advice to 
 patient, nurse, and family. The treatment of the 
 patient's mind. 
 
TABLE OF CONTENTS xxvii 
 
 CHAPTER IV 
 
 PAGE 
 
 How THE Sanatorium Treatment May Be 
 Adapted to and Imitated in the Home 
 OF THE Consumptive . . . -56 
 
 Sanatorium treatment at home. Proper housing. 
 Selection and equipment of bedroom. Aerotherapy. 
 Half-tent for the rest cure in the open air. Porches 
 for outdoor sleeping. Description of Dr. Millet's 
 sleeping shack. Tents for use in dry climates. De- 
 scription of Dr. Knopf's window-tent. Description of 
 Dr. Bull's aerarium. Preparation for outdoor sleep- 
 ing in cold weather. The Klondike bed. How to 
 guard against bright light in window-tent. Sputum 
 flask in window-tent. Screen. Precautions regarding 
 the open air treatment. Open air cure during the day 
 in the window-tent. How to become accustomed to 
 cold douches. Simple arrangement for taking the 
 cold douche. 
 
 CHAPTER V 
 
 How Sanitation and Proper Housing May 
 Help Toward the Prevention of Tuber- 
 culosis 84 
 
 Polluted air in large cities. Polluted air in the 
 homes of the poor. Effect of pure air on the develop- 
 ment of the chest. Advantages of wide streets and 
 lower buildings. Sanitary effect of woody regions. 
 Number of people employed in indoor occupations 
 in the United States. Time spent indoors by majority 
 of people. Construction of private houses with play- 
 
xx^'iii TABLE OF CONTENTS 
 
 PAGE 
 
 grounds. How to build sanitary houses. French 
 windows recommended. Limit to height of buildings. 
 Density of population in large cities. Necessity of 
 rapid transit facilities. Garden cities for the laboring 
 population. Short's model tenement house. De- 
 scription of an open air tenement house. Utilization 
 of flat roofs in cities. Roof playgrounds. "Roof 
 camping." Description of an open air private dwell- 
 ing. Individual economic sanitary house for laboring 
 man. Lodging houses. Internal arrangement of 
 homes. Night air. Dark and overcrowded bed- 
 rooms. Method of heating. Humidifier. Overheated 
 and dry atmosphere in houses. Hair hygrometer. 
 Avoidance of dust indoors. Rules for sweeping and 
 dusting. Traihng skirts. Cleaning of shoes. Brush' 
 ing of garments. 
 
 CHAPTER VI 
 
 The Duties of Modern Municipal Health 
 
 Authorities . .... 126 
 
 Smoke nuisance and its prevention. Preventive 
 measures in Chicago, London, and Manchester. Fire- 
 less locomotive. Cleaning of streets. Street sprink- 
 ling. Sweeping streets. Self-flushing cuspidors in 
 pubh'c buildings. Leaflets for the education of con- 
 sumptives and those living with them. New York 
 Health Department's short general circulars for the 
 laity. Circular to j^hysicians. Permanent tuljer- 
 culosis exhibitions. Lantern exhibits. Municipal 
 control of tuberculosis. Object of tuberculosis disj^en- 
 saries. Location and construction of ideal dispen- 
 
TABLE OF CONTENTS xxix 
 
 PAGE 
 
 sary. Description of New York Health Department's 
 clinic. Avoidance of multiplication of efforts. Pro- 
 vision for the family of the tuberculous breadwinner. 
 Municipal sanatoria and special hospitals for tubercu- 
 lous adults and children. Tuberculosis in almshouses 
 and orphan asylums. Chain of institutions. Police 
 power of the Health Department. Financial and 
 moral gain to a community which cares for its con- 
 sumptive poor. Municipal baths, parks, and play- 
 grounds. Hygienic city offices. Examination for 
 tuberculosis of all city employees. Exclusion from 
 indoor work of all tuberculous city employees. Civil 
 service examination and tuberculosis. Inspection of 
 milk. Badly ventilated public meeting places. Ex- 
 clusion of tuberculous employees from occupations 
 involving handling of food. 
 
 CHAPTER VII 
 
 The Duties of State and Federal Authori- 
 ties IN THE Combat of Tuberculosis . 171 
 Collaboration between State and municipal authori- 
 ties. Advantage of sanatoria in home climates. Lo- 
 cation of State sanatoria. How to avoid pauperi- 
 zation. Results obtained in Massachusetts State 
 Sanatorium. List and descriptions of State sanatoria 
 in the United States. State sanatoria in construction 
 or projected. Number of tuberculosis dispensaries in 
 the United States. Tuberculosis in insane asylums 
 and prisons. Tuberculous prisoners in detention pris- 
 ons. Tuberculosis in penal institutions. Rules for 
 prevention of tuberculosis in prisons. Infection. Dis- 
 
XXX TABLE OF CONTENTS 
 
 PAGE 
 
 infection of clothes, blankets, etc., in prisons. Venti- 
 lation and lighting. Frankel's mouth-mask. Danger 
 from whitewash. Exercise for prisoners. Bathing and 
 food. Effect of overwork on the predisposed prisoners. 
 Overcrowding in badly-ventilated workshops. Dan- 
 gerous occupations. Discharge of tuberculous pris- 
 oners. Agricultural colonies for tuberculous prisoners. 
 Wynne State Farm. Woman's labor, child labor, 
 sweatshop labor. Sanitary supervision of factories. 
 Bovine tuberculosis. Uniform bovine laws. Tuber- 
 culosis in United States Army and Navy. Tubercu- 
 losis in non-military government services. Tuber- 
 culosis in post offices. Cleaning and disinfecting 
 United States mail bags. Government sanatorium 
 for non-military tuberculous employees. Emigration 
 from city to country. Schools of forestry. Co- 
 operation of municipal and State authorities with 
 Federal Department of Health. President Taft on a 
 new Public Health Bureau. 
 
 CHAPTER VIII 
 
 What Employers of Every Kind Can Do to 
 Diminish Tuberculosis Among the Men 
 AND Women Working for Them . .228 
 Factory and office hygiene. Spitting regulations. 
 Danger of overheating. Dn)j)let infection. Indis- 
 criminate ex[;ectoration. Examination and reexam- 
 ination of all emjjloyecs. Lectures to employees. 
 Emjjloyer's duty toward family of the tuberculous 
 emjjloyee. Tuberculous miners. Tuberculous serv- 
 ants. Telephone hygiene. Duties of railroad cor- 
 
TABLE OF CONTENTS xxxi 
 
 PAGE 
 
 porations. Cleaning of cars. General railway sanita- 
 tion. Tuberculosis among telegraph and telephone 
 operators. Farmer's duty in the prevention of tuber- 
 culosis in man and beast. Tuberculin test in cattle. 
 Tuberculosis in horses, swine, goats, dogs, and par- 
 rots. Prevention of tuberculosis among sailors. 
 
 CHAPTER IX 
 
 The Duties of School Teachers, Educators 
 IN General and of the Public Press in 
 THE Combat of Tuberculosis . . . 246 
 Prevention of tuberculosis in pubHc schools. Con- 
 struction and equipment of schools. Playgrounds, 
 roof gardens, swimming tanks. Swimming lessons. 
 Respiratory exercises for school children. Outdoor 
 instructions. School hours and home lessons. Age 
 at which a predisposed child should attend school. 
 Description of Dr. Knopf's breathing exercises. Sing- 
 ing and recitation in the open air. Excursions to the 
 country. School farms. Malnutrition of school chil- 
 dren. Free luncheons for children of the poor. In- 
 struction of all pupils in the prevention of tubercu- 
 losis. Alphabet for school children in the prevention 
 of tuberculosis. Early signs of various forms of tuber- 
 culosis in children which teachers should be able to 
 recognize. Scrofulous children. Examination of all 
 children entering school. Open air school for tuber- 
 culous and predisposed children. Description of 
 Providence open air school. Open air school for 
 tuberculous children on the "Southfield" in New 
 York.. Open air schools for well children. Seaside 
 
xxxii TABLE OF CONTENTS 
 
 PAGE 
 
 sanatoria for tuberculous children. School sanatoria 
 for tuberculous teachers. Teaching of prophylaxis of 
 tuberculosis in colleges, etc. Evening lectures under 
 the auspices of the Board of Education. Anti-tuber- 
 culosis education through the public press. "Sure 
 consumption cure" advertisements. Cooking schools 
 and housekeeping centers. "Carohne Rest" school 
 sanatorium for mothers. Practical housekeeping 
 centers. Unwise Antagonism to Authorities. 
 
 CHAPTER X 
 
 The Duty of the Clergy, Philanthropists, 
 Charitable Individuals, and Charity 
 
 Organizations 284 
 
 Duties of the clergy in the prevention of tubercu- 
 losis. Church hygiene. Disinfection of objects of ad- 
 oration. Ritual circumcision. Individual commun- 
 ion cups and sanitary common communion cup. 
 Anti-tuberculosis sermons. Denominational hospi- 
 tals for the care of the tuberculous. Cremation. 
 Expensive Funerals. Anti-tuberculosis work of the 
 Emmanuel Church. Co-operation to form a spe- 
 cial tuberculosis committee. Purpose of a tuber- 
 culosis committee. Work accomplished by the 
 New York Charity Organization Society Tubercu- 
 losis Committee. Need of sanatoria for tuberculous 
 children. Value of sanatorium treatment. Diet- 
 kitchen association. Anti-tuberculosis work by phi- 
 lanthropists. Animal experimentation and vivisec- 
 tionists. Number of sanatoria in the United States. 
 Illustrations of different types of sanatoria of the 
 
TABLE OF CONTENTS xxxiii 
 
 PAGE 
 
 United States, Canada, and Europe. Social and medi- 
 cal mission of the sanatorium. Influence of the sana- 
 torium on private and official phthisiophobia. Mor- 
 tality statistics of localities near sanatoria. Sanatoria 
 as educational factors to physicians and nurses. The 
 alcohol question in the sanatorium. Intellectual and 
 educational advantages for sanatorium inmates. 
 Philanthropic consumptives. Day camps and night 
 camps. Dr. Richer's preventorium. Class method 
 feasible in sanitary tenement. The Shively sanitary 
 tenement. Institutional segregation of advanced 
 cases. 
 
 CHAPTER XI 
 
 The Duties of the People in the Combat 
 
 OF Tuberculosis . . . . .351 
 Early signs of pulmonary tuberculosis recognizable 
 by the layman. Education through free lectures and 
 literature. Overcoming an inherited tuberculous 
 predisposition. Early prophylactic measures. Hy- 
 giene for pregnant women. Hygiene in nursery. 
 Dress and hygiene for children. Dress for girls pre- 
 disposed to tuberculosis. Tight lacing. Child labor 
 at home. Alcoholism as a predisposing factor and its 
 prevention. Prohibition. Gothenburg system. Re- 
 sults of treating habit. Education a remedy for in- 
 temperance. Institutions for the cure of habitual 
 drunkards. Healthful amusements. Misery begets 
 alcoholism. Model tenement homes. Comfort sta- 
 tions. Hygiene in workshops and at home. Value of 
 econornical and practical housekeeping. The housefly 
 
xxxiv TABLE OF CONTEXTS 
 
 PAGE 
 
 as a propagator of disease. Open air life for every- 
 body. American National Red Cross anti-tubercu- 
 losis work. Number of anti-tuberculosis committees, 
 societies, and associations in the United States. Sana- 
 toria of fraternal organizations. Insurance against 
 tuberculosis. 
 
 CHAPTER XII 
 
 Prospect of Ultimate Eradication of Tuber- 
 culosis 379 
 
 Louis Pasteur and his encouraging and inspiring 
 words. How tuberculosis can be eradicated. Pre- 
 vention of tuberculosis and of social misery. 
 
ILLUSTRATIONS 
 
 FIG. NO. PAGE 
 
 1. Professor Robert Koch, discoverer of the tubercle 
 
 bacillus (from his latest photograph) . Frontispiece 
 
 2. A small particle of sputum seen through the micro- 
 
 scope. The red marks represent the tuberculosis 
 germs 1,200 times enlarged ..... 4 
 
 3. Knopf's cuspidor of metal. It has a large opening and 
 
 the cover is to be manipulated by the foot. To 
 avoid spattering it should be partially filled vt'ith wet 
 sawdust ........ 7 
 
 4. The same when closed ...... 7 
 
 5. Sanitary elevated cuspidor of gold-bronzed metal 
 
 When in use ........ 8 
 
 6. Sanitary elevated cuspidor of gold -bronzed metal 
 
 When closed 
 
 7. Knopf's oval, nickel-plated, irreversible flask for pocket 
 
 use, with removable funnel that can be manipulated 
 with one hand ....... 9 
 
 8. Metal sputum flask in use in the U. S. Marine Hospital 
 
 Service ......... 10 
 
 9. Dettweiler's pocket sputum flask of thick blue glass, 
 
 with metal mountings . . . . .10 
 
 10. Kny-Scheerer Sanitas cup for pocket use made of tin 
 
 with a removable pasteboard container . . .11 
 
 11. Johnson & Johnson's pasteboard purse for sputum 11 
 
 12. Seabury & Johnson's metallic frame for pasteboard 
 
 sputum cup . . . . . . . .12 
 
 13. Pasteboard container to Seabur}- & Johnson's cup . 12 
 
 14. Sanitary spitcup made of pressed pasteboard with 
 
 cover and handle ....... 13 
 
 XXXV 
 
xxxvi ILLUSTRATIONS 
 
 FIG. XO. PAGE 
 
 15. Knopf's half-tent for the rest-cure in the open air. 
 
 The detachable cover is made of sail canvas. When 
 
 not in use the frame may be folded flat ... 58 
 
 16. Sleeping balcony designed and used by a young tuber- 
 
 culous chemist of Boston ..... 60 
 
 17. Original sleeping balcony in Hanover, ]\Jass., used 
 
 since June, 1898 ....... 62 
 
 18. Latest model of sleeping shack designed by Dr. Millet 
 
 of Brockton, Mass. ...... 63 
 
 19. Plans of Dr. Millet's shack. South and east elevations 63 
 
 20. The Tucker tent for outdoor living .... 66 
 
 21. Knopf's window-tent for the open air treatment of 
 
 tuberculous patients. Tent in use with patient in 
 bed looking through the celluloid window into the 
 room, but breathing outdoor air only. ... 67 
 
 22. Sectional view showing the ventilation of Knopf's 
 
 window tent ........ 68 
 
 23. View of the window-tent and patient taken from the 
 
 outside 70 
 
 24. Knopf's window-tent raised, when not in use . . 71 
 
 25. Bull's aerarium for the open air treatment • • • 75 
 25a. Sectional view of Bull's aerarium .... 75 
 
 26. How to dress for outdoor sleeping in cold weather . 76 
 
 27. Children at play on the roof of a private house in New 
 
 York City .... ... 92 
 
 28. R. Thomas Short's prize plan for a model tenement 
 
 house ......... 95 
 
 29. Elevation of open air model tenement house . . 97 
 
 30. Plan for open air model tenement house ... 99 
 
 31. Group of children, operated on for surgical tubercu- 
 
 losis, at play on the roof of the N. Y. Post-Graduate 
 
 Medical School 104 
 
 32. Roof camping in midsummer in New York . . 105 
 33- Open air i>rivate dwelling (elevation) . . . . 108 
 34. First floor plan of private open air dwelling . . 109 
 
ILLUSTRATIONS xxxvii 
 
 FIG. NO. PAGE 
 
 35. Second floor plan of private open air dwelling . .110 
 
 36. Economical sanitary house for one family . . .112 
 
 37. First floor plan of economical sanitary house for one 
 
 family . . . . . . . . -113 
 
 ^8. Second floor plan of economical sanitary house for one 
 
 family . . . . . . . . .114 
 
 39. Barnes' Humidifier ....... 122 
 
 40. Direct reading hair-hygrometer to determine humidity 
 
 in rooms ........ 123 
 
 41. Knopf's elevated self-cleaning street and garden spit- 
 
 toon ......... 132 
 
 42. Knopf -Thiebert self -flushing elevated cuspidor with 
 
 cover for railway stations, etc. .... 132 
 
 43. A section of the International Tuberculosis Exhibit 
 
 held in New York, January, 1909, at the Museum 
 of Natural History, showing exhibits of various 
 States and countries ...... 144 
 
 44. New York State section of the International Ex- 
 
 hibit 145 
 
 45. New forms of shelter for consumptive cases as exhib- 
 
 ited at the Dublin Tuberculosis Exhibition . .146 
 
 46. Plan of Tuberculosis Clinic of the N. Y. Health De- 
 
 partment ........ 153 
 
 47. A porch of the Seabreeze Sanatorium for Children 
 
 suffering with surgical tuberculosis at Coney Island, 
 N. Y. Established by the Society for the Improve- 
 ment of the Condition of the Poor, now maintained 
 by Mr. John D. Rockefeller 158 
 
 48. Inland Sanatorium. Countrv^ branch of the N. Y. 
 
 Orthopaedic Dispensary and Hospital at White 
 Plains, N. Y. Acute cases of joint tuberculosis 
 "doing cures" in midwinter .... 159 
 
 49. Patients taking breathing exercises under the direction 
 
 of the physicians at Riverside Hospital Sanatorium 
 
 of the N. Y. Health Department .... 162 
 
XXXVIU 
 
 ILLUSTRATIONS 
 
 51- 
 
 52. 
 
 53- 
 
 54- 
 
 55- 
 56. 
 
 57- 
 
 58- 
 
 FIG. NO. PAGE 
 
 50. Boys without a playground ..... 165 
 First State Sanatorium erected in the United States, 
 
 located at Rutland, Mass. . . . . -174 
 Patients of the Massachusetts State Sanatorium 
 
 taking the open air cure at a temperature below 
 
 zero . . . . . . . . .176 
 
 Winter view of the N. Y. State Hospital for Incipient 
 
 Tuberculosis at Ray Brook, N. Y 188 
 
 Rhode Island State Sanatorium, situated at Wallum 
 
 Lake, R. 1 193 
 
 Proedohl's iron spittoon for use in workshops . . 202 
 
 Frankel's mouth mask 206 
 
 Plan of station for cleaning and disinfecting post-office 
 
 mail bags ........ 224 
 
 Hygienic device for telephone transmitter . . . 235 
 
 59. Roof playground of Public School No. 44, New York 
 
 City 247 
 
 60. Schoolgirls learning to swim at Corlear Street Public 
 
 Bath, New York City 249 
 
 61. Respiratory Exercise A 253 
 
 62. Respiratory Exercise B 254 
 
 63. Respiratory Exercise C 255 
 
 64. Respiratory Exercise D 255 
 
 65. Respiratory Exercise E ..... . 256 
 
 66. Respiratory Exercise F 257 
 
 67. Respiratory Exercise G 258 
 
 68. Children's School Farm at 
 
 Eleventh Avenue and F 
 City, where children crippled by tuberculosis or ac- 
 cidents are taken during the daytime for play and 
 in.struction in farming and gardening. Mrs. Henr>' 
 Parsons, founder anrl director .... 262 
 
 6g. Open air .school at Providence, R. 1 270 
 
 70. London City Council open air school at iiorniman 
 
 Park — Resting time 271 
 
 the DeWitt Clinton Park, 
 ifty-fourth St., New York 
 
ILLUSTRATIONS ^xxix 
 
 FIG. NO. PAGE 
 
 71. Open air school on the "Southfield," a discarded 
 
 ferryboat anchored at foot of East Twenty-sixth 
 Street, New York City . . . . . .272 
 
 72. Seaside sanatorium and school for the tuberculous 
 
 children of the city of Paris, located at Berck-sur- 
 Mer 277 
 
 73. Playground in midwinter for tuberculous children at 
 
 Seabreeze, Coney Island, N. Y. . . . .278 
 
 74. Rev. Ljunggren's hygienic chalice .... 288 
 
 75. The Philadelphia Protestant Episcopal City Mission 
 
 House for Consumptives, founded in 1877 . . 290 
 
 76. St. Joseph Hospital for Consumptives in all stages of 
 
 the disease, New York City 291 
 
 77. Nazareth Branch of Seton Hospital for consumptive 
 
 women and children, in charge of the Roman Catho- 
 lic Sisters of Charity 292 
 
 78. The National Jewish Hospital for Consumptives at 
 
 Denver, Colo., men's pavilion. Only incipient 
 cases are admitted 293 
 
 79. The National Jewish Hospital for Consumptives at 
 
 Denver, Colo. The balconies of the circular pa- 
 vilion for women ....... 294 
 
 80. An Emmanuel Church class patient taking the open 
 
 air treatment in a back yard of a Boston tene- 
 ment 302 
 
 81. Panoramic view of the Adirondack Cottage Sana- 
 
 torium, Trudeau, N. Y. For incipient and early 
 cases. Semi-philanthropic. The uniform charge is 
 $5.00 per week ....... 314 
 
 82. Adirondack Cottage Sanatorium. Piazza of the new 
 
 Medical and Reception Pavilion . . . .316 
 
 83. Marilla C. Wheeler Cottage of the Adirondack Cot- 
 
 tage Sanatorium, at Trudeau, N. Y. . , -317 
 
 84. Adirondack Cottage Sanatorium. Ground Plan of 
 
 McAlpin Cottage 318 
 
xl ILLUSTRATIONS 
 
 FIG. NO, PAGE 
 
 85. Agnes Memorial Sanatorium, Denver, Colo. Sleep- 
 
 ing gallery for women • 3'^9 
 
 86. Agnes Memorial Sanatorium, Denver, Colo. Male 
 
 patients taking the open air rest cure . . . 320 
 
 87. Bariow Sanatorium, Los Angeles, Cal. Semi- 
 
 philanthropic. Rates: $5.00 to $7.00 for those who 
 
 are able to pay. Others are cared for free of charge 322 
 
 88. Edward Sanatorium at Naperville, near Chicago. For 
 
 incipient cases only. Rates: $10.00 per week. Ten 
 free beds are maintained by the Chicago Visiting 
 Nurse Association ....... 324 
 
 89. Gaylord Farm Sanatorium, Wallingford, Conn. Semi- 
 
 philanthropic. Rates: $7.00 per week. The State 
 appropriates $7,500 annually. Deficit made up by 
 voluntar}' subscriptions ...... 325 
 
 90. Loomis Sanatorium at Liberty, N. Y. Sanatorium 
 
 proper. Private. Rates: $15.00 to $40.00 per week 326 
 
 91. Sleeping porch, Mary Lewis Reception Hospital of 
 
 Loomis Sanatorium ...... 328 
 
 92. Rest-a-While and original lean-to, Loomis Sana- 
 
 torium Annex for intermediate division. Rates: 
 $10.00 to $12.00 per week. There is also a semi- 
 philanthropic division for early cases only: $5.00 
 per week ........ 330 
 
 93. Patients at the Loomis Sanatorium exercising just 
 
 sufficiently to help along the cure .... 332 
 
 94. New Mexico Cottage Sanatorium, Silver City, N. Mex. 
 
 Private. For pulmonary and laryngeal tuberculosis 
 
 at curable stage. Rate: $83.00 per month . . ;^;^^ 
 
 95. Nordrach Ranch Sanatorium, Colorado Springs. For 
 
 the first and second stages. Private. Rates: $60.00 
 
 to $65.00 per month ...... 334 
 
 96. The Sharon Sanatorium; eighteen miles from Boston. 
 
 Semi-philanthropic. Rates: $5.00 ])er week. For 
 women of limited means 335 
 
ILLUSTRATIONS xli 
 
 FIG. NO. PAGE 
 
 97. A two room compartment tent of the Star Ranch, 
 
 Colorado Springs ....... 336 
 
 98. Muskoka Cottage Sanatorium, Gravenhurst, Canada. 
 
 Rates: $12.00 to $15.00 per week. Established 
 through private gifts. Maintained by the fees from 
 patients and a small grant from the Provincial 
 Government ........ 337 
 
 99. Red Cross Day Camp on the roof of the Vanderbilt 
 
 Clinic ......... 338 
 
 100. View of Davosplatz, Switzerland, where numer- 
 ous private and philanthropic sanatoria are lo- 
 cated ......... 339 
 
 loi. Sanatorium Falkenstein, near Frankfort on the Main, 
 Germany, with ruin of Falkenstein Castle in the 
 background. (Private.) ..... 340 
 
 102. Sanatorium Wehrawald and the village of Todtmoos, 
 
 in the Black Forest, Germany. (Private.) . . 341 
 
 103. Dr. Weicker's Sanatorium in Goerbersdorf, near 
 
 Breslau, Germany. (Private.) .... 343 
 
 104. Royal Hospital for Consumptives at Ventnor, Isle of 
 
 Wight, England 345 
 
 105. The Proposed Shively Sanitary Tenements; street 
 
 view. Built by Mrs. Wm. K. Vanderbilt, Sr. Henry 
 Atterbury Smith, Architect 346 
 
 106. The proposed Shively Sanitary Tenements; court view, 
 
 showing open staircases ..... 348 
 
 107. Situation of vital organs in a normal chest . . 359 
 
 108. Situation of vital organs in constricted chest . , 359 
 
 109. Skeleton of chest, permanently constricted by too tight 
 
 lacing 359 
 
 no. American National Red Cross Stamp for the year 
 
 1908 . . . . . . . . -370 
 
 III. Proposed quarters of the National Pythian Sana- 
 torium, Las Vegas, N. Mex. 1,300 acres have been 
 donated to this institution 373 
 
xlii ILLUSTRATIONS 
 
 FIG. XO. PAGE 
 
 112. Union Printers' Home for Consumptives. Estab- 
 
 lished and maintained by the International Typo- 
 graphical Union 374 
 
 113. " Krankenheim " of Dr. H. Weicker at Goerbersdorf, 
 
 Germany, to which life insurance companies send 
 their tuberculous policy holders immediately after 
 the recognition of the disease 375 
 
 114. Tuberculosis Sanatorium at Oderberg, Germany. 
 
 Erected by the State Invalidity Insurance Com- 
 panies for its tuberculous policy holders . -377 
 
 115. Louis Pasteur in his laboratory 380 
 
TUBERCULOSIS 
 
 CHAPTER I 
 
 WHAT A TUBERCULOUS PATIENT SHOULD KNOW 
 OF HIS DISEASE 
 
 Knowledge is power, and in no disease is the 
 knowledge of his condition more essential for the 
 well-being of the patient, nor is there any in which 
 the patient can by this knowledge help the phy- 
 sician more toward obtaining a complete and 
 lasting recovery than in the disease known as 
 tuberculosis pulmonum, phthisis pulmonalis, pul- 
 monary tuberculosis, or consumption. 
 
 The tuberculous patient should know that he is 
 afflicted with a chronic, infectious, communicable, 
 preventable, and curable disease. The disease 
 being of a chronic character, that is to say long 
 lasting, the patient must not expect to get well 
 within a few weeks. It may take months and 
 sometimes even years for a complete recovery. 
 Fortunately, in many cases the treatment can be 
 continued later on while the patient may be able 
 to do some work at the same time. 
 
4 TUBERCULOSIS 
 
 The tuberculous patient must, on account of 
 the nature of his disease, be exceedingly care- 
 ful not to infect others or reinfect himself. Per- 
 haps the most frequent cause of infection is the 
 careless disposal of sputum or spittle containing 
 the germs of tuberculosis which can be transmitted 
 or communicated from man to man, from beast to 
 man, and from man to beast. It must be remem- 
 bered that the germ of tuberculosis, called bacillus 
 tuberculosis and discovered by Professor Robert 
 Koch in 1882 {Frontispiece), is the only direct 
 cause of all tuberculous diseases, and that without 
 the presence of this bacillus the development of 
 tuberculosis is impossible. Koch called this germ 
 ''bacillus," which is the Latin for rod, because 
 under a powerful microscope, when subjected to 
 a certain red coloring agent, these minute forms 
 appear like little rods. (Fig. 2.) When these 
 germs enter any living organism they are apt to 
 multiply and by irritation cause the growth of 
 small elevations about the size of the head of a 
 pin, called tubercles, hence the name tuberculosis. 
 
 The bacilli may be found in countless numbers 
 in the lung or any other organ affected with 
 tuberculosis, and in the case of pulmonary con- 
 sumption quantities of them arc rejected when the 
 patient expectorates. The bacillus or germ of 
 tuberculosis is a little parasite, a fungus or mush- 
 
-f". 
 
 
 X 
 
 i'x 
 
 ■r^ 
 
 \^ 
 
 
 
 %#-^^ 
 
 -^k 
 
 .*%> 
 
 -^■^■K 
 
 
 
 
 #, 
 
 <g<). -^J^-. ^i>-~ 
 
 ^' 
 
 ■i*!.' 
 ^if 
 
 
 '4 
 
 '"'=?^~9C: 
 
 1^*- v: 
 
 ^ 
 
 > 
 
 <l.<s. 
 
 Fig. 2. A small particle of Sputum seen through the Alicro- 
 scop)e. The Red marks represent the Tuberculosis Germs 
 I200 times enlarged. 
 
INFECTIOUSNESS OF TUBERCULOSIS 5 
 
 room, belonging to the lowest scale of vegetable 
 life. It not only gradually destroys the lung sub- 
 stance through ulcerative processes, but gives off 
 at the same time certain poisonous substances 
 called toxins which are often the cause of serious 
 symptoms. 
 
 The manner in which the infection from man 
 to man occurs most readily is by the inhalation 
 of bacilli-laden dust. If, for example, a patient 
 expectorates on a floor or a wall where the sputum 
 has a chance to dry and become pulverized, it 
 is liable to float with the dust in the air, and any 
 predisposed individual breathing this air is in 
 danger of contracting the disease by inhalation. 
 
 Another w^ay in which infection may take place 
 is from close contact with tuberculous individ- 
 uals who are not only careless with the disposal 
 of their expectoration, but also careless w^hen 
 coughing. It is erroneous to suppose that the 
 patient who coughs but does not expectorate is 
 therefore harmless. He is only harmless when he 
 takes care always to hold his hand or handker- 
 chief before his mouth so as to prevent the expul- 
 sion of small particles of saliva during coughing. 
 These small particles or little drops of saliva may 
 contain the bacilli and, when taken into the system 
 of a predisposed individual by inhalation or inges- 
 tion, may cause a tuberculous infection. This 
 
6 TUBERCULOSIS 
 
 manner of communicating the disease from one 
 person to another is called droplet infection. 
 
 The next most frequent way in which tubercu- 
 losis may be transmitted to man is through the 
 digestive system. Tuberculous meat or milk can 
 give tuberculosis and, according to some authori- 
 ties, infection from the ingestion of tuberculous 
 milk is quite frequent. 
 
 Inoculation, that is to say, the penetration of 
 tuberculous substance through a lacerated skin 
 or any other kind of a wound, is most likely to 
 happen when proper care is not taken in cleaning 
 cuspidors which have been used by consumptives. 
 If the cuspidor is of glass or porcelain and should 
 be nicked or chipped, the wound and the inocula- 
 tion may occur at the same time. Occasionally, 
 physicians, students of medicine, or veterinary 
 science become inoculated with tuberculosis by 
 wounding themselves with instruments which had 
 been soiled with tuberculous matter. 
 
 Formidable as these multiple dangers of infec- 
 tion and reinfection appear, it should be said 
 right here that all that is necessary to avoid them 
 is to be careful, conscientious, and faithful. The 
 patient who is up and about should always expec- 
 torate into a cuspidor partially filled with water. 
 The cuspidor should have a cover and it should 
 have an opening large enough for the- individual 
 
INFECTION 
 
 using it to have no difficulty in depositing his spittle 
 in the interior of the receptacle, so that he will not 
 
 soil the brim on which 
 the tuberculous matter 
 would have a chance to 
 dry and become a source 
 of infection. (Figs. 3, 4, 
 5, 6.) The tuberculous 
 patient when outside of 
 
 Fig. 3. Knopf's cuspidor of met- ^is homC, should, of 
 al It has a large opening cOUrSe, be aS rcligioUsly 
 and the cover is to be manip- r i '.a ^ • ± 
 
 ^ , A u .^. ( . rj. .. careiul with his sputum 
 
 ulated by the foot. To avoid ^ 
 
 spattering it should be par- aS withiu it. When he 
 
 tiaiiy filled with wet sawdust. ^^^ ^^^ Conveniently ex- 
 pectorate in the usual type of cuspidor, he should 
 not let this serve as an excuse for careless ex- 
 pectorating and the dissemination of his disease. 
 He should always provide himself with a sputum 
 flask either of metal (Figs. 7, 8) or glass (Fig. 9), 
 or a pasteboard box 
 (Fig. 10), or purse (Fig. 
 11), which he can carry 
 in his pocket. For the 
 patient in bed, a me- 
 talhc frame (Fig. 12) 
 containing a box made of impermeable paste- 
 board (Fig. 13), or a box made entirely of paste- 
 board (Fig. 14), may serve as a convenient sputum 
 
 Fig. 4. The Same ^\'hen Closed. 
 
TUBERCULOSIS 
 
 receptacle. The contents (sputum) of the pocket 
 flasks should be poured into the water-closet and 
 
 the vessels after- 
 wards cleaned with 
 hot water. The 
 pasteboard recepta- 
 cles may be thrown 
 into the fire with 
 their contents. 
 
 It is conceivable 
 and pardonable 
 that, when in pub- 
 lic, patients should 
 not desire to make 
 use of a pocket 
 flask or purse which 
 would attract at- 
 tention to their mal- 
 ady. The only 
 thing such patients 
 can do is to use squares of soft muslin, cheese 
 cloth, cheap handkerchiefs, or Japanese paper 
 handkerchiefs especially manufactured for that 
 purpose, which can be burned after use. They 
 should also place in the pocket in which they 
 intend to put the soiled cloths a removable lin- 
 ing of rubber or other impermea])le material 
 which can be thoroughly cleaned. This additional 
 
 Fig. 5. Sanitary Elevated Cuspidor of 
 Gold-bronzed Metal. When in Use. 
 
INFECTION 
 
 Fig. 6. 
 Cuspidor When Closed. 
 
 lining could be fastened to the inside of the ordi- 
 nary pocket by clamps, and would thus be of no 
 
 inconvenience to the patient. 
 A pouch of vulcanized rub- 
 ber or an Oriental tobacco 
 pouch may be used in place 
 of the extra pocket or lining. 
 In any case it is well to have 
 more than one of these pock- 
 ets or pouches so that the pa- 
 tient need never be without 
 Sanitary Elevated one wliilc the Other is being 
 cleaned and immersed in 
 some disinfectant or in boiling water. Ladies 
 should divide their little handbags 
 or satchels into two compartments; 
 one for the clean and one for the 
 soiled cloths. Of course, all inva- 
 lids who use handkerchiefs, rags, or 
 Japanese paper as receptacles for 
 expectoration, are in danger of in- 
 fecting their hands, which they 
 should always wash thoroughly be- 
 fore touching food. To expectorate 
 in a handkerchief and use the same 
 for wiping the nose exposes the pa- 
 tient to reinfection. 
 
 It should also be remembered that the house-fly 
 
 Fig. 7, 
 oval 
 
 Knopf's 
 nickel- 
 plated irrevers- 
 ible flask for 
 pocket use, 
 with remov- 
 ab le f u nnel 
 that can be 
 m a n i p u 1 ated 
 with one hand. 
 
lO 
 
 TUBERCULOSIS 
 
 Fig. 8. Metal 
 sputum flask in 
 use in the U. S. 
 Marine Hospi- 
 tal Service. 
 
 and other insects are often the carriers of tuber- 
 culous infection, and a vessel of any kind intended 
 to receive tuberculous sputum 
 should not be without a cover. 
 The fly, for example, may not only 
 carry small particles of tubercu- 
 lous sputum on its feet and then 
 deposit them on some article of 
 food; but it has been demonstrated' 
 that even the dead fly which had 
 fed on tuberculous substances is 
 dangerous, for the tubercle bacilli 
 have been found in the dust coming from the 
 crumbled bodies of dead flies. 
 
 A tuberculous patient should be careful not 
 to kiss any one, particularly not 
 on the mouth. He should have 
 his own room if it is at all pos- 
 sible, but always his own bed. If 
 there must be more than one bed 
 in the room, they should be a 
 little more than three feet apart to i-io. 9. Dettweii- 
 avoid direct droplet infection. The ^^rs poc et spu- 
 
 ^ t u m 1 1 a s k o I 
 
 droplets expelled during the cough thic k blue glass, 
 rarely go further than three feet and with metal 
 
 11 1 mountings. 
 
 then fall to the ground, where they 
 
 are less likely to do harm than when directly 
 
 coughed into a person's face or on to one's cloth- 
 
INFECTION BY INHALATION 
 
 II 
 
 ing. The patient should remember ahvays to 
 
 hold his hand or handkerchief before his mouth 
 
 when coughing. 
 
 The physician treating the patient will, of 
 course, prescribe for the cough 
 when necessary; but he will also 
 tell the invalid that he must con- 
 trol useless coughing; in other 
 words, he should never cough un- 
 less he feels that he has to expec- 
 
 FiG lo Kny- toratc. The patient should un- 
 
 Scheerer Sanitas dcrstand that tO COUgh without 
 
 cup or poc-et gxpectoratinsj is yielding to an ir- 
 
 use made of tm ^ ■•■ ^ o j o 
 
 with a removable ritatiou of the throat which may in 
 pasteboard con- -j-jj^g bccomc a habit rather than a 
 
 tainer. . . .„ 
 
 necessity. A strong will can con- 
 trol the useless cough, or the cough of habit. 
 If the patient will consider it as impolite to cough 
 uselessly, particularly in 
 presence of others, just be- 
 cause he has a little tickling 
 in the throat, as it is impo- 
 lite to scratch one's head in 
 public because of a little 
 itching, he will be greatly fig. n. Johnson & john- 
 
 helped in his efforts. The ^^^'^ Pasteboard Purse 
 , T ,.,..,.. for Sputum. 
 
 other thought m disciplining 
 
 the cough should be that useless coughing is in- 
 
12 
 
 TUBERCULOSIS 
 
 Fig. 12. 
 
 jurious to the throat and invokes an unneces- 
 sary expenditure of force. 
 
 Besides these special hygienic 
 measures which the patient should 
 carry out, there is, of course, also 
 the very important general and 
 personal hygiene. He should keep 
 his skin in good condition by 
 Seabury weekly batlis and daily sponges. 
 'Jo nsons. e- g^^^.^ ^^^ mustachc should not 
 
 tallic rrame tor 
 
 Pasteboard Spu- be worn at all, or be closely cut. 
 
 turn Cup. ^g underwear the linen-mesh, 
 
 heavy weight in winter and light weight in sum- 
 mer, is to be highly recommended. If, as happens 
 in some cases, the patient feels cold even with the 
 heavy weight linen-mesh, it is advisable for him 
 to wear linen-mesh next to the 
 skin and an additional cotton, 
 silk, or very light woolen garment 
 over it. Linen-mesh underwear 
 is more suitable for the tuber- 
 culous because it dries quickly 
 when the patient perspires. It 
 produces a constant pleasant fric- 
 tion on the skin, and is prefer- 
 able to wool or cotton in that the 
 mesh allows a better ventilation of the skin and 
 renders the patient less apt to catch cold. The out- 
 
 FiG. 13. Pasteboard 
 Container to Sea- 
 bury & Johnson's 
 Cup. 
 
INFECTION BY INHALATION 13 
 
 side garments should be comfortable and accord- 
 ing to the season, light in summer, warm in winter; 
 but not too heavy so as to hin- 
 der free movement. All gar- 
 ments restricting free thoracic 
 or abdominal breathing should 
 be done away with. The high 
 collar for men and the high, ^^^^ ^^^ ^^^^^^ Spit- 
 
 tight, stiff, or boned collar for cup Made of Pressed 
 
 women, or anything else con- Pasteboard with Cover 
 •^ ° and Handle. 
 
 stricting the neck is injurious; 
 so is the tightly laced corset and tight belt. 
 Ladies' skirts should be partially suspended from 
 the shoulders and the steel corset should, when- 
 ever possible, be replaced by a comfortable waist. 
 With everything relating to his personal hygiene, 
 to the prevention of infection of others and rein- 
 fection of himself, the patient should be familiar. 
 But he should also know that if he is careful and 
 obeys the few necessary rules, people need not be 
 afraid but should gladly associate with him. He, 
 himself, because of his knowledge and the con- 
 sciousness of doing his duty, will be happier and 
 freer in mind. He can demonstrate that al- 
 though tuberculosis is a communicable disease, it 
 is by no means to be classed with the highly con- 
 tagious diseases (the word "contagion" comes 
 from the Latin contingere, to touch), such as small- 
 
14 TUBERCULOSIS 
 
 pox for example. The touch of the clean, con- 
 scientious consumptive can not give tuberculosis. 
 
 Another fact which should tend to cheer the 
 tuberculous patient, is that of all the chronic 
 diseases his is curable the most frequently. It is 
 not only true that as many as 80 per cent of cures 
 are reported when the patient's disease was dis- 
 covered in time and properly treated, but the 
 post-mortem examinations of hundreds and hun- 
 dreds of cases which died from accident or other 
 diseases than consumption have shown the scars 
 of a healed tuberculosis. It must be assumed 
 that in these cases they had had, at one time or 
 another, a little tuberculosis and that they recov- 
 ered perhaps without ever having known that they 
 had the disease. All this should be ample proof 
 of the curability of tuberculosis, and the consump- 
 tive should be hopeful and cheerful. If he is in 
 the earlier stages of the disease and submits him- 
 self to proper and timely treatment, he may be 
 reasonably certain of an absolute recovery. If he 
 has passed the earlier stages, he may still be much 
 improved and live a long time in comfort with 
 his earning capacity reestablished. 
 
 However, the one most important thing the 
 tuberculous patient should know of his disease is 
 that unless he follows the instructions of his 
 physician to the letter and has implicit confidence 
 
GENERAL PERSONAL HYGIENE 15 
 
 and trust in him, it will be difficult to accomplish 
 a cure. 
 
 In no disease is it so essential to attend to 
 minor details in the matter of sleeping quarters, 
 of dress, use of bath (cold or warm), exercise and 
 rest, food, and medicine, as in tuberculosis. The 
 implicit obedience to the physician's orders, the 
 performance with religious punctuality of all the 
 hygienic, dietetic, and other directions, are essen- 
 tial and important for a patient in no matter what 
 stage of the disease. It can not be emphasized 
 too much that the medical guidance and super- 
 vision are of paramount importance to the patient 
 whether he is in his own home, in a health resort, 
 or in a sanatorium, and no matter in what climate 
 he may live. The patient should not be sensitive 
 about any of the precautions necessary to prevent 
 the spread of the disease, but should take an 
 interest in helping those about him carry them out 
 to the most minute detail. 
 
CHAPTER II 
 
 "WBAT THOSE LIVING WITH PATIENTS SHOULD 
 KNOW CONCERNING THE DISEASE 
 
 Those living with the tuberculous patient should 
 know first all that the patient ought to know, that 
 is to say, what has been outlined in the preced- 
 ing chapter; but it will also be their duty to insist 
 with kindness but firmness, as long as the patient 
 is able to do so, on his carrying out absolutely the 
 precautions necessary to limit the danger of in- 
 fection to the smallest possible degree. If he is 
 not able, they must do it for him. Indulgence is 
 out of place in tuberculosis. It should be im- 
 pressed again and again upon the heedless patient 
 that his carelessness not only means danger to 
 others but also danger to himself by the possibility 
 of reinfection. It should be explained to him 
 that the inhalation of the bacilli which he has 
 rejected is as dangerous to him as to others. 
 
 When the patient is in the latter stages of the 
 
 disease and so helpless that he can not always 
 
 make use even of a light pasteboard (Fig. 14) or 
 
 aluminum hand spittoon, he should be provided 
 
 16 
 
 
NATURAL SOURCES OF DEFENSE 17 
 
 with moist cloths, kept within easy reach, into 
 which he should expectorate. These cloths should 
 in turn, while still moist, be wrapped up in paper 
 and then burned. They should be handled as 
 little as possible if the tuberculous sputum upon 
 them should have become dry. 
 
 When the patient and those living with him do 
 their duty, there is no danger of contracting the 
 disease; in fact, for the strong and well the 
 occasional inhalation of a few bacilli, the occa- 
 sional ingestion of tuberculous meat or milk is, 
 after all, not so dangerous. There exist powerful 
 means of natural defense against tuberculosis in 
 the healthy human being. The tubercle bacilh 
 which may be inhaled are taken in with the dust. 
 This dust is arrested by countless fine hairs in the 
 nasal cavities and during the act of blowing the 
 nose this bacilli-laden dust is usually expelled 
 with some of the nasal mucus. When, as it may 
 happen, some bacilli are not caught up by the fine 
 hairs, the very secretions of the nasal membranes 
 being bactericidal, that is to say, having germ- 
 killing properties, can render the bacilli harm- 
 less. Even if the germs should have passed these 
 two barriers and have entered the deeper respir- 
 atory tracts — the bronchial tubes — these in turn 
 are lined with cilia, very fine hair-like organs 
 which are in constant motion, and which expel 
 
i8 TUBERCULOSIS 
 
 foreign bodies with the mucus that the bronchial 
 tubes secrete. Lastly, even should the bacilli enter 
 the lung tissue itself, there again they will meet 
 the white blood corpuscles, and if the latter are 
 plentiful and in good condition they will over- 
 come the enemy — the bacilli — by swallowing them. 
 The great French scientist, Metchnikoff, called this 
 method of natural defense of the blood "phagocy- 
 tosis," from Greek words meaning a cell which 
 eats, indicating thereby that the white blood cor- 
 puscles devour the bacilli. 
 
 One thing that is important for those who are 
 living with the tuberculous to know is that while 
 it is a rare occurrence for a child to come into the 
 world with a tuberculous lesion, the child of a tuber- 
 culous father or mother very often inherits a certain 
 physiological poverty which is called a predis- 
 position. In other words, while all the organs may 
 be perfectly normal, the child brings with it as 
 an inheritance from a sick parent, a weak consti- 
 tution with little resisting power to tuberculosis 
 and other diseases. When now the offspring of 
 tuberculous parents is, in addition to its weakened 
 condition, exposed to the infection of tuberculosis, 
 its chances to contract the disease are certainly 
 very great. 
 
 A child should never be put to the breast of a 
 tuberculous mother. Not only may the child 
 
STERILIZATION AND PASTEURIZATION 19 
 
 become infected by the milk, but to nurse it is 
 also too great a drain on the mother's constitution. 
 While the woman during her pregnancy may seem 
 very much better, unfortunately her condition after 
 childbirth is usually worse, and it would be most 
 unwise to have her nurse her child even were there 
 no danger of direct infection from the mother's 
 milk. Such a child should have a healthy wet nurse 
 or be fed artificially with the best and purest milk 
 obtainable. If there is any doubt as to the purity 
 of the milk, pasteurization or steriHzation should 
 be resorted to. 
 
 Sterilization is usually accomplished by keeping 
 the milk at the boiHng point (212° F.) for half an 
 hour. 
 
 Pasteurization is the process of heating the milk 
 to a temperature between 140^ and 176° F. for 
 fifteen or twenty minutes. This is sufficient to 
 destroy the tubercle bacilli and most of the ordinary 
 milk germs without cooking the milk, which is 
 generally considered to render it less nutritive 
 and digestible. Even pasteurization deteriorates 
 the milk, therefore every effort should be made to 
 obtain it pure and fresh. Whether the milk comes 
 directly from the healthy cow, or is pasteurized or 
 sterilized, it should be cooled quickly and kept 
 cold and covered until it is to be used. 
 
 The closer the contact in which the tuberculous 
 
20 TUBERCULOSIS 
 
 mother and child Hve, the greater is the danger of 
 infection. If the mother kisses the child on the 
 mouth or puts the nipple of the milk bottle or the 
 spoon with which it is fed into her own mouth to 
 taste the milk in order to judge of its temperature 
 or sweetness before giving it to the child, it is 
 evident that infection can take place very readily. 
 If the mother coughs when carrying the child in 
 her arms, the little drops expelled during the 
 cough may reach the child's mouth or it may 
 inhale these bacilliferous droplets. If the tuber- 
 culous mother or those living with her will see that 
 the simple necessary precautions to avoid these 
 postnatal infections (infection after the child's 
 birth), are carried out, there will be an excellent 
 chance for the child to grow up without becoming 
 infected. Such a child should also be treated for 
 its inherited predisposition, that is to say, it should 
 have plenty of fresh air, proper hygiene, and care 
 in general; in fact, all hygienic measures tending 
 to make it strong and resistant to disease should 
 be inaugurated at the earliest possible moment. 
 
 For the further protection of those living with 
 the patient we would strongly advise that the 
 soiled personal and bed linen, sheets, pillow-cases, 
 underwear, napkins, handkerchiefs, etc., of a 
 consumptive be handled as little as possible when 
 dry. Immediately after removal from bed or body 
 
CARE OF PERSONAL AND BED LINEN 21 
 
 the soiled linen should be placed in water and be 
 washed separately or boiled before being put in 
 with the general laundry. Cleaning the room 
 should never be done w^ith a feather duster or 
 broom. If, on account of a fixed carpet, sweeping 
 is inevitable, let it be preceded by throwing moist 
 sawdust or moistened bits of paper on the floor 
 to allay the dust. It is well also while sweeping to 
 lower the windows from the top and keep them 
 closed at the bottom. The woodwork and furni- 
 ture should be wiped with a moist or slightly oily 
 cloth according to the nature of the surface. 
 Whenever possible, the cleaning should be done 
 by the pneumatic exhaustive or vacuum process. 
 This is the ideal method of cleaning the apartment 
 of the sick. There are portable devices now in the 
 market which can be procured at reasonable rates 
 and thus the consumptive poor may be able to 
 avail themselves of this hygienic mode of removing 
 dust. 
 
 It is necessary to remember that when table 
 utensils, such as drinking cups and glasses, forks, 
 spoons, etc., which come in direct contact with 
 the mouth, have been used by a consumptive, 
 they should never be used by any other person 
 before they have been thoroughly washed with soap 
 and hot water or placed in boiling water for a few 
 moments. No one else, of course, should use the 
 
22 TUBERCULOSIS 
 
 patient's napkin. If he cannot have a clean one 
 at every meal, it is well to keep it in some sort of an 
 impermeable case, or even a cover of washable ma- 
 terial so that it need not be handled unnecessarily. 
 
 With the training which teaches the invalid when 
 and when not to cough, of which we spoke when 
 discussing w^hat the patient should know of his 
 disease, a tuberculous invalid can be a very agree- 
 able companion at the table. To ask an honest, 
 conscientious, and well- trained consumptive to take 
 his meal separately is as unkind and unnecessary 
 as can possibly be, and certainly, if insisted upon, 
 it is enough to make the consumptive patient thor- 
 oughly unhappy. 
 
 It should be the privilege of those living with 
 the tuberculous patient to make him as happy, as 
 cheerful, and as hopeful as possible. Happy sur- 
 roundings, a cheerful face, a hopeful word for the 
 invalid from those about him will be no little 
 factor in accomplishing his cure. 
 
 Phthisiophobia, that is to say, the exaggerated 
 fear of contracting phthisis or consumption, is 
 entirely out of place when the patient is con- 
 scientious and careful. It is not only out of place, 
 })ut it is cruel. Some people in their fear and 
 prejudice go so far as not only to consider the 
 consumptive a physical danger but also as men- 
 tally peculiar or something worse. Phthisiophobia 
 
EXAGGERATED FEARS 23 
 
 resembles an epidemic disease which now and 
 then crops up in different locahties. That there 
 is no danger from the clean conscientious con- 
 sumptive has often been sufficiently demonstrated, 
 and to think him differently constituted mentally 
 from well persons or people affficted with other 
 physical ailments is quite absurd. 
 
 Not so very long ago a young physician startled 
 the medical and lay press by making the statement 
 that the average consumptive is afflicted with 
 mental and moral aberration. He made the to- 
 tally unwarranted assertion that in the typical 
 consumptive psychasthenia, the loss of self-control 
 and the rise of brute selfishness combine to distort 
 the clearness of his ethical perception. I replied 
 to this statement at the time in an address before 
 the Society of Medical Jurisprudence, entitled 
 '^A Plea for Justice to the Consumptive." To 
 strengthen the force of my own experience, I had 
 collected the opinions of twelve of the leading 
 authorities of this country on tuberculosis and 
 mental diseases, and all of them agreed with me on 
 the injustice of making the statement above re- 
 ferred to. 
 
 It would take too much space here to give all the 
 valuable letters and expressions of opinion received 
 at the time from such men as Professors Hermann 
 M. Biggs of New York, S. G. Bonney of Denver, 
 
24 TUBERCULOSIS 
 
 Mncent Y. Bowditch of Boston, E. D. Fisher of 
 New York, A. Jacobi of New York, Edward G. 
 Janeway of New York, Arnold C. Klebs of Chi- 
 cago, Wilham Osier of Oxford, England, Edward 
 O. Otis of Boston, E. L. Trudeau of Saranac 
 Lake, James Tyson of Philadelphia, and Dr. J. 
 B. Ransom, Prison Physician of Elmira, N. Y. I 
 will, however, reproduce the opinions of three men 
 who may justly be said to be leaders in the sci- 
 entific medicine of the English-speaking world. 
 Professor Edward G. Janeway, Dean of the Med- 
 ical Faculty of Bellevue and New York Univer- 
 sity, wrote me: ''I have not noticed any such 
 tendency as you inquire about on the part of 
 consumptives as regards immorality or crime as 
 compared with well people or with those ill with 
 other diseases, placed under similar circumstances. 
 It is to be remembered that criminals and the 
 insane are prone to be victims of tuberculosis, 
 and hence someone who studied this class of 
 people would be liable to form very unjust views 
 about the consumptive class as a whole. Nor is it 
 my experience that the average consumptive is 
 inclined to brute selfishness, loss of self-control, 
 and hence distortion of the clearness of ethical 
 perception. I have found so much to the contrary 
 that I am surprised at so broad a charge against 
 the consumptive invalid," 
 
TUBERCULOSIS INVALIDS 25 
 
 Dr. William Osier, Regius Professor of Medicine 
 of Oxford, England, wrote: "I quite sympathize 
 with you in your movement, and in reply to your 
 question I would say, first, I have never noticed 
 among consumptives any greater tendency to im- 
 morality or crime than in other individuals; I 
 should rather say the contrary. IMy impression is 
 that the unfortunate victims of tuberculosis are 
 above the average in their mental and moral char- 
 acter; secondly, I should say emphatically that the 
 average consumptive is neither inclined to brute 
 selfishness nor any special distortion of the ethical 
 perceptions. I am glad you called my attention to 
 the article in the ' New York Medical Journal.' 
 So far as my experience goes, such statements as 
 you say are made therein are an unwarranted 
 slander." 
 
 The last letter comes from a man to whom all 
 who know him personally, or know his works, 
 look up, not only as a great physician, scientist, 
 and specialist on tuberculosis and the pioneer of 
 the sanatorium treatment in this country, but also 
 as a great humanitarian and a most noble char- 
 acter. He is an example of what a man, though 
 consumptive himself, can do for his fellow-men. 
 Dr. Edward L. Trudeau, who twenty-five years 
 ago as a seemingly hopeless invalid, made his home 
 in the wilderness of the iVdirondack Mountains, 
 
26 TUBERCULOSIS 
 
 became through his untiring work, his unselfish de- 
 votion to science and the highest ideals of human 
 helpfulness, the founder of one of the most beau- 
 tiful and flourishing sanatoria for the consumptive 
 poor in the world, the founder of a prosperous 
 village crowded with consumptives of the wealthier 
 classes, a teacher to the medical profession of 
 practical phthisiotherapeutics, and a teacher of 
 practical philanthropy to the American public 
 and the world at large. These are his words: 
 
 ^'I have never noticed any greater tendency to 
 immorality or crime among consumptives than 
 is to be found in the average of the human race, 
 as far as it has come under my observation. On 
 the contrary, I have seen all the finer traits of 
 human nature developed to the fullest extent by 
 the burdens which chronic and fatal illness, often 
 slow in its progress, adds to the sum total of what 
 men and women usually have to endure in life. 
 I have seen certainly more patience, courage, 
 self-denial, and unselfish devotion to others in 
 consumptives than I have noticed in the majority of 
 healthy human beings. Indeed, the sanatorium 
 work never could have been carried on were it not 
 for the self-sacrificing devotion to the suffering 
 of others shown by my associates, the nurses, and 
 even the employees at the sanatorium, most of 
 them having come here originally because suffer- 
 
TUBERCULOSIS INVALIDS 27 
 
 ing from tuberculous disease. History is full of 
 instances which prove that tuberculosis does not 
 interfere with the development to the highest 
 degree of the intellectual, the moral, or the ethical 
 sides of man's nature." 
 
 It would hardly seem necessary after quoting 
 the opinions of these three distinguished au- 
 thorities to add my own opinion, though based 
 upon an experience of many years of practice 
 among consumptives in different climes and dif- 
 ferent countries, among men and women in all 
 stations of life. I may say that I have not only 
 practiced but also lived among them and with 
 them, and from all my experience I can only 
 confirm what has been said by the three great 
 physicians just mentioned. Never have I noticed 
 consumptives to be more inclined to immorality 
 than individuals afflicted with other diseases, or 
 even well people; only in a few instances have I 
 noticed real selfishness, and never what one could 
 call a distortion of the clearness of ethical percep- 
 tion, among them. On the contrary, as in the expe- 
 rience of Drs. Osier, Janeway, and Trudeau, it has 
 always seemed to me that many consumptives are 
 above the average in their mental and moral char- 
 acteristics. Instead of selfishness, I have fre- 
 quently witnessed the most touching evidence of 
 self-sacrifice and devotion. I have seen colleagues 
 
2S TUBERCULOSIS 
 
 in institutional and private practice, trained nurses 
 and sisters of charity, who, though they knew 
 they had contracted tuberculosis in the pursuit 
 of their professional duties, did not leave the 
 battlefield, but continued to labor and help their 
 consumptive fellow-sufferers. Two of my most 
 beloved teachers, to whom I owe an everlasting 
 debt of gratitude for the inspiration and help they 
 have given me in my work. Professor Grancher 
 of Paris and Geheimrath Dettweiler of Falken- 
 stein, were both consumptive. They taught and 
 practiced among consumptives for a quarter 
 of a century, and remained leaders in the anti- 
 tuberculosis crusade until the end of their most 
 useful lives. 
 
CHAPTER III 
 
 THE DUTIES OF THE PHYSICIAN TOWARDS HIS 
 PATIENT, THE FAMILY OF THE PATIENT, THE 
 COMMUNITY HE LIVES IN, AND OTHER COM- 
 MUNITIES 
 
 The duties of the family physician in regard to 
 the tuberculosis problem are manifold. We will 
 begin by the discussion of his duty towards the 
 patient. The first question to arise, if the care- 
 ful examination of an intelligent patient has shown 
 him to be tuberculous, is, should the physician tell 
 or not tell this fact to the patient ? I believe it to 
 be his sacred duty to inform an adult patient of 
 the true character of the disease and also to in- 
 form the family of the situation. To hide from the 
 intelligent adult the fact that he is tuberculous or 
 that a member of his family is afflicted with the 
 disease, is, in the light of our modern knowledge, 
 an absolute wrong; or it may even be called a 
 criminal neglect. That the family physician will 
 use the utmost tact in revealing such a condition 
 to the patient or to the friends of the patient is 
 
 a matter self -understood. What we know to-day 
 
 29 
 
30 TUBERCULOSIS 
 
 of the curability of an early tuberculosis makes 
 the task all the more easy. One can inspire the 
 patient and his friends with the hope of absolute 
 recovery when in the presence of an early tuber- 
 culosis. 
 
 In order to overcome the shock which the reve- 
 lation of the presence of the disease at times 
 causes the patient, it has been my practice to say 
 to him, "Be grateful for this early discovery of a 
 curable condition, which, when overcome, may 
 leave you a stronger and more vigorous man than 
 you ever were before." 
 
 After having inspired the patient with hope and 
 gained his complete confidence, the next duty of 
 the physician is naturally to tell the patient what 
 he should know of his disease; in other words, to 
 impart to him such knowledge and information 
 as it has been our endeavor to give in the first 
 chapter. 
 
 While it is desirable that the physician should 
 have leaflets of instructions ready to hand to the 
 patient for careful perusal, the spoken word, the 
 verbal instruction must not be neglected. What- 
 ever literature the physician may give to his 
 patient, it should always be supplemented by a 
 few words of explanation. 
 
 All preventive measures intended to protect 
 those living and associating with a consumptive 
 
INSTRUCTION TO THE PATIENT 31 
 
 from infection and himself from reinfection, should 
 be inaugurated at once. It is sometimes difficult 
 to make the necessary installation for the home 
 treatment. It is not wise nor judicious to put a 
 family of moderate means to the expense of build- 
 ing porches for outdoor sleeping, of changing domi- 
 cile, of buying window- tents, reclining chairs and 
 other paraphernalia when it is in the interest of 
 the patient and of his family that he should be 
 sent to a sanatorium, hospital, or health resort. 
 
 Whether it is best for the patient to go to an 
 institution, sanatorium, or hospital, to make a cli- 
 matic change or to remain at home, will depend 
 upon the financial and other circumstances of the 
 family, upon the patient's character, his peculiari- 
 ties and above all, upon his condition. A com- 
 petent physician will know when a change of 
 climate is desirable, feasible, or immaterial. He 
 will bear in mind the patient's peculiarities and 
 recall that patients much attached to home life 
 are apt to suffer from nostalgia (homesickness) 
 when sent away, and because of depression and 
 lonehness do badly under those circumstances. 
 The homesick patient eats little and in his de- 
 spondent moods is very apt to forget to follow the 
 directions about outdoor life, breathing, walking, 
 careful exercise, etc., so essential to his well-being. 
 On account of this peculiarity, some patients do 
 
32 TUBERCULOSIS 
 
 better at home even in a less congenial climate, 
 because they are happy and contented there and 
 willing to obey all the necessary hygienic and 
 dietetic directions. The physician will also recog- 
 nize the class of patients who must go away and 
 should be in some special institution because at 
 home they will not obey the instructions so es- 
 sential to increase their chances of recovery. Some 
 patients for w^hom a climatic change is desirable 
 may do well in a health resort under the guidance 
 of a physician. 
 
 If the patient is to remain at home, it is, of 
 course, presumed that the home is so situated 
 that all the preventive and curative measures es- 
 sential to the treatment can be carried out. Since 
 experience has shown that the sanatorium method 
 of healing tuberculous patients is the best, we 
 will in the following chapter describe how this 
 treatment may be adapted to and imitated in the 
 homes of the well-to-do or the poor. There are, 
 of course, instances when the physician may be 
 in the presence of an advanced case for which a 
 change of climate may be useless, and for people 
 in moderate circumstances the sacrifice of sending 
 a patient away may mean a good deal. This the 
 conscientious physician will take into considera^ 
 tion. 
 
 If it is ];x:)ssiblc for a family in which tubercu 
 
MAXIMS IN CHOICE OF CLIMATE 33 
 
 losis has appeared to leave the large overcrowded 
 city for a healthful country district, or even less 
 congested portions of the city, where they will be 
 able to support themselves just as well and have 
 in addition greater comfort, purer air, and more 
 outdoor life, it is the physician's duty to urge such 
 a change. 
 
 Not all physicians can be expected to be thor- 
 oughly familiar with the climatic conditions of 
 the various parts of the country, therefore the 
 following maxims for the selection of climate in 
 pulmonary, laryngeal, and bone tuberculosis may 
 be helpful. These maxims I presented at the 
 occasion of a discussion on climate in the treat- 
 ment of tuberculosis before the Clinical and 
 Clim.atological Section of the National Association 
 for the Study and Prevention of Tuberculosis, at 
 the second annual meeting in Washington, May 
 18, 1906. They are the result of long experience, 
 and have guided me in years of practice among 
 the tuberculous whenever I was called upon 
 to decide or advise on a climatic change for a 
 patient. 
 
 (i) To deny the beneficial influence of certain 
 climatic regions as a valuable adjuvant in the 
 treatment of tuberculosis is as dangerous and un- 
 scientific as the belief in the specific curative 
 quahty of any particular climate. 
 
34 TUBERCULOSIS 
 
 (2) A change of climate, though not necessarily 
 a marked one, except in the very latter stages of 
 the disease if of either a pulmonary or laryngeal 
 character, is nearly always good. While a change 
 from an unfavorable climate to a favorable one, 
 or from a good to a better, must naturally be con- 
 sidered preferable, this rule is by no means in- 
 flexible. When the patient has contracted tubercu- 
 losis in a favorable climate, a change to another, 
 even to a seemingly less favorable one, may ac- 
 complish as much good for this invalid as the 
 reverse in others. 
 
 (3) The native locality of the tuberculous must 
 be taken into consideration when making a cli- 
 matic change. The patient who spent his early 
 youth in Norway or other parts of northern Europe, 
 or one born in Massachusetts, Maine, or northern 
 New York where the winters are rigorous, will 
 usuallv do better in such climates as Colorado, 
 the Adirondacks, Sullivan or Orange counties of 
 New York offer. The sons and daughters of sunny 
 Italy and Americans born in the warmer zones, 
 will do better in climates such as arc to be found 
 in southern California, New Mexico, Arizona, 
 North and South Carolina, Virginia, Florida, Ber- 
 muda, etc. 
 
 (/\) To the foregoing rule there are exceptions, 
 and besides considerations of nativity one should 
 
CHOICE OF CLIMATE 35 
 
 be guided in a large measure by the patient's 
 personal experience. For example, a cold climate 
 may be selected if the patient has found that he 
 feels more comfortable and less distressed in win- 
 ter. A change to a warmer climate is indicated 
 when the reverse is the case. When the experience 
 of the patient has demonstrated that he felt better 
 when near the seacoast, or vice versa, this factor 
 must also serve as an indication for his domicile 
 while seeking cure. 
 
 (5) There exist idiosyncrasies in regard to 
 climatotherapeutics and aerotherapeutics (a pecul- 
 iar constitutional disposition or susceptibility) as 
 there exist in hydrotherapeutics, electrotherapeu- 
 tics, and medicinal therapeutics. These idiosyn- 
 crasies cannot be discovered beforehand, they 
 can only be learned by experience. 
 
 (6) High (above 3,000 feet), moderately high 
 (1,500 to 3,000 feet), and low altitudes, hot and 
 cold regions, seacoast, and ocean climates, pro- 
 longed voyages, and life on house boats, on rivers 
 and lakes, extreme dryness and moisture have all 
 proved advantageous conditions in numbers of 
 cases. 
 
 (7) The value of any climate to a tuberculous 
 patient can not be determined by or compared 
 with any other, unless the patient lives under 
 careful medical guidance in a sanatorium or 
 
36 TUBERCULOSIS 
 
 private home, and follows the best hygienic and 
 dietetic treatment. 
 
 (8) Laryngeal cases (tuberculosis of throat), in 
 the earlier stages with relatively little pulmonary 
 involvement, are often benefited by a change to a 
 moderately high or to a warm moist climate with 
 between 500 and 1,500 feet of altitude, particu- 
 larly when there is a chronic feeling of dryness in 
 the throat. When there is a tendency to moist 
 catarrh, even very dry and hot climates, provided 
 dust storms are not frequent, are often beneficial. 
 In pulmonary cases a weak heart, distinctive heart 
 or kidney lesions, emphysema, constant fever, and 
 extreme nervousness are contra-indications to high 
 altitudes. Whenever such pathological conditions 
 do not exist, high altitudes, and cold or cool, or hot 
 and dry regions, if dust free, will always prove a 
 valuable adjuvant in the treatment of tubercu- 
 losis. Early pulmonary hemorrhage per se need 
 not be considered in determining a choice of 
 climate. However, as a rule, and particularly 
 in cases inclined to frequent haemoptysis (spitting 
 of blood), long journeys should Ijc made with 
 frequent rests and high altitudes approached 
 gradually. Not a few cases with slight bronchial 
 symptoms (bronchitis), but with weak hearts and 
 evidences of mixed infection do well at the seacoast 
 for the greater part of the year. Prolonged ocean 
 
CHOICE OF CLIMATE 37 
 
 voyages may also prove beneficial in such cases. 
 The patient, however, must not be subject to sea- 
 sickness, must be fond of the ocean, and be in a 
 situation to travel in comfort and with ease, on a 
 steamer or large ship which has a medical ofhcer 
 on board. 
 
 (9) The ideal climate for the average pulmonary 
 patient in the earlier and more hopeful stages of 
 the disease, is one where the extremes of tempera- 
 ture are not great, with a pure atmosphere, rela- 
 tively little humidity, much sunshine, and all 
 conditions which permit the patient to live com- 
 fortably out of doors the largest number of days 
 out of the year, and the largest number of hours 
 out of the twenty-four. For tuberculosis of the 
 bones and joints and scrofulous affections of child- 
 hood, the seacoast climates in our temperate zones 
 come nearer to deserving the term specific than 
 anything else. The peculiarly beneficial influence 
 of seacoast climate in glandular, bone, and joint 
 tuberculosis is doubtlessly to be ascribed to the 
 aseptic and ozonic quality of the air, and the 
 iodides and other salts suspended therein. But 
 pure air and outdoor life, in whatever locality, 
 can and should be utilized in the treatment of 
 tuberculosis and of scrofulous affections of chil- 
 dren. Very anaemic pulmonary cases with dry 
 catarrhal symptoms of the upper resDiratory tract 
 
38 TUBERCULOSIS 
 
 often do ^Yell in the warmer seacoast climates. 
 The colder seacoast climates are perhaps only 
 suited for tuberculous patients when they are 
 fairly robust. 
 
 (lo) In the choice of locality for a climatic 
 change for any patient, besides the pathological 
 considerations enumerated in paragraph 8, many 
 factors must be taken into account. These are: 
 
 (a) If the patient wishes to return to his former 
 home after improvement or restoration to health, 
 may he do so safely or not ? Experience has shown 
 that when great climatic changes have been made, 
 patients frequently have relapsed on returning to 
 their former home. 
 
 (h) If the patient is married or single, young or 
 old, willing or unwilling to leave; if the patient is 
 subject to nostalgia, and generally much attached 
 to home environments, sending him far away, 
 particularly if against his wish, may produce 
 disastrous results, for mental depression aggra- 
 vates pathological conditions and retards recovery. 
 
 (c) If the patient is sanguine and cheerful he 
 will usually do well even at long distances from 
 home, in isolated regions, within or outside of a 
 sanatorium. 
 
 {(l) For the morose and hypochondriac patient, 
 isolation or long distances away from home have 
 often profluced the same results as nostalgia. 
 
THE PHYSICIAN'S DUTY 39 
 
 (e) To remove an advanced and evidently hope- 
 less case from his home to a long distance is as 
 cruel as it is unscientific, unless it is done by the 
 patient's special request and with the likelihood 
 of lessening his sufferings and making him happier 
 in general. Slight climatic changes with short 
 distances to travel are often beneficial in such far 
 advanced cases when the patient is perfectly 
 willing to go. 
 
 (/) The patient's financial condition must be 
 such, that by his removal to distant localities and 
 his subjecting himself to the hygienic and dietetic 
 treatment in special institutions or health resorts, 
 he will not become destitute and a burden to the 
 community which has extended its hospitality to 
 him. His means should be sufficient to avoid all 
 possible anxiety and worry in this regard. 
 
 (11) When the situation is such that the choice 
 of home climate or home treatment must be taken 
 into consideration, we should bear in mind the 
 following: The patient will do better in the out- 
 skirts of the city than in the city proper ; better in 
 the higher parts of the locality than in the lower; 
 better in a clear or relatively clear, dustless at- 
 mosphere than in a dusty one; better in a pure, 
 smokeless or relatively clear and smokeless locality, 
 than in one full of smoke and odors; better in a 
 locality where he may get the benefit of whatever 
 
40 TUBERCULOSIS 
 
 sunshine there is than in a valley, canon, or narrow 
 street surrounded by high buildings; better where 
 there are few houses than many; better where 
 there are relatively few people than where there is 
 overcrowding; better where there is little traffic 
 and little noise than the reverse. 
 
 (12) Lastly, we must consider that the majority 
 of consumptives are recruited from the laboring 
 classes and those we must cure in the same or 
 nearly the same climate in which they will have 
 to live and labor after their restoration to health. 
 While the cure of the consumptive individual in 
 his home climate, which is in most instances far 
 from the ideal, may often necessitate a longer 
 space of time, in the end there is an advantage in 
 this. Experience has demonstrated that relapses 
 among this class of patients are fewer, and the cures 
 more assured and lasting than those obtained in 
 more congenial climates. 
 
 The duties of the physician toward the family of 
 the patient are as important as those to the patient. 
 In a family where there is a consumptive, every 
 member should be examined and periodically 
 reexamined for tuberculosis, that is to say, their 
 chests should be gone over carefully every three 
 to six months. The discovery of cases of tuber- 
 culosis in the very incipient stages will naturally 
 be much more frequent if this is done than is 
 
THE PHYSICIAN'S DUTY 41 
 
 usually the case. As is well known, the earlier a 
 case of tuberculosis is discovered the greater are 
 the chances for cure, if timely and judicious treat- 
 ment is given. 
 
 For the practitioner who is not the family phy- 
 sician, but is called in to take care of a consump- 
 tive patient, it is naturally a delicate task to seek 
 to examine all the members of the family. Few 
 physicians can afford to work in every instance for 
 nothing and small minds may interpret the honest 
 desire of a physician to do his duty as a scheme 
 to make money. There is only one way of avoiding 
 this suspicion; that is, for the physician to tell 
 these families to have their regular family phy- 
 sician examine them, or if they have none, to call 
 in some physician they may have consulted be- 
 fore, when in need of medical advice. 
 
 The physician treating a family where there is 
 a consumptive should bear in mind the multiple 
 sources of postnatal infection and insist upon the 
 carrying out of the precautions to prevent them. 
 He should see that an inherited predisposition in 
 any one of the members is overcome by the proper 
 care that should be bestowed upon them. If at all 
 possible, predisposed children should be sent to 
 open air schools; but they should never be sent to 
 school before the age of eight. 
 
 The physician of such a family has a great 
 
42 TUBERCULOSIS 
 
 responsibility in regard to the lives of the children. 
 When the time comes for them to choose a trade 
 or profession, they should not follow occupations 
 which are likely to increase their susceptibility 
 to tuberculosis. They should be prevented from 
 following the occupation of the father if the phy- 
 sician has cause to believe that the employment 
 in which a consumptive parent had been engaged 
 was in a measure responsible for the development 
 of the disease. Thus, for example, the daughter 
 of a consumptive seamstress should not also be- 
 come a seamstress; the son of a consumptive 
 tailor, hat maker, weaver, stonecutter, etc., should 
 not follow the same confining or predisposing oc- 
 cupation. 
 
 Young men or women with hereditary predis- 
 positions to tuberculosis, should seek occupation 
 which will assure a good deal of open air exercise, 
 without, however, exposing them to great physical 
 strain and unusually hard work. 
 
 When the physician lives in a community where 
 compulsory or even only voluntary notification 
 of tuberculous cases is required, it is his bounden 
 duty to report each case. He will thus enable 
 the health authorities to have correct statistics 
 and also enable them to trace and remove, in 
 many instances, underlying causes of the preva- 
 lence of tuberculosis in certain localities, districts, 
 
THE PHYSICIAN'S DUTY 43 
 
 Or even houses. The health authorities of any city, 
 even if the notification is compulsory, will not 
 interfere with the physician's patients if the 
 former assumes the responsibility that the neces- 
 sary precautions to prevent tuberculous infec- 
 tion will be carried out. 
 
 The physician, besides being the medical ad- 
 viser of the family, is also a citizen and may at 
 times be called upon for medical advice by the 
 municipality in Avhich he lives. In his double 
 capacity of physician and citizen he is particu- 
 larly fitted to organize and help the popular 
 crusade against tuberculosis. In communities 
 where there are no anti-tuberculosis committees 
 or associations, the progressive physician should 
 see that they are started, maintained, and do the 
 necessary work. He should be helpful to combat 
 tuberculosis in his community in every way his 
 time and means allow. 
 
 The physician treating tuberculous patients 
 not only has a responsibility toward the community 
 in which he lives, but also one toward the many 
 communities located in regions reputed for cer- 
 tain climatic advantages. Should a physician 
 send a patient in the curable stage of a tuber- 
 culous disease, who has little or no means, to 
 a far away climate in the hope that in a few weeks 
 he may find light employment, when this patient 
 
44 TUBERCULOSIS 
 
 is still in need of rest and care? To do this is 
 an injustice to the community to which the patient 
 is sent. Even a patient in the very early stages 
 of the disease should not be sent to such a distant 
 climatic resort, unless the physician is pretty cer- 
 tain that his patient will be able to work in a few 
 weeks and to find work that will permit him to 
 complete his cure. Not unless such a patient can 
 with reasonable certainty be pronounced curable 
 should he be sent away, and not without being 
 provided with funds sufficient to last him at least 
 a year. 
 
 If the patient is well to do and the physician 
 knows that he will never become a burden to 
 the community, it is his right and duty to send 
 him to any climatic resort or institution where 
 he thinks the patient will do well. Even in the 
 advanced stages, if the patient has a desire for a 
 change, the physician may yield to his wishes and 
 allow him to go to a climate where he thinks he 
 will feel more comfortable. The invalid should, 
 of course, be accompanied by a trained nurse or 
 attendant so that he will not be a source of danger 
 to any one on the trip or in the place where he may 
 become permanently located. 
 
 If a patient in the later, or even the earlier 
 stages of the pulmonary tuberculosis is being 
 treated in his own home and the physician finds 
 
DISINFECTION OF ROOMS 45 
 
 that a disinfection of the rooms in which the 
 patient hves is desirable, he should not hesitate 
 to inform the family and see that a thorough 
 formaldehyde disinfection is made. The occa- 
 sional disinfection of the personal effects of the 
 patient is often advisable. In case of decease it 
 is always best that everything the consumptive 
 might have come in contact with — furniture, 
 bedding, clothing, books, etc., should be thor- 
 oughly disinfected. In many communities such 
 disinfection is now attended to by the board of 
 health. 
 
 Where the aid of a health board can not be 
 secured, the following directions will enable one 
 to make a thorough disinfection by formalde- 
 hyde gas: I. All cracks or openings in the plas- 
 ter, in the floor, or about the doors or windows 
 should be caulked tight with cotton or strips of 
 cloth. 2. The linen, quilts, blankets, carpets, 
 etc., should be stretched out on a line in order to 
 expose as much surface as possible to the disin- 
 fectant. They should not be thrown into a heap. 
 Books should be suspended by their covers, so 
 that the pages will fall open and be freely ex- 
 posed. 3. The walls and the floor of the room and 
 the articles contained in it should be thoroughly 
 sprayed with water. If masses of matter or 
 sputum are dried on the floor, they should be 
 
46 TUBERCULOSIS 
 
 soaked with water and loosened. No vessel of 
 water should, however, be allowed to remain in 
 the room. 4. One hundred and fifty cubic centi- 
 meters (live ounces) of the commercial forty-per- 
 cent solution of formalin for each one thousand 
 cubic feet of space should be placed in the dis- 
 tilling apparatus and be distilled as rapidly as 
 possible. The keyhole and spaces about the door 
 should then be packed with cotton or cloth. 
 5. The room thus treated should remain closed 
 at least ten hours. If there is much leakage of 
 gas into the surrounding rooms, a second or 
 third distillation of formalin should be made at 
 intervals of two or three hours. 
 
 Whether the patient is treated at home for a 
 little while or all the time, the supervision and 
 guidance of the physician are essential. Whether 
 the patient himself will be competent to carry out 
 all the instructions given or whether it will be 
 necessary for a member of the family, a friend, 
 or a trained nurse to help the doctor, will depend 
 upon the individual case. The extent of the dis- 
 ease, the character, the disposition, and the social 
 environrhents of the patient will all have to be 
 taken into consideration. 
 
 As has Ijcen said in the preface, this book is not 
 intended to replace the physician, and the follow- 
 ing instructions are only given to aid the physi- 
 
GENERAL ADVICE 47 
 
 cian in a general way and give him a foundation 
 to which to add the more minute and individual 
 advice each case may demand. Some of the 
 necessary precautions indicated in this general 
 advice have been already dw^lt on in Chapter I. 
 They are repeated here because of the conviction 
 that when they are given by the physician of 
 the family, their chances of being obeyed are 
 materially increased. 
 
 General Advice to the Consumptive Patient. 
 
 Be hopeful and cheerful, for your disease can be 
 cured. 
 
 Avoid anxiety and worry as far as possible. 
 
 Do not talk to any one about your disease or symp- 
 toms except to your physician or nurse. 
 
 When indoors remain in the sunniest and best venti- 
 lated room. It is better to have no carpets or heavy 
 hangings in the room ; small rugs and washable curtains 
 may be allowed. Cleaning should be done in such a 
 way as not to raise any dust in the room. 
 
 Never sleep or stay in a hot room. Have your own 
 sleeping room if possible, but always have your own 
 bed, which should be freely aired during the daytime. 
 In cold weather you may have a fire in the room, but 
 keep the window wide enough open not to have the 
 room warmer than 60° to 65° F. 
 
 Keep at least one window always open in your bed- 
 room. Night air is as good and in cities even better 
 than day air. 
 
4^ TUBERCULOSIS 
 
 Have at least nine hours' sleep in the twenty-four and 
 retire early. If you have to work during the week and 
 feel as if you do not get a sufficient amount of rest, re- 
 main in bed all Sunday morning and get thoroughly 
 rested. 
 
 If you are directed to sleep outdoors in a tent, on a 
 veranda, on a porch, or in a window tent, begin gradu- 
 ally, and in cold weather be particular to dress warmly 
 for the night and have plenty of bed covering. Your 
 feet must be kept warm. 
 
 Remain in the sunshine as much as possible, except 
 in very hot weather; but always protect your head. If 
 there is no sheltered spot outdoors or on a veranda, the 
 best place to take a sun-bath is in front of the open win- 
 dow. Extend yourself on a comfortable lounge with 
 your head in the shade and the body bathed by the rays 
 of the sun; remain there as long as you feel comfortable. 
 
 A feeling of discomfort, headache, or a rise of tem- 
 perature are an indication that you have been exposed 
 too much to the sun and that you must seek the advice 
 of the physician before resuming the sun-baths. 
 
 Live as much as you can in the open air. Do not be 
 afraid of cold weather; in snowy or rainy weather always 
 wear rubber shoes and an outer garment which will 
 keep you dry and warm. Remain indoors only on very 
 windy and stormy days. 
 
 The rest cure in the open air on a reclining chair can 
 and should be taken in all kinds of weather, providing 
 you protect yourself against rain or too strong winds. 
 Whether you are taking your rest cure outdoors during 
 
GENERAL ADVICE 49 
 
 the day, are sleeping outdoors, in a window-tent, or 
 in a room with the windows wide open, if you suffer 
 from the cold, it is time to return to the house or close 
 part of the window. Protect yourself better the next 
 time, for the air does not do you any good when you 
 become chilled. 
 
 Dress yourself comfortably, but not so heavily as to 
 hinder your movements. Discard chest-protectors, for 
 they only tend to make you take colds more easily. 
 Wear a suit of linen-mesh underwear; but do not change 
 from wool to linen in cold weather unless you begin by 
 wearing the linen-mesh next the skin and some warmer 
 under-garment of cotton or wool over it. Keep your 
 feet dry and warm, particularly when you are taking the 
 rest cure in the open air in cold weather. Use a heated 
 soapstone or hot water bag if necessary. 
 
 Take a bodily and mental rest on your comfortable 
 reclining chair for about thirty minutes before and after 
 the principal meals. 
 
 Do not take any kind of medicine (patent or other), 
 peculiar food-substances, or exercises, except such as 
 are prescribed by your physician. 
 
 Avoid all unnecessary exertions, mental or physical. 
 Avoid exciting conversation. Never run nor lift heavy 
 weights. Never take any exercises when you are tired, 
 nor take them to the extent of getting tired. Avoid get- 
 ting into perspiration. 
 
 When walking against the wind, riding in carriage or 
 automobile, do not converse but keep your mouth 
 closed and breathe through the nose only. 
 
so ' TUBERCULOSIS 
 
 Take your walking exercises as you have been di- 
 rected, and when feasible begin with walking slowly 
 uphill; the return will then be easier. 
 
 Take your breathing exercises regularly as pre- 
 scribed; always breathe through the nose. 
 
 Avoid strong draughts, dust, and dampness, and all 
 places where the air is bad, such as theaters, concert 
 halls, crowded meeting places, etc. 
 
 In cold weather bathe and dress in a warm room. 
 If you sleep in a tent, have a fire made before rising; if 
 on a veranda, have your bed rolled into a warm room 
 or go there quickly, covering yourself with a coat 
 or blanket. If you sleep in a window-tent, close 
 the window and wait until the room is sufficiently 
 warm before dressing. As a rule in winter do not 
 leave the house until an hour after sunrise, because 
 the air before that time is usually very much colder. 
 By taking these precautions you will avoid being 
 chilled. 
 
 Try to control your cough. You should train your- 
 self to cough only when you have to expectorate. 
 
 All expectoration, discharges from the lungs and 
 throat, contain germs. Some of these, especially when 
 there is throat, bronchial, or lung trouble, are dangerous. 
 Thus, it is best to be careful and gather all the ex- 
 pectoration, of whatever nature, and destroy it before 
 harm can be done by it. To this end one should always 
 expectorate in a proper receptacle and see to it that its 
 contents are destroyed. Carelessness in this respect is 
 sure to cause the spread of the disease to others. This 
 
GENERAL ADVICE 51 
 
 method of disposing of the sputum also protects the 
 patient himself from taking the same germs into his 
 system again, either by inhaling dust containing parti- 
 cles of the dried sputum or by infecting himself through 
 sores. Be particularly careful when you have any 
 wound or scratch on your hands, for if tuberculous 
 matter comes in contact with an open wound local in- 
 fection, or inoculation, may take place. It is not safe to 
 use a handkerchief to spit into since in this way an in- 
 fection of the nose is possible. 
 
 When at home always expectorate in a spittoon filled 
 partially with water, or better, with water into which 
 you have put one part of carbolic acid to twenty parts 
 of water (five per cent solution). When you can not 
 conveniently get at the stationary spittoon use a pocket 
 spittoon. When away from home or if the use of such a 
 pocket flask or spittoon is not practicable, use squares 
 of muslin simulating handkerchiefs, or use Japanese 
 handkerchiefs to expectorate into. Keep them in a 
 leather pouch or in a pocket lined with impermeable 
 material until you can burn them on your return home. 
 Ladies should divide their handbags into two compart- 
 ments to serve the same purpose. For people who five 
 in flats where the cooking is done over gas, it may be 
 difficult to find a place to burn the cheap handkerchiefs, 
 rags, pasteboard pocket spittoons, or paper. While the 
 thin paper might be thrown into the water-closet, this 
 can not be done with rags or pasteboard. Individuals 
 thus situated should use thin paper which they can 
 throw into the water-closet, or a pocket flask of metal or 
 
52 TUBERCULOSIS 
 
 glass which snould be emptied into the closet and 
 cleaned ^Yith hot water. There are small and conven- 
 ient ones to be had that can be hidden in the folds of 
 a handkerchief when used. 
 
 All stationary spittoons should be covered, for flies 
 and other insects may crawl over them, partake of the 
 tuberculous matter and by depositing the latter on arti- 
 cles of food or elsewhere, become propagators of tuber- 
 culosis. 
 
 Whether sick or well never expectorate on the side- 
 walk but always in the gutter if there is no spittoon. 
 
 Never swallow your expectoration. Never use the 
 same handkerchief to wipe your nose which you use to 
 wipe your mouth after having expectorated. Always 
 cover your mouth with a handkerchief or the hand 
 while coughing or sneezing. Never kiss any one on the 
 mouth nor allow it to be done to you. 
 
 Handle soiled personal and bed linen, especially 
 handkerchiefs, as little as possible in the dry state. 
 When soiled, place these articles in water until ready to 
 be washed. 
 
 It is best not to wear any mustache or beard, but if 
 worn they should be closely clipped. 
 
 Always wash your hands thoroughly before touching 
 food. 
 
 Directions Concerning Food, Drink, Stimulants, 
 
 ETC. 
 
 Live on a mixed diet, that is to say, meal, fish, oys- 
 ters, vegetables, especially spinach, lentils, cauliflower; 
 
GENERAL ADVICE 53 
 
 fresh and cooked fruit, particularly grapes; plenty of 
 fresh milk, fresh eggs; all sorts of easily digested fats, 
 especially butter. Thick, nourishing soups should be 
 eaten with the principal meals. Raw, chopped or 
 scraped beef is especially to be recommended. Whole- 
 wheat bread being more nourishing than white bread, 
 is to be preferred. Do not cat the inside of fresh bread; 
 bread with a hard crust, toast and stale bread are more 
 easily digested and more nourishing. 
 
 Eat slowly, chew your food well, take the milk in 
 small swallows; take but little liquid during and shortly 
 after meals. Keep your teeth in good condition; use 
 toothpick and brush after each meal. 
 
 Never take any alcoholic beverages (wine, beer, or 
 liquor) without special consent and the direction of 
 your physician. Too much sweets (sugar, pies, pastry, 
 etc.) should also be avoided, as well as all kinds of fried 
 food. 
 
 Drink plenty of good, pure water between meal- 
 times. 
 
 Do not use tobacco in any form; smoking cigarettes 
 and inhaling the smoke is particularly injurious. 
 
 Directions Concerning Baths and the Use of 
 Cold Water. 
 
 Take a short warm bath once a week, followed by a 
 rapid sponging with cool water and a vigorous rubbing 
 with a rough towel. 
 
 Wash your neck and chest every morning with cold 
 water. 
 
54 TUBERCULOSIS 
 
 Take a cold douche every morning when so directed 
 by your physician. If the reaction does not follow rap- 
 idly, seek his advice. 
 
 Special Advice to the Patient, Nurse, and the 
 
 Family 
 
 Any intercurrent trouble, such as fever, indigestion, 
 diarrhoea, constipation, increased cough, pain, reddish 
 expectoration, or hemorrhage, should be at once re- 
 ported to the physician. Do not, however, be alarmed 
 if a hemorrhage occurs, as it is but one of the phases of 
 the disease, and does not lessen the chances for re- 
 covery. Let the patient remain quiet on a reclining 
 chair or on the bed and, until the arrival of the physi- 
 cian, place a cold compress or ice bag over the heart. 
 In case of fever, particularly when it is as high as 
 1 00° or more, it is best for the patient to go to bed 
 and await instructions from the physician. 
 
 A careful and obedient patient has all possible 
 chances of getting well, while he who is careless and 
 disobedient may forfeit all possibility of recovery. 
 
 To All Whom It May Concern 
 The careful, clean, and conscientious consumptive 
 who is trained in the prevention of the disease, is not 
 dangerous to those with whom he may live and work. 
 Signature of the Attending Physician. 
 
 The conscientious physician to whom the tuber- 
 culous patient comes for treatment, v^ill not content 
 himself with merely giving directions how to live 
 
SPECIAL ADVICE 55 
 
 and what to eat, or prescribing medicine if such 
 is needed. He will realize that he can not treat 
 the patient successfully without having a knowl- 
 edge of the latter's home environments. While 
 the patient may be well enough to get about 
 (ambulant) and to come regularly to the phy- 
 sician's office to report or be reexamined, to see 
 the patient occasionally in his home and talk with 
 those with whom he is living, is an essential part 
 of the judicious management of a tuberculous 
 case. 
 
 The physician will not infrequently have to 
 enter into the very soul life of the patient. To 
 keep him hopeful and of good cheer he will often 
 have to appeal for help to those living or associ- 
 ated with the patient. Worry and anxiety should 
 as far as practicable be removed from the sick. 
 A brooding mind is the worst thing for a con- 
 sumptive, for he will not eat nor breathe as he 
 should and his digestion will become more and 
 more impaired. The more cheerful the physician 
 is himself, the more hope and genuine sympathy 
 he has as an equipment for his calling, the more 
 certain will he be to benefit the tuberculous in- 
 valid. 
 
CHAPTER IV 
 
 HOW THE SANATORIUM TREATMENT MAY BE 
 ADAPTED TO AND IMITATED IN THE HOME OF 
 THE CONSUMPTIVE 
 
 Many cases of tuberculosis, some among the 
 well-to-do and some among the poor, will have 
 to be treated at home; and when this is necessary 
 w^e must seek to imitate in the home the methods 
 in vogue in sanatoria where, so far, the best re- 
 sults have been obtained in the treatment of tuber- 
 culosis. 
 
 The first thing in all cases is to see that the pa- 
 tient is properly housed. Among the well-to-do 
 and those having their own house, he should have 
 two or three rooms on an upper floor at his dis- 
 posal. In all cases where this is not feasible, 
 select the best lighted and best ventilated room, 
 preferably with southern exposure, for the pa- 
 tient to sleep in. It goes without question that 
 even in the poorest family the patient should 
 have his own bed, and if he is in the latter stage of 
 the disease and obliged to spend day and night in 
 bed, nothing will be so pleasant for him as to 
 
 56 
 
TREATMENT AT HOME 57 
 
 have two beds at his disposal, one to rest in during 
 the day and one to sleep in during the night. The 
 furniture should be plain and simple, the chairs 
 of wood, cane seated or leather covered. Plush 
 furniture or any dust-catching material, heavy 
 curtains, and fixed carpets should be avoided. 
 Still, the room need not be made cheerless. A 
 few small rugs, washable curtains, and some 
 cheerful pictures to decorate the w^all should be 
 allowed. 
 
 As the most important curative agent in the 
 modern treatment of tuberculosis we must first 
 consider fresh, pure air. The home treatment 
 can be made most successful when we imitate, as 
 far as practicable, all the salient features of aero- 
 therapy as practiced in the sanatorium treatment. 
 In these institutions the patients live outdoors 
 virtually twenty-four hours of the day. 
 
 Let us now see how we can imitate this aero- 
 therapy of the sanatorium treatment in the home 
 of the patient. In summer we have all the win- 
 dows open and during the day we place our 
 patient in the yard, on the veranda, or on the 
 roof, whenever and wherever conditions permit 
 us to have him take what is known as the rest- 
 cure in the open air. Here he rests on a reclining 
 chair which should have a proper knee bend and 
 a comfortable back. If the patient can afford it, 
 
58 
 
 TUBERCULOSIS 
 
 we get him also a half-tent. (Fig. 15.) This half- 
 tent is composed of a frame of steel tubing which 
 
 can be folded together 
 when not in use. Over 
 this frame strong sail 
 duck is stretched and se- 
 cured by snap buttons on 
 the inside, which protects 
 the patient against wind 
 and sun. To prevent the 
 tent from being over- 
 turned by the wind, the 
 frame has ground spikes 
 holding it securely. The 
 reclining chair is placed 
 Fig. 15. Knopf's half-tent for in this half-tcnt in such 
 
 the rest-cure m the open air. ^ manner that the floor 
 1 he detachable cover is made 
 
 of sail canvas. When not in braciug attached to the 
 
 use the frame may be folded frame is held down by 
 flat. . . 
 
 the chair, which adds to 
 its security. A beach chair of wickerwork can 
 also be made to do the service of the half-tent. 
 After the seat has been removed, the inner walls 
 of the wicker chair are lined with padding. A 
 reclining chair is placed with its back in the in- 
 terior, and the whole arranged so that the patient 
 is protected from the wind and sun. Whenever 
 the patient is on the chair he should be so com- 
 
TREATMENT AT HOME 
 
 59 
 
 fortable as to allow complete muscular relaxa- 
 tion. Mind and body must be at rest. For poor 
 patients the simple steamer chair and a few boards 
 joined together to support the canvas will have to 
 replace the more costly reclining chair and half- 
 tent. A large and stout umbrella, such as is often 
 used at seaside resorts, can be fastened to the back 
 of the steamer chair and will make a good sub- 
 stitute when the tent can not be provided. 
 
 The poor patient in a city will probably be 
 obliged to resort to the roof for his rest-cure, as 
 the small yard of a tenement house, with many 
 children playing in it, will scarcely be suitable. 
 I do not favor the use of the fire escape for this 
 purpose. A recent conflagration in the city of 
 New York where lives were lost owing to the ob- 
 struction of the fire escape, showed the WTong of 
 evading the law in this way. On the reclining 
 chair in the open air the patient should remain 
 during the day whenever he is not taking any 
 exercise. In the modern American and also in 
 some European sanatoria the majority of patients 
 have their beds moved out on the veranda during 
 the night, and there they sleep often in the coldest 
 weather. That excellent results are obtained from 
 sleeping outdoors in cold weather when everything 
 is carefully arranged, is now a well-established fact. 
 
 When the patient has his own home and lives 
 
6o 
 
 TUBERCULOSIS 
 
 Fig. i6. Sleeping Balcony Designed and Used by a Young Tubercu- 
 lous Chemist of Boston. 
 
 in a village or small town, it is often very easy to 
 arrange for sleeping on the veranda. Even a 
 special porch for the exclusive use of the patient 
 can often be built with relatively little expense. 
 The accompanying picture (Fig. i6) shows such a 
 porch which was devised by a young Massachu- 
 setts chemist, himself a sufferer. Realizing the 
 value of fresh air treatment by day and l)y night, 
 he had an outdoor bedroom constructed which 
 was built in the south corner between the ell and 
 the main portion of his house, covered at the top 
 
PROPER HOUSING 6i 
 
 and open on two sides. The dimensions of this 
 little room were approximately 6 by lo feet; it 
 was firmly secured along two sides to the house, 
 and supported at the outer corner by a stout 
 timber from the ground. For the height of about 
 2 1 feet from the floor there was a sheathed wall, 
 the rest being open to the roof, which had a wide 
 overhang to prevent as far as possible the dripping 
 in of the rain. Curtains of canvas were provided, 
 which pulled up from beneath, but which were 
 used only in case of storm or wind. The window 
 was cut down into a door to provide easy access 
 from the house. This room was simply con- 
 structed, the outer wall being of pine sheathing. 
 It had a tight double floor. The interior was a 
 natural wood finish with no attempt to hide the 
 rough beams, and the roof was covered with heavy 
 roof paper known as rubberoid . The total expense 
 for construction and painting was about $104. 
 The location of the room was such that it was thor- 
 oughly protected from the north and west winds, 
 and the situation of the house was quite favorable 
 in that it was surrounded by open areas with 
 numerous trees. A much simpler and less ex- 
 pensive construction is shown in Fig. 17, repre- 
 senting an original sleeping balcony in Hanover, 
 Mass., used since June, 1898. 
 
 When the building of a special veranda or porch 
 
62 
 
 TUBERCULOSIS 
 
 Fig. 17. Original Sleeping Balcony in Hanover, Mass., Used Since 
 
 June, 1898. 
 
 is not feasible and there is plenty of ground 
 around the house, a so-called shack can be built 
 and turned into most comfortable sleeping quarters 
 for a patient. One of the latest and most practical 
 shacks I have seen is the one designed by Dr. 
 Millet of Brockton, Mass., to whom I am in- 
 debted for the illustration (Figs. 18 and 19) and 
 description of this construction, so valuable in the 
 treatment of the consumptive at home. 
 
 The following description will aid any one in 
 a position to have such a shack to know how 
 to build it. It should ])e remembered that the 
 shack for tuberculous patients must have all the 
 air and sun which can possibly ])e admitted to it, 
 consistently with shelter from rain, snow, and 
 
PROPER HOUSING 
 
 6S 
 
 Fig. i8. Latest Model of Sleeping Shack Designed by Dr. Millet of 
 
 Brockton, Mass. 
 
 <5(XJTri D-tVATION 
 
 Cast Clzva.tion 
 
 Fig. 19. Dr. Millet's Shack. South and East Elevations. 
 
64 TUBERCULOSIS 
 
 violent winds. For this purpose it should face the 
 south; the front should be as open as possible, 
 and should be much higher than the back, so 
 that the sun's rays may reach all parts of the in- 
 terior. There should be openings on all the other 
 sides to give cross-currents of air, although all the 
 openings, except those toward the south, should 
 have provision for closing them in cold and stormy 
 weather. Even the south openings should have 
 screens of some sort for protection against south- 
 erly rains, but they will not often be brought into 
 use. If the shack is near a dwelling house which 
 the patient can reach easily, nothing more than a 
 simple structure, 12 feet square, with three walls, 
 a roof and floor, standing on posts, and costing 
 about Sioo complete, will be required; but for 
 greater comfort, especially for patients unable to 
 walk far, a dressing room may be added for about 
 double the cost, such as is shown in the picture 
 of Dr. Millet's shack. This building is 12 by 
 18 feet, supported on cedar posts, boarded and 
 covered with shingles, with a shingled roof. It 
 faces due south, and the roof rises toward the 
 front at an angle with the horizon of 26^7 degrees, 
 known to builders as 'Vjuartcr pitch." The in- 
 terior is divided into a bedroom 12 by 12 feet, 
 and a dressing room 6 ])y 12 feet. The front of 
 the bedroom is entirely open. Sashes can be fitted 
 
PROPER HOUSING 65 
 
 into the spaces between the posts if thought neces- 
 sary, but experience shows that they are not 
 required; hght screens, covered with paraffined 
 cloth, are found sufficient to exclude rain and 
 snow. These screens are hinged to the top of the 
 openings and are drawn up to the under side of the 
 roof when not in use. The north wall of the bed- 
 room is about 6i feet high, and has three openings, 
 closed in bad weather by hinged w^ooden shutters. 
 Toward the wTst is the door from the outside 
 and a window, and on the east is a sliding door 
 leading into the dressing room which has a window 
 opposite the door and also a south window\ In 
 the dressing room is a chimney and a stove, a 
 set washbasin wath running water, a water-closet, 
 and a movable bureau, and a wardrobe. In 
 pleasant weather the windows and door of the 
 dressing room are kept open; in cold weather 
 they are closed so that the water pipes may not 
 freeze; but the bedroom openings are practically 
 never closed. Except that of the chimney, the 
 whole construction is of wood. There is no plas- 
 tering, the partitions being of wood sheathing. 
 The floor is double, the upper floor being of nar- 
 row rift North Carolina pine. The cost of this 
 structure is $300, including the chimney, stove, 
 and plumbing. 
 
 In places where the climate is relatively dry, 
 
66 
 
 TUBERCULOSIS 
 
 some sort of a tent may also serve the purpose of 
 
 outdoor living. Figure 20 is an illustration of a 
 
 suitable tent with a wooden floor. 
 
 With the devices just described, the open air 
 
 cure can be carried out day and night in a small 
 
 town or village, even 
 in the homes of the 
 relatively poor, with 
 ease and little cost. 
 
 What worried me 
 for years was the fact 
 that we could provide 
 this open air trcat- 
 
 FiG. 20. The Tucker Tent Tor CJut- YXieut at night for 
 door Living. 1 i.- 1 n 
 
 such a relatively small 
 number of patients in our large cities, when there 
 are so many who need it particularly among the 
 consumptive poor. I believe I have been fortu- 
 nate enough to solve this problem in a measure by 
 an unpretentious device which I call a 'Svindow- 
 tent." After much experimenting, modelling, and 
 remodelling to overcome the defects which I 
 learned through my own experience and that of 
 others in the use of the tent, I believe I am able 
 to present to the profession and to the public a 
 model as nearly complete and perfect as possil3le. 
 Many of the unfortunate poor will, however, not 
 even be able to pay the modest price at which 
 
WINDOW-TENTS 
 
 67 
 
 Fig. 21. Knopf's window- tent for the open air treatment of tuber- 
 culous patients. Tent in use with patient in bed looking through 
 the celluloid window into the room, but breathing outdoor air only. 
 
 the window-tent is now put on the market, but 
 with the illustrations before them they may have 
 sufficient mechanical skill to imitate the device at 
 very little cost. 
 
 As will be seen, this window-tent (Fig. 21) is an 
 awning which, instead of being placed outside of 
 the window, is attached to the inside of the room. 
 It is so constructed that the air from the room 
 can not enter or mix with the air in the tent. The 
 
68 
 
 TUBERCULOSIS 
 
 patient lying on the bed, which is placed parallel 
 with the window, has his head and shoulders 
 resting in the tent. By following the description 
 
 closely, it will be seen 
 (Fig. 22) that the venti- 
 lation is as nearly per- 
 fect as can be produced 
 with so cheap a device. 
 The tent is placed in 
 the lower half of an 
 American window, but 
 it does not quite fill the 
 lower half of the frame ; 
 a space of about three 
 inches is left for the 
 escape of the warm air 
 in the room. By lower- 
 ing the window, this 
 space can be reduced 
 to one inch or less, ac- 
 cording to need. On 
 extremely cold and 
 windy nights there need 
 not be left any open 
 space at all above the tent frame. The patient's 
 breath will rise to the top of tlic tent, the form 
 of which aids in the ventilation. The tent is con- 
 structed of a series of four frames, made of Bcsse- 
 
 P'lG. 22. Sectional View Showing 
 the Ventilation of Knopf's Win- 
 dow-Tent. 
 
WINDOW-TENTS 69 
 
 mer rod suitably formed and furnished with 
 hinged terminals, the hinges operating on a stout 
 hinge pin at each end with suitable circular wash- 
 ers to insure independent and easy action in 
 folding. 
 
 The frame is fitted with a cover of extra thick 
 yacht sail twill having elongated ends, to admit 
 of their being tucked in under and around the 
 bedding to prevent the cold air from entering the 
 room. The patient enters the bed and then the 
 tent is lowered over him; or with the aid of a 
 cord and a little pulley attached to the upper 
 portion of the window, he can manipulate the 
 lowering and raising of the tent himself. Shutters 
 and Venetian blinds, whether they are attached 
 on the inside or on the outside of the window, 
 can be utilized in conjunction with the window- 
 tent as a screen to intercept the gaze of the 
 neighbors (Fig. 23), and in stormy weather as a 
 protection. The bed can be placed by the window 
 to suit the patient's preference for sleeping on 
 his right or left side, so that he has the air most 
 of the time in his face. The bed being placed 
 alongside of the window will be convenient for a 
 majority of the poor who have small rooms. If, 
 however, the bed must be placed at a right angle to 
 the window, this can be arranged as well. A piece 
 of transparent celluloid is placed in the middle 
 
70 
 
 TUBERCULOSIS 
 
 portion of the tent to serve as an observation 
 window for the nurse or members of the family 
 
 to watch the pa- 
 tient if this is nec- 
 essary. It also 
 SLTvcs to make the 
 patient feel less 
 outdoors and more 
 in contact with his 
 family. He can, 
 if he desires, see 
 what is going on 
 in the room. If 
 the window-tent 
 must be placed at 
 a right angle to 
 the window, the 
 observation glass 
 can be put in on the side. It is a general rule that 
 patients should not smoke; when, in exceptional 
 cases, this can be allowed, the danger of the cel- 
 luloid window becoming ignited must be impressed 
 upon them and the greatest caution urged. I 
 prefer celluloid to glass because there is no danger 
 of cuts or scratches with the possibility of tuber- 
 culous inoculation, as there would be if the glass 
 should break. 
 
 If it is necessary to raise the bed to the height 
 
 Fig. 23. \'ie\v of the Window-Tent and 
 Patient Taken from the Outside. 
 
WINDOW-TENTS 
 
 71 
 
 Fig. 24. Knopf's Window-Tent Raised When Not in Use. 
 
 of the window-sill, this can be done with little 
 expense. If the bed is of iron, a few additional 
 inches of iron piping can be attached to the legs 
 by any plumber or one handy with tools; raising 
 a wooden bed can be accomplished with equal 
 facility. If the window-tent is to serve the patient 
 only during the night, it can be pulled up (Fig. 24) 
 and the bed moved away from the window during 
 the day, and the window closed. Or the tent can 
 be taken from the hooks and put out of the way. 
 The window-tent will, of course, be of greatest 
 service to the consumptive sufferer in winter. If 
 he is feverish, or his stay in bed is advisable, he 
 can spend his entire time in the window-tent. If 
 
72 TUBERCULOSIS 
 
 the people are poor and the room where the con- 
 sumptive sufferer hes serves as hving room for 
 the rest of the family, the fact that the well mem- 
 bers need not shiver and yet the patient can take 
 his open air treatment, is of vital importance in 
 many respects. While the room will not be quite 
 as warm as if the window was entirely closed, it 
 will be much warmer than if there was no tent 
 in front of the open window. Leaving aside the 
 economic advantages to a poor family when not 
 obliged to heat more than one room, the patient 
 feels that he does not deprive his loved ones of 
 comfort and warmth, and that he is less a burden 
 and hindrance to their happiness. The other 
 members of the family, on the other hand, feel 
 that they can give the patient all the air he needs 
 and that he will not have to suffer for their 
 comfort. 
 
 Besides the just mentioned advantages, there 
 is another benefit derived from the use of the 
 window -tent arrangement which will add to the 
 patient's physical and mental comfort. His pro- 
 longed rest cure in bed will be more endurable 
 when he is permitted to look out on the street 
 and watch life there, than when ol^liged to gaze 
 at the four walls of his room. An important ad- 
 vantage which the window-tent offers is the fol- 
 lowing: patients who can only be persuaded with 
 
WINDOW -TENTS 73 
 
 difficulty to sleep with the window wide open 
 will not hesitate when they have this tent as an 
 inducement. Draught, which the consumptive 
 patient usually dreads, particularly in cold weather 
 and when he perspires, need not be feared when 
 sleeping in a window -tent. The construction is 
 such that even should the shoulders be accidentally 
 exposed, the three tent walls protect the patient 
 from violent currents of air which may be pro- 
 duced by leaving opposite doors in the room open. 
 In this respect the window- tent even has an ad- 
 vantage over sleeping on porches when they are 
 not properly inclosed. 
 
 Lastly, an important point gained by the use of 
 the window-tent for consumptives is in regard to 
 the drop infection already explained in Chapter I. 
 While, as a matter of course, the patient will 
 have been taught always to hold his hand or 
 handkerchief before his mouth when he coughs 
 or sneezes, this is not always done and can not 
 be done when coughing in sleep. To limit the 
 possible infection to the interior of the window- 
 tent is obviously a great advantage. First, the 
 constant exposure to air and light of the bacilli 
 which may have been expelled with the saliva 
 and remain adherent to the canvas, will soon 
 make them innoxious; secondly, the canvas of the 
 tent is attached to the frame by simple bands, and 
 
74 TUBERCULOSIS 
 
 its removal from the frame for thorough cleansing, 
 washing, or disinfection is thus made easy. 
 
 Another ingenious device, which can be applied 
 very easily in a country town and in private 
 houses, is Bull's aerarium. The fact that this 
 device was not exactly suitable for consumptive 
 dwellers in the tenement houses of a great city 
 caused me to think out the window-tent just de- 
 scribed. The aerarium of Dr. Bull is a double 
 awning attached to the outside of the window with 
 a special ventilating arrangement. (Fig. 25.) 
 The head of a cot-bed is put through the window 
 and thus the patient's head rests out of doors. 
 (Fig. 25a.) 
 
 The veranda arrangement for the outdoor sleep- 
 ing of the tuberculous patients was first suggested 
 and carried out by Dr. C. S. Millet of Brockton, 
 Mass., who showed that this could be done with 
 benefit to the patient even in midwinter in the 
 rigorous climate of Massachusetts. 
 
 In cold weather the patient's bed must be 
 covered with a sufficient number of blankets to 
 assure his absolute comfort and warmth through- 
 out the night. Still, the covering should not be 
 so heavy as to press down upon the Ixxly and 
 make the patient feel uncomfortaljle or tire him. 
 The tightly woven blanket is a better protection 
 than the loosely woven one. The poor, whose 
 
OPEN AIR TREATMENT 
 
 75 
 
 Fig. 25. Bull's Aerarium for the 
 Open Air Treatment. 
 
 Fig. 25a. Sectional View 
 of Bull's Aerarium. 
 
 supply of blankets is, alas, often very limited, 
 may be advised to put several layers of newspapers 
 between the coverings or sew a dozen layers of 
 newspapers between two layers of dark colored 
 cotton flannel. In extremely cold weather the 
 patient, while sleeping in the window-tent or 
 any other outdoor sleeping device, should wear a 
 sweater and protect his head and ears with a 
 woolen cap, shawl, or woolen helmet, such as is 
 shown in the accompanying illustration. (Fig. 26.) 
 In order to insure absolute warmth for the 
 patients sleeping on the veranda, in an open shack, 
 
76 
 
 TUBERCULOSIS 
 
 or in the window-tent, it may sometimes be neces- 
 sary to resort to a special way of arranging the 
 
 bed. There exist two meth- 
 ods of making a bed (which 
 has been named the ''Klon- 
 dike Bed") suitable for out- 
 door sleeping. One method 
 which originated at the 
 Loomis Sanatorium is as fol- 
 lows : 
 
 Place two or three layers 
 of heavy wrapping or build- 
 ing paper under the mattress. 
 Several layers of newspapers 
 Fig. 26. iiov. to Dress ^ould also auswcr the pur- 
 for Outdoor Sleeping in posc. Placc a hcavy blanket, 
 
 Cold Weather. ^^j^ ^^^^^^^ ^^^^^^ ^j^^ ^^^ 
 
 with half of it extended over one side. Place 
 another one likewise half extending over the 
 other side of the bed. Now use a thin, wash- 
 able double blanket lengthwise with closed end 
 at foot. This one is to sleep between. Have 
 end of the upper half of this blanket extend up 
 to head of the bed and make an underfold of 
 the corners of each side at the top. Place two 
 or three heavy double blankets lengthwise of the 
 bed, allowing sufficient on the top one to tuck in 
 well at the foot. Now fold over the flaps of the 
 
OPEN AIR TREATMENT 77 
 
 two blankets which were placed crosswise of the 
 bed and tuck in at the sides. 
 
 In getting into the "Klondike" bed it is neces- 
 sary to slide in at the top and if one lies on his 
 side, the blanket which he is between (and which 
 was placed up to the head of the bed with corners 
 folded under) can be used to bring over the head 
 and under the shoulders, tucking the opposite 
 side under the chin so that the face only is exposed. 
 This is considered to be one of the best features 
 of this method of making the bed. The blanket 
 is sufficient covering for the head, and for a quiet 
 sleeper more comfortable than the knitted hood 
 or cap. If one lies on his back a thin cap would 
 be required to keep the ears warm, and the blanket 
 can be tucked in around the neck. The bed made 
 in this way can not easily get disarranged and 
 requires to be made over entirely about twice a 
 week. 
 
 Another way to make the ''Klondike" bed is 
 described in a circular on the Prevention of 
 Tuberculosis issued by the Illinois State Board 
 of Health. This method is as follows: 
 
 Make the bed in the usual way, allowing the 
 coverings to fall loose on either side. Now gather 
 up the coverings on one side and pass them be- 
 neath the blanket sheet to the center of the bed. 
 Likewise do the same on the opposite side. Fold 
 
78 TUBERCULOSIS 
 
 in the clothing at the foot of the bed beneath the 
 blanket sheet and the Klondike bag is ready to 
 sleep in. 
 
 The usual manner of placing the pillows will 
 be found unsuitable for cold winter nights, when 
 the thermometer drops below zero, as it does 
 sometimes in the Adirondacks. The cold wind 
 is sure to blow down one's back. This may be 
 overcome by arranging the pillows in the form 
 of a V, w^ith the apex at the head and the other 
 ends reaching under the clothing. 
 
 Some patients complain that the bright light 
 awakens them too early in the morning, and that 
 they have difficulty in going to sleep again. In 
 such instances they may place a piece of some 
 light weight but dark colored material (such as a 
 black lisle-thread hose) over the eyes. This usu- 
 ally suffices to obviate the inconvenience caused 
 by the bright light. 
 
 The pulmonary invalid when in bed should 
 be provided with a bell to communicate with his 
 nurse, relatives, or friends who take care of him. 
 He should, of course, have a small sputum cup 
 or pocket flask handy to receive his expectoration. 
 I prefer the flask for use in the window-tent, 
 for it seems to me that any kind of cuspidor 
 which had to stand on the window-sill would not 
 be as safe, as there is always a danger of its falling. 
 
OPEN AIR TREATMENT 79 
 
 A urinal should also be placed at the bedside, so 
 that the patient will not have to leave the bed in 
 the night and be uselessly chilled. 
 
 When arranging for the rest-cure in the re- 
 clining chair during the day, whether it is in the 
 half tent, in the garden, on the veranda, in the 
 sleeping shack, on the roof, or on a balcony, one 
 should always bear in mind that it is much more 
 agreeable and conducive to the well-being of the 
 patient to have a pleasant view to look upon. 
 In building sanatoria the greatest attention is paid 
 to the proper selection of the place for the rest- 
 cure gallery or veranda. The more pleasing and 
 entertaining the outlook from these places, the 
 more certain one is to keep the patients quiet and 
 restful. 
 
 Where the choice of a place is limited, one will 
 have to do the best he can. If there is no garden, 
 veranda, porch, or flat roof that the patient may 
 use, the window-tent can be put into service also 
 for the rest-cure during the day. The bed is moved 
 away and the reclining chair is put in its place. 
 The latter can be raised to the necessary height 
 by wooden blocks or a platform, and with the aid 
 of blankets and comforters the air from the room 
 can be excluded and the patient in front of the 
 open window will breathe only outdoor air. 
 
 Sometimes the patient is so poor or so situated 
 
8o TUBERCULOSIS 
 
 that the purchase of an aerarium or window-tent 
 is out of question. Or, again, a suitable outdoor 
 or indoor arrangement for the fresh air cure can not 
 be made at once. What, then, is the patient to do ? 
 He should move his bed as near as possible to 
 the window and open the lower sash almost as 
 wide as it will go, lowering the upper one a few 
 inches from the top. If he finds that there is a 
 draught, that the direct air in his face is too 
 much, or if he does not wish to be seen by his 
 neighbors, he can obviate all these difficulties 
 by moving the bed about one or two feet from 
 the window and placing a screen between the 
 window and himself. To avoid draught he need 
 not raise the windoAV above the height of the 
 screen. An even simpler device is a sheet tacked 
 to the window- frame and drawn out over the bed 
 to serve as an improvised-window tent. 
 
 When beginning the aerotherapy, or open air 
 treatment, it is essential to do it gradually and 
 according to the susceptibility of the patient to 
 cold. The fact should be impressed upon him 
 that night air is as pure as day air. If the treat- 
 ment is started in midwinter, one should select 
 the milder days for the beginning of outdoor 
 sleeping or outdoor resting and start with a few 
 hours at a time. A hot water -bag or hot soap- 
 stone for the feet, either in bed or in the chair, 
 
USE OF COLD WATER 8i 
 
 may often be necessary in extremely cold weather. 
 The patient's feet must be kept warm if he is to 
 benefit from the open air treatment. 
 
 There is no reason why hydrotherapy, that is 
 to say, the use of cold water as a curative agent, 
 should not be employed in the home as well as in 
 the sanatorium. It is a most valuable tonic and 
 serves to prevent the patient from contracting 
 colds, which are always apt to give him a set-back 
 in the cure. 
 
 The physician will direct the hydrotherapy as 
 well as the open air treatment. He will get his 
 patient accustomed to the use of cold water by 
 degrees. He will begin with a friction of the 
 whole body with pure alcohol once or twice a day, 
 for a number of days. This is followed by friction 
 with half alcohol and half water, then for the 
 same length of time with water alone; thus we 
 come gradually to douches of cold water, which 
 should be taken first with a temperature of 60° 
 and gradually decreased to 40° F. 
 
 The physician will instruct his patient that a 
 chilly sensation after the bath is a sign that he 
 has not reacted well and that then the water must 
 be more carefully tempered. Individualizing is 
 most important in hydrotherapy for the tubercu- 
 lous, and the use of cold douches or shower baths 
 should not be resorted to without the special advice 
 
^2 TUBERCULOSIS 
 
 of the physician. Children and the aged do not 
 react as well as the adult or middle-aged, and in 
 cold weather douches should never be given in 
 cold rooms. 
 
 No elaborate hydrotherapeutic appliances are 
 necessary in order to give a douche. In the families 
 of the poor the luxury of the douche apparatus 
 is unknown, and often they have not even a bath- 
 room. In such instances I give the following 
 advice: Procure a circular English bathtub, about 
 three feet in diameter and ten inches high, and 
 pour about five inches of cold or tepid water into 
 it. The bather jumps into the water, keeping his 
 feet in motion for a few seconds, then a second 
 person pours quickly one or two pitcherfuls of 
 water over each shoulder, thoroughly wetting the 
 whole body. It is best to keep the head dry. 
 The patient might be able to pour the water on 
 himself, but the help of a second person will much 
 facilitate the operation. If a hose can be attached 
 to a near-by faucet, a douche, bath, or direct jet 
 can be improvised. If the ambulant patient is 
 obliged to attend to the douche himself, he should 
 place a large empty washbowl or a small tub near 
 the bed on the floor to stand in, and have a smaller 
 washbowl filled with cold water placed at the 
 height of the table with a good sized sponge. 
 He may go to bed first and get thoroughly warm. 
 
USE OF COLD WATER 83 
 
 then rise, remove his night clothes and take his 
 douche by standing in the larger bowl and squeez- 
 ing out the sponge soaked in the cold water in the 
 smaller basin once over his left shoulder, once 
 over his right, once in front of the neck, and once 
 over the back of the neck. Thus, the whole body 
 will be douched. He should dry himself quickly, 
 and if he feels chilly he can return to the warm 
 bed. Unless the patient has been in the habit of 
 using cold water and his reaction is perfect, that 
 is to say, unless he experiences quickly a pleasant 
 warm sensation after the application of cold water, 
 the precaution just described of going first to bed 
 to get warm and using warm water in the big tub 
 to stand in, is to be strongly recommended. 
 
CHAPTER V 
 
 HOW SANITATION AND PROPER HOUSING MAY HELP 
 TOWARD THE PREVENTION OF TUBERCULOSIS 
 
 Hygiene and sanitation stand for the preven- 
 tion of diseases, and in regard to tuberculosis it 
 is our duty to trace the primary predisposing 
 causes as well. as the direct causes, and prevent 
 them as far as lies in our power. One of the most 
 important primary predisposing causes of tuber- 
 culosis is to be found in foul air due to unsanitary 
 housing, overcrowding, and the narrow streets in 
 cities which do not permit sufficient light and air 
 to enter into the living apartments, shops, or fac- 
 tories situated on them. 
 
 It is doubtlessly in the polluted condition of the 
 atmosphere that we must look for one of the 
 causes of the great mortality from tuberculosis in 
 large centers of population and in manufactur- 
 ing districts. In our large cities, particularly 
 in the lower strata of air where there is less dif- 
 fusion of gases, complete change only takes 
 place when it is sufficiently windy, and when the 
 
 streets are wide enough and not lined by a row of 
 
 84 
 
POLLUTED AIR IN LARGE CITIES 85 
 
 houses so high that there is almost no sunhght in 
 them. 
 
 The diffusion of the gases of the air is, of course, 
 still more limited in a closed room, and a change 
 of air is impossible. The more individuals that 
 occupy a limited inclosed space, the sooner will 
 the air be unfit for human beings to breathe. At 
 one time it was supposed that the diminution of 
 oxygen and the increase of carbonic acid in an 
 atmosphere vitiated by respiration were the chief 
 causes of its noxious effect on the persons breath- 
 ing it. The experiments of recent investigators, 
 however, have thrown considerable doubt on that 
 explanation. 
 
 The amount of carbonic acid ordinarily in the 
 air, is from 3 to 4 parts in every 10,000, and the 
 presence of this quantity will not be perceived by 
 the normal human organism. Even as large a 
 proportion as i per cent can be borne for some 
 time without giving rise to disturbance; and air 
 containing as much as 4 per cent has been breathed 
 for ten minutes without harm (Huggard). 
 
 Carbonic acid owes its evil reputation chiefly, 
 not to its own bad qualities, but to its bad 
 company. Where the atmosphere of a room has 
 been vitiated by respiration to such a degree that 
 the amount of carbonic acid is 3 per 1,000, the 
 air is distinctly unfit for breathing. The sub- 
 
86 TUBERCULOSIS 
 
 stances that cause the deterioration are unknown; 
 but in such circumstances the carbonic acid serves 
 as a measure of their amount. Air containing 
 from 30 to 40 per cent of carbonic acid proves 
 immediately fatal when a person enters it from 
 the fresh air. The symptoms of poisoning from 
 smaller quantities are generally paralysis and loss 
 of consciousness. Carbonic acid gas exists in the 
 blood chiefly in chemical combination with the 
 salts of soda and with the haemoglobin. The 
 portion united with the haemoglobin is displaced 
 by oxygen at each inspiration. 
 
 Pure air strengthens and invigorates the body 
 and increases the resisting power to disease; but 
 it is most remarkable how the human system will, 
 to a very large extent, become insensible to the 
 fact that it is gradually being starved for w^ant 
 of a sufficient amount of pure air and thus poi- 
 soned by the various noxious by-products of res- 
 piration. Some one has described breathed air 
 which is saturated with respiratory impurities 
 as containing air sewage. As has been said, it 
 does not seem to be so much the excess of car- 
 bonic acid as the additional by-products of ex- 
 pired air — vapors charged with toxic substances— 
 which undermine the health. It would seem that 
 when the human system reabsorbs the poisons 
 exhaled from a pulmonary surface, by breathing 
 
EFFECT OF PURE AIR 87 
 
 the air already breathed, a particularly suitable 
 field of growth of the bacilli of tuberculosis is 
 created. 
 
 In my labors among the poor of the tenement 
 house districts in large cities I have often been 
 amazed to see that people could live in an atmos- 
 phere which was so evidently vitiated and poison- 
 ous. The result of living under such conditions, 
 be they produced in the home of the poor or the 
 well-to-do, in factory or workshop, by ignorance 
 or greed, is a diminished desire for deep, natural 
 breathing; the respiratory centers become dulled 
 by the excess of carbonic acid and the poisonous 
 by-products of respiration in the atmosphere. The 
 respiratory capacity of the lungs becomes more and 
 more diminished and the individual receives only 
 just enough oxygen to sustain life. A truly physi- 
 ological haematosis, that is to say, a full physiolog- 
 ical exchange of arterial (oxygenated) for venous 
 blood in the lungs takes place but rarely. The 
 thoracic or respiratory muscles in the chest, being 
 little used, become atrophied (thinned and weak- 
 ened), the individual assumes a stooping attitude 
 and before he realizes it himself he has acquired 
 the typical hahitiis phthisicns, that is to say, a 
 narrow chest, stooping shoulders, and a pale and 
 emaciated appearance. If such an individual 
 should be exposed to the inhalation of the tubercle 
 
88 TUBERCULOSIS 
 
 bacilli in the form of tuberculous dust, should in- 
 gest tuberculous substance in the form of meat or 
 milk from tuberculous cattle, should be accident- 
 ally inoculated with tuberculous matter through a 
 scratch or ^YOund, or be in close contact with a 
 careless tuberculous patient, he is most liable to be- 
 come infected. 
 
 The lower strata of the air in many city streets 
 are very little stirred up by the winds passing over 
 them, and this is all the more the case when the 
 city is built in a valley. 
 
 In a country like the United States where the 
 founding of new cities is nothing unusual, the 
 builders of the future should bear in mind that 
 a city situated on high ground with wide streets 
 will be a healthy city and relatively free from 
 tuberculosis. In existing cities the widening of 
 streets and the lowering of too high buildings will 
 help the freer circulation of air, and the admit- 
 tance of sunlight will very materially improve the 
 sanitary condition. 
 
 The city of Chicago is one of the healthiest 
 cities in the United States, and while I gladly pay 
 homage to the men at the head of its excellent 
 sanitary supervision, there is no doubt in my mind 
 that the wind to which the city is so much exposed 
 is in no small degree responsible for its healthy 
 condition, 
 
EFFECT OF PURE AIR 89 
 
 Another important matter, which has a vital 
 relation to tuberculosis and, in fact, to all diseases 
 of the respiratory organs, should be taken into 
 consideration by the builders of new cities. When 
 it is possible, a city should be located near a 
 wooded region, and the wanton destruction of the 
 trees should never be allowed. Climate and at- 
 mosphere will always be more favorable, and 
 diseases like tuberculosis, bronchitis, and pneu- 
 monia will be relatively rarer in wooded districts. 
 
 To give plenty of sunlight and air to the indoor 
 workers of the city, houses should not be built 
 higher than the wndth of the street. The greatest 
 angle of direct light from the sky for the first 
 floor should be 45°. The streets in all our cities 
 should be laid out wide enough to permit the 
 planting of trees on both sides, and the necessity 
 for plenty of small parks and playgrounds should 
 be borne in mind if the city is expected to have a 
 low mortality from tuberculosis. 
 
 Of factory and workshop hygiene we will speak 
 later on. Here we desire to show the importance 
 of fresh and good air indoors because of its value 
 as a preventive in tuberculosis. 
 
 All civilized men spend one-third of their lives 
 indoors for sleep, and of all workers in the various 
 fields of human activity by far the greater number 
 have indoor occupations. According to the United 
 
go TUBERCULOSIS 
 
 States census of 1900, there were 29,073,233 per- 
 sons over ten years of age engaged in earning 
 their livehhood in some one of 303 specified occu- 
 pations, out of which only 46 could be strictly 
 called outdoor occupations. The total number 
 engaged in these latter were 12,058,671. The 
 number engaged in the 257 indoor occupations 
 would thus be 17,014,562. If we add to this the 
 time all classes of people spend indoors for eating, 
 for resting, for amusement, instruction or worship, 
 well may we say that the greater part of the people 
 of the United States virtually spend their lives 
 indoors. 
 
 In order that the houses where people live 
 should assure the individual the greatest possible 
 amount of security against disease, particularly 
 against tuberculosis, all human habitations, as 
 far as practicable, should be built on good porous 
 soil, preferably coarse sand or gravel; the next 
 best is rock, and only third in order comes clay. 
 
 Private houses, whether occupied by one or 
 two families, whether in the city or country, 
 should be built so that there will be no dark 
 rooms. All the living rooms should have southern 
 exposure, even at the risk of having the kitchen 
 and the rarely frequented parlor facing north. 
 
 In the absence of public playgrounds in large 
 towns or cities^ house-owners, either by single 
 
CONSTRUCTION OF PRIVATE HOUSES 91 
 
 endeavor or by combining with their immediate 
 neighbors, might provide a private playground 
 for the children. If this is not feasible, the roof 
 of the house, with the aid of strong wire netting, 
 should be transformed into a safe roof-garden and 
 serve as a play place for the children. The ac- 
 companying picture (Fig. 27) shows how the roof 
 of an ordinary city house can be made into an 
 attractive playground for children.^ In building 
 individual private homes the sanitation often 
 suffers from the desire for too many rooms; there 
 must be a certain number, no matter how small, 
 and usually they become badly lighted and ven- 
 tilated on that account. 
 
 I consider our American windows, of which 
 only one-half can be opened, inferior to the French 
 casement window^s which allow twice the amount of 
 bad air to escape and good air to come in. 
 
 In the construction of even the better class 
 hotels and apartment houses in which so many 
 American families now make their homes, the 
 same criticism of small rooms and the absence of 
 a playground for children may be made. In 
 building hotels and apartment houses, I consider 
 it well-nigh criminal to raise them to such a height 
 that the houses opposite or on the side are deprived 
 
 1 There would be fewer children killed or injured by street vehicles 
 if playgrounds were provided for them on the roofs. 
 
92 
 
 TUBERCULOSIS 
 
 Fig. 27. Children at Play on the Roof of a Private House in New 
 
 York City. 
 
 of sunshine and light the greater part of the day. 
 It would seem that a law limiting the height of 
 buildings, particularly in the residential section 
 of our American cities, is an urgent necessity. 
 
 The problem of housing our lal^oring popula- 
 tion in large cities where, owing to lack of transit 
 
GARDEN CITIES 93 
 
 facilities, the masses must remain near their places 
 of work, has baffled the minds of our philan- 
 thropists, city authorities, and sanitarians. The 
 congestion in some cities is something fearful to 
 contemplate. This is particularly true of the city 
 of New York, in some sections of which there are 
 more people to the square mile than in either Lon- 
 don, Paris, or Berlin. Our only salvation from this 
 fearful situation, not only for New York but for 
 many other American cities, lies on one hand in 
 good and extensive rapid transit facilities, con- 
 comitant with the building of sanitary homes for 
 the laboring masses where they can have comfort 
 and home life at reasonable rentals; and on the 
 other, in the building of model tenements in the 
 cities. 
 
 There is a third way of solving this problem 
 which is known as the Garden City movement. 
 It originated in England, and has already found 
 its imitators in the United States in what is known 
 as the Garden Cities Association of America. 
 Briefly stated, the aim of this splendid humani- 
 tarian movement is the founding and development 
 in the country of industrial garden cities, in which, 
 amid beautiful and healthful surroundings, fac- 
 tories, stores, or other forms of business may be 
 established; and where the workers may have at- 
 tractive, though inexpensive homes, well ventilated 
 
94 TUBERCULOSIS 
 
 and lighted, each with its own garden, and all to 
 combine as many as possible of the attractions 
 both of city and of country. 
 
 The Garden City Association of Great Britain 
 is now building its first garden city at Letch- 
 worth, Hertfordshire, England. 
 
 It will be some time, however, before such 
 movements can benefit the majority of workers, 
 and we must consider the tenement houses as they 
 will have to be erected in many cities. Ideal 
 tenement houses were planned for the New York 
 Tenement House Exhibition, and I give a repro- 
 duction of the one by Mr. R. Thomas Short, to 
 which the prize was awarded in a competition of 
 175 architects. (Fig. 28.) I consider the model 
 tenement house such an important feature in 
 the prevention of tuberculosis that I feel it my 
 duty to speak of this excellent plan somewhat 
 in detail. It is designed for a tenement house 
 on a lot 100 feet wide by 100 feet deep. A space 
 10 feet in width and 100 feet in length is left 
 at the rear of the building for light and air, as 
 required by the New York Building Laws. The 
 main feature of the plan is the large street court, 
 which in its narrowest part is 12 feet wide and 
 one-half of which is 24 feet wide. This court 
 is 60 feet in total depth, and provides an abund- 
 ance of light and air for all the rooms. Being 
 
MODEL TENEMENT HOUSES 
 
 95 
 
 USHT AND AUt irACt 
 
 3«V,)t 
 
 CLEAR RENTAIU AUA 
 
 ABOUT fO % 
 U APABTMEXTt 
 ■10 FRONT APAfmiEim 
 
 44 R00M5 3t cLoaers 
 private hall' to lach 
 apartuent 
 
 m'section of TWI* 
 plan conforiit to all 
 
 THE REQUIREUEKTI tf 
 CLASH 
 
 Fig. 28. R. Thomas Short's Prize Plan for a Model Tenement 
 
 House. 
 
 open to the street, it permits free circulation of 
 air at all times, and has the additional advantage 
 of giving a number of rooms an outlook upon the 
 street, thus creating a greater number of "front 
 apartments," and materially increasing the rental 
 values of the building. The plan provides ac- 
 commodations for fourteen families on a floor, 
 having a total of forty- four rooms, and an abund- 
 ance of closets. The lack of closet space has been 
 one of the serious inconveniences of tenement 
 house life. Besides this, the plan possesses the 
 
96 TUBERCULOSIS 
 
 further advantage of having a private hall for 
 every set of rooms, thus insuring privacy to the 
 tenants. Every family has its own water-closet 
 entirely within its control. There is no part of 
 the building more than two rooms deep. This is 
 the secret of the whole tenement-house problem, 
 because it means that there are no dark interior 
 rooms. Besides these many advantages, there 
 are four light staircases and staircase halls pro- 
 vided for the tenants, thus securing greater safety 
 in case of fire, and removing to a large extent much 
 of the social friction that exists in the ordinary 
 tenement house. A large open court also provides 
 a natural playground for the children, and does 
 away with the necessity of subjecting them to the 
 influence of the street. 
 
 This plan is most excellent, but it does not 
 quite realize my idea of what a model tenement 
 house in our large cities should be, which is de- 
 signed to help solve the tuberculosis problem. 
 From what has been said in the preceding chap- 
 ter, it must ])e clear to the reader that fresh air 
 flay and night is the best preventative and also 
 one of the most important curative factors in 
 tuberculosis. As we have seen, sleeping outdoors, 
 weather permitting, is particularly useful in the 
 treatment of tuberculosis, and it is of equal value 
 in the prevention of the disease. I am sure that 
 
o 
 B 
 
 o 
 
 O 
 
 c 
 .2 
 
 > 
 
 
98 TUBERCULOSIS 
 
 if the tenement house population of any large city 
 would be convinced of this and, at the same time, 
 facilities provided for them to sleep in the open 
 air, tuberculosis would soon be eradicated among 
 the masses. 
 
 A problem which I have longed to solve for 
 years has been how to build tenement houses 
 where, if all the inmates could not have balconies 
 to sleep on, at least those might who would be 
 greatly benefited thereby, whether because they 
 were predisposed or actually tuberculous, or were 
 convalescent from some other disease. On this 
 subject I have consulted many times with my 
 friend and fellow student. Professor John Van Pelt 
 of the School of Architecture of Columbia Uni- 
 versity. It is thanks to his cooperation that I am 
 able to present drawings and descriptions of such 
 an open air tenement house in this little volume. 
 
 As the name indicates, this building (Fig. 29) 
 is primarily designed to give plenty o£ light and 
 air to each room and apartment, thereby assur- 
 ing ventilation which can not be secured in the 
 ordinary tenement. Furthermore, balconies are 
 provided on which a number of the inmates may 
 sleep in the open air. 
 
 The plan (Fig. 30) is so arranged that there 
 will be large courts opening out upon the street 
 insuring light at all hours of the day. These 
 
O 
 
 
loo TUBERCULOSIS 
 
 courts are 37' wide and 60' long. It is especially 
 important that these courts open to the south, 
 that the sun may penetrate to the rear of the 
 court and dry both sides. It is also important 
 that the interrelation between the height of the 
 building, the depth of the court and its width be 
 so proportioned that the lower floor and rear of 
 the court shall receive several hours sunlight dur- 
 ing the day. 
 
 In order to stimulate the movement of the air 
 currents, it is important that the enclosure on the 
 street side be as open and as low as possible. The 
 present design shows a simple iron fence. 
 
 Moreover, the ground has been inclined up 
 from the street so that moisture will tend to drain 
 to the front of the court and not remain in a damp 
 pocket at the back, and so that the colder, more 
 impure, and heavier air of the court, tending to 
 fall, will move toward the street and be replaced 
 by fresher air coming from above. A grade of 
 -^ inch to the foot or 5 per cent would not be too 
 high for other practical purposes and would be 
 useful from this point of view. 
 
 The building is divided into nineteen apart- 
 ments on each floor. These apartments consist of 
 two, three, four, and five rooms. The five-room 
 apartments are the only ones that have a parlor. 
 The others have living room and bedrooms. 
 
MODEL TENEMENT HOUSES lot 
 
 All the apartments have some rooms on the 
 sunny side. Each apartment has either a balcony 
 or a recessed loggia; those upon the street being 
 protected from view by an open-work screen with 
 a space between the bottom of the screen and the 
 floor, leaving the top open. This gives perfect 
 circulation of air, yet would make them service- 
 able for sleeping. 
 
 The balconies are not run across the whole face 
 of the wall so as not to cause any useless shade, 
 and to allow as much light as possible to enter the 
 windows of the rooms which are without balco- 
 nies. The balconies are provided with open-work 
 screens on either side, these being so installed 
 that they can be folded back against the house 
 like shutters during the daytime and in fine 
 weather. When opened, they give privacy and 
 some protection from severe winds. These screens 
 might be advantageously fitted with louvres which 
 could be closed. 
 
 French casement windows are used throughout 
 the building, the whole window space opening to 
 permit the maximum of fresh air and sunlight to 
 enter. 
 
 The stairways and stairway hall are also very 
 open. They are reached directly from the large 
 courts and eliminate the dark, dreary stairways of 
 the ordinary tenement. 
 
I02 TUBERCULOSIS 
 
 Since an elevator would considerably increase 
 the cost and maintenance of the building, a com- 
 fortable settee is installed at the end of each stair- 
 case to give the pulmonary invalid a chance to 
 rest before mounting another flight. 
 
 Toilets are so placed that they will have ample 
 ventilation and their quota of sunlight. They are 
 kept free of the balconies. 
 
 It is probable that such a building would be of 
 the semifireproof type. A fireproof construction 
 is, however, far more advisable in that it affords 
 less facility for the passage of vermin from one 
 point to another. On account of the nature of the 
 problem, it is evident that the expense in con- 
 struction must be greater proportionately than 
 that of the ordinary tenement, but such an in- 
 crease can be kept within bounds and yet permit 
 a high degree of efficiency in the sanitary condi- 
 tions which will be afforded. 
 
 The courts, on account of their size and open- 
 ness, afford space for the children to play in, 
 keeping them off the street. Besides this, a roof 
 garden is provided which can be made use of 
 during the day and night. Separate water-closets 
 for men and women are provided on the roof. 
 The design shows plants which might be main- 
 tained in boxes on the roofs, the verdure serving 
 to make the outlook more attractive. 
 
MODEL TENEMENT HOUSES 103 
 
 It will probably be a long time before all the 
 tenement houses in our large cities will have 
 balconies for outdoor sleeping and such well 
 ventilated bedrooms as to assure the greatest pos- 
 sible amount of pure air to those sleeping indoors ; 
 but can not something be done in the meantime 
 to utilize the hundreds of acres of space repre- 
 sented by the fiat roofs of a large city, such, for 
 example, as New York? The hospitals in our 
 large cities, whose ground space is necessarily 
 limited, have already realized the inestimable 
 value of the roofs for the open air cure of diseases 
 of all kinds, not only tuberculosis. The accom- 
 panying picture (Fig. 31) shows a group of happy 
 children, several of them operated on for surgical 
 tuberculosis, on the roof of the New York Post- 
 Graduate Medical School and Hospital. The 
 Presbyterian Hospital treats its pneumonic chil- 
 dren on the roof even in midwinter. 
 
 On page 92, Fig. 27, we showed a picture of 
 the roof of a private house transformed into a 
 playground. What a boon it would be to many 
 a tenement dweller, and even to those dwell- 
 ing in private homes and apartments, if dur- 
 ing the sweltering heat of our summer nights 
 comfortable sleeping quarters could be provided 
 for them on the roofs! I am indebted to INIr. 
 Frederick D. Greene for the accompanying inter- 
 
ROOF CAMPING AND PLAY GROUNDS 
 
 105 
 
 Fig. 32. Roof Camping in Midsummer in New York. 
 
 esting picture illustrating what he calls ''roof- 
 camping" in New York City (Fig. 32); and what 
 he says in his interesting article, "The Roofs of 
 New York," which appeared in ''Charities and 
 the Commons," (now "The Survey") of August 
 15, 1908, may guide us in the better utilization of 
 our housetops : 
 
 "The fact that New York roofs would not accommo- 
 date all who have been allowed by social negligence to 
 herd under them to a degree that no intelligent breeder 
 of hens or cattle would permit, is no reason why we 
 should not at once turn to the roofs for the relief from 
 night discomfort and congestion that they can afford to 
 large numbers, 
 
io6 TUBERCULOSIS 
 
 "Of course, there are difficulties to be surmounted 
 under present conditions by those who would sleep on 
 the roof. In many houses and even tenements the only 
 access is up a ladder and through a scuttle two feet 
 square. A parapet to prevent people from walking or 
 rolling off is generally lacking. Points of attachment 
 for supporting an awning or tent in case of rain are 
 hard to find. The question of privacy and of safety 
 from thieves must be considered. But all these diffi- 
 culties can and must be overcome in order that this great 
 boon — God's fresh air that blows over the city as well 
 as over the country — may be enjoyed to the full. 
 
 "A readily accessible roof that can stand wear, and 
 which is protected by a wall or iron fence, should be 
 required by law as a sine qua non of every tenement 
 and apartment house. This would put a safe, clean 
 breathing spot within the reach of every mother, ''little 
 mother," and babe, without the crossing of a street. 
 
 "The roofs of the cities are undiscovered countries. 
 In spite of incredulous smiles and friendly warnings 
 the writer has been forming a delightful acquaintance 
 with this country for some weeks." 
 
 Many of the roofs of the now existing tenement 
 and apartment houses could be transformed, v^ith 
 relatively little expense, into secure playgrounds for 
 children and decent and respectable sleeping ac- 
 commodations for a goodly number, at least in the 
 summer. 
 
 In cities and towns where land is relatively 
 
OPEN AIR PRIVATE DWELLING 107 
 
 cheap and many individuals own and build their 
 own houses, the construction can easily be such 
 that not only are there no dark and sunless bed- 
 rooms, but that any one of the members of a 
 family can, if he wishes to accustom himself to it, 
 enjoy the luxury of outdoor sleeping. 
 
 To plan for the construction of the open air 
 private dwelling as well as for the open air tene- 
 ment house already described, I consulted with 
 Professor Van Pelt, who has devised a feasible 
 way to construct such an ideal dwelling. The 
 following is the plan and technical description of 
 it which Mr. Van Pelt has been good enough to 
 work out at my suggestion : 
 
 The residence shown in the accompanying pic- 
 ture and plans (Figs. 33, 34, 35) is designed so that 
 it may have the best possible ventilation and sun- 
 light in all its parts, to induce and realize, to the 
 greatest extent, the out-of-door life. 
 
 The entrance vestibule, necessary for the middle 
 of the winter, is so planned that it can be removed 
 in summer, giving direct exit from the interior. 
 
 French windows are used wherever possible, per- 
 mitting them to open to the full size of the window 
 space. 
 
 Large fireplaces are introduced to give cheer 
 and increase the ventilation. 
 
 This particular design shows the kitchen and 
 
c 
 .2 
 
 > 
 
 Q 
 
 'in 
 i-i 
 
 O 
 
 
 O 
 
 
 
 
OPEN AIR PRIVATE DWELLING 
 
 109 
 
 'HkM ri u n v PI /\n 
 
 Fig. 34. First Floor Plan of Open Air Private Dwelling. 
 
 servants' wing entirely separated from the main 
 portion of the house, which precludes the dis- 
 agreeable permeation of the odors of cookery 
 through the atmosphere of the main portion of 
 the dwelling. The connecting porch between the 
 kitchen and butler's pantry is roofed, and, in win- 
 ter, this can be enclosed at either end so as to pro- 
 tect the servants ; but the enclosures of this porch 
 can be taken away when warm weather not only 
 renders such protections unnecessary, but increases 
 the invading quality of kitchen smells. 
 
no 
 
 TUBERCULOSIS 
 
 ■^rMiNii minu PI AfT 
 
 Fig. 35. Second Floor Plan of Open Air Private Dwelling. 
 
 The refrigerator is so planned that not only can 
 ice be put into an upper compartment or tray 
 from the outside, but a limited space can be opened 
 up from the hall to keep a few bottles and cigars. 
 
 An open breakfast porch forms an extension to 
 the dining room and is large enough to be used 
 for other meals. 
 
 The especial feature of the house is the arrange- 
 ment of the second floor, where the four bedrooms 
 are situated in the four corners of the house, each 
 one having windows on two 3ides to give cross- 
 
OPEN AIR PRIVATE DWELLING in 
 
 ventilation, and each having an exposure which 
 v^ill permit sunHght to enter during a large portion 
 of the day. Moreover, these bedrooms are con- 
 nected either directly or through the bathroom, 
 with out-of-door sleeping verandas, where the in- 
 mates may sleep winter and summer. Movable 
 louvres and screens enclose these verandas so that 
 they can be protected from mosquitoes, flies, and 
 excess of light in the early morning, if that is de- 
 sirable. 
 
 The second story sitting room would have 
 louvres in the partition between it and the upper 
 hall, so as to give cross-ventilation from one side 
 of the house to the other. A passage from the 
 main stairs to the servants' wing gives access for 
 the maids. 
 
 The general material for the construction of 
 this particular house is frame, and a Colonial 
 style has been adopted; but the peculiar features 
 of cross-ventilation, wide balconies, porches, and 
 out-of-door sleeping verandas, can be accom- 
 phshed in any style or building material. 
 
 The problem of providing cheap but good in- 
 dividual homes for our laboring classes where 
 land is reasonable, but in a region easily accessible 
 to their centers of work, is a very important mat- 
 ter. To see how reasonably such a home could 
 be built, I consulted again with Mr. John Van 
 
112 
 
 TUBERCULOSIS 
 
 Fig. 36. Economical Sanitary House for One Family. 
 
 Pelt. I give the following illustrations, descrip- 
 tion, and plans (Figs. 36, 37, 38) which he worked 
 out for this purpose: 
 
 The building has been planned in the most 
 economical manner possible. A single chimney 
 placed in the middle of the house affords a fire- 
 place and contains flues from the heater and 
 kitchen range. 
 
 All rooms, except the smallest bedroom, have 
 two windows in different walls, insuring cross 
 ventilation and at least one sunny exposure. 
 The fireplace in the living room acts as an as- 
 pirator for foul air and has a 12'' by ^2" flue. 
 
JECONOMiCAL SANITARY HOUSE 
 
 113 
 
 Klhir^T Kl|.4^hL HAN 
 
 Fig. 37. First Floor Plan of Economical Sanitary House for One 
 
 Family. 
 
 Hot air heating is adopted with the cold air in- 
 take, bringing air directly from the exterior, each 
 room being provided with a riser, conducting this 
 warmed air to the different parts of the house. 
 The cellar stairs go down under the main stairs, 
 and a door leading from these stairs to the ex- 
 
114 
 
 TUBERCULOSIS 
 
 2E7PLSH: 
 
 '(/w////mj^M/ ^ ^ ^J^^ W 2^^////////, i w/ wwwvmm 
 
 =Q — m 
 
 Fig. 38. Second Floor Plan of Economical Sanitary House for One 
 
 Family. 
 
 terior makes it possible to carry the ashes, which 
 descend to the ash pit in the cellar through a dust 
 chute from the fireplace and those which also accu- 
 mulate from the hot air furnace, directly out of 
 doors without spreading dust through the house. 
 The plumbing is centralized, a single soil pipe 
 
ECONOMICAL SANITARY HOUSE 115 
 
 being sufficient, and the hot water boiler is placed 
 in a compartment behind the chimney so as to 
 alleviate the conditions that lead to an overheated 
 kitchen. The laundry tubs have been placed in the 
 kitchen, as the wives of workmen must do all 
 their work and should be as near their family as 
 possible. Space has been provided on the back 
 porch for the refrigerator, a lattice surrounding 
 the same to give shade. 
 
 All of the bedrooms have closets, and a broom 
 and linen closet is also provided on the upper 
 floor. 
 
 In the interior treatment of the house, dust- 
 gathering projections are avoided as much as 
 possible. Reentrant corners are rounded, and a 
 cove and sanitary base are used. The framework 
 is stud partition with rubble or cement block 
 foundation wall, according to locality. A half- 
 timber effect is obtained with stucco in between, 
 the house being sheathed and covered with build- 
 ing paper before the latter is put on. The roof 
 is shingled. The floor and wainscot of the large 
 sleeping balcony of the second story are made of 
 one of the magnesite compositions which have 
 lately been used most economically and success- 
 fully in similar cases. 
 
 The house is piped with gas, but not wired 
 for electricity on account of the expense. If the 
 
ii6 TUBERCULOSIS 
 
 cost permits, such houses should be painted on 
 the interior, the last coat being laid on flat; but 
 if this is impossible, ^Yater color can be substi- 
 tuted. 
 
 Under favorable circumstances, such a house 
 should be built for $2,800. In smaller propor- 
 tions it can be built for $1,650. What is most 
 valuable and interesting in this individual work- 
 ingman's house, which can be constructed at so 
 low a figure, is that there is enough veranda space 
 for the majority of the members of a family to 
 sleep outdoors if they desire to do so. As in the 
 open air tenement house, the balconies are pro- 
 vided with openwork screens on either side, these 
 being so installed that they can be folded back 
 during the daytime and in fine weather. They 
 also serve to give privacy and protection from 
 severe winds. 
 
 The next subject which we have to consider is 
 the problem of lodging houses. Those who have 
 ever visited a cheap private lodging house will 
 understand why I favor municipal lodging houses, 
 which are of necessity under better control. My 
 visits to lodging houses in the various parts of 
 the country have shown me that, owing to the large 
 number of individuals who usually occupy these 
 hostelries, the ventilation is always insufficient, 
 particularly at night. If there is any class of 
 
LODGING HOUSES ii; 
 
 buildings where our American windows should be 
 replaced by the French type, it is in our private 
 and public lodging houses. 
 
 There is so much tuberculosis to be found in 
 lodging houses that the transmission of the dis- 
 ease from the consumptive lodger to the healthy 
 inmate is altogether too frequent. In view of the 
 fact that droplet infection is possible at a shorter 
 distance than three feet, I consider any lodging 
 house law not quite up to date which does not 
 require a passageway of at least three feet be- 
 tween the beds, and that the beds should be so 
 arranged that the air can circulate freely under 
 each of them. At least 500 cubic feet of air should 
 be provided for each bed and lodger, and no more 
 beds should be permitted than those provided in 
 this way, unless unusually free and adequate means 
 of ventilation exist and are approved of by the 
 local Board of Health. 
 
 The internal arrangements and sanitation of 
 our homes has as much to do with tuberculosis 
 as the choosing of sites for future cities and the 
 erection of buildings, and some of the defects 
 referred to in the preceding paragraph on lodg- 
 ing houses are also found in many homes of rich 
 and poor alike, and even in fashionable hotels. 
 
 We select for our bedrooms, as a rule, not the 
 best but the worst lighted rooms. The majority 
 
ii8 Tuberculosis 
 
 of our city apartment and tenement houses are 
 built in such a manner that only the two end 
 rooms of the flat receive direct air and light. 
 Thousands and thousands of persons in our 
 large cities are thus compelled to spend their 
 nights in rooms where sunlight has never entered. 
 The strange custom of reserving the very best 
 room, that is to say the room which might be the 
 best lighted and best ventilated, to receive an 
 occasional guest is not confined to country folks 
 and poor city apartment or tenement dwellers. 
 I have seen this done by well-to-do people who 
 could have done better and should have known 
 better. I recall one instance from my own prac- 
 tice where two anaemic children of six and eight 
 years of age were forced to sleep in a dark bed- 
 room and play in the dark dining room or ill 
 ventilated kitchen, while the large front room, the 
 so-called parlor, with two large windows where the 
 sun would stream in a good part of the day if 
 admitted, was locked all the time except on Sun- 
 days when visitors were expected. The little 
 ones were not allowed to go in there for fear 
 that they might do harm to the good furniture. 
 It was with the greatest of difficulty that these 
 otherwise good parents were persuaded to trans- 
 form the large parlor into a bedroom and playroom 
 for the children. 
 
NIGHT AIR 119 
 
 The reader will recall, from what has been said 
 before, that the blood is one of our most powerful 
 defenses against the invasion of bacilli. In the 
 anaemic person the blood is so impoverished that 
 the corpuscles would no longer have the power 
 to annihilate the germs of tuberculosis if they 
 should happen to enter the system. 
 
 Some people are not only afraid of sunlight and 
 fresh air during the day, but they are particularly 
 afraid of night air. The fear of night air, this 
 nightmare of our ancestors, has not a little to do 
 with the development and propagation of indoor 
 diseases, and particularly tuberculosis. In this 
 respect the heads of institutions where there are 
 dormitories for the inmates are often the greatest 
 violators of this first principle of hygiene. To have 
 two or three and sometimes four children sleep in 
 one bed, whether in a private home or an institu- 
 tion, should be considered absolutely unhygienic. 
 People should learn that it is the best economy in 
 the end to use the best lighted and best ventilated 
 rooms for bedrooms and sitting rooms, and when- 
 ever it is possible there should be a single bed for 
 each member of the family. 
 
 That the method of heating also has a great 
 deal to do with diseases, particularly those of the 
 respiratory organs, is well known. From what 
 I have learned by personal experience and from 
 
I20 TUBERCULOSIS 
 
 conversations with persons who are authorities on 
 the subject, it would seem that the best method 
 of heating buildings in general is one that brings 
 warm fresh air into the rooms. The objection 
 to a furnace is that it overheats a small quantity 
 of air which it forces into the rooms after it may 
 have been burned. A better system, therefore, is 
 one of direct heating, whereby a large quantity 
 of moderately warmed air is brought into the 
 room say over steam, or better yet, hot water coils. 
 A hot air furnace installation is the cheapest, and 
 is therefore the best that can be used for the poor. 
 Ordinarily, the poor heat with stoves which com- 
 bine the objectionable features of systems that 
 heat the air contained in the rooms without chang- 
 ing it, with the objections to systems that burn 
 the air; moreover, presenting great danger of al- 
 lowing gas to escape. Especially is carbon monox- 
 ide given off through the pores of the iron when 
 these stoves become red-hot. The usual systems 
 adopted in homes on account of the balancing be- 
 tween expense, convenience, and hygienic reasons 
 are steam heat, or better but more expensive, hot 
 water, with radiators placed directly in the rooms. 
 There are so many cracks in tjie ordinary house 
 that considerable ventilation is assured. More- 
 over, most houses have fireplaces which promote 
 some ventilation even if there is no fire burning. 
 
METHOD OF HEATING 121 
 
 Many of our American houses, however, are too 
 tightly built, are kept at too high temperature and 
 the air is not changed often enough. Besides all 
 this, the air we breathe in many of our overheated 
 houses is altogether too dry to be sanitary. Ex- 
 perience has proven that we can be perfectly com- 
 fortable in a temperature of 65° F. and even a 
 little lower, provided that the relative percentage 
 of moisture is 60. If this moisture falls to 30 or 
 20 per cent, then the dry throat, dry nose, and dry 
 skin are in evidence. The explanation is simple. 
 The dry air absorbs the moisture from the body 
 and causes discomfort. The drying of mucous 
 membranes in this way lays them open to the 
 invasion of the organisms causing colds, grippe, 
 pneumonia, and tuberculosis. Thus, the exces- 
 sively dry atmosphere of many city and country 
 homes in winter often gives rise to nasal catarrh, 
 a condition which everybody, but especially those 
 suffering from pulmonary diseases or prone to 
 them, should be anxious to avoid. 
 
 Besides keeping the water pan in the furnace con- 
 stantly filled, there should be in the sitting room 
 and sleeping rooms some evaporating arrange- 
 ment, such as the one known as a humidifier. 
 (Fig. 39.) More simple evaporating devices, how- 
 ever, such as a vessel filled with water and a cloth 
 suspended above it touching the water so as to 
 
122 
 
 TUBERCULOSIS 
 
 i I 
 
 lUMiniFIER'T^ 
 
 (>wi> i?i=.oisri;i;> 
 
 2\v.\Tl;P TANKJ 
 f 3 SHLlfTS OF 
 
 OITON f[-:lt. 
 
 i'lG. 39. Barnes' Humidifier. 
 
 produce capillary attraction, will render the at- 
 mosphere sufficiently moist. To determine the 
 proper humidity, the direct reading hair hy- 
 grometer (Fig. 40) answers all practical purposes. 
 After vitiated air, dust is the next most important 
 as a predisposing factor to tuberculosis. Even 
 the so-called sterile dust of the mineral or vegetable 
 kind, if constantly inhaled, will irritate and inflame 
 the respiratory tract and leave the mucous mem- 
 brane in a condition for the ready invasion of any 
 of the pathogenic microorganisms. It must be 
 remembered that even in the normal individual 
 we not infrequently find the pneumonia producing 
 pncumococcus and the Klebs-Leffier l^acillus which 
 is the specific organism of diphtheria. The indi- 
 vidual a little below par in general health or who 
 
AVOIDANCE OF DUST 123 
 
 has his upper respiratory tract irritated by the 
 
 constant inhalation of dust, may thus fall a prey 
 
 to the microorganisms of pneumonia or diphtheria 
 
 of which he was the host, or 
 
 to the bacillus of tuberculosis 
 
 or of grippe from external 
 
 sources. 
 
 The dust problem is so 
 great and so important that 
 we should give it our special 
 attention. The amount of 
 dust that orie^inates in our 
 
 Fig. 40. Direct Reading 
 houses from wear and tear. Hair-hygrometer to De- 
 
 etC, should be minimized by termine Humidity in 
 1 . r- , -I Rooms. 
 
 havmg as tew carpets and 
 hangings as may be, and by sweeping and clean- 
 ing in the proper way. The following rules for 
 sweeping and dusting compiled by Professor T. 
 Mitchell Prudden, a member of our New York 
 Tuberculosis Committee, deserve the widest dis- 
 tribution : 
 
 When you sweep a room raise as little dust as possi- 
 ble, because this dust when breathed irritates the nose 
 and throat, and may set up catarrh. Some of the dust 
 breathed in dusty air reaches the lungs, making parts 
 of them black and hard and useless. 
 
 If the dust in the air you breathe contains germs of 
 consumption (tubercle bacilli) which have come from 
 
124 TUBERCULOSIS 
 
 consumptives spitting on the floors, you run the risk 
 of getting consumption yourself. If consumptives use 
 proper spit-cups and are careful in coughing or sneezing 
 to hold the hand or handkerchief over the nose and 
 mouth so as not to scatter spittle about in the air, the 
 risk of getting the disease by living in the same room is 
 mostly removed. 
 
 To prevent making a great dust in sweeping, use 
 moist sawdust on bare floors. When the room is car- 
 peted, moisten a newspaper and tear it into small scraps 
 and scatter these over the carpet when you begin sweep- 
 ing. As you sweep, brush the papers along with the 
 broom and they will catch most of the dust and hold it 
 fast, just as the sawdust docs on the bare floors. Do 
 not have either the paper or the sawdust dripping wet, 
 only moist. 
 
 There is also an amount of dust, sometimes 
 dangerous, that is carried in on our shoes and 
 clothing, especially on the ladies' long skirts. It 
 is to be hoped that the requirements of health will 
 so dictate to fashion that trains will never be seen 
 on our streets. In the opposite event I am willing 
 to be put down as one who favors the enactment 
 and enforcement of a law prohibiting the trailing 
 of skirts in public highways. 
 
 When, on account of the presence of a tubercu- 
 lous invalid or susceptible children in the home, 
 one wishes to be particularly careful to exclude 
 
AVOIDANCE OF DUST 125 
 
 street dirt, one may have in front of the door lead- 
 ing to his apartment an apparatus composed of 
 two blocks over which is stretched a slightly 
 moistened canvas. After a thorough cleaning on 
 the mat or scraper outside, one passes his soles 
 over this moistened canvas for a final cleaning. 
 An ordinary doormat may serve to dry the moist 
 soles. When, out of consideration for the con- 
 sumptive member of the family, we wish to 
 diminish the dust which is brought in on our out- 
 side garments, we should make it a practice to 
 keep overcoats or dusters in a wardrobe near the 
 door and brush them as well as all other garments 
 in the open air. It is astonishing how much less 
 dirt is carried into the rooms if these two simple 
 means are conscientiously employed. 
 
 Against the dust which blows into the rooms 
 from building material, we are powerless. Per- 
 haps if Edison's plan of using reinforced concrete 
 for the complete construction of houses comes into 
 general use, we shall have less dust to cope with. 
 This material would seem to be well adapted for 
 homes for the masses, as houses such as the one 
 of which the great inventor recently showed me 
 the plan, can well be constructed for about $1,000. 
 The moulds are set up in place and the whole 
 house is made in one piece. 
 
CHAPTER VI 
 
 THE DUTIES OF MODERN MUNICIPAL HEALTH 
 
 AUTHORITIES 
 
 One of the many causes of impurity of the 
 atmosphere in cities is the imperfect combustion 
 of fuel. How to do away with the smoke nuisance 
 is an exceedingly difficult problem. In many cities 
 the use of soft coal cannot be forbidden by law 
 because hard coal is not available, or available 
 only at a very high price. It has been demon- 
 strated that with care the skilled stoker can di- 
 minish the amount of smoke produced even by 
 the lowest grade of coal. It would thus seem that 
 in cities and towns where hard coal can not be 
 universally used on account of its price, the mu- 
 nicipality should offer gratuitious instruction in 
 the proper methods of burning soft coal to all 
 those handling furnaces. Where this is done, city 
 ordinances should be enacted and enforced with 
 a view to minimizing the smoke nuisance. 
 
 The futility of merely placing an ordinance on 
 
 the law books of a city has been demonstrated 
 
 by the fact that Pittsburg, Cleveland, Cincinnati, 
 
 126 
 
PREVENTION OF SMOKE 127 
 
 and Chicago have not been able to make the 
 slightest headway against the tremendous pro- 
 duction of smoke. It is only now that Chicago 
 is beginning to gain any ground, and this is due 
 to the fact that Mr. Bird, the smoke inspector, 
 has adopted entirely new tactics. In the first 
 place. Mayor Busse has spent his whole life in 
 the coal business and knows more or less about 
 smoke prevention. He appointed Mr. Bird, who 
 is a practical man, and then arranged to give 
 him an advisory board of three expert engineers. 
 Among them is Mr. Bement who designed the 
 plant for the Commonwealth Edison Company. 
 Shortly after taking ofhce, Mr. Bird announced 
 that he did not propose at once to fine the owner 
 of a building the chimney of which was smoking. 
 He said that he would go into the fire room of the 
 offending building and would study conditions. 
 He and his advisory board would then map out a 
 plan for the prevention of smoke, taking into 
 consideration the grade of coal habitually burned. 
 He would submit this plan free of cost to the 
 owner of the building and would give a reasonable 
 length of time for the compliance of the owner 
 with these requirements of the city department. 
 If, at the expiration of this reasonable time, the 
 ■chimney was still smoking and no progress had 
 been made toward the installation of a new sys- 
 
128 TUBERCULOSIS 
 
 tern which would avoid smoke, the law would be 
 invoked and the maximum penalty would be 
 imposed. I am indebted for this information to 
 ''A Practical Campaign for Smoke Prevention," 
 by George H. Gushing, which appeared in the 
 "American Review of Reviews," July, 1908. 
 
 From a very interesting report on smoke in 
 relation to health, by Prof. A. Jacobi of New 
 York, the Nestor of American physicians, who has 
 taken a lifelong interest in the combat against 
 tuberculosis, we learn that the latter disease and 
 also bronchitis and pneumonia have decreased 
 since 1895 in London, Liverpool, and Manchester; 
 that is to say, since the time an active anti-smoke 
 crusade was started in those cities. One of the 
 most important features of this crusade is a law 
 limiting the time when black smoke may be ex- 
 pelled. Thus, in London and Manchester no 
 factory chimney may expel black smoke for more 
 than a minute every hour. In Professor Harvey 
 Littlejohn's report on causes and prevention of 
 smoke from manufacturing chimneys (city of 
 Sheffield, 1897) are enumerated twenty-two cities 
 which enforce a duration of not more than from 
 one to fifteen minutes in which black smoke may 
 be expelled each hour. 
 
 The official work of the health boards has been 
 aided by a number of coal smoke abatement 
 
PREVENTION OF SMOKE 129 
 
 societies in London and elsewhere, which employ 
 their own watchers and inspectors alongside those 
 employed by the government. It will not be very 
 long before manufacturers and engineers will 
 cease to object to the compulsory avoidance of 
 smoke on account of the acknowledged economic 
 advantage due to a saving of coal. 
 
 That coal will be replaced by gas, which burns 
 without smoke, appears more probable from year 
 to year. Even in America where we are some- 
 what slow in adopting sanitary measures, we have 
 begun to replace coal by gas for domestic purposes. 
 A cheap gas may be, and has been manufactured 
 in South Staffordshire and in London, w^hich, 
 while not fit for illumination, is perfectly so for 
 developing smokeless heat. 
 
 In a presidential address before a conference 
 on smoke abatement, in 1906, Sir Oliver Lodge 
 admonished his audience directly not to permit 
 the combustion of coal in cities, but to insist on 
 the regular preparation of cheap gas instead. I 
 am afraid in America we have been too slow even 
 to utilize natural gas as we should have done. 
 
 There is no doubt but with a combined effort of 
 municipalities, individual owners of factories and 
 workshops, and the educated and willing citizens, 
 much can be done to minimize the danger arising 
 from the incomplete combustion of coal and 
 
130 TUBERCULOSIS 
 
 from the inhalation of organic and inorganic 
 dust. 
 
 The smoke nuisance in a large city can be 
 considerably decreased by insisting that all in- 
 coming and outgoing trains, from a certain neces- 
 sary distance beyond the city limits, must be drawn 
 by electric engines or by what is called the fireless 
 locomotive. This locomotive, of which the motive 
 power is a steam tank filled at a power station, 
 is suited for use on railways where the question 
 of fire protection is almost a first consideration, 
 as, for example, where there are powder plants 
 or cotton mills, or on wharves, and other places 
 where the presence of an ordinary type of loco- 
 motive, or even electric power would be unsafe. 
 
 Some day our federal government will have to 
 step in and help the municipal and state govern- 
 ments to solve this great problem. Our bureaus 
 of forestry, geology, and commerce will have to 
 institute research work in order to minimize the 
 smoke nuisance, not only on account of the sani- 
 tary conditions but for purely economic reasons. 
 Millions and millions of dollars go to waste by 
 inefficient combustion. It is the duty of the 
 government to see that the fuel resources of the 
 country, upon which the future prosperity of the 
 nation depends, are utilized to their highest effi- 
 ciency. 
 
GASES AND DUST 131 
 
 Besides the smoke, a modern city government 
 also should strive to do away with the presence of 
 noxious gases and needless dust. In manufactur- 
 ing centers special ordinances may be necessary 
 to prevent the escape of poisonous gases into the 
 air, but in every city we have to cope with the 
 dust. 
 
 Streets should be sprinkled regularly in dry and 
 warm weather, and while flushing them with a 
 moderate force of water is excellent, too great a 
 force wears pot holes in the asphalt paving, thus 
 doing more harm than good. A sprinkling cart or 
 a hose of small caliber should be used. 
 
 If the street car companies could be induced to 
 cooperate with the city by sprinkling their tracks, 
 much comfort would surely be assured to their 
 patrons, and some of the dangers from dust re- 
 moved. Any one who has noticed the cloud of 
 dust that follows a swiftly moving car or the 
 amount that is carried in by the back draught 
 when the weather permits having the rear doors 
 open, would appreciate the abatement of this un- 
 hygienic and unpleasant condition. 
 
 As stated before, the inhalation of a great deal 
 of dust has a tendency to irritate the mucous 
 membrane of the respiratory tract, thus making 
 it more vulnerable to germs and particularly to 
 those of tuberculosis. 
 
132 
 
 TUBERCULOSIS 
 
 Fig. 41. Knopf's elevated 
 self-cleaning street and 
 garden spittoon. 
 
 ^' 
 
 Fig. 42. Knopf -Thiebert 
 self-flushing elevated 
 cuspidor with cover for 
 railway stations, etc. 
 
 The cleaning of streets should be done, as far 
 as possible, during the night and the collecting of 
 ashes, garbage, etc., at least in the hours of the 
 forenoon when the traffic is at its minimum. 
 Collecting ashes should be done in such a manner 
 that on windy days it has no chance to be blown 
 about during the process of being dumped into 
 the collecting wagons. 
 
 Public buildings which are much frequented 
 should bt swept with moist sawdust once or twice 
 
CUSPIDORS IN PUBLIC BUILDINGS 133 
 
 a day according to the need. While the tubercu- 
 lous sputum which has mingled with the dust in 
 the street may be considered less harmful because 
 it has been exposed to light and air, indiscriminate 
 expectoration within buildings, halls, street cars, 
 etc., is absolutely dangerous; and the enactment 
 and enforcement of anti-spitting ordinances is of 
 vital moment, and is one of the most important 
 duties of a municipality. To forbid expectorating 
 in such and such a place will not, however, be 
 alone sufficient; it is also essential to provide 
 well-kept cuspidors in pubhc places. The ideal 
 cuspidor for the purpose is, of course, the self- 
 flushing one with cover, having a supply and 
 waste pipe. (Figs. 41, 42.) 
 
 Every progressive municipality must be awake 
 to the fact that to prevent tuberculosis, to have 
 the consumptive poor and those of moderate 
 means cared for at the right time, at the right 
 place, and by the right men, means the sanitary 
 and moral improvement of the town or city, and 
 actual financial gain in the end. 
 
 Having been associated for many years with 
 the Health Department of the City of New York, 
 which, through its efficient work under the leader- 
 ship of Dr. Hermann M. Biggs, has accomplished 
 so much in the prevention of tuberculosis ; and hav- 
 ing convinced myself of the excellent results and 
 
134 TUBERCULOSIS 
 
 collaborated in the work, I am in a position to speak 
 somewhat in detail of what the municipal health 
 authorities of the City of New York have been 
 and are doing, which will serve as an illustration 
 of what can and should be done. 
 
 First of all, the New York Health Department 
 keeps up a constant educational campaign. For 
 this purpose it issues a circular which I reproduce 
 here with some slight modifications and additions. 
 
 Consumption Is a Preventable and Curable Disease. 
 
 Information for Consumptives and Those Living 
 
 WITH Them. 
 
 consumption, also called pulmonary tuberculo- 
 sis, IS chiefly caused by the filthy habit of 
 
 SPITTING. 
 
 Consumption is a disease of the lungs, which is taken 
 from others and is not simply caused by colds, although 
 a cold may make it easier to take the disease. It is 
 caused by very minute germs, which usually enter the 
 body with the air breathed. The matter which con- 
 sumptives cough or spit up contains these germs in 
 great numbers — frequently millions are discharged in a 
 single day. This matter, spit upon the floor, wall or 
 elsewhere, dries and is apt to become powdered and 
 float in the air as dust. Thus dust contains the germs, 
 
HEALTH DEPARTMENT CIRCULARS 135 
 
 and thus they enter the body with the air breathed. 
 Thus dust is especially likely to be dangerous within 
 doors. The breath of the consumptive does not con- 
 tain the germs, and will not produce the disease. A well 
 person catches the disease from a consumptive only by 
 in some way taking in the matter coughed up and spit 
 out by the consumptive, or coughed out with little drops 
 of saliva, even when the patient does not spit. 
 
 Consumption can often be cured if its nature be recog- 
 nized early and if proper means be taken for its treat- 
 ment. In a majority of cases it is not a fatal disease. 
 
 It is not dangerous to live with a consumptive if the 
 matter coughed up by him be promptly destroyed. 
 This matter should not be spit upon the floor, carpet, 
 stove, wall, or sidewalk, but always, in some sort of a cup 
 kept for that purpose. The cup should contain w^ater so 
 that the matter will not dry, or better, carbolic acid in a 
 five per cent watery solution (six teaspoonfuls in a pint 
 of water). This solution kills the germs. The cup 
 should be emptied into the water-closet at least twice a 
 day, and carefully washed with boiling water. 
 
 Great care should be taken by consumptives to pre- 
 vent their hands, face, and clothing from becoming 
 soiled with the matter coughed up. Anything thus 
 soiled, should be at once washed with soap and hot 
 water. Men with consumption should wear no beards 
 at all, or only closely cut mustaches. When consump- 
 tives are away from home, the matter coughed up should 
 be received in a pocket flask made for this purpose. If 
 cloth§ must be used^ they should be immediately burned 
 
136 TUBERCULOSIS 
 
 on returning home. If handkerchiefs be used (worthless 
 cloths, which can be at once burned, are far better), 
 they should be boiled at least half an hour in water by 
 themselves before being washed. When coughing or 
 sneezing, small particles of spittle or mucus containing 
 germs are expelled, so that consumptives should always 
 hold a handkerchief or cloth before the mouth during 
 these acts; otherwise the use of cloths and handkerchief 
 to receive the matter coughed up should be avoided as 
 much as possible, because it readily dries on these, and 
 becomes separated and scattered into the air. Hence, 
 when possible, the matter should be received into cups or 
 flasks. Paper cups are better than ordinary cups, as the 
 former with their contents may be burned after being 
 used. A pocket flask of glass, metal, or pasteboard, is 
 also a most convenient receptacle to spit in when away 
 from home. Cheap and convenient forms of flasks, 
 cups, and purses may be purchased at many drug stores. 
 Patients too weak to use a cup should use moist rags 
 which should at once be burned. If cloths are used 
 they should not be carried loose in the pocket, but in a 
 waterproof receptacle, which should often be boiled. 
 A consumptive should never swallow his expectoration. 
 A consumptive should always have his own bed, and 
 if possible, his own room. The room should always 
 have an abundance of fresh air: the window should be 
 ojK-n day and night. The patient's soiled wash, clothes 
 and bed linen, should be handled as little as possible 
 when dry, but should be placed in water until ready for 
 washing. 
 
HEALTH DEPARTMENT CIRCULARS 137 
 
 If the matter coughed up be rendered harmless, a 
 consumptive may frequently not only do his usual work 
 without giving the disease to others, but may also thus 
 improve his own condition and increase his chance of 
 getting well. 
 
 Whenever a person is thought to be suffering from 
 consumption the Department of Health should be noti- 
 fied. If the person has no physician, a medical in- 
 spector will call and examine him to see if he has con- 
 sumption, and then, if necessary, will give proper direc- 
 tions as to treatment. 
 
 Rooms which have been occupied by consumptives 
 should be thoroughly cleaned, scrubbed, whitewashed, 
 painted, or papered before they are again occupied. 
 Carpets, rugs, bedding, etc., from rooms which have 
 been occupied by consumptives, should be disinfected. 
 Such articles, if the Department of Health be notified, 
 will be sent for, disinfected and returned to the owner 
 free of charge, or if he so desire, they will be de- 
 stroyed. 
 
 When consumptives move they should notify the De- 
 partment of Health. 
 
 Consumptives are warned against the many widely 
 advertised cures, specifics, and special methods of treat- 
 ment of consumption. No cure can be expected except 
 through the regularly accepted treatment, which de- 
 pends upon pure air, an outdoor life, nourishing food, 
 and continuous medical supervision. 
 
 Consumptives unable to pay a private physician will 
 receive treatment (including medicines) free of charge 
 
138 TUBERCULOSIS 
 
 at the three special tuberculosis dispensaries of the 
 Health Department (Manhattan, Fifty-fifth Street and 
 Sixth Ave.; Brooklyn, 361 Jay Street; Bronx, Third 
 Ave. and St. Paul's Place). To these dispensaries 
 tuberculosis cases may also be referred by physicians, 
 charitable organizations, and others. 
 
 In deserving cases, milk and eggs will be supplied. 
 Pocket sputum cups can also be obtained there, and re- 
 quests may be left for nurses to visit patients at their 
 homes. 
 
 Persons desiring additional information or assistance 
 should apply to the Department of Health, Sixth Avenue 
 and Fifty-fifth Street, New York, the Association for 
 Improving the Condition of the Poor, 105 East Twenty- 
 second Street, or the Charity Organization Society, 
 No. 105 East Twenty-second Street. 
 
 If the population for which the circulars are 
 intended is presumably not able to read English, 
 it is advisable to follow the example of the New 
 York Health Department which has its popular 
 circulars translated into such languages as Bohe- 
 mian, Chinese, German, Hebrew, Hungarian, 
 Italian, Polish, Ruthenian, Russian, etc. 
 
 To encourage the foreign population within the 
 borders of the United States to study the health 
 regulations in the language of their adopted 
 country, the Health Department has the circular 
 in English on one §id^ of the page and in the Ian- 
 
HEALTH DEPARTMENT CIRCULARS 139 
 
 guage of the country whence the new American 
 citizen came on the other. 
 
 Besides this the most important educational 
 leaflet, cards, folders, etc., in much more concise 
 language, are issued by the department on which 
 at the same time is printed a list of all the tuber- 
 culosis dispensaries of the city and a map showing 
 where they are located : 
 
 CONSUMPTION. 
 
 How TO Keep from Getting It 
 How TO Keep from Giving It 
 DON'T SPIT 
 
 DEPARTMENT OF HEALTH 
 CITY OF NEW YORK, 
 Hermann M. Biggs, M. D., 
 
 General Medical Officer. 
 
 Thomas Darlington, M. D., 
 Commissioner of Health. 
 
 CONSUMPTION 
 
 IS chiefly caused by the filthy habit of 
 
 SPITTING. 
 
 Take This Card Home 
 
 And Show It to Your Family, Friends, and Neighbors. 
 
 Consumption is a disease of the lungs, which is taken 
 from others, and is not simply caused by colds, although 
 a cold may make it easier to take the disease. 
 
I40 TUBERCULOSIS 
 
 The matter coughed up and sneezed out by consump- 
 tives is full of living germs or ''tubercle bacilli," too 
 small to be seen. These germs are the cause of con- 
 sumption, and when they are breathed into the lungs 
 they set up the disease. 
 
 Dox't Get Consumption Yourself. 
 
 Keep as well as possible, for the healthier your body 
 the harder for the germs of consumption to gain a foot- 
 hold. Every person should observe the following 
 rules : 
 
 Don't live, study, or sleep in rooms where there is no 
 fresh air. Fresh air and sunlight kill the consumption 
 germs and those causing other diseases; therefore have 
 as much of both in your room as possible. 
 
 Don't live in dusty air; keep rooms clean; get rid of 
 dust by cleaning with damp cloths and mops. 
 
 Don't sweep with a dry broom. 
 
 Keep one window partly open in your bedroom at 
 night, and air the room two or three times a day. 
 
 Don't eat with soiled hands: wash them first. 
 
 Don't put hands or pencils in the mouth, or any 
 candy or chewing gum other persons have used. 
 
 Don't keep soiled handkerchiefs in your pockets. 
 
 Take a warm bath at least once a week. 
 
 Don't neglect a cold or a cough, but go to a doctor or 
 dispensary 
 
 On the back of this card a list of dispen- 
 saries IS printed. 
 
HEALTH DEPARTMENT CIRCULARS 141 
 
 HOW TO GET WELL IF YOU HAVE CONSUMPTION. 
 
 If you or any one in your family have consumption, 
 you must obey the following rules if you wish to get 
 well : 
 
 Don't waste your money on patent medicines or ad- 
 vertised cures for consumption, but go to a doctor or 
 dispensary. If you go in time, you can be cured; if you 
 wait, it may be too late. 
 
 Don't drink whiskey or other forms of liquor. 
 
 Don't Sleep in the same bed with any one else and, 
 if possible, not in the same room. 
 
 Good food, fresh air, and rest are the best cures. 
 Keep out in the fresh air and in the sunlight as much 
 as possible. 
 
 Keep your windows open winter and summer, day 
 and night. 
 
 If properly wrapped up you will not catch cold. 
 
 Go to a sanatorium while you can and before it is too 
 late. 
 
 The careful and clean consumptive is not dangerous 
 to those with whom he lives and works. 
 
 Don't give consumption to others. 
 
 Many grown people and children have consumption 
 without knowing it, and can give it to others. There- 
 fore every person, even if healthy, should obsen-e the 
 following rules: 
 
 Don't Spit on the sidewalks, playgrounds, or on 
 the floors or hallways of your home or school. It 
 spreads disease, and is dangerous, indecent, and un- 
 lawful. 
 
142 TUBERCULOSIS 
 
 When You ^Iust Spit, spit in the gutters or into a 
 spittoon half filled with water. 
 
 Don't Cough or Sneeze without holding a hand- 
 kerchief or your hand over your mouth or nose. 
 
 Take this Card Home and Show it to Your Family. 
 
 The New York Health Department also issues 
 a circular to physicians. I reproduce here part of 
 this circular with some slight changes which seem 
 to me advisable. The circular in this shape will, 
 I hope, prove helpful in the crusade against tuber- 
 culosis as far as the profession is concerned. 
 
 First: Incipient tuberculosis tends to recovery. 
 
 Second: More advanced cases of tuberculosis 
 may improve and life be prolonged and made use- 
 ful by proper care and judicious and proper 
 treatment. 
 
 Third: In all coughs which last more than a 
 few weeks and which are not associated with 
 asthma, emphysema, or cardiac diseases, tuber- 
 culosis is to be suspected as a cause. 
 
 Fourth: Successful treatment and prophylaxis 
 demand the earliest possible diagnosis. 
 
 Fifth: The diagnosis of incipient pulmonary 
 tuberculosis properly so called, is made positive 
 when tubercle bacilli are found in the expectora- 
 tion. 
 
 Sixth: Repeated examinations of the expecto- 
 ration are frequently necessary to demonstrate 
 
CIRCULAR TO PHYSICIANS 143 
 
 the presence of the tubercle bacilH in incipient 
 cases of pulmonary tuberculosis. 
 
 Seventh: While the presence of tubercle bacilli 
 in the sputum will confirm a physical diagnosis 
 of tuberculosis, the absence of bacilli in the sputum 
 does not exclude tuberculosis. 
 
 Eighth: In tuberculosis, suspected because of 
 the result of a physical examination, the physician 
 should not wait to inaugurate the preventive and 
 curative measures until the appearance of the 
 bacilli in the sputum. 
 
 Ninth: In order that the bacteriological ex- 
 aminations of sputa may be at the service of 
 physicians in all cases, the Health Department is 
 prepared to make such examinations, if samples 
 of the sputa, freshly discharged, are furnished in 
 clean, wide-necked, tightly stoppered bottles, ac- 
 companied by the name, age, sex, and address of 
 the patient, duration of the disease, and the name 
 and address of the attending physician. 
 
 Permanent tuberculosis exhibitions composed 
 of charts, photographs, maps, models, diagrams, 
 and all sorts of paraphernalia that have to do with 
 the study, prevention, and treatment of tubercu- 
 losis, should be installed in all large cities. Thus, 
 for example, a life-size model of a dark interior 
 bedroom, dirty and crowded with furniture; and 
 
144 
 
 TUBERCULOSIS 
 
 Fig. 43, A section of the International Tuberculosis Exhibit held 
 in New York, January, 1909, at the Museum of Natural History, 
 showing exhibits of various states and countries. 
 
 adjoining it a similar room with open windows 
 and clean cot spread with blankets, between 
 which have been sewed newspapers as a cheap 
 and at the same time warm covering, representing 
 the change wrought by a visiting nurse, will be 
 the best ocular demonstration of how to prevent 
 and treat consumption. 
 
 The photographs here reproduced (Figs. 43 and 
 44) are illustrations of sections of the Interna- 
 tional Tuberculosis- Exhibition which was held 
 in New York recently, and which must be con- 
 
146 
 
 TUBERCULOSIS 
 
 Fig. 45. New l-orms of Sneiier for Consumptive Cases as Exhibited 
 at the DubHn Tuberculosis Exhibition. 
 
 sidered one of the most successful ever held at 
 any time or an}^vhere in the world. During its 
 six weeks' stay in New^ York, the exhibition was 
 visited by nearly a million people, men, women, 
 and children, in all stations of life and from all 
 parts of the city. 
 
 Fig. 45 shows a section of a local tuberculosis 
 exhibition recently held at Dublin, Ireland. 
 
 As an educational measure, the New York 
 Health Department imitated the open air lantern 
 exhibit which originated with Dr. Oscar H. Rogers 
 of Yonkers. During the summer of 1908 in twenty- 
 five of the small parks of the city and at five rec- 
 reation piers on the river front, there were shown, 
 before crowds varying in number from several hun- 
 dred to two or three thousand, a set of stcrcopticon 
 slides giving in short sentences easily understood 
 
LANTERN EXHIBITS 147 
 
 advice in relation to tuberculosis. Interspersed 
 with these sentences, pictures were thrown upon 
 the screen which showed the ways in which the 
 bacilli causing tuberculosis are transmitted by 
 the cough and expectoration of those who have it; 
 the effect of the disease on the lungs; how over- 
 crowded, dirty, badly ventilated rooms and tene- 
 ments cause and spread it; how these conditions 
 are being remedied by the enforcement of better 
 building laws; how the Department of Health 
 renovates rooms infected with the germs of con- 
 sumption by fumigation and the removal and 
 disinfection of bedding and furnishings; how it 
 cares for patients in the various hospitals; and 
 finally, the possibility of arresting and curing 
 many cases in country sanatoria. 
 
 Instead of giving a list of the very numerous 
 slides which were exhibited in New York, I will 
 give, as very suitable for imitation, a hst of Dr. 
 Rogers' 19 views. They are as follows: 
 
 1. Plan of a street in Yonkers showing infected houses. 
 
 2. Plan of another street in a different part of the city. 
 
 3. A graphic illustration of the mortality among peo- 
 
 ple of various nationalities. 
 
 4. A graphic illustration of the mortality in various oc- 
 
 cupations. 
 
 5. A photograph of tubercle bacilli. 
 
 6. Section of normal lung showing air-vesicles. 
 
148 TUBERCULOSIS 
 
 7. Section of diseased lung showing tubercles. 
 
 8. A sketch showing infection through spitting. 
 
 9. A sketch showing infection through cougliing 
 
 (droplet infection). 
 
 10. Photograph of a gelatin plate infected by a fly 
 
 which had just been walking in tuberculous spit. 
 
 11. A gelatin plate infected by bacilli expelled by a 
 
 tuberculous patient in the act of coughing. 
 
 12. Photographs of various spitcups. 
 
 13. Dark, close room in a tenement, showing lounge on 
 
 which a consumptive lay dying. 
 
 14. Same tenement with lounge near an open window 
 
 and arranged by visiting nurse — an effective il- 
 lustration of the \alue of the visiting nurse. 
 
 15. Home treatment on roof of tenement house. 
 
 16. Window-tent for use in home treatment. 
 
 17. Shack treatment as carried on at Liberty, N. Y. 
 
 18. Shack treatment as carried on at Wards Island, 
 
 N. Y. 
 
 19. Model of inexpensive shack. 
 
 In the large centers of population, in fact, per- 
 haps in all larger communities w^here there are 
 a considerable number of poor or relatively poor 
 people, the tuberculosis dispensary, or, at least, a 
 special tuberculosis class in an ordinary dispen- 
 sary, is one of the most important factors in the 
 crusade against tuberculosis. 
 
 Let me state the object and purpose of a tu- 
 berculosis clinic as it has been set forth in the 
 
HEALTH DEPARTMENT CLINIC 149 
 
 first report of our Clinic for Pulmonary Diseases 
 of the Health Department, prepared by its di- 
 rector, Dr. John S. Billings, Jr. 
 
 " It was early recognized that the establishment of a 
 tuberculosis clinic or dispensary would be of great assist- 
 ance in the attainment of the following desired objects: 
 
 "i. The Early Recognition and Accurate Diagnosis 
 of Pulmonary Tuberculosis. — It is now generally ad- 
 mitted that tuberculosis is frequently a curable disease, 
 and that incipient tuberculosis, under favorable condi- 
 tions, tends to recovery; but to insure such recovery the 
 diagnosis must be made at the earliest possible moment. 
 Not only should careful physical examination be made, 
 together with repeated sputum examinations as re- 
 quired in connection with the clinical history, but in 
 addition, when necessary, the tuberculin test. X-ray ex- 
 aminations and radiography should be employed to as- 
 sist in arriving at an early and correct diagnosis. 
 
 "2. The Intelligent Supervision of Patients Under 
 Treatment. — This supervision should include not only 
 hygienic and medical treatment, but also the furnishing 
 of circulars in various languages, containing informa- 
 tion as to the nature of the disease, and careful instruc- 
 tions as to the precautions necessary to be taken to pre- 
 vent the infection of others. Paper sputum cups, paper 
 handkerchiefs, and proper food (milk and eggs) should 
 be supplied to indigent and needy cases. 
 
 ''3, The Continued Observation of the Homes of 
 Indigent, Needy, and Ambulant Cases, Including All 
 
150 TUBERCULOSIS 
 
 Those Discharged from the PubHc Institutions of the 
 Cily. — A special staff of trained nurses should visit the 
 patients at their homes to see that the instructions given 
 arc obsen-ed, that the sanitary surroundings are satis- 
 factor}', and to aft'ord such assistance as is required. 
 Suitable cases should be referred to the various charita- 
 ble organizations for food, fuel, ice, etc. Special atten- 
 tion should be paid to the children in the families of 
 tuberculous persons, and every effort made to prevent 
 their infection. 
 
 "4. The Removal of Cases Requiring Such Care to 
 Hospitals or Sanatoria. — These cases fall under four 
 heads: (a) Advanced or bedridden consumptives, with 
 profuse expectoration, who will not or can not take the 
 necessary precautions against spreading the disease, and 
 whose presence at home is a menace to others in the 
 family; (b) consumptives who are able to get about, but 
 who are unable to work and are entirely dependent upon 
 their earnings for their hvelihood; (c) incipient cases, 
 who stand a good chance of recovery if removed to sana- 
 toria outside of the city; (d) consumptives living in lodg- 
 ing houses, and those having no home. 
 
 "5. The Provision of a Municipal Institution to 
 Which Cases of Tuberculosis May Be Referred. — 
 (a) By physicians (indigent patients, etc.); (b) by in- 
 stitutions (on the discharge of consumptive patients 
 from hospitals or sanatoria); (c) by the various charita- 
 ble organizations throughout the city which keep tuber- 
 culous cases under observation; (d) by other persons 
 doing individual charitable work who may come in con- 
 
HEALTH DEPARTMENT CLINIC 151 
 
 tact with such persons, and (e) by other city depart- 
 ments. 
 
 "6. The Extension and Strengthening of the Sanitary 
 Control of Tuberculosis Among the Poor by the De- 
 partment of Health. 
 
 "7. The Care of Laryngeal Cases. — The involve- 
 ment of the larynx is one of the saddest complications of 
 pulmonary tuberculosis, and the pain, distress, and dis- 
 comfort of the patients are great. While the prognosis 
 in these cases is extremely grave, yet under proper 
 treatment recovery takes place in some instances, and in 
 most the distress of the patient can, in some degree at 
 least, be relieved. Special attention should be paid to 
 such cases in a fully equipped throat clinic." 
 
 For communities which have not yet established 
 a tuberculosis dispensary, the following sugges- 
 tions for building and the description of an ex- 
 isting one may be of value. The ideal dispensary 
 should be placed on elevated ground, in a locality 
 where there is relatively little traffic, yet easy of 
 access, and where the air is as pure as can be 
 found within the city limits. Not all these ideal 
 conditions existed when, in 1903, the New York 
 Health Department decided to establish its first 
 municipal tuberculosis dispensary. For obvious 
 reasons the name "Clinic for Communicable Pul- 
 monary Diseases" was decided upon. The lot 
 being narrow, and between high structures, and 
 
152 TUBERCULOSIS 
 
 all the available ground space being required, 
 windows could only be had on the ends. The 
 building was therefore limited in height to one 
 story, with a cellar below, in order that each 
 room could be lighted by a ventilating skylight. 
 (Fig. 46.) To ensure further ventilation square 
 openings were cut high up in the walls of the vari- 
 ous rooms, connecting them with each other and 
 with the halls, and electric fans were installed 
 in suitable places. The subdivisions are as fol- 
 lows: (i) entry; (2) registration room in which all 
 applicants are received, their history taken and 
 all records filed ; (3 and 4) waiting room for male 
 and female patients, each with its water-closet; 
 (5 and 6) dressing rooms for physicians and 
 nurses, each containing a closet for clothes, a wash- 
 stand and water-closet; (7) throat clinic, with 
 complete outfit, including compressed air spray 
 apparatus, electric sterilizer for instruments, in- 
 strument cabinets, and full stock of all necessary 
 instruments and apparatus; (8) X-ray room, the 
 equipment of which consists of a twelve-inch coil 
 with electrolytic breaks and micro-rheostatic con- 
 trol, Crookes tubes of several patterns and sizes, 
 fluoroscopes, tube stands, examination table, sup- 
 ply and apparatus cabinet, etc. (a dark room for 
 the immediate development of radiographic plates 
 is located in the basement of the clinic, beneath 
 
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 A. 
 
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 Cl, 
 
 
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154 TUBERCULOSIS 
 
 the X-ray room); (9 and 10, 11 and 12) male and 
 female examination and patients' dressing rooms, 
 containing desks, stools, etc., also a pneumatic cab- 
 inet for compressed or rarified air treatment; and 
 (13) drug rooms, containing in enameled metal 
 cabinets a full supply of all medicines furnished 
 by the drug laboratory of the Department of 
 Health. The floors are of cement and all corners 
 and angles are rounded to prevent accumulation 
 of dirt; all furniture is enameled metal. In the 
 basement, lockers are placed for physicians' and 
 attendants' gowns, individual stethoscopes, etc. 
 The supplies (blanks, circulars, cards, etc.) of the 
 clinic are also stored there. Large signs indicat- 
 ing that it is prohibited to spit on the sidewalk 
 are placed at the entrance door of the clinic, and 
 the following signboard in four languages greets 
 the patient on his arrival in the waiting room: 
 
 Do not spit on the floor or in anything but in the 
 brown paper envelope furnished for the purpose. 
 
 When you cough, hold a piece of muslin before your 
 mouth; use the muslin also for wiping the mouth after 
 spitting. 
 
 Men are forbidden to smoke or wear their hats while 
 in the Clinic. 
 
 Because of lack of room, we had to content our- 
 sdves with one door. Whenever it is feasible, I 
 
MUNICIPAL SANATORIA 155 
 
 would recommend having two doors, one for the 
 entrance and one for the exit of patients. 
 
 To avoid multiplication of efforts, that is to 
 say, to prevent patients from applying to several 
 dispensaries at the same time for medical advice, 
 medicine, and food in any city where there are 
 two or more of such institutions, there should be 
 cooperation between these dispensaries. If it is 
 possible to divide the city into certain districts with 
 dispensaries located in each, the work will be all 
 the more easy. This is done in New York. A 
 patient living in Harlem, even if he applies to a 
 down-town dispensary, will be referred to the 
 up-town institution and vice versa. 
 
 The municipality will not be able to do effect- 
 ive work in the prevention of tuberculosis unless 
 it makes provision to examine all the members of 
 a family who live with a consumptive. This is 
 particularly important when there are children 
 in the family. Through this careful examination 
 of all members of any family, likely to be exposed 
 to contracting tuberculosis or having already con- 
 tracted it, the greatest amount of preventive treat- 
 ment can be inaugurated. 
 
 Every municipality should have sufficient hos- 
 pital and sanatorium facilities to treat the con- 
 sumptive poor, adults and children who arc in 
 need of institutional treatment. To this end, 
 
156- TUBERCULOSIS 
 
 every large city should have a hospital, located at 
 not too great a distance from the city, where all 
 cases of tuberculosis referred by private practi- 
 tioners or dispensary physicians could be received 
 at once. There they should remain for a definite 
 time, sufficiently long for the visiting or house 
 physicians to determine whether it would be better 
 for the patient to remain there, return home to rel- 
 atives and friends, or be sent to a sanatorium at 
 a greater distance from the city for the purpose of 
 completing the cure. From the sanatorium where 
 the patient's disease is cured or arrested, he should 
 not at once be permitted to return home to his 
 former environment and occupation where or 
 wherein he contracted the disease, but he should 
 be given an opportunity to make his cure more 
 lasting. To this end municipalities should have 
 agricultural and horticultural colonies where the 
 patient should gradually become accustomed to 
 harder work without the fear of a relapse. 
 
 Besides these three kinds of institutions, every 
 large city should have a special hospital or sana- 
 torium to accommodate the children suffering 
 with diseases of the bones and glands, and those 
 suffering with pulmonary diseases. To this in- 
 stitution might v/ell be added a division for the 
 care of those children of the consumptive poor who, 
 if they were to remain at home, would be likely to 
 
MUNICIPAL SANATORIA 157 
 
 contract the disease from their parents. The lat- 
 ter division might justly be called "preventorium." 
 
 Whether or not these three institutions for chil- 
 dren can be combined in one, with a pavilion for 
 each kind of cases, or whether each institution 
 should be located separately, will largely depend 
 upon the size of the community and the number of 
 tuberculous children in need of care. While it is 
 now generally conceded that tuberculosis of the 
 bones and glands in children is very successfully 
 treated at the seaside (Fig. 47), for the comfort of 
 the inland communities it may be said that sana- 
 toria located in any healthy region are just as suc- 
 cessful in the treatment of tuberculous children. 
 (Fig. 48.) Almshouses and orphan asylums, by 
 reason of overcrowding and the commingling of 
 the tuberculous with the non-tuberculous inmates, 
 very often become centers of infection. The ex- 
 amination for tuberculosis of all inmates of such 
 institutions and their periodic reexamination, the 
 isolating of the tuberculous from those not affected 
 and the treatment of the former according to the 
 best and most approved methods in the same in- 
 stitution but in different rooms, when it is not 
 possible in special tuberculosis institutions, is a 
 duty that must not be neglected. 
 
 It is most important for every municipality to 
 remember that a single anti-tuberculosis measure, 
 
is8 
 
 TUBERCULOSIS 
 
 Fig. 47. A porch of the Seabreeze Sanatorium, for children suffering 
 with surgical tuberculosis, at Coney Island, N. Y. Established by 
 the Society for Improving the Condition of the Poor, now main- 
 tained by Mr. John I). Rockefeller. 
 
 while it may be useful in one direction, will not be 
 sufficient to solve the many phases of the problem 
 presented in every large city. It requires a chain 
 of institutions; a health department, to educate 
 the masses and control all existing cases; dispensa- 
 ries, to furnish treatment and care to cases among 
 the consumptive poor which can or need not be 
 received in the hospitals and sanatoria; reception 
 hospitals, to serve as a sort of clearing house for 
 
MUNICIPAL SANATORIA 
 
 159 
 
 Fig. 48. Inland Sanatorium. Country Branch of the X. Y. Ortho- 
 paedic Dispensary and Hospital at White Plains, New York. Acute 
 cases of joint tuberculosis " doing cures " in midwinter. 
 
 hospital and sanatorium cases where all bed cases 
 can be received; and a sanatorium or sanatoria 
 at a greater distance from the city, for the earlier 
 and more curable cases of adults and children. 
 Besides this, there should be a disinfecting station 
 or bureau for the purpose of rendering clean 
 and sanitary the premises occupied by the tu- 
 berculous and also their bedding or personal 
 property. 
 
 A municipality having such a chain of insti- 
 tutions and a wide-awake health department with 
 police power as the first link, will not only master 
 and control tuberculosis within a comparatively 
 
i6o TUBERCULOSIS 
 
 short time, but will also in the end be the moral 
 and financial gainer. The Riverside Hospital- 
 Sanatorium having 300 beds for indigent male 
 and female consumptives, receives, besides the 
 few forced-in cases, annually a large number of 
 New York's consumptive poor in the second and 
 third stages of the disease. When they improve 
 sufficiently they are transferred to the Health 
 Department's Country Sanatorium at Otisville, 
 N. Y. To this latter institution, with a capacity 
 of 250, early and seemingly curable cases are 
 sent directly from the various dispensaries of the 
 city. A goodly number return from Otisville 
 annually completely cured or with their disease 
 sufficiently arrested so that thsy can again resume 
 work. 
 
 Thanks to its police power, the New York 
 Health Department has a right to remove to its 
 Riverside Sanatorium on North Brother Island 
 any individual suffering from tuberculosis who 
 constitutes a menace to his family or friends. 
 The patient is retained at this institution until he 
 is cured or more sanitary arrangements have 
 been made at his home. These so-called forced-in 
 cases very soon become docile patients and learn 
 to appreciate the care bestowed upon them. The 
 accompanying picture (Fig. 49) shows a group of 
 the North Brother Island patients taking respira- 
 
HNANCIAL AND MORAL GAIN i6i 
 
 tory exercises under the direction of the physicians 
 in charge. 
 
 To be convinced that from these methods a 
 financial and moral gain accrues to the com- 
 munity, one only needs to remember that when a 
 patient is taken hold of in the early stage of his 
 disease he has a good chance to be cured within 
 one year, at little more than he would cost the com- 
 munity for a year in an almshouse, a general hospi- 
 tal, or at home when he or his family had to be sup- 
 ported. The only difference is that he may linger 
 at home or in the almshouse an invalid for several 
 years and never get well, and before his demise 
 may have infected all his children, his wife, and 
 other relatives and friends who may have come in 
 close contact with him. Let us take, for example, 
 a community which has 10,000 consumptives ab- 
 solutely poor. They will sooner or later have to 
 be taken care of by the municipality either in the 
 almshouse, general hospital, or their own homes. 
 They will cost at the lowest possible rate in a 
 general hospital $7,500 a day, or $2,737,500 a 
 year. In the almshouse, where no tuberculous 
 patients should ever be, they will at least cost 
 $5,000 per day, or $1,725,000 a year. They are 
 apt to Hnger at least two years deprived- of their 
 earning capacity and, even if they stay at home, 
 when the consumptive is the breadwinner, the 
 
FINANCIAL AND MORAL GAIN 163 
 
 expense of maintaining the family is likely to be 
 even higher than the maintenance of the individual 
 in hospital or almshouse. 
 
 Now, it has been demonstrated that with ju- 
 dicious administration and economy a consumptive 
 can be maintained and treated in a sanatorium at 
 $1.00 per day. His chances of cure there are at 
 least 75 per cent. Thus, the cure of 7,500 consump- 
 tives would cost the city, even if the cure should 
 take a whole year, $2,737,500. Xot cured, they 
 would cost the city at least twice the amount, that 
 is to say, $5,575,000. The remaining 2,500 cases 
 not cured, will probably cost the city $912,500 for 
 two years. Of the latter many will return to their 
 homes, if not cured, at least temporarily improved, 
 educated in the prevention of tuberculosis, general 
 hygiene, and personal cleanliness, and by their 
 training will become veritable missionaries in the 
 crusade against tuberculosis. Thus, taking care 
 of 10,000 consumptive poor at the right time, at 
 the right place and in the right way : that is to say, 
 in the sanatorium, in the early and curable stages 
 of the disease, by the most approved methods at 
 the hands of experienced phthisiotherapeutists, 
 will cost a total of $3,650,000. Xot curing the 
 7,500 nor taking proper care of the rest, will cost 
 the community $5,575,000. Thus, by directly 
 saving the lives of 7,500 people, the community 
 
i64 TUBERCULOSIS 
 
 has saved $1,925,000. The number of other valu- 
 able lives which will have been saved by the isola- 
 tion of the patients in the proper institutions can 
 hardly be calculated when we remember that the 
 careless individual can expectorate seven billion 
 bacilli in 24 hours, and that it only requires the 
 inhalation or ingestion of a few bacilli by the pre- 
 disposed individual to cause a typical pulmonary 
 tuberculosis to develop in a relatively short time, 
 making him again a center of infection, and so 
 ad infinitum. 
 
 Consumption is a disease which usually attacks 
 an individual at a time of life when he is most 
 useful and most productive, and the economic 
 loss to the community is naturally correspondingly 
 great when it fails to do its duty towards its con- 
 sumptive poor. 
 
 The municipality which is in earnest to wipe 
 out tuberculosis from its midst must also make 
 provisions which tend to improve the general 
 health of its inhabitants, especially that of its 
 children. There should be plenty of parks and 
 playgrounds, public baths, swimming pools, and 
 gymnasiums. In regard to the need of play- 
 grounds in cities, in the interest of the health and 
 morals of our children, the accompanying picture, 
 ''Boys without a playground," (Fig. 50) will 
 speak for itself. Parks are the lungs of a city. 
 
MUNICIPAL PARKS, ETC. 
 
 165 
 
 Fig. 50. Boys Without a Playground, 
 
 The larger and more numerous they are, the purer 
 will be the air which the inhabitants will breathe. 
 Playgrounds, swimming pools, and gymnasiums 
 tend to make the young more resistant to disease, 
 and particularly to tuberculosis. 
 
 A city government, of course, always has its 
 courthouse and the offices of its various admin- 
 istrations. These offices should be models of 
 ventilation, proper heating, and lighting. Anti- 
 spitting ordinances should be enforced in munici- 
 pal buildings more strictly than anywhere else. 
 Every officer and employee of the city government 
 whose duties are within doors where, if tuber- 
 
i66 TUBERCULOSIS 
 
 culous, he might infect some one else, should be 
 excluded from office duty or indoor occupation. 
 All city officials should be examined for tuber- 
 culosis on entering the employ of the government 
 and should be reexamined for tuberculosis at least 
 once a year. The civil service examination of all 
 city employees should include questions on the 
 simple principles of hygiene and the prevention 
 of tuberculosis, and a candidate not able to an- 
 swer the questions satisfactorily should be refused 
 employment until he has mastered these subjects. 
 If a municipality wishes to combat all possible 
 sources of tuberculosis, it must', of course, see 
 that the inhabitants are provided with pure milk, 
 free from tuberculous and other germs. The surest 
 way of having pure milk is to watch over its 
 source, its transportation, its preservation, and 
 its methods of delivery. Farms and dairies should 
 be inspected, and cows found tuberculous on 
 physical examination or by tuberculin test should 
 be purchased by the state or municipality and 
 disposed of by them. An efficient health depart- 
 ment will have visiting milk inspectors who will 
 also see that cows and stables are kept clean and 
 that wholesale and retail milk dealers handle the 
 milk in such a way that infection is made virtually 
 impossible. It has been shown by the health de- 
 partments of a number of American cities, such 
 
MUNICIPAL PARKS, ETC. 167 
 
 as New York, Chicago, Rochester, and others, 
 that a great deal can be done in this direction and 
 that a city can be supplied with good, pure milk. 
 In the opinion of such authorities as Health Com- 
 missioner Darlington of New York, Health Com- 
 missioner Evans of Chicago, and Health Officer 
 Goler of Rochester, the methods of supervision 
 of the milk supply such as are in vogue in their 
 cities are superior to sterilization. According to 
 the Year Book of the U. S. Department of Agri- 
 culture, it was demonstrated at the competitive 
 exhibit of milk and cream at the National Dairy 
 Show in Chicago in February, 1906, which was 
 in charge of the Dairy Division, that milk and 
 cream produced under sanitary conditions could 
 be shipped long distances and kept sweet for sev- 
 eral weeks, without any other means of preserva- 
 tion than cleanliness and low temperature. 
 
 In Chapter II we emphasized the fact that 
 pasteurized milk is inferior in digestive and nutri- 
 tive qualities to raw, fresh, pure milk. One of 
 the chief objections to general and commercial 
 pasteurization, as has been stated by Dr. M. J. 
 Rosenau, Director of the Hygienic Laboratory 
 of the United States Public Health and ]\Iarine 
 Hospital Service, is that such a practice might 
 promote carelessness and discourage the efforts 
 to produce clean milk. It is believed that the gen- 
 
i68 TUBERCULOSIS 
 
 eral adoption of pasteurization would set back 
 improvements at the source of supply, and en- 
 courage dirty habits. It would cause the farmers 
 and those w^ho handle milk to believe that it is 
 unnecessary to be quite so particular, as the dirt 
 that got into the milk would be cooked and made 
 harmless. It would be well if every community 
 could have a committee to teach mothers the im- 
 portance of nursing their babies and, in the event 
 of their being unable to do so, to teach them how 
 to modify and prepare cows' milk at home. 
 
 All slaughter houses should be inspected to 
 prevent the sale of tuberculous or otherwise in- 
 fected meat. 
 
 A very important duty of every health depart- 
 ment, be it of a city, town, or village, should be the 
 sanitary supervision of places of amusement, of 
 popular, and even of religious instruction. A 
 theater, a music hall, a dance hall, a lecture 
 room, or a church has no right to exist if its bad 
 ventilation, bad or dangerous lighting arrange- 
 ments, or lack of j)rovision against fire make it a 
 menace to the health and life of the audience, 
 performers, or speakers. I am convinced that a 
 thorough airing after each performance and a 
 thorough cleaning by the pneumatic process of 
 floor and furniture of every theater, church, or 
 assembly hall, would remove many sources of 
 
TUBERCULOUS EMPLOYEES 169 
 
 direct and indirect infection, not only from tuber- 
 culosis but from other communicable or con- 
 tagious diseases of the respiratory organs. 
 
 There are in every community a number of 
 tuberculous individuals employed in occupations 
 which are not suitable for them, and where their 
 presence is in some degree dangerous to the com- 
 munity at large. I refer to bakers and confec- 
 tioners, milk, fruit and vegetable dealers, and 
 butchers. The community which will insist that 
 any one following these occupations must have a 
 clean bill of health will make another step toward 
 the prevention and eradication of tuberculosis. 
 
 What has always seemed to me rather unclean 
 and unhygienic is the way in which bread is al- 
 most universally handled. We have already re- 
 ferred to the possibility of infection from a tuber- 
 culous baker, but the danger does not end there. 
 The probability of infection is still more evident 
 when one considers through how many hands the 
 bread passes before it enters the mouths of the 
 consumers, and that, probably, nobody ever thinks 
 of cleaning bread before eating it. A very recom- 
 mendable practice is now in vogue in some large 
 bakeries in connection with the handling and 
 transporting of bread. The moment the bread 
 comes out of the oven, while it is still too hot to 
 be handled, it is placed, with the aid of a shovel, 
 
lyo TUBERCULOSIS 
 
 upon a piece of wrapping paper large enough to 
 envelop the whole loaf. By twisting the two ends 
 of the wrapper the bread is completely enclosed. 
 
 There are also other sources of possible in- 
 fection which could be prevented by care and 
 municipal supervision. Thus, for example, it 
 should be against the law to expose candy for 
 sale uncovered. This law should not only be 
 applied to the small candy dealer or peddler, but 
 also to the fashionable confectionery stores or 
 department stores. The dust floating in the air 
 of a store, whether large or small, is apt to be 
 infectious and should not constitute a part of our 
 food. 
 
CHAPTER VII 
 
 THE DUTIES OF FEDERAL AND STATE AUTHORI- 
 TIES IN THE COMBAT OF TUBERCULOSIS 
 
 City, state, and federal governments must work 
 hand in hand if tuberculosis as a disease of the 
 masses is effectually to be combated. What has 
 been said of the establishment of institutions for 
 the tuberculous may devolve upon the legislators 
 of the state. Thus, it may often be of mutual 
 advantage to have a state institution to which all 
 the cities and counties of a state can send their 
 incipient tuberculous cases. Such an institution, 
 most properly called a sanatorium (from the Latin 
 word sanare, to heal), is usually situated so that 
 it can be easily reached from the greater centers 
 of population. While high altitude and climatic 
 advantages naturally favor the cure of tubercu- 
 losis, these factors are by no means indispensable. 
 
 In the maxims on climatology we stated that 
 since the majority of the tuberculous poor are 
 from the laboring classes, they should, as far as 
 possible, be treated in the same, or nearly the 
 same climate where they will have to live and 
 
 171 
 
172 TUBERCULOSIS 
 
 labor after their restoration to health. While the 
 cure in such a home climate is apt to take a little 
 longer than in regions renowned for their par- 
 ticularly congenial climate, the patient's chances 
 for remaining cured are greater. This is cer- 
 tainly the experience of the majority of phthisio- 
 therapeutists. 
 
 The sanatorium which is to do the greatest 
 amount of good to the largest number of people 
 should not be more distant from the center of 
 population than three to five hours by rail. 
 It should be in a region known for the relative 
 purity of its atmosphere where there is freedom 
 from injurious gases, smoke, and dust. If possi- 
 ble, it should be where the extremes of tempera- 
 ture are not too pronounced and, if the region is 
 a mountainous one, at an altitude of from five 
 hundred to fifteen hundred feet. The site should 
 be a pleasant one, with a southern exposure, and 
 protected from cold winds by higher mountains 
 and woodlands (pine-woods should be given the 
 preference). The ground, of course, should be 
 dry and porous. 
 
 As will have been seen from our maxims on 
 climatology just referred to, it is not absolutely 
 necessary to fulfill all these conditions. What 
 is essential is the careful outdoor life, the judicious 
 use of cold water, plenty of good, plain, and nu- 
 
STATE SANATORIA 173 
 
 tritious food, and constant niedical supervision. 
 If the choice had to be made between sending 
 a patient to what is usually considered an ideal 
 or specific climate, where he would not have any 
 guidance or supervision but would do as he hap- 
 pened to please, or keeping him at home in a fairly 
 pure atmosphere and applying the hygienic and 
 dietetic treatment under constant medical super- 
 vision, I should choose the latter method of treat- 
 ment and think the patient had a far better chance 
 of recovery. 
 
 After a state legislature has provided a san- 
 atorium for its consumptive poor and those of 
 moderate means, it becomes its duty also to see 
 that pauperization is avoided. All persons seek- 
 ing admission to a state sanatorium should be vis- 
 ited by local agents who should determine whether 
 the patient is able to pay all or only a part of 
 his expenses during his stay at the sanatorium. 
 The first state sanatorium v^as established in the 
 United States by the commonwealth of INIassachu- 
 setts in 1895, and opened to patients in October, 
 1898. (Fig. 51.) It is located near the center 
 of the state, at Rutland, Mass., about fifty miles 
 from Boston and eleven miles from Worcester; at 
 an elevation of 1,200 feet. The buildings are on 
 a southern slope, protected on the northwest by a 
 wooded hill. The pavihons for the patients are 
 
STATE SANATORIA 175 
 
 one or two stories high, extending to the south, 
 each terminating in a solarium and piazza (Fig. 52) 
 and all connected on the north by a covered corri- 
 dor. 
 
 The primary object of the institution is the 
 arrest of the disease, and only such patients will 
 be admitted as are deemed not too far advanced 
 for a reasonable hope of radical improvement; 
 the purpose being to give sanatorium treatment 
 only. 
 
 Residents of Massachusetts only are admitted, 
 preference being given to citizens of the United 
 States. Patients who do not improve after a stay 
 in the Sanatorium sufficiently long to test the effect 
 of treatment will be advised not to remain, and 
 their friends will be expected to arrange their 
 removal. In consideration of the nominal charge 
 made for board and treatment, all patients who 
 are physically able are expected to do some work 
 daily under medical supervision. The institution 
 has a capacity for 400 patients and the uniform 
 charge is $4.00 per week, which covers less than 
 half of the actual expense for each patient. It is 
 difficult to estimate the great value of such a 
 state institution in the warfare ae^ainst tuberculosis. 
 Leaving aside the great number of actual cures and 
 the great educational influence such an institution 
 exerts, many patients returning improved to their 
 
o 
 
 ■"I ~ 
 c 
 
 ^ O 
 
 N 3. 
 
 ?r 
 
 O 
 
 O 
 
 3 
 
 "I 
 
 n 
 
STATE SANATORIA 
 
 177 
 
 former environments become what might be termed 
 economic cures. In the interesting volume pre- 
 pared by the Tuberculosis Committee of the state 
 of Massachusetts for the International Tubercu- 
 losis Congress held at Washington last year, is 
 quoted a table of comparative results expressed in 
 percentage for the first 8 years of the Sanatorium's 
 activity. These tables are most instructive. They 
 read as follows: 
 
 Comparison of Percentage in the First, Second, Third, 
 Fourth, Fifth, Sixth, Seventh, and Eighth Years 
 
 
 i8g8 
 
 iSgg 
 
 I goo 
 
 igoi 
 
 igo2 
 
 1903 
 
 igo4 
 
 1905 
 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 
 iSgg 
 
 I goo 
 
 igoi 
 
 igo2 
 
 igo3 
 
 1904 
 
 1905 
 
 1906 
 
 Per cent of "arrested" or "ap- 
 
 
 
 
 
 
 
 parently cured " cases 
 
 34-28— 
 
 42-35 
 
 46.12 
 
 48.31 
 
 48.97 
 
 44.S 
 
 33-7 
 
 39-1 
 
 Per cent of all classes of "im- 
 
 
 
 
 
 
 
 
 
 proved" cases 
 
 39-36 — 
 
 44.70 
 
 47.64 
 
 44-51 — 
 
 33-0 — 
 
 47-7 
 
 sS.g 
 
 52.1 
 
 Per cent of "not improved" 
 
 
 
 
 
 
 
 
 
 cases 
 
 26.04 — 
 
 12. gs 
 
 5-74 
 
 6.73- 
 
 7.go — 
 
 7-4 
 
 7-4 
 
 8.8 
 
 Percentage of Incipient Cases "Arrested " or "Apparently 
 
 Cured " 
 
 "Arrested" or "apparently cured" 
 
 iSgS 
 
 to 
 
 iSgg 
 
 64.60 
 
 iSgg 
 
 to 
 
 I goo 
 
 72. go 
 
 I goo 
 
 to 
 
 I go I 
 
 73.00 
 
 igoi 
 
 to 
 
 igo2 
 
 72.00 
 
 igo2 
 to 
 igo3 
 
 72.60 
 
 igo3 
 to 
 1904 
 
 75-8 
 
 igo4 
 
 to 
 
 1905 
 
 64.2 
 
 1905 
 
 to 
 
 igo6 
 
 74-4 
 
 "A quotation from a study of the subsequent histories 
 of patients who had left the Sanatorium, taken from the 
 ninth annual report of September 30, 1905, is also 
 added. 
 
I7S 
 
 TUBERCULOSIS 
 
 ''Subsequent Histories to Date {Oct. i, 1905) oj Former 
 
 Patients oj Both Departments Treated in the Sa^ia- 
 
 torium Previous to October i, 1904. 
 
 "The subsequent histories of former patients make 
 the crucial test of any method of treatment, and are of 
 vital importance. 
 
 "For the first time in the history of the Sanatorium, 
 tabulations of the results of former treatment have been 
 made with painstaking care, and are hereby appended. 
 That they give us convincing proof of the value of the 
 work at Rutland during the last six years we think no 
 one can deny. 
 
 Total number treated 
 
 
 Able to work 
 
 • 1,179 
 
 Not able to work 
 
 34 
 
 No reply to letter 
 
 377 
 
 No trace 
 
 49 
 
 Dead . 
 
 . . 561 
 
 2,200 
 
 Total number of " arrested " and 
 "apparently cured" 
 Able to work 
 Not able to work 
 No reply to letter 
 No trace 
 Dead . . . , 
 
 2,200 
 
 743 
 14 
 
 139 
 19 
 
 74^ 
 
 989 
 
 989 
 
 1 Four have died from causes other than tuberculosis. 
 
STATE SANATORIA 179 
 
 "In reading these figures, it must be remembered, 
 moreover, that failure to receive repHes or inabihty to 
 trace the patient does not mean necessarily that the re- 
 sult has been unfavorable. In many of the earlier cases 
 we have failed to receive news for months after the first 
 inquiries have been made. Oftentimes, too, favorable 
 accounts have been received of former patients through 
 others. It is reasonable to suppose, therefore, that 
 many of those from whom we have not heard as yet are 
 still alive and at work." 
 
 There are now many states which have followed 
 the example of Massachusetts. To statesmen, 
 legislators, and also to private citizens a short de- 
 scription of the existing state sanatoria, of where 
 they are situated and how they are managed, will 
 prove of interest ; and I trust that to those in whose 
 state there is as yet no provision for the tubercu- 
 lous, this splendid array of existing institutions 
 will be an incentive to emulation. 
 
 According to the latest directory of our National 
 Association for the Study and Prevention of Tuber- 
 culosis, the following states have state sanatoria 
 for consumptives. 
 
 District, of Columbia: "Tuberculosis Hos- 
 pital of the District of Columbia," 14th and Van- 
 ness Sts., N. W. (opened July i, 1908). For 
 indigent consumptives in all stages of the disease. 
 Capacity 120 beds. There are no charges, 
 
i8o TUBERCULOSIS 
 
 The grounds of the Sanatorium comprise a plot 
 of 30 acres, overlooking the City of Washington. 
 Two car lines run within three blocks of the insti- 
 tution. 
 
 With the opening of this hospital, the spe- 
 cial building at the Washington Asylum Hos- 
 pital was closed. The new hospital is the only 
 place in the district for the accommodation of 
 consumptive patients. Application should be 
 made to the Board of Charities of the District 
 of Columbia. 
 
 Iowa: ''State Sanatorium for the Treatment 
 of Tuberculosis" (opened February i, 1908). 
 For the treatment of incipient cases or those who 
 offer a fair chance of recovery. Capacity: 80 
 beds. Rates: $30 per month, for those who are 
 able to pay; otherwise expenses are paid by the 
 state. 
 
 The Sanatorium is located five miles northwest 
 of Iowa City, directly on the Cedar Rapids and 
 Iowa City Electric Interurban Railway. The site, 
 which consists of 280 acres, is of a comparatively 
 high altitude, affording good drainage facilities. 
 The farm will be utilized for the growing of vege- 
 tables, fruits, etc. 
 
 The buildings consist of a three-story brick ad- 
 ministration buikling, two large pavilions, a power 
 house, and laundry. In the administrative build- 
 
STATE SANATORIA i8i 
 
 ing are rooms for the superintendent, the nurses 
 and other employees, as well as offices, laboratory, 
 dining room, kitchen, and an amusement room 
 with open fireplace. The pavilions consist of a 
 central building with rooms for nurses, diet kitchen, 
 bath and toilet rooms. There are wings on either 
 side containing ten rooms for two patients each, 
 and in front is a twelve-foot open porch. Accom- 
 modations are thus afforded for eighty, patients, 
 and the state will doubtless increase the capacity 
 as the exigencies require. 
 
 Application should be made to the examining 
 physicians of the different counties, who fill out 
 admission blanks and send them to the superin- 
 tendent who, in turn, decides on the suitability of 
 the applicant. 
 
 Maryland: "The Maryland State Sanatorium " 
 (opened in the summer of 1908). For all classes 
 of tuberculosis which are deemed curable. White 
 persons only admitted. Capacity is now about 
 100; full scheme provides for 250. Rates: 50 
 cents per day. Free cases will be received only 
 after approval of trustees. 
 
 This Sanatorium is the outgrowth of the labors 
 of the Second Tuberculosis Commission of Mary- 
 land, appointed in 1904. Up to April i, 1908, 
 most of the $100,000 originally appropriated had 
 been expended. The Legislature of 1908 appro- 
 
i82 TUBiERCULOSIS 
 
 priated $175,000 more to complete the institution, 
 which will doubtless be one of the finest state sana- 
 toria in the United States. 
 
 Sabillasville is located in Frederick County in 
 the heart of the Blue Ridge iMountains at an eleva- 
 tion of 1,500 feet. The site comprises 198 acres. 
 The detached pavilion system of building is being 
 employed. Each cottage will be sufficiently far 
 removed from all others to give it plenty of air and 
 sunlight. The cottages will each accommodate 
 sixteen patients. 
 
 Application blanks for admission may be ob- 
 tained from the municipal or county health officer 
 in the district in which the applicant lives, or by 
 writing to any member of the Board of Directors. 
 Applicants must have been residents of the state 
 of Maryland for at least one year preceding the 
 date of the application. 
 
 Michigan: ''Michigan State Sanatorium '^ 
 (opened September i, 1907). For incipient cases 
 only. Capacity: 38. Rates: $1.00 per day; $7.00 
 per week. Those unable to pay are cared for as 
 state and county charges. 
 
 The Michigan State Sanatorium was established 
 by a special act of the Legislature in 1905 "for the 
 treatment of such persons as shall be proven by 
 proper bacteriologi-clinical examination to be suf- 
 fering from tuberculosis." 
 
STATE SANATORIA 183 
 
 The Sanatorium is situated two and one-half 
 miles southwest of the village of Howell, Living- 
 ston County, at the highest point of the natural 
 watershed of the lower peninsula, and is approxi- 
 mately 1,100 feet above the sea-level. The prop- 
 erty consists of 270 acres, 192 of which was given to 
 the state by the citizens of Howell, the money being 
 raised by popular subscription. It is of a rolling, 
 sandy loam, well adapted for the growing of fruits 
 and vegetables, and permits, from a sanitary point 
 of view, of the best possible drainage. An ad- 
 mirable water-supply is secured from a series of 
 natural springs on the property, and, by pumping 
 this into an elevated reservoir, ample pressure is 
 afforded for all practical purposes as well as pro- 
 tection in case of fire. A superior quality of ice is 
 also secured from a small lake at the main entrance 
 fed by these same springs. 
 
 The Sanatorium proper consists of an adminis- 
 tration building, around which is grouped a num- 
 ber of shacks. The administration building con- 
 tains the dining hall, offices, laboratories, kitchen, 
 laundry, staff and help quarters, and two infirmary 
 wings accommodating ten patients each. The in- 
 firmary v/ings, which are provided for patients 
 requiring special care and nursing, are so con- 
 structed as to give perfect ventilation and allow 
 each patient the privacy of his own bedroom and 
 
i84 TUBERCULOSIS 
 
 the opportunity to sleep out of doors on a sheltered 
 veranda if advisable. 
 
 Application should be made on printed blanks 
 to the superintendent through a regular examining 
 physician. 
 
 Minnesota: "State Sanatorium for Consump- 
 tives" (opened January i, 1908). For persons in 
 the early stages of pulmonary tuberculosis who 
 have been residents of Minnesota for at least one 
 year. Capacity: 60. Rates: $7.00 per week. No 
 free beds, but county and city officials pay expenses 
 of some patients. 
 
 This Sanatorium is the result of the labors of a 
 commission, appointed under an act of the Legis- 
 lature of 1 90 1, to study the tuberculosis question. 
 This same commission was later, in 1903, in- 
 structed by the Legislature to erect a sanatorium, 
 the state appropriating $25,000 for this purpose. 
 
 A location was selected near Leech Lake in Cass 
 County, 740 acres of land were procured, and the 
 institutional buildings begun. Two cottages and 
 one of the wings of the main building were ready 
 for occupancy on January i, 1908. It is near the 
 town of Walker, on the Minnesota and Interna- 
 tional Railway, 200 miles due north of St. Paul. 
 The lake, which furnishes an excellent water- 
 supply, is a quarter of a mile distant and about 200 
 feet below the buildings so that the dampness from 
 
STATE SANATORIA 185 
 
 the water will not reach the patients. The sandy 
 soil allows excellent drainage. Railway facilities 
 are nearby, the sanatorium station being on the 
 grounds one-half mile distant from the building. 
 There is an admirable opportunity for gardening 
 and grazing, making possible the production of 
 vegetables, milk, and eggs for use in the sanato- 
 rium. 
 
 The buildings are planned especially for the 
 carrying out of the open air treatment. The pres- 
 ent main building is but a part of the general plan 
 and has been adapted to present needs, containing 
 the dining room, kitchen, laundry, apartment for 
 superintendent, roomis for other employees, and a 
 ward each for men and women patients, with 
 locker rooms and excellent bathing facilities. The 
 piazzas are sufficiently large for all patients to sit 
 out at one time, and are thoroughly screened. 
 The two cottages are erected on the plan of the 
 open air ''lean-to," used at other sanatoria. Each 
 has a central section, heated and containing a sit- 
 ting room and a bath room well equipped, includ- 
 ing shower baths and lockers; and a sleeping 
 pavilion extending out on either side, open to the 
 south, screened and provided with canvas cur- 
 tains to be used during inclement weather. Pa- 
 tients sleeping in the pavilions are practically out 
 of doors. 
 
i86 TUBERCULOSIS 
 
 Application should be made to the local medical 
 examiners in various parts of the state or to any of 
 the city or county officials of the poor. 
 
 Missouri: "^Missouri State Sanatorium for In- 
 cipient Pulmonary Tuberculosis " (opened August 
 1,1907). For incipient cases only. Capacity: 50. 
 Rates: $5.00 per week for county patients; $50 a 
 month for private patients. 
 
 The IMissouri State Sanatorium for Incipient 
 Pulmonary Tuberculosis is located in Mount Ver- 
 non, twelve miles from Aurora and sixty miles 
 from Springfield, on a branch of the Frisco rail- 
 road extending from Greenfield to Aurora. The 
 Sanatorium is situated on a bluff, with an altitude 
 of 1,400 feet above sea-level. 
 
 The plans of the architect call for a group of 
 twelve or fifteen buildings. There are to be eight 
 villas, which will be for the use of patients. Four 
 will be for women and four for men. The villas 
 are one story in height, so that a thorough system 
 of ventilation can be installed, and so that patients 
 will not need to climb stairs. 
 
 Each villa accommodates twenty-four patients. 
 When entirely completed, the sanatorium will 
 have a capacity for 200. 
 
 Applications should ])e made to the superin- 
 tendent through the local medical examiners. 
 
 New Jersey: ''New Jersey Sanatorium for Tu- 
 
STATE SANATORIA 187 
 
 berculous Diseases" (opened October 25, 1907). 
 A state sanatorium for cases of a curable nature. 
 Capacity: 104. Rates: $5.00 per week. Patients 
 are admitted without charge whose inabihty to pay 
 $5.00 a week is determined by a competent court. 
 
 The New Jersey State Sanatorium for Tuber- 
 culous Diseases is located at Glen Gardner, Hunt- 
 erdon County, on the Central Railroad of New 
 Jersey, fifty-two miles from New York and sixteen 
 from Phillipsburg, about 1,000 feet above sea- 
 level. The site of the Sanatorium is on the slope 
 of a mountain where the state has acquired 600 
 acres. The slope has been cut away and leveled 
 for a considerable space, and here the buildings 
 are constructed. 
 
 The buildings consist of a service building, 
 administration building, and east and west wards. 
 The service building is 84 by no feet, three stories, 
 including basement, in which is the engine room 
 and electric-light plant. Two boilers of 125 horse- 
 power each, furnish steam to run the dynamos, and 
 the exhaust steam is utilized for heating the build- 
 ing. 
 
 All the buildings are built of field stone, stuccoed 
 on the outside and finished with white plaster in 
 the interior. The floors are of hard maple and 
 concrete, and the trimmings are of poplar. Each 
 building has its own heating apparatus. Bath and 
 
1&& 
 
 TUBERCULOSIS 
 
 \Vinter View of the New York State Hospital for Incipient 
 Tuberculosis at Ray Brook, N. Y. 
 
 toilet rooms are located on each floor, with special 
 shower baths on the second floor of the ward build- 
 ing. The buildings are so constructed that addi- 
 tions may be made. 
 
 The buildings are erected on the southern slope 
 of the hill and are protected from northwesterly 
 winds by thick forests on the north and west sides. 
 These forests in the future will be converted into 
 parks with shaded walks and drives. The grounds 
 are spacious; tents and wooden shacks for sum- 
 mer can be added as they are required. 
 
 Application for admission should be made to 
 any one of the local medical examiners who reside 
 in any of the principal cities of the state. 
 
 New York: ''State Hospital for the Treat- 
 ment of Incipient Pulmonary Tuberculosis," Fig. 
 53 (opened July i, 1904); situated at Ray Brook, 
 
STATE SANATORIA 189 
 
 Essex County. Primarily for the poor, but pay 
 patients will be received when there is room for 
 them; one year's residence in this state is a re- 
 quired condition. Incipient cases only are ad- 
 mitted. Capacity: 120. 
 
 By a provision of its charter, the hospital is re- 
 quired to give preference to the indigent, admitting 
 others only when vacancies occur. The authorities 
 by whom the patients are sent, are required to pay 
 transportation to and from the Hospital and $5.00 
 per week for maintenance. 
 
 The State Hospital is located in the Adiron- 
 dacks, four miles southeast of Saranac Lake and 
 six miles west of Lake Placid. There is an admin- 
 istration building, with a pavilion on each side con- 
 nected with the central building by wings to be 
 used as sun rooms. The 516 acres of land adjoin 
 the Forest Preserve. The altitude is 1,625 feet. 
 
 Application should be made to the nearest public 
 authorities having charge of the relief of the poor, 
 or to the official medical examiners, w^hose names 
 may be obtained from the superintendent. 
 
 North Carolina: ''The North Carolina State 
 Tuberculosis Sanatorium" (opened August, 1908). 
 For incipient cases only. Capacity: 30. Rates: 
 $10.00 per week, or actual cost of maintenance. 
 
 The site of the new State Sanatorium of North 
 Carohna comprises 936 acres of land, situated in a 
 
I90 TUBERCULOSIS 
 
 dry, sandy country at an elevation of 650 feet. The 
 Sanatorium buildings are located on a plateau of 
 about 200 acres. The site provides plenty of land 
 for reservation purposes, a good farm, an abund- 
 ance of fuel, and water for motive power. 
 
 The buildings are on the cottage plan, being 18 
 by 40 feet in dimension, and provided with piazzas 
 14 feet wide. The capacity of the institution will 
 be enlarged as occasion demands. It is the inten- 
 tion of the directors to establish a camp about a 
 half mile from the main building, where patients 
 may be able in part to care for themselves at $7.00 
 per month. Application should be made to the 
 superintendent. 
 
 Ohio: "Ohio State Sanatorium" (opened Jan- 
 uary I, 1909)- For incipient cases only. Capacity: 
 220. Rates: $5.00 per week. Ten per cent 
 of the cases may be taken free or at a reduced 
 rate. 
 
 The site of the Ohio State Sanatorium, at Mount 
 Vernon, comprises 335 acres of fertile, porous soil; 
 125 acres of woodland. Two large springs, with a 
 daily capacity of 250,000 gallons, furnish water 
 for the Sanatorium. The site is two miles from 
 the city of Mount Vernon, near the center of the 
 state. The capacity for 100 patients was pro- 
 vided in January, 1909. The completed plans 
 call for more than double this number of beds. 
 
STATE SANATORIA 191 
 
 Dr. CO. Probst advocated paying $5 a week to 
 patients doing work, as an inducement to stay 
 and make their cure more complete. 
 
 Pennsylvania: "Pennsylvania State South 
 Mountain Sanatorium " (opened in 1908). For cit- 
 izens of Pennsylvania suffering from pulmonary 
 tuberculosis and unable financially to go to private 
 sanatoria. Capacity: 350. There is no charge ex- 
 cept for laundry, the w^ashing being for the present 
 done at neighboring farmhouses. Patients are ex- 
 pected to pay for their own transportation and to 
 come well supplied with clothing. Shelter and 
 food are entirely free. 
 
 This Sanatorium was made possible by an ap- 
 propriation of $600,000 by the Legislature of 1907. 
 It includes and supersedes the small South Moun- 
 tain Camp Sanatorium, formerly conducted by the 
 Commissioner of Forestry, and also the private 
 Sanatorium of the Doctors Rothrock. The site 
 which includes about 600 acres is in the heart of 
 the Blue Ridge Mountains, on land formerly set 
 apart by the Forestry Commission. The grounds 
 include abundant water-supply and facility for 
 water-power, sewage, and drainage. 
 
 As soon as the money for this institution was 
 made available, in June, 1907, work was at once 
 commenced, and by August i, 1908, the Sana- 
 torium had accommodation for 350 patients. The 
 
192 TUBERCULOSIS 
 
 permanent unit of the Sanatorium will be a frame 
 cottage with the dimensions 27 by 24 feet, accom- 
 modating two persons in each of the four equal- 
 sized rooms. The cottages will be one story high 
 with an air space for ventilation, and will be so ar- 
 ranged that they can be throwm open to the air, 
 but protected from violent storms when necessary. 
 The heating ^vill be by stoves, and the roofs built 
 of asbestos shingles as a safeguard against fire. 
 The cottages will be twenty-five feet apart and 
 the streets will be fifty feet wide. 
 
 Dining rooms will be in common, one for each 
 four hundred patients. There will be bath houses 
 provided w^ith spray, douche, and shower baths, 
 but no bath tub. 
 
 Dr. Samuel G. Dixon, State Commissioner of 
 Health, says: ''It is anticipated that the South 
 IMountain Sanatorium will in a few years have a 
 capacity of three thousand patients." 
 
 Application should be made to the County 
 Medical Examiner in the district where the patient 
 lives. 
 
 Rhode Island: ''Rhode Island State Sanato- 
 rium" (Fig. 54), for incipient and early cases of 
 tuberculosis. Capacity: jio. Rates: $5.00 per 
 week. Trustees may admit patients free of 
 charge. 
 
 The State Sanatorium is located at Wallum 
 
194 TUBERCULOSIS 
 
 Lake, 650 feet above sea level, in the northwestern 
 corner of Rhode Island, on the Providence to 
 Southbridge branch of the N. Y., N. H. & H. 
 R.R. 
 
 The institution is built on the ward plan and 
 has a capacity of no beds. As the Sanatorium is 
 designed for the treatment of early cases, only 
 those patients are admitted who present a reason- 
 able prospect of arrest or cure, and patients who 
 fail to improve after admission will not be kept 
 indefinitely. The charge is $5.00 weekly, payable 
 in advance, but the Board of Trustees has au- 
 thority to admit patients free of charge. 
 
 Dr. H. L. Barnes, who is in charge of the insti- 
 tution, remains in touch with the physicians who 
 send patients there, not only while they are in the 
 institution but also afterwards. 
 
 Wisconsin: "Wisconsin State Tuberculosis 
 Sanatorium" (opened November 7, 1907). For 
 incipient and moderately advanced cases of tuber- 
 culosis. Capacity: 80. Rates: $10.00 per week 
 for those able to pay. Others are admitted free, 
 as county charges. 
 
 Wales, near which the State Sanatorium is 
 located, is on the Madison division of the Chicago 
 and Northwestern Railroad, 28 miles west of Mil- 
 waukee and 54 miles east of Madison. 
 
 The five buildings which comprise the sana- 
 
STATE SANATORIA 195 
 
 torium are about two miles from Wales, at an ele- 
 vation of 600 feet above sea-level. All of the service 
 buildings, except the administration building, are 
 of the "shack" type of construction. High moun- 
 tains on every side surround the Sanatorium and 
 shut off the cold winds. When entirely completed, 
 the institution will cost $120,000. 
 
 Application for admission must be made by ex- 
 amining physicians to the superintendent. In the 
 case of indigent patients, admission is by order of 
 the county judge. 
 
 Vermont: The State of Vermont has been so 
 fortunate as to receive from Senator Redfield 
 Proctor as a gift, a sanatorium which has been 
 erected and endowed at a cost of $200,000. The 
 control of the sanatorium is vested in a board of 
 fifteen trustees, which is a self-perpetuating body. 
 
 The Sanatorium is located near Pittsford in the 
 heart of the Green Mountains, in the western part 
 of the state a few miles north of Rutland. 
 
 The site consists of about 250 acres; two-thirds 
 of the tract is covered by woods or growing trees 
 and affords a natural park for summer camps. 
 
 The main building has a frontage of over 100 
 feet, the two cottages of about 80 feet each; the 
 three buildings with their connecting corridors 
 make a frontage of 400 feet. The buildings front 
 slightly east of direct south. They are situated 
 
196 TUBERCULOSIS 
 
 near the front of a high gravelly plateau. The 
 buildings are of brick veneer construction. The 
 interior finish is natural ash, with a few rooms in 
 birch. The floors are of hard wood. 
 
 All patients' rooms front either direct south 
 or southwest or southeast, and each two rooms 
 have a private outdoor porch where the patients 
 can sit out in the daytime and, if desired, sleep at 
 night. The doors are so arranged that the patients' 
 beds can be rolled out of the rooms on to these 
 private porches. 
 
 The sanatorium is intended for incipient and 
 moderately advanced cases of tuberculosis and has 
 at present a capacity of ^2 beds. The price is $7.00 
 per week. There are no free beds. 
 
 Applications should be made to the superin- 
 tendent. 
 
 It is an encouraging sign that besides the above 
 mentioned states which have already established 
 institutions, sanatoria are at this time either in con- 
 struction, or at least projected, in the following 
 states: Alabama, Connecticut, Indiana, Kentucky, 
 New Hampshire, and West Virginia. Equally 
 encouraging is the number of tuberculosis dis- 
 pensaries established during the last five years. 
 On April i, 1909, they numbered in the United 
 States 289. 
 
 If any community is in earnest in its anti- 
 
CONSUMPTIVE CRIMINALS 197 
 
 tuberculosis work, it must not limit its labors to 
 the man and woman morally and mentally sound, 
 but must extend them also to those temporarily or 
 seemingly permanently unsound in mind and mor- 
 als. I refer, of course, to prisoners and the in- 
 sane. 
 
 That consumptive insane patients may be 
 treated successfully for their tuberculous lesions, 
 and the condition of their minds be improved at 
 the same time, has been demonstrated during the 
 last few years in a large number of American 
 insane asylums. It is a hopeful and encouraging 
 sign that more and more attention is being paid to 
 this phase of the tuberculosis problem, for it can 
 not be denied that in former years many an insane 
 person has contracted tuberculosis during his stay 
 in the asylum. Of course, it must not be forgotten 
 that certain types of insanity as, for example, the 
 hypochondriac and others where the physical 
 vitahty in itself is lowered, strongly predispose to 
 tuberculosis. 
 
 The tuberculosis situation in many of our prisons 
 and reformatories is, perhaps, the most deplorable 
 of all. Three times as many prisoners die of tu- 
 berculosis as free men. It has been my privilege to 
 have been commissioned to examine a number of 
 prisons and to have appeared before associations 
 of prison physicians and general prison associa- 
 
198 TUBERCULOSIS 
 
 tions. As a result of all these studies I plead to- 
 day, as I often have before, for the examination 
 of every prisoner committed to a penal institution 
 at the time of his entrance, and periodically after- 
 wards; and I plead also for the examination of 
 individuals in detention prisons. As far as I could 
 learn from my visits to detention prisons in many 
 states, prisoners who are simply held for trial or 
 are waiting to be removed to the penitentiary, 
 are never examined by any physician unless they 
 are quite ill and in actual need of medical attend- 
 ance, or obviously afflicted with tuberculosis. It 
 must be evident that in this way a latent tuber- 
 culosis has a good chance to develop for, even 
 in the better city prisons, the usual overcrowding 
 will render the atmosphere vitiated, particularly 
 in winter. If we add to this the lack of exercise 
 and the depressing psychical influence of confine- 
 ment, nostalgia, and worry, we cannot wonder that 
 prisoners arriving at the penal institution are often 
 found to be tuberculous, some even with very ac- 
 tive lesions, while they may have entered the prison 
 of detention seemingly in good health. Again, 
 some may have been a little below par, underfed 
 or weakened by exposure, and as a result have 
 contracted tuberculosis from consumptive fellow 
 prisoners while in jail. I say this with no disre- 
 gard for the heroic attempts of many wardens 
 
CONSUMPTIVE CRIMINALS 199 
 
 and physicians to render modern detention prisons 
 as sanitary as possible. 
 
 In many city prisons the accused sometimes 
 await trial for six months or longer. They are not 
 occupied with anything, and are allowed to exer- 
 cise in the open air only once a week and for about 
 an hour and a half. It is well known that many de- 
 tention prisons are not at all hygienically built, and 
 that there exist additional depressing factors in 
 many of them well calculated to further tubercu- 
 lous diseases. 
 
 What can be done to strike at the root of this 
 deficiency in dealing with the tuberculosis problem 
 in prisons ? A competent staff of expert diagnos- 
 ticians should be attached to every detention prison 
 to examine each prisoner for tuberculosis, syphilis, 
 or other infectious diseases. The seeming increase 
 of expense which would arise from this, will 
 in the end result in a financial and sanitary 
 benefit to the community at large. I can also 
 see no reason why the prisoner who has means 
 should not be taxed to defray the expense for a 
 measure through which he himself derives the 
 greatest benefit. If he is himself unknowingly 
 afflicted with tuberculosis, the early recognition 
 may mean to him the saving of his life. If the 
 disease is recognized in one of his fellow prisoners, 
 he is protected from contracting it. 
 
200 TUBERCULOSIS 
 
 If prisoners would only have to remain in de- 
 tention prisons a short time, the enforced idle- 
 ness with one hour and a half open-air exercise 
 weekly might not be very injurious; but when 
 their time of detention is longer than three or 
 four weeks, a physical, mental, or moral deteriora- 
 tion is almost inevitable. No prisoner should be 
 detained for trial longer than four weeks, unless 
 it be in the interest of justice. It is at the very 
 beginning of incarceration and enforced idleness 
 that these factors produce the most depressing 
 effects, and if there is any predisposition to 
 tuberculosis, it is sure to develop then. When- 
 ever practicable, even detention prisoners should 
 be occupied with something useful and health- 
 sustaining. By this I do not mean forced labor. 
 Lastly, there should be some arrangement in the 
 detention prison to give the prisoner a sufficient 
 amount of exercise in the open prison court to 
 assure his physical well-being; not weekly, but 
 daily. 
 
 It would thus seem that the first step toward 
 the prevention of tuberculosis in penal institutions 
 should be a most careful examination of each 
 individual, and the weeding out and isolating of 
 all tuberculous prisoners detained in jails. The 
 tuberculous patient should remain isolated in the 
 detention prison as well as in the penal institution, 
 
CONSUMPTIVE CRIMINALS 201 
 
 and he should be given the benefit of hygienic 
 and dietetic treatment from the first moment he 
 becomes a ward of the state or city. 
 
 When the time for his transfer comes, the history 
 card of his disease and the recommendation of 
 the physician should be transmitted with the other 
 papers of the prisoner to the penal institution. 
 After his arrival at the prison in which he is to 
 stay for some length of time, the physician will de- 
 cide whether he is able to work or not, and what 
 kind of work might be most conducive to his re- 
 covery. There is no gainsaying that the ideal 
 occupation for the tuberculous prisoner is agricul- 
 ture or garden work. 
 
 I have stated before that not only should there 
 be a careful examination of every prisoner for tu- 
 berculosis when he enters the prison of detention 
 or the penal institution, but his chest should be 
 reexamined periodically at least once every three 
 months. With this periodical examination a very 
 incipient case, which might have escaped detec- 
 tion during the "entrance" examination, is sure to 
 be discovered before the disease has progressed to 
 any considerable extent. 
 
 Expectorating, except in proper receptacles 
 placed for that purpose in cells, workshops, 
 chapels, schools and on the grounds, should be 
 punished by severe disciplinary measures, That 
 
202 
 
 TUBERCULOSIS 
 
 there may never be an excuse for violating this 
 rule, I would go further. I would not only provide 
 a sufficient number of fixed, 
 elevated, suspended (Fig. 55), 
 simple, or self-flushing cuspi- 
 dors, such as or similar to the 
 ones illustrated (Figs. 40, 41), 
 but I would see that each pris- 
 oner has some sort of pocket 
 flask, or receptacle made of 
 metal, glass, or pasteboard. 
 (See Figs. 7,9, 11.) 
 
 A prison is, perhaps, the only 
 place in the world where spit- 
 ting regulations can be rigorously 
 enforced, and it is but fair that, if we say to an in- 
 dividual "don't spit here" and "don't spit there," 
 we should give him a chance to spit somewhere 
 when he has an excess of sahva, a cold, etc. I am 
 firmly convinced that with such a measure not 
 only would tuberculosis diminish in prisons but 
 epidemics of pneumonia or grippe would be less 
 to be feared and more easily controlled. I should 
 even like to recommend as a regulation that every 
 prisoner must hold his hand before his mouth 
 when coughing, whether this coughing spell is 
 followed by expectoration or not. Thus, tubercu- 
 Jous droplet infection will be avoided, and since 
 
 Fig. 55. Proedohl's 
 Iron Spittoon for 
 Use in Workshops. 
 
DROPLET INFECTION 203 
 
 the coccus of pneumonia is so very prevalent even 
 in the mouths of healthy individuals, this precau- 
 tion may perhaps also tend to the diminution of 
 pneumonia. As an additional measure to prevent 
 droplet infection, it might be well never to put 
 prisoners too close together at the work tables. 
 It goes without saying that the personal and bed 
 linen of the tuberculous prisoner, as well as his 
 clothing, should be regularly subjected to disin- 
 fection. The handkerchiefs of this class of pris- 
 oners should consist of squares of cheap muslin, 
 which should be burned after use. 
 
 To judge from the appearance of the various 
 kinds of blankets, comforters, and quilts which 
 were lying on the cots of the prisoners' cells in 
 some of the penitentiaries I have visited, it seemed 
 to me that these coverings might become a means 
 of spreading infection, not only in tuberculosis 
 but in a good many other communicable and con- 
 tagious diseases. The blanket and comforter are, 
 as a rule, the private property of the prison inmate. 
 He brings these articles with him, or they are 
 given to him by visiting friends or by fellow 
 prisoners who have been discharged. In most 
 prisons these coverings, as well as the clothing 
 which the prisoner wears on entering the penal 
 institution, are carefully disinfected. This pre- 
 caution does not, however, suffice to prevent the 
 
2o4 TUBERCULOSIS 
 
 bed covering from becoming thoroughly infected 
 aften^^ards, particularly with the germs of tubercu- 
 losis. Pulmonary tuberculosis is so insidious in 
 the early stages that the prisoner may have infected 
 his bed clothing long before his disease has been 
 discovered by the prison physician, unless, of 
 course, frequent and thorough examinations of 
 all prisoners are in vogue. To guard against in- 
 fection which may arise from blankets, comforters, 
 etc., having been soiled by infectious sputum or 
 other infectious material, I would suggest that 
 after thoroughly disinfecting these articles w^hen 
 they are brought to the prison, they be incased in 
 a covering of light-colored washable material (not 
 necessarily white), as one uses a pillow-case. By 
 basting the blanket in its "blanket-case" it can be 
 manipulated with as much ease as if uncovered. 
 With comforters and quilts the same method 
 should be pursued. There should be two sets 
 of cases so that the blankets need not remain un- 
 covered while one is being washed ; thus the blank- 
 ets need never come in direct contact with the 
 prisoner's body. I am convinced that with such 
 a system and with the injunction that the washing 
 must be done regularly, one factor of transmitting 
 tuberculosis and other infections from prisoner 
 to prisoner will be done away with. 
 
 Even the prisoner who is only suspected of 
 
CONSUMPTIVE CRIMINALS 205 
 
 having tuberculosis should have a separate cell 
 and, in any case, the placing of two prisoners in one 
 cell should be avoided as much as possible. The 
 bucket system for receiving the ejecta of prisoners 
 during the night and during the day when con- 
 fined to their cells, is most deplorable. It is un- 
 sanitary in general, and as far as it permits the 
 emanation of odors and gases, it is deleterious 
 to the health of the inmate. The individual cell 
 water-closet, with a perfect trap and cover, such 
 as is used for example in our New York Tombs 
 and other new prisons, is certainly to be recom- 
 mended in place of the bucket system. 
 
 The more advanced cases of tuberculosis, par- 
 ticularly those with constant fever and in whom 
 there is disintegration and corresponding abundant 
 expectoration of bacilli, should be treated in special 
 wards; and in summer, perhaps, in special tents 
 of the prison hospital. 
 
 In view of the probable indifference to hygienic 
 regulations of the inmates of the hospital, I would 
 insist, for the purpose of preventing droplet infec- 
 tion, that all patients in the more advanced stages 
 must wear a mouth mask. Patients in a number 
 of European hospitals for consumptives are told 
 to make use of mouth masks in order to protect 
 themselves as well as the other patients. Figure 
 56 shows such a device. It is known as Professor 
 
2o6 
 
 TUBERCULOSIS 
 
 Frankcl's mouth mask. I really think it a valuable 
 means to prevent droplet infection which, with 
 
 the advanced 
 
 cases among 
 
 a, <^g..^y^^^^:B^}::^f^ ^ ^^ consumptives, is 
 
 quite a serious 
 factor in the 
 propagation of 
 the disease. By 
 impregnating 
 the gauze which 
 
 Fig. 56. Frankel's Mouth Mask. j^ j^^j^ j^ pj^^^ 
 
 by the metallic frame of the mask with some me- 
 dicinal substance, the inhalation of which allays the 
 cough and is soothing to the inflamed pulmonary 
 surface as, for example, 10 or 15 drops of a mixture 
 composed of equal parts of menthol, eucalyptus 
 oil or creosote, and spirits of chloroform, the 
 prisoner wearing the mouth mask is likely to be 
 benefited and the protection of others is assured. 
 
 The custom of whitewashing a room in which 
 ordinary and healthy individuals stay but a short 
 time might be considered a hygienic procedure. 
 When, however, this process has been adopted 
 for the sake of doing away with tlie danger of 
 tuberculosis, I doubt its efhcacy. If a cell has 
 been previously occupied by a tuberculous pris- 
 oner, he will surely have infected its walls; if not 
 
DANGER FROM WHITEWASH 207 
 
 directly by expectorating on them, he will have 
 done so by droplet infection. Whitewashing is 
 well-nigh useless in such a case, since dried white- 
 wash is apt to scale off, especially when there are 
 several coats, and it will produce a certain amount 
 of dust in a small room like a cell. This dust is 
 irritating to a sensitive lung, and it is not unlikely 
 that it may be an aggravating factor with prisoners 
 who enter the penal institution only slightly 
 tuberculous, or predisposed. The new occupant, 
 if at all debilitated, physically or mentally de- 
 pressed, is much exposed to the contraction of 
 tuberculosis in such an environment. The new 
 coat of whitewash is apt to scale off with the un- 
 derlying infected layer, and turning into dust 
 makes an infection by inhalation par excellence. 
 
 That tuberculous germs may be inhaled from 
 infected walls has been demonstrated again and 
 again, not only inside of prisons, but in the tene- 
 ment houses of the poor and even in the apartments 
 of the rich. My friend Dr. Ransom of the Danne- 
 mora prison, with whom I had many conversa- 
 tions on the subject, expresses himself as follows: 
 "Observation and experiment show that white- 
 wash really promotes the spread of tuberculous 
 disease. The fine scales and floating particles 
 that emanate from the dried whitewash, when 
 disturbed, not only irritate the bronchial mucous 
 
2o8 TUBERCULOSIS 
 
 membranes, but they are also carriers of infection 
 to the point irritated." 
 
 To remedy the danger arising from whitewash- 
 ing small cells, I would suggest that the white- 
 wash be replaced by oil paint which can be washed 
 with disinfecting fluids. The cells should, of 
 course, never be smaller than five hundred to 
 six hundred cubic feet, w^ll ventilated and well 
 lighted by natural light in daytime, and by elec- 
 tric light at night (gas illumination absorbing too 
 much oxygen). 
 
 As to the general sanitation of prisons as far 
 as it is related to tuberculosis, I only wish to say 
 that a prison with all its annexes should be con- 
 structed so that there is plenty of light and venti- 
 lation, and on a soil that is dry and porous. 
 
 To avoid acquiring a predisposition or develop- 
 ing an incipient case, I would suggest the follow- 
 ing: All prisoners should be given a chance to 
 exercise several times during the day in the open 
 air, even if only for a short time, and during that 
 time they must not only be permitted, but should 
 be enjoined to take deep inhalations, or better yet, 
 regular respiratory exercises. The exercise in the 
 open air should, however, not be limited to week- 
 days. According to the prison regulations now in 
 vogue in most penal institutions, prisoners are 
 confined to their cells not only from the hour of 
 
EXERCISES FOR PRISONERS 209 
 
 five in the afternoon to six in the morning, but 
 also during almost the entire twenty-four hours of 
 Sundays and holidays, and when a holiday follows 
 a Sunday, or vice versa, the prisoners are necessa- 
 rily locked up in their cells for two successive days. 
 That such close long confinement in a small, ill- 
 ventilated cell must be harmful is self-evident. 
 
 In well-conducted prisons the inmates are re- 
 quired to bathe regularly, and their skin is usually 
 in good condition. To the prisoner predisposed 
 to tuberculosis or one whose case is so incipient 
 that constant medical supervision is not neces- 
 sary, permission for daily cold douches should be 
 given. To this class of prisoners, predisposed or 
 incipient, it seems to me also that it would pay 
 the state to give food containing a little more of 
 the nitrogenous substances and the carbohydrates 
 than the regular prison fare now supplies. 
 
 One predisposing factor to tuberculosis in 
 prisons, which seems to have been overlooked 
 in most of the reports on the subject, is over- 
 working the prisoners. While it is true that in 
 the majority of prisons the hours of work are 
 rarely more than those of the average free laborers, 
 we must not forget that the free man, laboring 
 eight or ten hours a day, has a relatively better 
 quality of food, the exhilarating influence of 
 freedom of action, and naturally superior hygiene. 
 
2IO TUBERCULOSIS 
 
 I do not wish to make this statement in the spirit 
 of criticism, but simply to point out the general 
 likelihood of a predisposed individual develop- 
 ing tuberculosis more rapidly under conditions of 
 confinement than when in normal environments. 
 
 It is not necessary to speak of any particular 
 prison here, but in many of them the workshops are 
 very badly ventilated, overcrowded with workers, 
 often overheated, and where there should be dust 
 collectors these are wanting. Tobacco workers, 
 for example, are prone to tuberculosis under the 
 best conditions. How much more must they 
 be in danger in a prison workshop full of dust, 
 where there is hardly elbow room and where the 
 air is greatly vitiated ! Since it is a very common 
 practice for cigarmakers to paste the final leaf with 
 saliva, it must be evident that no prisoner, even 
 slightly afflicted with tuberculosis, should be per- 
 mitted to make cigars, leaving aside the fact that 
 such conditions are sure to aggravate his disease. 
 
 I can not leave the subject of tuberculosis in 
 prisons without referring to one phase of it which 
 appertains rather to the welfare of the community 
 at large. I refer to the pardoning of prisoners far 
 advanced in tuberculosis. Whether the practice 
 of restoring the pardoned prisoners to their often 
 poor families is always a wise one, I venture to 
 question seriously. It is sad enough that prisoners 
 
EXERCISES FOR PRISONERS 
 
 211 
 
 who have contracted tuberculosis in prison, or 
 whose tuberculosis has been aggravated through 
 prison life, should be discharged upon the com- 
 munity at the expiration of their sentence without 
 any regard to where they will go or what they 
 will do. They will invariably constitute a source 
 of infection unless they have been prophylactically 
 trained and are willing to continue to be careful. 
 Prisoners virtually dying from tuberculosis should 
 not be pardoned and sent home, unless the au- 
 thorities are sure that the unfortunate sufferer will 
 be able to find support and not become a source 
 of infection. 
 
 The treatment of advanced cases has already 
 been referred to, but in this connection I wish to 
 say a word about the admirable w^ork done at 
 the Texas tuberculosis agricultural prison colony, 
 known as the Wynne State Farm, under the scien- 
 tific and humane management of Dr. Fowler. 
 The statistics of four years' working of this farm 
 are as follows : 
 
 Total number discharged 
 
 • 34 
 
 (I u 
 
 pardoned 
 
 . 30 
 
 ft il 
 
 transferred 
 
 . 37 
 
 il 11 
 
 died 
 
 . . 46 
 
 it a 
 
 on hand 
 
 • 33 
 
 Total number treated 
 
 . 180 
 
212 TUBERCULOSIS 
 
 At the conclusion of Dr. Fowler's interesting 
 report he comments on the statistics as follows: 
 ''I will say that the thirty-seven men transferred 
 are virtually cured, at least one-half of those 
 pardoned and discharged were in good physical 
 condition, and the majority on hand are improv- 
 ing. The labor of the one hundred and eighty 
 men was practically of no value anywhere else in 
 the prison as most of them had reached an ad- 
 vanced stage of tuberculosis before their recep- 
 tion at the Wynne Farm. The farm is more than 
 self-sustaining, if the expense of guarding the 
 prisoners is deducted. The men all occupy the 
 same building, as they have to be guarded day 
 and night." 
 
 From the report it is evident that tuberculosis 
 has been on the decrease in that prison, and there 
 is no doubt in my mind that the tuberculous 
 prisoner, cured by a healthful and invigorating 
 agricultural pursuit, will be returned to society 
 after the expiration of his sentence many times a 
 better member of it than he was formerly. 
 
 A most important feature in the prevention of 
 tuberculosis, or more exactly, in the prevention 
 of a predisposition to tuberculosis, is the restric- 
 tion of child and woman labor. It is impossible 
 to resist the invasion of the bacilli when the in- 
 dividual is in a state of physiological poverty. 
 
WOMAN'S AND CHILD LABOR 213 
 
 This condition is sometimes called being "below 
 par." A woman, who in perfect health and under 
 normal conditions may do her physical and mental 
 labors as well as anybody else, should not, in a 
 civilized and enlightened country, be allowed to 
 work in either factory, workshop, sweatshop, or 
 at home until virtually the last day before her 
 delivery; nor should she be allowed to resume her 
 labors until a month or two after confinement. 
 That horrible condition known as child labor, 
 still in existence in some of our states, should for- 
 ever be done away with, and laws should be 
 enacted and enforced that will make it impossible 
 for a child to be forced to spend hours and hours, 
 sometimes ten, twelve, or fourteen a day, in a 
 factory or workshop, often under the most un- 
 hygienic conditions. 
 
 The growing organism of a child is in need of 
 all the fresh air and outdoor exercise it can pos- 
 sibly get, and to confine it indoors during the 
 years of its physical development, often in an 
 overheated, dusty, and smoky atmosphere, and to 
 overtax its muscular and nervous system by long 
 hours of work, is the very thing which causes the 
 physiological poverty above referred to. If a 
 child has contracted tuberculosis during infancy, 
 and because of a certain amount of outdoor play 
 and good care during early childhood the tuber- 
 
214 TUBERCULOSIS 
 
 culosis has become latent, though not entirely 
 cured, it is almost certain to develop and become 
 active if he is put to work between the ages of ten 
 and fourteen. The child's body is arrested in its 
 development and his chest capacity becomes much 
 below normal. Lack of sleep and recreation cause 
 him to become an easy prey to the tubercle bacilli 
 under these conditions, even if his system has 
 not been invaded by them in infancy. No child 
 between the ages of eight and fourteen should be 
 allowed to do more than his school work. The 
 home, the school, and the playground should be his 
 only abodes. 
 
 By reason of their environment, and unfortu- 
 nately also often by reason of example in home or 
 workshop, children that are compelled to work 
 become very readily addicted to the use of alcohol. 
 Their humdrum existence often makes them in- 
 different to any moral issue; their weakened ner- 
 vous system can not resist temptation and often 
 craves for stimulation and excitement. Alcohol 
 predisposes to tuberculosis in the child as well as 
 in the adult, and the prevention of child labor will 
 in many instances prevent both alcoholism and 
 tuberculosis. 
 
 Sweatshops, that is to say the manufacture of 
 any article in the crowded homes of the poor, 
 should be absolutely prohibited everywhere. In 
 
WOMAN'S AND CHILD LABOR 215 
 
 my work in the tenement homes I have again 
 and again seen overcrowded rooms used as work- 
 rooms during the day and as bedrooms at night, 
 and among the workers I often found more than 
 one tuberculous individual in the most active 
 stage of the disease. When we recall the numerous 
 sources of infection from close contact, do we need 
 to wonder that tuberculosis is most frequent 
 among the toilers in the tenements and particu- 
 larly among those who work at home ? 
 
 The sanitary supervision of all factories with 
 reference to proper ventilation, dust catchers, pre- 
 vention of overcrowding, proper washroom and 
 toilet facilities, must form an important part of 
 the legislation of any state desiring to protect its 
 laborers against contracting tuberculosis. The 
 hours of work should be regulated by law, so that 
 overwork and overstrain maybe avoided, and thus 
 a predisposing factor to tuberculosis removed. 
 It might even be wise to issue anti-spitting regula- 
 tions for factories, to compel the employers to 
 provide a sufficient number of well-kept cuspi- 
 dors, and to make promiscuous expectorating on 
 floor and walls punishable by discharge. The 
 automatic flushing spittoons already shown in 
 Figs. 41 and 42 and the Proedohl's spittoon of 
 iron (Fig. 55) seem to be particularly well adapted 
 for sputum receptacles in factories, workshops, etc. 
 
2i6 TUBERCULOSIS 
 
 Industries which are particularly dangerous re- 
 garding tuberculosis, should be made the subject 
 of special study on the part of the legislators in 
 order to minimize, as far as possible, the danger 
 to the workmen and the hardship to the manu- 
 facturer. 
 
 In Chapters II and VI we have spoken of the 
 prevention of tuberculosis through the milk and 
 meat supply. It is necessary here to say a few 
 words on the duties of state legislation regarding 
 bovine tuberculosis. Every state should have 
 bovine laws so framed that by their enforcement 
 no injustice can be done to farmer, consumer, or 
 resident in a neighboring state. When, with the 
 aid of tuberculin or other tests, cattle are found 
 tuberculous to a degree that their destruction 
 becomes necessary, it should be the duty of the 
 state to compensate the farmer for his loss. No 
 tuberculous meat should be allowed to reach the 
 market. There should be reciprocity between 
 neighboring states; for if one state has good 
 bovine laws, destroys the cattle and compensates 
 the owner, and the other state has no bovine laws 
 at all, this will at times tempt unscrupulous 
 individuals, under the shadow of the night, to 
 drive their tuberculous cattle into the neigh- 
 boring state with good bovine laws where they 
 will be paid for. When all states will have these 
 
GOVERNMENT SANATORIA 217 
 
 laws, such unscrupulous conduct will not be 
 possible. 
 
 Our federal government has also its part to 
 play in the combat of tuberculosis. The one class 
 of men in the United States government employ 
 among whom tuberculosis is relatively rare, is the 
 army and, perhaps, also the navy. This is due, 
 on the one hand, to the fact that men of weak 
 constitution are not accepted for mihtary service, 
 and on the other, to the thorough training of our 
 military and naval physicians, who examine every 
 candidate for the army and navy most carefully 
 for the possible existence of tuberculosis, and thus 
 avoid sources of infection in the military or naval 
 service. When a soldier or sailor does develop 
 tuberculosis during his service, his condition, as 
 a rule, is readily discovered; he is isolated and 
 treated and usually transferred to one of the exist- 
 ing federal sanatoria, situated at Fort Stanton, New 
 Mexico, for the Marine Hospital Service; at Fort 
 Bayard, New Mexico; and at New Fort Lyon, 
 Colorado, for the army. 
 
 It would, nevertheless, be an admirable thing 
 and helpful in the prevention of tuberculosis, to 
 instruct every United States soldier and sailor in 
 the simple principles of the prevention of tubercu- 
 losis. This would not only be helpful to the men 
 themselves, but would make them educational fag- 
 
2i8 TUBERCULOSIS 
 
 tors in hygiene when they returned to civil hfe or 
 entered other spheres of federal activity. 
 
 There is also an army of men in the government 
 non-military services whose mortality from tu- 
 berculosis could be vastly decreased. I refer par- 
 ticularly to the thousands of post-office employees. 
 The Postmaster-General's order, No. 855; in the 
 Daily Bulletin, No. 7,966 of Aprils, 1906, contains 
 the following: 
 
 Regulations to Prevent the Spread of Tubercu- 
 losis IN Government Buildings, Offices, and 
 Workshops. 
 
 1. All persons in Government employ are positively 
 
 forbidden to spit upon the floors. 
 
 2. Rooms, hallways, corridors, and lavatories shall be 
 
 freely aired and effectually cleaned at least once a 
 day, and not during working hours. 
 
 3. Spittoons shall receive a daily cleansing with very 
 
 hot water and when placed ready for use must 
 contain a small quantity of water. 
 
 4. Dust must be removed as completely as possible by 
 
 means of dampened cloths or mops. It should 
 never be needlessly stirred up l)y a broom or 
 duster, as this practice only spreads the dust and 
 germs. 
 
 5. Floors of tiling, brick, or stone must be frequently 
 
 scoured with soap and water. 
 
 6. The senior clerks in charge of workrooms will take 
 
GOVERNMENT REGULATIONS 219 
 
 measures to secure, during working hours, the ad- 
 mission of as much fresh air and sunshine as the 
 conditions will permit. 
 
 7. The use of individual drinking glasses is recom- 
 
 mended. 
 
 8. Persons in Government employ who suffer from 
 
 pulmonary tuberculosis shall, when possible, be 
 separated from others while at work. 
 
 9. Such persons will not be permitted to use the public 
 
 spittoons, but must provide themselves with in- 
 dividual sputum receivers, preferably of easily 
 destructible material, and carry these with them 
 on arrival and departure. They will be held 
 strictly responsible for the disposal and destruc- 
 tion of their own sputum, so that no other per- 
 son's health may be endangered therefrom. 
 
 10. Such persons must provide their own drinking 
 
 glasses, soap, and towels, and shall not use those 
 provided for the general use. 
 
 11. Plainly printed notices, reading as follows: "Do 
 
 Not Spit on the Floor; To Do So May 
 Spread Disease," shall be prominently posted 
 in rooms, hallways, corridors, and lavatories of 
 public buildings. 
 
 These regulations as a whole are excellent, but 
 from conversations I have had with a number of 
 post-office employees and even postmasters, it 
 seems that there are unfortunately not enough 
 helpers, such as charwomen, janitors, and cleaners, 
 
22d TUBERCULOSIS 
 
 to carry out these admirable instructions. The 
 floors are not scrubbed and cleaned nearly often 
 enough when one considers how many men work 
 in these rooms. There should be more workrooms 
 in all of our post-offices so that one section can al- 
 ways be cleaned without interference with the work, 
 and in this cleaning and scrubbing the pigeonholes, 
 which are natural dust-collectors, should not be 
 forgotten. The cleaning should naturally be done 
 when the smallest number of employees are in the 
 office, and preferably always by the pneumatic 
 cleaning process. The corridors, lobbies, and other 
 portions of the average post-office building to 
 which the public has access, are usually kept in 
 pretty fair condition; but it is not always so with 
 the rooms in which the men work behind the 
 screens. 
 
 There is no government service which touches 
 the people so directly or to so great an extent as 
 does the postal service, and this induces me to 
 speak of another source of infection to which too 
 little attention has been paid heretofore. There 
 is scarcely a citizen of this country who does not 
 sooner or later receive matter through the medium 
 of the mails. This mail is conveyed from one 
 place to another in receptacles made of canvas; 
 these receptacles are used until they become un- 
 patchablc, but arc never cleaned. As these sacks 
 
CLEANING MAIL BAGS 221 
 
 become torn, they are sent to the mail-bag repair 
 shop and are patched. When in use they are 
 more or less heavy and are thrown from the cars 
 or dragged by the cords over the railroad plat- 
 forms and approaches, and also through the ofhce. 
 If a consumptive is on the platform waiting for 
 his train and has expectorated before the mes- 
 senger comes along dragging the mail over the 
 platform in the canvas sack to the car, this sputum 
 is wiped up by the canvas sack and dries, and the 
 next time the sack is thrown out or handled in the 
 post-ofhce, the air is impregnated with bacilli-laden 
 dust. The man handling the sack, sooner or later 
 has his hand to his mustache or mouth, in ad- 
 dition to being exposed to inhahng the infec- 
 tious dust. 
 
 It has been said that the mail is on the inside 
 and the infection on the outside of the bag, but 
 this is begging the question. Eventually, all of 
 these sacks are rounded up in some depository 
 for shipment, and the result is that some nineteen 
 sacks are folded and placed inside the twentieth 
 sack as a receptacle. This is the manner in which 
 they are stored and shipped. If a sack full of these 
 empties is shipped from Chicago to New York, 
 the outsides of the nineteen bags are rubbing 
 against the inside of the twentieth bag all the way 
 to New York, and the filth and dirt is left inside 
 
222 TUBERCULOSIS 
 
 this nventieth bag, in which mail is deposited at 
 New York for delivery at some other office, and 
 this mail rubs up against the inside of the sack 
 and then proceeds to a thousand homes or com- 
 mercial offices. 
 
 It would seem entirely practical to clean these 
 mail receptacles or sacks. It could be done with 
 very little expense in the following manner, which, 
 briefly stated, is to establish at, at least three 
 points, one central and one on each coast, deposito- 
 ries for mail sacks to which they could be sent to be 
 disinfected and cleaned. There should be a suf- 
 ficient supply of equipment so that, for instance, 
 all sacks coming into New York, Chicago, San 
 Francisco, or other selected points, could be sent 
 to some place for treatment before being used 
 again; and all of those which, upon inspection, 
 showed the need of cleaning could be sent direct 
 to the nearest depository. A one-story structure 
 built along a railroad, where shipping facilities 
 could be provided and preferably where water- 
 power could be obtained, would be required. 
 This building w^ould have at one end a receiving 
 room, in which the office for the necessary records 
 would be situated, and the sacks would be sepa- 
 rated according to size and character and trans- 
 fered to the next room, where there should be 
 cylindrical washing machines revolving in a pit. 
 
CLEANING MAIL BAGS 223 
 
 in which the water could be boiled by steam pipes 
 and into which and from which it could pass by 
 means of large cocks. Disinfectants should be 
 used in this water, and after the bags had been 
 boiled, disinfected, and washed, they could be re- 
 moved to the opposite side of this room, adjoining 
 which would be a dry room; this dry room would 
 have a travelling link belt with hooks upon it, 
 which would pass through drums to change its 
 direction, so that the bags would go in through 
 trapdoors at one side of the room, pass back and 
 forth and out at the further corner. Here they 
 could be removed automatically from the hooks, 
 dropped into a slide, and run through a mangle 
 simply to smooth them out. From this they 
 could be reassembled and stored in a shipping 
 room at the farther end, from which they could be 
 sent out again for general use. 
 
 I am indebted to a friend, who has had a large 
 experience both in post-ofhce work and in public 
 sanitation, for a little sketch which I take pleasure 
 in reproducing here, showing how the cleaning 
 and disinfection of empty mail bags can be done 
 easily and cheaply. (Fig. 57.) 
 
 This is, of course, only intended as the rough 
 suggestion of a general plan, and the details 
 would have to be v/orked out. 
 
 I wish to say one more word about preventing 
 
224 
 
 TUBERCULOSIS 
 
 D t~^ 
 
 E ^ 
 
 Fig. 57. 
 
 Plan of Station for Cleaning and Disinfecting Post-office 
 Mail Bags. 
 
 the development of tuberculosis among our post- 
 office employees and other men in federal civil 
 service. First of all, a very strict and careful 
 physical examination by a competent physician 
 should be made of every one who is now an em- 
 ployee in these services. Secondly, every applicant 
 to one of these services should be examined, and 
 only if found free from tuberculosis should he be 
 admitted to the service. To each large post-office 
 should be attached a physician to whom employees 
 might apply for reexamination at stated intervals. 
 Should any one be discovered to be tuberculous, 
 he should be at once excluded from indoor service 
 and be placed under proper treatment. One of 
 the physician's duties should also be to watch over 
 
GOVERNMENT EMPLOYEES 225 
 
 the sanitation of the post-office buildings and 
 workrooms. 
 
 To make the treatment of the government's 
 tuberculous employees possible, it would be a most 
 excellent thing for the United States government 
 to have not only a sanatorium for its consump- 
 tive soldiers and sailors, but also one for its 
 faithful servants who contract tuberculosis in the 
 non-military service of the government. 
 
 To municipal authorities, state, and federal au- 
 thorities alike, we would finally recommend the 
 establishment of horticultural and agricultural 
 colonies and similar kinds of outdoor labor centers 
 where the relatively cured consumptive could have 
 a chance, by healthful labor and careful living, 
 to complete his cure or make it more lasting. 
 There is to my mind no greater fallacy and no 
 greater waste of money than for the state or mu- 
 nicipality to cure the tuberculous poor who come 
 from the most unhygienic surroundings and most 
 unhealthful occupations, and then to return them 
 again to the same unhygienic environments or to 
 the same unhealthful occupation from which they 
 came. In my humble opinion, it would even pay 
 to have a municipal or state labor bureau, by the 
 aid of which suitable occupations could be found 
 for individuals leaving the sanatorium. 
 
 I must not forget in this chapter to mention one 
 
226 TUBERCULOSIS 
 
 more matter which is most important in the cru- 
 sade against tuberculosis. Our statesmen should 
 do all in their power to stem the ever rising tide of 
 emigration from village to city. We should strive 
 to reverse this tendency. The interests of the 
 farmer should be considered so that farming will 
 have more attraction to the rising generation than 
 it has had in the last few decades. If philanthro- 
 pists can be interested in this work, all the better; 
 but the state should be rich enough in itself to 
 endow institutions for instruction in scientific and 
 profitable agriculture, and also to provide health- 
 ful amusements, good libraries, and other educa- 
 tional institutions in country districts, thus making 
 living outside of large cities more interesting and 
 attractive to young people; in short, the love of 
 nature and life in the open air should be more cul- 
 tivated. In the proportion in which this is done, 
 tuberculosis will decrease. 
 
 The creation of schools of forestry in connection 
 with the preservation and cultivation of forests in 
 many states where a wasteful destruction. of trees 
 is now carried on, would give useful and healthful 
 employment to numbers of people, as well as ren- 
 der the region more healthful. It would offer 
 attractive careers to young men seeking to over- 
 come hereditary or accjuired tendencies to tuber- 
 culous diseases. 
 
GOVERNMENT METHODS 227 
 
 To combat tuberculosis successfully in a coun- 
 try like our own, there must be cooperation of 
 municipal, state, and federal governments. Such 
 cooperation exists in most European countries 
 where there is either a Department of Public 
 Health with a minister at its head or a bureau 
 equivalent in rank, as for example "das Reichs- 
 gesundheitsamt " in Germany and the "Conseil 
 Superieur de Sante Pubhque" of France. It is 
 most gratifying to learn that the Hon. Wm. H. 
 Taft, President of the United States, has recently 
 pronounced himself distinctly in favor of such a 
 department or federal bureau of health. Shortly 
 after his inauguration last March, one of his first 
 actions was to approach the Surgeon-General of 
 the Public Health and Marine Hospital Service as 
 to the advisabihty of establishing, in Hne with prac- 
 tical government methods, a new Public Health 
 Bureau, as suggested to him by the Committee of 
 One Hundred, the American Health League, and 
 the American Medical Association. Thus, it seems 
 that President Taft has realized that to combat 
 tuberculosis successfully requires not only well- 
 trained physicians and an intelligent people, but 
 also a wise government taking an active part in 
 the work. 
 
CHAPTER VIII 
 
 WHAT EMPLOYERS OF EVERY KIND CAN DO TO 
 DIMINISH TUBERCULOSIS AMONG THE MEN AND 
 WOMEN WORKING EOR THEM 
 
 Factory hygiene and sanitation should not be 
 merely a matter attended to because of the laws 
 enacted and enforced by the state or city. Fac- 
 tory inspectors, employers of large forces of men 
 and women, factory owners and managers, store- 
 keepers, and all others having men and women in 
 their employ, should realize that the better the hy- 
 gienic conditions are which environ their employ- 
 ees, the better the work will be done and the fewer 
 will be the absences on account of illness. The 
 employer who has the welfare of his employees at 
 heart can do an infinite amount of good in the pre- 
 vention of fb'sease, and particularly of tuberculosis. 
 To this end, he shoukl begin by seeing that the 
 lighting, heating, and ventilation are as perfect as 
 they can possibly be in factory, workshop, ofiice, 
 store, or kitchen, and the amount of dust and odors 
 in all such places should be reduced as much as 
 
 possible. Spitting regulations should be enforced 
 
 228 
 
FACTORY AND OFFICE HYGIENE 229 
 
 and suitable well-kept cuspidors placed through- 
 out the buildings. 
 
 In the preceding chapters I have spoken of 
 factory hygiene, but we must not forget that be- 
 sides the factory workers there are thousands of 
 employees and clerks in offices and stores, who are 
 often exposed to the inhalations of vitiated air 
 and dust not infrequently mingled with disease- 
 producing organisms, among which those of 
 tuberculosis are almost sure to be found. 
 
 Often in the offices of the wealthiest corporations, 
 bankers, and great commercial concerns, the air 
 is about as foul and vitiated as it can well be. 
 These conditions are, no doubt, permitted to exist 
 through ignorance of the importance of fresh air. 
 It is interesting to observe that the heads of the 
 offices expose themselves to the same unhygienic 
 environments as their employees. They seem to 
 forget that a glass wall, a few feet in height, 
 does not prevent them from breathing the air 
 exhaled and used up by their employees. If 
 the artificial ventilation is not sufficiently per- 
 fect to assure fresh, good air all the time in these 
 offices, the only remedy is to open the windows fre- 
 quently to change the air, and this change of air 
 should be made even when the weather is cold. 
 Wherever possible, the lighting of any office or fac- 
 tory, workshop, store, or even kitchen should be by 
 
230 TUBERCULOSIS 
 
 electricity. Gas consumes the oxygen needed for 
 the human beings, and unless there is a constant 
 supply of fresh air in any room lighted by gas and 
 filled with human beings, the atmosphere is bound 
 to be deficient in oxygen and with carbonic acid 
 gas in excess. Toilet and washing facilities should 
 be perfect everywhere, but particularly so where a 
 great many people are employed. 
 
 There are industries in which, during the hours 
 of work, laborers are often exposed to a high 
 temperature. In some occupations the laborers 
 work half stripped, as otherwise they could not 
 stand the heat. In such cases especial facilities 
 should be provided for the laborers to cool off 
 gradually in order to avoid the often serious con- 
 sequences of going from an overheated room half 
 nude into a cold apartment to dress. In industries 
 connected with a great deal of dust, special dust- 
 collectors should be installed and, if necessary, la- 
 borers should be provided with respiratory masks. 
 
 These precautions will do much for the pre- 
 vention of the predisposing factors to tuberculosis, 
 for as it has been said before, fresh, pure air and 
 cleanliness are powerful agents in protecting an 
 individual from the attacks of disease. 
 
 We have already spoken of the anti-spitting 
 regulations and the needs of their enforcement in 
 order to diminish the direct sources of infection 
 
FACTORY AND OFFICE HYGIENE 231 
 
 which heretofore have caused so many employees 
 in factories, workshops, stores, and ofhces to be- 
 come victims of consumption from the dissemina- 
 tion of bacilh through indiscriminate expectorating. 
 To such ordinances there should be added a rule 
 something like this: It is just as important to 
 hold a hand or handkerchief before the mouth 
 when coughing as it is to expectorate into a proper 
 receptacle. This can not be mentioned too often, 
 for the possibility of droplet infection has been 
 much overlooked, and because of its insidious- 
 ness it is all the more dangerous when men work 
 close together indoors. 
 
 Another important step to prevent direct infec- 
 tion from tuberculosis, here as elsewhere, is the 
 careful examination of every employee entering 
 a workshop, factory, store, office, etc.. By this 
 method a patient afflicted with an open tuber- 
 culosis, that is to say, with the disease in a stage 
 in which he needs treatment and care and in which, 
 unless he receives treatmient and care he may con- 
 stitute a source of infection to others, may be ex- 
 cluded. This exclusion is, of course, particularly 
 necessary when the work which is expected of the 
 patient is arduous and when he is placed in close 
 contact with other workmen. 
 
 To prevent tuberculosis in these places w^here 
 many people work, it does not suffice merely to 
 
232 TUBERCULOSIS 
 
 examine the patient on entering the employment; 
 it will also be necessary to reexamine all employees 
 at least once, but, better yet, twice a year in order 
 to ascertain whether tuberculosis may not have 
 developed since their entrance. Besides this, the 
 employees should know that they have the privilege 
 to call at any time on the factory physician for ex- 
 amination, if a suspicious symptom should show 
 itself. 
 
 It will be in the interest of the employer to engage 
 a physician to enlighten the employees by an 
 occasional lecture on the subject of tuberculosis; 
 to teach them what they should know about it and 
 how they can help to diminish the spread of the 
 disease. But the responsibility of the employer 
 regarding tuberculosis does not end here. It will 
 be necessary also for him to see that, when one 
 of his employees is found to be tuberculous, he 
 receives immediate care and treatment at home 
 or in a special institution. The benevolent em- 
 ployer who has the welfare of his employees at 
 heart, will not even content himself with that, but 
 will also sec that his employee's family, now de- 
 prived of its breadwinner, will not be in want. 
 Whether the employee, if found tuberculous, can 
 be treated at home or must be sent to a special 
 institution, will depend on circumstances. In some 
 instances it may be advisable for the patient, when 
 
MINERS 233 
 
 cured, not to return to the same occupation, but 
 to seek outdoor employment or lighter labor. 
 
 Proper sanitation and proper safety devices in 
 the mines and collieries where so many people 
 are engaged will prevent tuberculosis and other 
 diseases. The inhalation of coal dust in mines 
 can be minimized by proper ventilation, and by 
 judicious division of labor the health of the miners 
 can be improved, if the owner will only do his duty 
 in this respect. 
 
 I have often wondered why it is that we have in 
 our large cities so many tuberculous servants. 
 Many of these were born in foreign countries 
 and nearly all, even those born in this country, 
 had never been ill before they came to the city; 
 but while serving as domestics they contracted 
 tuberculosis. The reason for the frequency of 
 tuberculosis among servants in the city must be 
 primarily ascribed to the very often unhygienic 
 methods of housing them. The majority of them 
 come from rural districts and have been accus- 
 tomed to fresh air and outdoor life. In the city 
 they are often cooped up in the smallest room of 
 the fiat which itself receives neither too much sun- 
 shine or air. In winter the room is often over- 
 heated, or else it is without heat at all. 
 
 It would seem as if it w^re in the powxr of 
 every one employing servants to see that the con- 
 
234 TUBERCULOSIS 
 
 ditions productive of tuberculosis are done away 
 with. 
 
 Telephone operators, who are principally women, 
 belong to a class of employees whose occupation 
 demands confinement indoors, and close confine- 
 ment, as has been pointed out, not infrequently 
 predisposes to tuberculosis. The remedy for this 
 lies, of course, in ventilation and care from infec- 
 tion. The air in the operating room should be 
 kept cool and fresh even in winter. The girls 
 should be warmly clad and should work in a good 
 deal lower temperature than is usually to be found 
 in these rooms. Work should be divided so that 
 the physical strain is not too great. All operators, 
 male or female, should be examined for tubercu- 
 losis and periodically reexamined. The transmit- 
 ter should be washed out with some antiseptic 
 solution every time a man or woman goes on duty, 
 thus there will be an assurance that whatever germs 
 may have been expelled, be they grippe or tu- 
 bercle bacilli, pneumonia cocci or other disease- 
 producing microorganisms, will not gain entrance 
 into their systems. But the telephone company 
 also owes to its patrons the duty of protecting them 
 against possible infection from the use of the pub- 
 lic telephone. A simple device, as illustrated in 
 the accompanying picture (Fig. 58), would suffice 
 for all practical purposes to protect from possible 
 
HYGIENIC TELEPHONE TRANSMITTER 235 
 
 infection. A roll of thin paper is attached to the 
 telephone as a protective screen, so that the end 
 passes over the transmitter. After or before each 
 time the telephone is used, 
 the paper is pulled down so 
 that a fresh portion covers 
 the mouthpiece, and the end 
 torn off. The torn-off pieces 
 should be collected in a special 
 receiver and burned at night. 
 The thin piece of paper does 
 not interfere with the trans- 
 mission of the voice. Similar 
 arrangements are already in fig. 58. Hygienic De- 
 use in some of the Western ^'^^^ ^°^ Telephone 
 
 . . , Transmitter. 
 
 health resorts. 
 
 There are, perhaps, no employers or corpora- 
 tions which are responsible for the safety and 
 health of so many people as the railroad compa- 
 nies. What has been said in the preceding para- 
 graphs on the duty of employers and employees, 
 on the sanitation of workshops, on the examina- 
 tion and reexamination of employees for tubercu- 
 losis, and on taking care of those who may have 
 developed or contracted the disease while in their 
 employ, certainly applies most strongly to railroad 
 corporations. But also, because of the difficulty of 
 the service, managers of railroads should bear in 
 
^36 TUBERCULOSIS 
 
 mind that physical oven\^ork and overstrain not 
 only lead often to serious railroad accidents, but 
 that individual employees exposed to constant 
 overw^ork or overstrain more readily contract 
 tuberculosis than other individuals. 
 
 Besides the duty of an employer toward his em- 
 ployees regarding their health, a railroad company 
 has an equally great responsibility not only regard- 
 ing the safety, but also the health of its patrons, 
 ^luch has been done for the sanitation of our 
 railroad coaches and sleeping cars, but much more 
 needs to be done. The ventilation in all these 
 conveyances can still be improved; and it is an 
 unfortunate fact that in the smoking compart- 
 ments, except of the first class, there are no spit- 
 toons. Usually in the smoking cars or compart- 
 ments of the second class, people spit where they 
 please. Some companies have placed anti-spitting 
 signs in the ordinary day coaches, but they have 
 failed to supply cuspidors for those who will spit. 
 
 A thorough cleaning and airing of all the 
 coaches after each trip, and on long trips at least 
 every six hours, would certainly render these 
 coaches more sanitary. What has been said of 
 the day coaches applies also to the parlor cars, and 
 particularly to the Pullman cars which are often 
 used by consumptive travellers. The spittoons 
 which one fmds in the Pullman cars, while almost 
 
DUTIES OF RAILROAD CORPORATIONS 237 
 
 always neat and clean on the outside, never con- 
 tain any water, and the sputum has an excellent 
 chance to dry in the flat cuspidors. The danger 
 from dried sputum has been dwelt upon enough 
 in the preceding pages to need no further mention. 
 
 Consumptive travellers going from one place 
 to another in search of health are quite careful 
 as a rule ; still, I wonder if it would not be a good 
 practice to oblige every Pullman car conductor 
 or porter to report to the proper authorities when 
 they have had a consumptive among their passen- 
 gers, so that the car may be disinfected with for- 
 maldehyde gas before it is used again. On certain 
 roads where it is well known that consumptives 
 travel a great deal, every car should be disinfected 
 on the arrival at its final destination. I have often 
 thought it would be a good thing and would pay 
 such companies to have special ambulance cars 
 for the transportation of consumptives to and from 
 health resorts. 
 
 I must not leave the subject of railroad hygiene 
 without speaking of one of the most annoying and 
 unsanitary practices. I refer to the Pullman por- 
 ters' habit of dusting the garments of passengers 
 leaving the car, in the faces of those remaining. 
 The windows are, of course, closed. This prac- 
 tice, besides being a nuisance, must be considered 
 unsanitary and dangerous. There can be no ob- 
 
238 TUBERCULOSIS 
 
 jection to the porter brushing a passenger in the 
 vestibule, but I repeat most emphatically that 
 brushing the garments which the traveller wears — 
 his overcoat, hat, and even his valise — in the midst 
 of a car crowded with passengers and with the win- 
 dows closed, I consider to be a practice which tends 
 to propagate diseases of the respiratory organs. 
 
 The railroad companies should pay careful at- 
 tention, as has been often mentioned, to pro- 
 viding properly ventilated office rooms for their 
 employees ; and telephone and telegraph companies 
 should not forget that the same duty devolves upon 
 them. The best possible ventilation and the best 
 possible method of lighting and heating these 
 offices will assure less indisposition, better work, 
 and fewer cases of tuberculosis, which are alto- 
 gether too frequent among telephone and tele- 
 graph operators. 
 
 The farmer has an opportunity for preventing 
 tuberculosis in more than one direction. He can 
 prevent a predisposition by having his own home 
 and the sleeping and living apartments of his 
 help properly ventilated. It is astonishing how 
 little people living in the country, and particularly 
 farmers, make use in their houses of the good, 
 pure air which is at their very door. For a farmer 
 to overwork a farm hand and not provide him 
 with sufficiently good food and also, which happens 
 
TUBERCULOSIS IN ANIMALS 239 
 
 not infrequently, to deprive his own family of the 
 best products of his farm, is as foolish and as 
 uneconomic in the end as anything can be. 
 
 To help in the direct prevention of tuberculosis, 
 the farmer can familiarize himself with the few 
 necessary facts regarding the modes of infection 
 in man on the one hand, and on the other, can 
 study and practice carefully what is necessary for 
 the prevention of tuberculosis among cattle. 
 
 While it is beyond the scope of this book to 
 speak in detail of the prevention of tuberculosis 
 in cattle and other domestic animals, I will, at 
 least, point out the essentials with which the farmer 
 should be familiar regarding the subject. In 
 animals as well as in man, the direct cause of this 
 disease is the tubercle bacillus. Bovine tubercu- 
 losis is prevalent in nearly every country. The 
 symptoms of the disease are much like those in 
 man. They begin with relatively shght func- 
 tional disturbances. The way the germ of tuber- 
 culosis is transmitted from animals to men has 
 already been explained. A tuberculous farm hand 
 or anybody else expectorating on the meadows 
 over which cattle graze, a tuberculous individual 
 expectorating in the stable where cattle are housed, 
 may give the disease to the animals. The point 
 has been disputed, but it is now generally conceded 
 and has been shown experimentally that the trans- 
 
240 TUBERCULOSIS 
 
 mission of tuberculosis from animals to men and 
 men to animals can take place. Although the 
 bacillus is not identically the same, the one of the 
 bovine type may adapt itself to thrive in the human 
 system, and vice versa. The contagion, or rather 
 the propagation, of the disease among animals 
 takes place in various ways: First, by drop in- 
 fection, that is to say, little particles which are ex- 
 pelled during the seemingly dry cough, the same 
 as in man. Secondly, by the discharge from the 
 lungs or also from the glands of the throat, coughed 
 up in the ordinary way. Thirdly, through tubercu- 
 lous matter coming from the bowels. Fourthly, 
 through secretions coming from the sexual organs 
 (vagina and uterus). Fifthly, through the milk 
 if the udder is tuberculous, or if the whole body 
 of the animal is invaded by the disease. Finally, 
 the disease may be directly transmitted from the 
 tuberculous cow to the calf. 
 
 As to the frequency of the various ways in 
 which the contagion takes place and the best 
 methods of prevention, the author does not believe 
 that he can do better than to refer those interested 
 in this important subject to the Bureau of Animal 
 Industry in Washington, which gratuitously sends 
 out literature giving explicit directions as to stable 
 hygiene, testing cattle for tuberculosis, removal 
 and disposal of diseased animals, disinfection, and 
 
TUBERCULOSIS IN ANIMALS 241 
 
 other preventive measures. It may, however, be 
 well to explain here what is meant by testing 
 cattle for tuberculosis. This is done with the aid 
 of a substance known as tuberculin. The process 
 of manufacturing this substance was discovered 
 by Professor Robert Koch. Tuberculin is used 
 principally for the purpose of diagnosing tuber- 
 culous diseases in man or beast, and in certain 
 cases it is employed as a remedial agent. It is a 
 fluid made from cultures of the germs of tuber- 
 culosis, but it does not contain either the dead 
 or living germs. It is sterilized by heating, thus 
 killing the germs, and filtered through porcelain, 
 so that after they are destroyed they are com- 
 pletely removed from the fluid. 
 
 In making the test in cattle, it is necessary to 
 determine the normal temperature of the animal, 
 and then inject a small quantity of the tuberculin. 
 If the animal has tuberculosis, its temperature 
 will rise within from eight to sixteen hours after 
 the injection, but it does not suffer from tuber- 
 culosis, if the temperature is not influenced. 
 
 The tuberculin test should always be applied 
 by a competent veterinarian, and then no danger 
 will arise to the animals, for, when properly ap- 
 plied, the healthy animal is never affected by it. 
 
 Of course, there are conditions in animals, as 
 there are in man, which predispose to the disease 
 
24^ TUBERCULOSIS 
 
 The breed, as well as the conditions under which 
 an animal is compelled to live, determines its sus- 
 ceptibility. We believe it to be perfectly safe to 
 say that the suggestions made regarding the pre- 
 vention of tuberculosis in man are also applicable 
 to animals. Light, air, cleanliness, proper food, 
 and sufficient exercise are essential in combating 
 tuberculosis in the bovine race. After a herd has 
 been freed from its tuberculous members and a 
 strict stable hygiene has been instituted allowing 
 plenty of room for every animal, there will be 
 little danger of a new outbreak of the disease. 
 
 Tuberculosis among swine is not so rare as is 
 usually assumed. While the disease among cows 
 may not always be recognized by the loss of fat 
 and general bad appearance (for even tubercu- 
 lous cattle can be fatted), in swine tuberculosis 
 manifests itself at a very early date by a marked 
 emaciation. Very often these swine are then 
 quickly slaughtered and the meat made into 
 sausages. That through such procedures the 
 health of the consumers is endangered is evident, 
 especially when one considers that many kinds 
 of sausages are eaten without being cooked. 
 Tuberculosis among young swine manifests itself 
 most frequently in the form of intestinal troubles. 
 The main symptoms of the disease are the loss of 
 flesh and bad appearance already mentioned, a 
 
TUBERCULOSIS IN ANIMALS 243 
 
 pale mucous membrane — that is to say, the inner 
 lining of the mouth loses its reddish color — a 
 marked diarrhoea, flatulency, and discharge of 
 gases. If there is tuberculosis of the lungs, cough 
 and vomiting are additional symptoms. In both 
 forms of tuberculosis a swelling of the glands 
 around the neck is often observed. When these 
 animals are slaughtered, one can see little tubercles 
 or elevations and ulcerations along the inner walls 
 of the guts, and on the surface of the lungs. As 
 soon as the disease is discovered among the ani- 
 mals, the sick swine should be separated from the 
 healthy ones. A veterinarian should then be con- 
 sulted, who will give directions for the destruc- 
 tion of the tuberculous meat and the disinfection 
 of the sties. 
 
 The prevention of tuberculosis among swine is 
 not so diflicult when one thinks of the causes of 
 the disease. A sucking pig can be infected by a 
 tuberculous sow. The most frequent source of 
 tuberculosis among hogs, however, comes from 
 feeding them on skimmed milk and other dairy 
 products from tuberculous cows. A few cases are 
 also known where hogs became tuberculous from 
 eating the expectoration of consumptives. 
 
 Tuberculous of horses is rare and diflicult for 
 a layman to recognize. When a horse with a 
 seemingly good appetite has a bad appearance 
 
244 TUBERCULOSIS 
 
 and loses flesh, tires easily, and is short of breath, 
 one should think of tuberculosis. jMuch urinat- 
 ing and a high temperature (fever) are additional 
 symptoms of tuberculosis in horses. When such 
 conditions are discovered, it is, of course, self- 
 evident that the animal should be isolated until 
 the veterinarian arrives. 
 
 Tuberculosis among goats is extremely rare. 
 In the few cases which have been recorded the 
 origin of the disease could be traced to the in- 
 gestion of milk from tuberculous cows. Parrots 
 and dogs take the disease when living with con- 
 sumptive people, and the infection probably takes 
 place through ingesting and inhaling infectious 
 substances and very often through kissing. 
 
 Not only tuberculosis, but diphtheria and 
 other diseases can be and have been transmitted 
 through kissing cats and dogs. Such habits should 
 be discouraged, and particularly in children. 
 
 Shipbuilders, shipowners, and captains should 
 bear in mind that the excessively crowded quarters 
 to which the average sailor is confined during his 
 hours of rest and sleep, arc absolutely detrimental, 
 and even the outdoor life during the hours of work 
 can not counteract the deleterious influence which 
 the vitiated air of the forecastle must have on the 
 health of the seaman. Of course, we are aware 
 that the space given to each individual on board 
 
TOBERCULOSIS among sailors 245 
 
 ship must, of necessity, be limited; still there can 
 be some improvement, and the ventilation can be 
 made more perfect. For the very reason that 
 sailors have to live in crowded quarters the danger 
 of infection on board ship is very great. A tubercu- 
 lous sailor still at work is almost certain to infect 
 his comrades. But shipboard is not the only place 
 where sailors are exposed to the disease. When 
 on shore they mostly frequent and sleep in houses 
 where the accommodations consist of bunks and 
 straw, and where sanitation is so neglected that 
 they are in the greatest danger of contracting the 
 disease. To prevent the spread of infection among 
 sailors there is but one remedy, and that is the 
 regular periodic examination of every sailor on 
 board ship, and the exclusion from service of in- 
 dividuals suffering from pulmonary tuberculosis. 
 Two New Methods of Antituberculosis Educa- 
 tion. — Since the first edition of this book the fol- 
 lowing new methods have been put forward in the 
 antituberculosis propaganda. One of them, which 
 originated in California, is to send through the 
 State a railroad car equipped with a complete min- 
 iature tuberculosis exhibit, a demonstrator accom- 
 panying the car from place to place. The second 
 method is to hold a U. S. National Tuberculosis 
 Sunday. The latter has been appointed for April 
 24, 19 10. Sermons on the prevention and treatment 
 of tuberculosis are to be preached to 33,000,000 
 churchgoers. 
 
CHAPTER IX 
 
 THE DUTIES OF SCHOOL TEACHERS, EDUCATORS 
 IN GENERAL, AND OF THE PUBLIC PRESS IN 
 THE COMBAT OF TUBERCULOSIS 
 
 The child of to-day will be the man of to-morrow, 
 and during school life, the time when the growing 
 organism is most susceptible to good physical de- 
 velopment and the growing mind most receptive 
 to all kinds of teaching and example, it must be 
 evident that much can be done in the prevention 
 of tuberculosis. 
 
 Let us first say a word concerning school con- 
 struction with a view to preventing disease in 
 general and with special reference to tuberculosis. 
 The essentials for the construction of a modern 
 school are well known to all sanitarians and up- 
 to-date architects. I would suggest only a few 
 points. Where the site or locality does not permit 
 of having a large playground, a roof garden which 
 can be covered in winter is absolutely necessary. 
 (Fig. 59.) Instead of our American windows, 
 which can only be opened to one-half of their ex- 
 tent, I would wish to see in every schoolhouse, 
 
 246 
 
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248 TUBERCULOSIS 
 
 French windows, windows that shde into the wall, 
 or those that turn on a pivot, all of which make 
 possible twice as large an opening as our ordi- 
 nary windows do. Heating and general ventila- 
 tion should, of course, be of the most improved 
 kind. The walls and woodwork of schoolrooms 
 should be plain, in order to make the accumu- 
 lation of dust virtually impossible and the clean- 
 ing easy. A smooth coat of oil paint makes a 
 good surface. All corners should be rounded 
 off. The interior equipment, that is to say, the 
 school furniture, benches and desks, should be 
 arranged so that they can easily be moved or 
 folded together, and a thorough cleaning of the 
 floors made possible after each daily session. It 
 goes without saying that the drinking-cup should 
 be replaced by the hygienic drinking fountain, 
 which makes the use of a cup unnecessary, and 
 thus eliminates one method of transmission of 
 microbic disease. 
 
 Every public school should have a well-equipped 
 gymnasium and a swimming tank with constantly 
 running fresh or salt water, warmed to a suitable 
 temperature in winter. (Fig. 60.) Each pupil 
 should be given the opportunity to bathe several 
 times during the week. To learn to swim should 
 be made obligatory, and every class should be 
 supervised by a competent swimming master. 
 
Fig. 6o. Schoolgirls Learning to Swim at Corlear St. Public Bath, 
 
 New York City. 
 
250 TUBERCULOSIS 
 
 Leaving aside the great hygienic gain to be de- 
 rived from such an installation, especially when 
 the pupils are recruited from homes where bath- 
 rooms are rare and where regular bathing is con- 
 sidered superfluous, the swimming lessons will be 
 of value to every boy and girl. In case of such 
 disasters as the Slocum tragedy which some years 
 ago befell residents of New York, there will be a 
 much smaller loss of life. 
 
 There is hardly a college in existence in Amer- 
 ica where the gymnasium and the swimming tank 
 do not form an important part of the equipment, 
 and a college without them ..would surely suffer 
 in prestige. The public school where the children 
 of the masses receive their education should not 
 be behind the private college in matters that ap- 
 pertain to health. 
 
 I am convinced that the public school which 
 has a well-equipped swimming establishment, and 
 which makes regular bathing and instruction in 
 swimming obligatory -for every pupil, will not only 
 have fewer cases of infectious and contagious 
 diseases, particularly scrofula and tuberculosis, 
 but that the intellectual and moral status of its 
 pupils w^ill also- be higher. 
 
 Superintendents and principals of schools should 
 bear in mind that judicious physical exercises, 
 outdoor life, and as much fresh air as possible are 
 
PREVENTION IN CHILDREN 551 
 
 most essential for the normal development of their 
 pupils. There is too great a tendency in the 
 present age to develop the intellect of our children 
 to the detriment of their physical welfare. They 
 work too much, they do not play enough, and they 
 sleep too little. This overwork, because of too 
 many school hours, too many lessons at home, 
 and too much loss of sleep, is responsible for our 
 national disease, neurasthenia, particularly per- 
 ceptible in the young. I was deeply impressed 
 recently, when reading the recommendations of 
 the committee which was appointed by the French 
 government and the city of Paris with a view to 
 diminish tuberculosis among the school children, 
 by the fact that they insisted upon a minimum of 
 nine to ten hours of sleep ; only after the age of ten 
 may the hours of sleep be somewhat shortened. 
 The duration of a lesson should likewise be graded 
 according to the age of a child, and for small 
 children this time should be made shorter than is 
 now the custom. To ask the child seven or eidit 
 
 o 
 
 years of age to sit absolutely still for one hour is 
 bordering on cruelty. I have often wondered if it 
 would not be better to allow no children to enter a 
 public or private school for regular attendance 
 before the age of eight. A child predisposed to 
 tuberculosis should certainly never enter upon 
 school life before its eighth year. 
 
2^2 
 
 TUBERCULOSIS 
 
 \Vhile all the organs of a child should be given 
 opportunity for full development, the respiratory 
 system should receive particular care and attention. 
 I would suggest that breathing exercises should 
 not only be taken now and then, but that they 
 should form an important item in the curriculum 
 of all the schools. I do not believe that there is 
 any better, greater, and more efficacious barrier to 
 becoming consumptive than a good pair of lungs, 
 and it would seem to me that it should not only 
 be a great duty, but also a great privilege and 
 pleasure to make strong, vigorous men and women 
 out of all children attending school. 
 
 There are a number of systems of breathing 
 exercises in vogue in schools and I would not wish 
 to criticise any, but I may be pardoned for recom- 
 mending the following system since during a some- 
 what extensive experience I have found it the best 
 adapted for both school children and adults with 
 a view to developing their chest capacity. It goes 
 without saying that these exercises should always 
 be taken in fresh, pure air, preferably outdoors; 
 but if that is not possible, always with the windows 
 open. In school they should be taken at the begin- 
 ning of the recess, and no class should last longer 
 than three-quarters of an hour. These exercises 
 can be taken when the child is mentally tired, but 
 never when physically tired. It is better to have 
 
RESPIRATORY EXERCISES 253 
 
 them play afterwards than to take these exercises 
 when they are tired out by running or the usual 
 gymnastics. 
 
 The teacher should strive to have his pupils 
 learn to love these exercises as the average boy or 
 girl loves general gymnastics. The following is 
 as concise a description of my favorite exercises 
 as can be given to enable one to teach them. 
 
 To begin with, the pupil has to learn to stand 
 straight, assuming the position of the military 
 "attention," heels together, body erect, and hands 
 on the sides. With the mouth closed, he takes a 
 deep inhalation (that is, breathes in all the air pos- 
 sible), and while doing 
 so raises the arms to a 
 
 horizontal position (Fig. ■^---- ' 
 
 61), remains thus hold- 
 ing the air inhaled for 
 four or five seconds, and 
 while exhaling (breath- 
 ing out) brings the arms 
 
 down to the original pO- Fig. 61. Respiratory Exercise A. 
 
 sition. The act of exhal- 
 ing, or the expiration, should be a little more 
 rapid than the act of inspiration. 
 
 The act of inhalation occupies about four, the 
 act of exhalation about three seconds, and as has 
 already been said, the act of retention of the air 
 
254 TUBERCULOSIS 
 
 about live seconds. The child should be taught 
 to count mentally during these three acts so as to 
 be systematic about holding the air. One can 
 move the hands up and down twice, counting four, 
 and on the fifth second begin to 
 lower the arms and exhale. 
 
 When the first exercise (A) is 
 thoroughly mastered one may com- 
 mence with the second exercise (B). 
 The pupil places his hands one 
 above the other, in front of the 
 chest, with the fingers bent. (Fig. 
 Fig. 62. Respira- 62.) Thc amis and shouldcrs make 
 lory Exercise B. ^ backward movcmcnt, the hands 
 moving, apart with a motion as though wanting 
 to tear open the chest (the fingers remaining bent) 
 while he takes a deep inhalation, holds the breath 
 counting four by tapping the chest four times 
 with both hands, and at the fifth second he starts 
 to exhale, bringing the hands and forearms into 
 the position from which they started. This exer- 
 cise has the advantage that it can be taken in the 
 sitting position, or even when lying down on the 
 back. 
 
 The third exercise (C) consists in raising the 
 arms from the sides to the horizontal and then 
 above the head (Fig. 63), taking a deep inhalation 
 during this act; then bending backward as far as 
 
RESPIRATORY EXERCISES 
 
 255 
 
 Fig. 63. Respira- 
 tors' Exercise C. 
 
 one can and remaining in that position four seconds 
 
 while retaining the air, counting the seconds by 
 
 moving the hands alternately, for- 
 ward and backward, and on the 
 
 fifth second one exhales gradually 
 
 while resuming the original posi- 
 tion. During this exercise it should 
 
 be borne in mind that when the 
 
 arms are raised until the hands 
 
 join, one should not bring the arms 
 
 close to the head, but rather form 
 
 a circle above the head by bending 
 
 the arms outward enough so that 
 
 the meeting of the index fingers and thumbs form 
 
 a triangle. 
 
 The fourth exercise (D) is for the purpose of 
 bringing the abdominal muscles also 
 into play, or in other words, com- 
 bining abdominal and chest breath- 
 ing. To this end one assumes an 
 erect position, like the beginning of 
 all the exercises, the hands meeting 
 in front, with the little fingers and 
 the edge of the palms touching the 
 abdominal muscles. (Fig. 64.) 
 
 Fig. 64. Respira- While taking a deep inspiration 
 
 tory Exercise D. • i i • i . . • 
 
 raise the diaphragm, concentrating 
 all attention on this act, and while doing so move 
 
-^56 
 
 TUBERCULOSIS 
 
 the joined hands upward, shding them along the 
 thorax up to the chin, then turning them and 
 continue to raise them until they are above the 
 head, as in Exercise C, Fig. 63. Remain bent 
 backward during the four seconds while retaining 
 the air, and then exhale, lowering the arms grad- 
 ually to the horizontal and to the original position 
 of ''attention." 
 
 The fifth breathing or respiratory exercise (E), 
 which may also be called a dry swim, requires 
 more strength and endurance. It should not be 
 undertaken until the others have 
 been practiced regularly several 
 times a day for a few weeks, and 
 , until an evident improvement in 
 P^^ breathing and general well-being 
 has been observed. One takes 
 the usual military position of '' at- 
 tention" and then stretches the 
 arms out as if in the act of swim- 
 ming (Fig. 65), the backs of the 
 hands touching each other. Dur- 
 ing the inspiration one moves the arms outward 
 until they finally meet behind the back, remains 
 in this position for the usual four seconds, count- 
 ing by moving the hands while retaining the 
 air, and on the fifth second exhales, bringing 
 the arms forward again ready to start for an- 
 
 \ 
 
 Fig. 65. Respira- 
 tory Exercise E. 
 
RESPIRATORY EXERCISES 257 
 
 other swim; or if this is the end of the dry swim, 
 the arms return to the original position of ''at- 
 tention." This somewhat difficult exercise can be 
 facilitated and be made more effective by rising 
 on the toes during the act of in- 
 spiration, and descending during 
 the act of expiration. 
 
 It will be seen that with the aid 
 of these five respiratory exercises 
 every muscle of the body, from the 
 nostril down to the toes, is put into 
 play. The face alone is at rest 
 and can serve as an indicator that 
 
 Fig. 66. Respira- 
 
 the exercises are properly done ; tory Exercise f. 
 for it must be borne in mind that 
 they should be taken with the muscles not actu- 
 ally in use, relaxed, and all unnecessary contrac- 
 tion of muscles or tremor-like movements must be 
 avoided. 
 
 Of course, when out of doors one can not always 
 take these exercises with the movements of the 
 arms without attracting attention. Under such 
 conditions one assumes a position similar to "at- 
 tention," raises the shoulders, making a rotary 
 backward movement during the act of inhaling 
 (Fig. 66); remains in this position, holding the 
 breath for four seconds and then exhales while 
 moving the shoulders forward and downward, 
 
25S 
 
 TUBERCULOSIS 
 
 assuming again the normal position. This exercise 
 (F) can be easily taken while walking, sitting, or 
 riding in the open air. 
 
 Young girls and boys, and especially those who 
 are predisposed to consumption, often acquire a 
 habit of stooping. To overcome 
 this, the following exercise (G) is 
 to be recommended. The child 
 makes his best effort to stand 
 straight, places his hands on his 
 hips with the thumbs in front and 
 then bends slowly backward as far 
 as he can during the act of inhaling. 
 (Fig. 67.) He remains in this posi- 
 tion from four to five seconds while 
 holding the breath, and then rises 
 again somewhat more rapidly during the act of 
 exhalation, assuming the original position with 
 hands on hips. 
 
 The following general rule concerning breath- 
 ing exercises should always be remembered. Com- 
 mence with the easier exercises (A), and do not 
 go on to the more difficult ones until the former 
 are completely mastered. Take from four to six 
 respiratory exercises (one of A, one of B, one of C, 
 one of D, or one of E) or when outdoors simply 
 exercise F, four to six times every half hour or 
 hour, or at least four to six times a day, and on 
 
 Fig. 67. Respira 
 tory Exercise G. 
 
RESPIRATORY EXERCISES 259 
 
 rising in the morning and retiring at night. Con- 
 tinue this practice until deep breathing has be- 
 come a natural habit. 
 
 These exercises are not intended for children 
 who are already tuberculous, and they should be 
 taught gradually and according to the strength, 
 development, and understanding of the child. I 
 believe them to be of incalculable benefit as a 
 means of helping a child to overcome a tubercu- 
 lous predisposition; but they are not indicated in 
 all cases. They can do harm if the child is very 
 delicate and not judiciously advised and guided 
 in the gradual development of its physique as a 
 whole. They will never be harmful to the healthy 
 child unless grossly overdone. Children, as a rule, 
 take kindly to these exercises, and their love for 
 fresh, pure air, and distaste for foul air becomes 
 very strongly developed. There should be no 
 fear that in so-called flat-chested children these 
 exercises can do harm. It is in these very cases 
 that breathing exercises are indicated, for it must 
 be remembered that in young children the bony 
 structure yields to the pressure exercised from 
 within. Thus, with the aid of such respiratory 
 exercises a flat or hollow-chested child can develop 
 into a strong, broad-chested man or woman. 
 
 It is for all these reasons that I plead to have 
 breathing exercises made a regular and frequent 
 
26o TUBERCULOSIS 
 
 practice in schools, so as to develop all the children's 
 chests and bodies in general and make their system 
 as resistant as possible to the bacillus of tubercu- 
 losis. As I have already mentioned, it will be 
 seen from the careful study of the movements 
 described in these exercises, that all the muscles 
 of the body are exercised, and without any vio- 
 lence. 
 
 Some children develop a habit of drooping one 
 shoulder or the other, and gradually a distinct 
 lateral curvature of the spine is developed. I have 
 often wondered if the practice of some school au- 
 thorities or teachers of forcing the little girl or boy 
 to carry a veritable load of books every day to 
 and from school, often up three or more flights of 
 stairs, is not a factor in producing this unnatural 
 and unhealthy attitude of some children. Surely, 
 every municipality should be willing to spend 
 enough money so that there may be duplicate 
 books — one set for home and one set for school 
 use — and thus the injudicious and often dangerous 
 physical strain imposed upon the small children 
 will be removed. 
 
 As an additional means to develop the lungs of 
 children when in school, we can not too strongly 
 recommend the practice of frequent singing and 
 recitation in the open air. Singing and recitation 
 outdoors have a most beneficial action on the 
 
OPEN AIR SCHOOLS 261 
 
 vocal organs, on the lungs, and on the heart, and 
 will help much in the development of the chest. 
 
 Modern schools should have it a part of their 
 curriculum for all children, according to age and 
 understanding, to visit zoological gardens and 
 nearby farms, to go on botanizing tours and ge- 
 ological excursions, and do mountain climbing. 
 In large cities where the visits to a farm will not 
 often be feasible, there should be school farms in 
 or near the city so that they can be visited by the 
 children without too much loss of time. 
 
 The accompanying picture (Fig. 68) gives a 
 good idea how the vacant lots of a city may be 
 utilized for such a purpose. 
 
 When one deals with the subject of tuberculosis 
 in childhood, and particularly at the school age, one 
 must not fail to recognize the sad fact that many 
 pupils in the districts of the poor become pre- 
 disposed to tuberculosis not only by reason of the 
 general causes outlined in what has preceded, but 
 by reason of particularly bad home hygiene, over- 
 work brought about by child labor at home, and 
 lastly, by underfeeding and malnutrition. Of the 
 two former, the home hygiene and the child labor 
 at home, we have already spoken in the preced- 
 ing chapters. Here we wish to discuss particu- 
 larly what really concerns the school authorities. 
 
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LUNCHES 263 
 
 that many a child has to go to school with a very- 
 inadequate breakfast and at noon has to content 
 itself with a very meager lunch — both meals not 
 sufficient to supply the want of a growing organism. 
 Much has been written and said on this subject. 
 Many pedagogic authorities and philanthropists 
 have urged the giving of free, substantial lunches 
 at noon time. The opponents of such a scheme 
 have argued that it would tend to pauperize many 
 parents who could well afford to provide their 
 children with good and sufficient lunches. What- 
 ever may be the arguments pro and con for pro- 
 viding pupils of public schools with good lunches, 
 the fact remains that in many European and in 
 some American communities where the children 
 have been provided with lunches consisting of 
 meat sandwiches and a glass of milk — hot in winter 
 and cold in summer — they have all increased in 
 weight, have done better work at school than 
 prior to the inauguration of the lunch era, and 
 last but not least, have all been made more happy. 
 It would seem to me that the objection to the ab- 
 solutely free distribution of lunches could be met 
 by providing them to the children at cost price. 
 If the parents felt that they could not afford to 
 pay this trifling amount, they should be instructed 
 to make application to the proper authorities who 
 would investigate the case and see to it that meal 
 
264 TUBERCULOSIS 
 
 tickets were given gratuitously to these children 
 when it was necessary. Nearly every American 
 city and town has its Charity Committee whose 
 important function it is to investigate reported 
 cases of poverty and distress, and to see that 
 pauperization is avoided. By reporting to such 
 organizations the families which had asked for 
 free lunch tickets for their children, injustice and 
 mistakes would be avoided and cases of true dis- 
 tress discovered. Not to make the child feel hu- 
 miliated because it must receive free lunches on 
 account of its parents' poverty, all children should 
 have tickets; those who are able should pay for 
 them; to those not able they should be given dis- 
 creetly by the teacher or sent to the parents to be 
 handed to the child. 
 
 The danger of occasionally giving a free lunch 
 to a child whose parents ought to pay for it 
 should not deter us from providing the hungry chil- 
 dren not only with sufficient, but also with nutri- 
 tious food. Sometimes the children are given 
 money by their parents, and instead of buying 
 substantial lunches they spend the money for 
 candy or indigestible pastry. 
 
 All pupils and students in public, parochial, and 
 private schools and colleges should be instructed, 
 according to their age and understanding, in the 
 principles of the prevention of tuberculosis and in 
 
INSTRUCTION FOR CHILDREN 265 
 
 hygiene in general. While for older pupils much 
 of what has been said in the preceding chapters 
 may be readily understood and digested, for smaller 
 children simplicity and directness are essential if 
 we wish to make the pupil remember. 
 
 Following is an alphabet which I have com- 
 piled, believing that it will suit the understanding 
 of younger pupils in public or private schools. 
 In this alphabet I have endeavored to point out 
 the numerous sources of tuberculous infection to 
 which the child may be exposed at school, and 
 what the child itself can do to overcome the possible 
 sources of infection. I should like to see this 
 alphabet, or some similar directions and rules, 
 read and explained by the teachers in public and 
 private schools, say about once a month, and copies 
 of them distributed to the children to take home, 
 to be read by the parents and reread by themselves. 
 
 Alphabet in the Prevention of Tuberculosis. 
 A is for Anybody who can help prevent consumption, 
 
 a child just as well as a grown person. 
 B is for Breathing which you should learn to do deeply; 
 
 often take deep breaths in fresh air. 
 C is for Coughing which you should never do in any 
 
 one's face, nor should you sneeze in any one's face. 
 
 Turn away your head and hold your hand before 
 
 your mouth. 
 D is for Don't, Don't swap apple cores, candy, chew- 
 
266 TUBERCULOSIS 
 
 ing gum, half-eaten food, whistles, bean-blowers, 
 or anything you put in your mouth. 
 
 E is for Eating no fruit that has not been washed or 
 peeled, or anything that is not clean. 
 
 F is for Fingers which should not be put in the mouth 
 nor wet to turn the pages of books. 
 
 G is for Giving a good example to your fellow pupils 
 and playmates by being always neat and clean, 
 just as much so at home as at school. 
 
 H is for Handkerchief which should be used only to 
 wipe your nose and not your slate, desk, or 
 shoes. 
 
 I is for Illness of other kinds besides consumption 
 which following these rules will help prevent, such 
 as colds, measles, grippe, diphtheria, and pneu- 
 monia. 
 
 J is for Joints where children have tuberculosis more 
 often than in their lungs. 
 
 K is for Keeping your finger-nails clean. A scratch 
 from a dirty finger-nail may make a bad sore. 
 
 L is for Learning to love fresh air, and not for learn- 
 ing to smoke. 
 
 M is for Mouth which is meant to put food and drink 
 into, and not meant for pins and money or any- 
 thing not good to eat. 
 
 N is for Nose which you never should pick nor wipe 
 on your hand or sleeve. 
 
 O is for Outdoors where you should stay just as much 
 as you can; always play outdoors unless the 
 weather is too stormy. 
 
INSTRUCTION FOR CHILDREN 267 
 
 P is for Pencils which you should not wet in your 
 mouth to make them write blacker. 
 
 Q is for Questions which you should ask the teacher if 
 you don't understand all these rules. 
 
 R is for Roughness in play by which you may hurt 
 yourself or your comrades. If you have cut your- 
 self, been hurt by others, or feel sick, don't fear to 
 tell the teacher. 
 
 S is for Spitting which should never be done except in 
 a spittoon, or a piece of cloth, or handkerchief used 
 for that purpose alone. Never spit on a slate, on 
 the floor, the playground, or the sidewalk. 
 
 T is for Teeth which you should clean with toothbrush 
 and water after each meal, or when you get up in 
 the morning and before you go to bed at night. 
 
 U is for Unkind which you should never be to a con- 
 sumptive. 
 
 V is for Vessel like drinking cups and glasses which 
 
 should not be used by one child after another 
 without being washed in clean water each time. 
 
 W is for Washing your hands with soap and water be- 
 fore each meal, even if it is only lunch. 
 
 X is for the X-ray which sometimes helps to discover 
 consumption or other forms of tuberculosis. 
 
 Y is for You who should never kiss anybody on the 
 
 mouth nor allow them to do so to you. 
 Z is for Zeal in carrying out these rules. 
 
 In order to combat tuberculosis in the public 
 schools, the teachers should receive special in- 
 
568 TUBERCULOSIS 
 
 structions so that they may recognize the outward 
 symptoms of the disease in childhood. A child 
 which grows more indifferent to its studies, be- 
 comes irritable or morose, tires easily, has a little 
 fever in the afternoon, seems to lose in weight, 
 looks pale, shows swelling of glands, even if it 
 does not cough, should be reported at once to the 
 school physician for examination, as such condi- 
 tions are typical and often precede the outbreak 
 of pulmonary tuberculosis. To weigh the pupils 
 periodically and keep a record of the results will 
 often be helpful in discovering a beginning of the 
 disease. 
 
 The early symptoms of tuberculosis of the bones 
 and joints manifest themselves in lameness and 
 easy tiring of the arm or leg affected. A light 
 pressure in the region of the joints causes a sudden 
 severe pain. If the spinal column is affected, the 
 symptoms will depend upon the location of the ver- 
 tebra which is attacked by the disease. For ex- 
 ample, if this should be in the region of the neck, 
 there will be difficulty in swallowing, in breathing, 
 or a frequent dry cough. If any one of the verte- 
 brae in the region of the chest is affected, a feeling 
 of constriction like a tight band around the chest 
 will be observed, accompanied often ])y digestive 
 troubles. If the seat of the disease is in the lower 
 portion of the spinal column, there will be irrita- 
 
SCROFULOUS CHILDREN 269 
 
 tion of the bladder and lower bowels, an inclina- 
 tion to much urinating, and radiating pains toward 
 the hips. 
 
 The above mentioned pulmonary type of tuber- 
 culosis is relatively rare in children. On the other 
 hand, among the little ones tuberculosis manifests 
 itself very often not only as the bone and joint 
 affections just described, but also in another form 
 known as scrofula or scrofulosis and which might 
 be considered almost exclusively a disease of chil- 
 dren. The scrofulous child is usually pale, with 
 flabby skin and muscles. The glands around the 
 neck are swollen, and skin disease, sore eyes, and 
 running ears are frequent symptoms. The little 
 patient usually manifests a phlegmatic condition, 
 but we may also find some that are nervous and 
 irritable. The latter often have a particularly 
 white, delicate skin which makes the veins visible. 
 Fever is usually present in the beginning of the pul- 
 monary type of tuberculosis; it must be borne in 
 mind that we occasionally find a high temperature 
 also in scrofulosis. 
 
 All children on entering school should be ex- 
 amined for tuberculosis or, at least, have a certifi- 
 cate from their family physician showing freedom 
 from this disease. 
 
 When the child in the public school has been 
 discovered to be tuberculous, or strongly predis- 
 
270 
 
 TUBERCULOSIS 
 
 Fig. 69. Open Air School at Providence, R. I. 
 
 posed, what then? For those shghtly affected 
 with pulmonary or glandular tuberculosis, there 
 should be provided an open air school, such as 
 was first established in this country in Providence, 
 R. I. (Fig. 69), and later in New York and other 
 cities of the United States. If I am rightly in- 
 formed, the first one established in England was 
 the London County Council open air school at 
 Horniman Park, Lordship Lane, of which I give 
 an interesting illustration. (Fig. 70.) 
 
 The school in Providence, R. L, was the out- 
 growth of the work of the local Society for the 
 Prevention of Tuberculosis and owes its incep- 
 tion mainly to the enthusiasm of Dr. J. Perkins, 
 
OPEN AIR SCHOOLS 
 
 271 
 
 Fig. 70. London City Council Open Air School at Horniman Park — 
 
 Resting Time. 
 
 a member of that association. The school was 
 opened January 27, 1908. It is situated in Meet- 
 ing Street, where there was an old schoolhouse 
 that could be utilized for the purpose. The accom- 
 panying picture will show that a part of the 
 brick wall had to be taken out in order to make it 
 truly an open air school. The part of the building 
 thus opened was fitted with large window sashes 
 which let into the schoolroom air and sunshine in 
 large quantities. The physicians interested in the 
 plan have volunteered their services for visitation 
 and inspection of the school, and also interested 
 themselves in the necessary food supply. The regu- 
 larly prescribed studies of the public school course 
 
272 
 
 TUBERCULOSIS 
 
 Fig. 71. Open Air School on the " Southfield," a Discarded Ferry- 
 boat Anchored at Foot of East 26th Street, New York City. 
 
 are taught, and teachers peculiarly fitted for the 
 kind of work required, have been appointed. 
 
 The schoolroom is large and airy, having win- 
 dows on three sides. On the south side are the 
 five large windows where the wall was removed, 
 reaching from the ceiling nearly to the floor, so ar- 
 ranged with hinges and pulleys that they can be 
 swung inward, practically opening the entire side 
 of the building. These windows are kept open in 
 all weathers except when snow or rain beat in. So 
 far they have never l)een closed. 
 
 To temper the air at one end of the room are 
 
OPEN AIR SCHOOLS 273 
 
 two stoves, one for heating simply; the other, a 
 cook stove, for warming the soapstones and the 
 mid-forenoon soup. The temperature of the room 
 in winter frequently goes below 40° F. 
 
 The room is equipped with adjustable desks and 
 chairs on platforms so that they may be moved at 
 will. They have been fitted to the needs of each 
 individual child. The sun enters the schoolroom 
 at 9 130 and remains there all day, and the desks are 
 so moved that while breathing the fresh air the 
 pupils also get the benefit of a sun bath. 
 
 The pupils are supplied with large, wadded 
 bags reaching from the feet to the waist, and for 
 extreme cold weather soapstones are provided. 
 They wear outer wraps and hats or not, according 
 to their needs. At 10:15, strong, hot soup is given 
 them; a gallon a day is provided. The morning 
 session is from 9 to 11:45, ^^i^h thirty minutes in- 
 termission, and the afternoon session from i :45 to 
 
 3-30- 
 Another interesting experiment in the line of 
 
 outdoor schools has been made in New York in 
 connection with a day camp for the consumptive 
 poor of that city. Of the mission of the day camp 
 we will speak in a subsequent chapter. Here it 
 may simply be stated that this camp owes its ex- 
 istence to the enthusiasm and energy of Drs. John 
 W. Brannan, the President of Bellevue Hospital 
 
274 TUBERCULOSIS 
 
 Board, and to his co-worker Dr. James Alexander 
 Miller. It is located on the old discarded ferry- 
 boat, the ''Southfield," which is anchored at the 
 foot of East 26th Street, near the grounds of 
 Belle\Tie Hospital. The ''Southfield" open air 
 school (Fig. 71) admits any child of school age. 
 ]\Iost of the children come from very poor homes, 
 and a large proportion are orphans. All those 
 who attend the class are either tuberculous or 
 undoubtedly predisposed to it. 
 
 The problem of teaching the tuberculous child 
 who comes from the districts of the poor and who, 
 by reason of his illness, has often had more freedom 
 than is good for him, is a difficult one. The chil- 
 dren at the Southfield school have to learn that at- 
 tendance at school is not at their own whim or 
 pleasure; that school means work; that each child 
 must not only come every day, but must come 
 early enough to get his breakfast and begin work 
 at 9 o'clock. 
 
 We have already mentioned phthisiophobia in 
 relation to adult consumptives. Some people carry 
 their fear so far as to include the children. I 
 know that in a western town strong objections 
 were made recently to the establishment of an 
 open air school. To all those sharing such a preju- 
 dice, I may say that my personal experience and 
 that of the teachers of schools for tuberculous 
 
OPEN AIR SCHOOLS 275 
 
 children, has shown that children as a rule cough 
 less and expectorate less than adults; that when in- 
 structed to be careful they usually are so ; and that 
 in mental equipment and deportment the tubercu- 
 lous children are, as a rule, on a par with any un- 
 exceptional class of children from average homes. 
 In one of our New York open air schools, with 
 which I am familiar, the children come from more 
 destitute and worse regulated homes than the av- 
 erage, yet these little ones have become just as am- 
 bitious to work and just as well behaved as any 
 others. 
 
 There must come a time, and soon, when we 
 will have to have a good many more open air 
 schools, not only for the predisposed and actually 
 tuberculous children, but also for the seemingly 
 normal, healthy child. It is well known to all 
 pathologists and to physicians with large ex- 
 perience in the treatment of diseases of children, 
 that many a child has a latent tuberculosis which 
 does not show nor develop until the age of man- 
 hood or womanhood. Thus, it would seem to 
 me that to increase the resisting power of the 
 child during the school age (8 to 14), we should 
 give it an abundance of fresh air. In some sec- 
 tions of our country, such as southern California 
 and some of the southern states, I should think 
 the climate would permit open air schools pretty 
 
276 TUBERCULOSIS 
 
 nearly all the year around. In some other sec- 
 tions they could be held at least part of the spring, 
 summer, and fall, provided the children are prop- 
 erly clad. 
 
 A child afflicted with more advanced pulmonary 
 tuberculosis should not even go to the public open 
 air school of the city. It should be sent to a sana- 
 torium. The same must be said of children af- 
 flicted with bone and joint tuberculosis. For both 
 classes of children the sanatorium treatment is 
 essential. Surgical cases at times need to be op- 
 erated upon. 
 
 We reproduce here a picture of the first san- 
 atorium established for tuberculous children in 
 France, known as I'Hopital pour les Enfants Tu- 
 berculeux a Berck-sur-Mcr. (Fig. 72.) It is main- 
 tained by the municipality of Paris, and attached 
 to it is a public school. Children suffering with the 
 surgical type of tuberculosis are here treated and 
 cared for. Those able to pay are charged a mod- 
 erate price and the poor are treated gratuitously. 
 We also reproduce the playground in midwinter of 
 our first American Sanatorium for children suffer- 
 ing with tuberculous bone diseases, at Sea Breeze, 
 Coney Island. (Fig. 73.) 
 
 It goes without saying that no sanatorium for 
 children should exist without proper educational 
 facilities so that the intellectual development of the 
 
3 
 
 u 
 
 D 
 
 h 
 
 
278 
 
 TUBERCULOSIS 
 
 Fig. 73. Playground in Midwinter for Tuberculous Children 
 at Sea Breeze, Coney Island, New York. 
 
 child may go hand in hand with its physical im- 
 provement. 
 
 In Boston this work is under the direction of 
 Dr. Edwin A. Locke, and while teacher and 
 physician work in perfect harmony, the latter is 
 the supreme authority in the mental as well as 
 the physical care of the children. 
 
 A tuberculous teacher, that is to say, one suffer- 
 ing with an open and active pulmonary tubercu- 
 
ANTI-TUBERCULOSIS EDUCATION 279 
 
 losis, coughing and expectorating, should not, for 
 his own sake as well as that of the pupils, be per- 
 mitted to teach in public schools. He should 
 be given opportunity to be cured of his disease 
 either in a sanatorium, a health resort, or at 
 home. 
 
 If his tuberculous trouble has been arrested or 
 cured, in order to have the cure made more per- 
 manent or to prevent a relapse, he should be 
 employed as a teacher in one of the open air 
 schools or in the school attached to a children's 
 sanatorium. 
 
 Since tuberculosis is very justly considered a 
 disease of the masses, the teaching of hygiene and 
 prophylaxis of tuberculosis should be made a part 
 of the curriculum in high schools, colleges, semi- 
 naries, and universities where teachers and edu- 
 cators receive their training. 
 
 Evening lectures on hygiene and tuberculosis, 
 given for the adults in the public school buildings, 
 such as were inaugurated some years ago by 
 Dr. Henry M. Leipziger of the New York Board 
 of Education, have proved a most valuable feature 
 in educating the public on this vital subject. 
 From personal experience I know that intense in- 
 terest has been manifested by the public in such 
 lectures. 
 
 One of the best educators of the masses, how- 
 
28o TUBERCULOSIS 
 
 ever, is the public press. Short articles on the 
 various phases of the tuberculosis problem writ- 
 ten by competent physicians in the language of 
 the people, should appear frequently in every 
 daily newspaper. A vast amount of education 
 can thus be effected and people who can not be 
 reached by any other means will be made famil- 
 iar with the principal points in the prevention of 
 tuberculosis. 
 
 There is also another way in which the public 
 press, more than any other agent, can serve the 
 public weal and the anti-tuberculosis cause at 
 the same time. That is by refusing to publish 
 any patent medicine advertisements, secret rem- 
 edies, methods which promise sure consumption 
 cures, or anything that may in any other way 
 mislead the public and prevent them from seeking 
 proper medical advice and scientific treatment 
 while there is still a chance for improvement and 
 cure. 
 
 School authorities or other educational bodies 
 should consider the education of the future mothers 
 of the nation an important factor not only in tu- 
 berculosis, but also in all other diseases. There 
 should be no girls' schools where cooking and 
 housekeeping do not form a part of the curric- 
 ulum. The duties of the future mother or house- 
 wife should be taught to our girls, and the now ex- 
 
ANTI-TUBERCULOSIS EDUCATION 281 
 
 isting uneducated mothers and housewives should 
 be taught what they do not know. The rearing of 
 healthy children is the most valuable asset to a 
 nation's strength and prosperity. 
 
 An institution known as "Caroline Rest" was 
 recently established in Hartsdale, Westchester 
 County, N. Y., by Mr. Geo. H. F. Schrader, in 
 memory of his mother, and presented to the New 
 York Association for Improving the Condition of 
 the Poor. This institution is not only a sanatorium 
 for mothers with infants, but serves above all as 
 a school where, under the most favorable condi- 
 tions, mothers of the poor will receive instruc- 
 tion in the duties of motherhood, in personal hy- 
 giene, the care of their children, and the right 
 conduct of their homes. It was planned to meet 
 the pathetic needs of that great number of poor 
 mothers who are compelled to leave their beds 
 within a week after childbirth, in order to re- 
 turn to the factory or to the care of the house- 
 hold, thus laying the foundation of a lifelong 
 invahdism. 
 
 The work at Hartsdale is supplemented in the 
 city by the Caroline Rest nurses who visit mothers 
 before and after confinement, and through in- 
 struction and special care promote their health 
 and that of their children. The experience of the 
 Caroline Rest nurses has definitely shown that by 
 
282 TUBERCULOSIS 
 
 protecting the health of mothers before the com- 
 ing of the new hfe, it is possible greatly to reduce 
 the mortality among infants under one year of 
 age, of whom approximately 17,000 now die in 
 Greater New York every year from causes largely 
 preventable. A\niat such care of mothers and such 
 prenatal and postnatal care of children means 
 in the prevention of tuberculosis must be evident. 
 
 There exist already in a few cities in the United 
 States what are known as practical housekeeping 
 centers. The first of these was established in 
 1 90 1 by ]\Iiss LiUian D. Wald, head of the Henry 
 Street Nurses' Settlement of New York City. 
 Such a center is an institution in the shape of a 
 model flat or model house, and teaches the in- 
 experienced mother or girl, by precept and ex- 
 ample, how to cook, how to train children, and 
 how to keep even the modest home neat, clean, 
 and attractive. These centers meet the need of 
 the inexperienced mother of to-day, of to-morrow, 
 and of the mother ten years hence. 
 
 To show the value of such educational and 
 practical housekeeping centers, I can not do better 
 than quote from the writings of that well-known 
 teacher of mothers and girls, and philanthropic 
 worker, Mrs. Florence Kelly. Here is what she 
 has to say: 
 
 ''If the practical housekeeping centers can be 
 
ANTI-TUBERCULOSIS EDUCATION 2^3 
 
 made permanent and numerous enough, if they 
 can be made as much a part of the hfe of the com- 
 munity as the pubhc schools are now, intergraded 
 in time with the schools, these problems — intem- 
 perance, infant mortality, and reduced vitality of 
 the working class families — can be reduced to their 
 lowest terms. Clean, orderly homes, in which air 
 is pure, food is attractive and wholesome, and beds 
 are clean and comfortable, give the baby the 
 maximum chance for life and health, and his 
 father an opportunity for keeping himself fit for 
 his work, and a hope of escaping his deadliest 
 enemy — drink and tuberculosis." 
 
 Finally, educators of all kinds should not fail 
 to impress upon the minds of those with whom 
 they come in contact that whatever is done for 
 the anti-tuberculosis crusade is for the good of 
 the whole community. Many parents have been 
 antagonistic to the medical inspection of school 
 children, nevertheless this, and the special ex- 
 amination for tuberculosis so thoroughly carried 
 out in New York under the direction of Dr. Wal- 
 ter Bensel, the Sanitary Superintendent, Drs. 
 John J. Cronin and Josephine Baker of the De- 
 partment of Child Hygiene, and Dr. Bertram H. 
 Waters, Chief of IMunicipal Clinics, have been of 
 incalculable service in the early recognition of tu- 
 berculosis and have saved many a young life. 
 
CHAPTER X 
 
 THE DUTY OF THE CLERGY, PHILANTHROPISTS, 
 CBL4RITABLE INDIVIDUALS, AND CHARITY OR- 
 GANIZATIONS 
 
 The clergyman has as great a mission to perform 
 in the prevention of tuberculosis as a disease of 
 the masses as anybody else. Every clergyman 
 should inculcate ideas on general sanitation, the 
 value of good, pure air and proper living into the 
 minds of the people under his charge. He and 
 they should feel a pride in having their churches 
 and Sunday schools hygienically constructed and 
 well ventilated. To close the church doors and all 
 the windows immediately after divine service on 
 Sunday, is an unpardonable hygienic sin which no 
 clergyman ought to allow. A church should be 
 aired before being closed for the week and again 
 before service is held. The air in a church or Sun- 
 day school should be as good as anywhere, if not 
 better. Fixed carpets should not be used in places 
 of worship where many people congregate. Kiss- 
 ing the bible when taking an oath should be dis- 
 couraged ])y jurists and divines. Bacteriological 
 
 284 
 
CHURCH HYGIENE 285 
 
 examinations of bible covers used for that purpose 
 have more than once shown the danger of such a 
 practice. The bacilli of tuberculosis have often 
 been found on these covers in great numbers. 
 
 In Roman and Greek Catholic churches all ar- 
 ticles of adoration such as crosses, statues, and 
 pictures, which are often kissed by devout Catho- 
 lics, should be disinfected frequently. I am pleased 
 to note that there are some very progressive priests 
 in the Roman Catholic church who are fully aware 
 of the danger which may come from such practices 
 and who insist upon a thorough cleansing of these 
 articles. The Bishop of Fano in Italy even goes 
 a little further. In a circular issued by him, he 
 asks the priests of his diocese to comply with the 
 following rules: 
 
 1. In every church the floor must be regularly cleaned 
 with sawdust, saturated with a strong sublimate solu- 
 tion. This thorough cleaning should take place par- 
 ticularly after holidays when great masses of people 
 have visited the church. 
 
 2. Every week all ordinary chairs and confessional 
 chairs must be thoroughly cleaned with moist rags. 
 
 3. The grate of the confessional chairs must be 
 washed every week with lye and then polished. 
 
 The ritual circumcision practiced according to 
 the orthodox Jewish rite may, if the operator hap- 
 
286 TUBERCULOSIS 
 
 pens to be consumptive, be the cause of the in- 
 fant contracting tuberculosis. The operation of 
 circumcision, when skillfully and rapidly per- 
 formed, is in itself trifling; but the application of 
 the operator's lips afterwards for the purpose of 
 stopping the bleeding makes it dangerous. 
 
 Since it will be difficult to stop this practice by 
 a simple protest on the part of physicians, and as 
 the law can not interfere with the free exercise of 
 a religious rite, I should suggest as a remedy that 
 only such persons should be allowed to perform 
 circumcision as have shown the necessary skill 
 before a medical board of examiners, and that 
 every time they are called to perform the rite they 
 should submit themselves to a medical examina- 
 tion. Only when bearing a certificate from a 
 regular physician, stating the absolute freedom 
 from specific diseases, should they be allowed to 
 perform ritual circumcision. As another reliable 
 measure against the possibility of inoculating the 
 child, when the parents insist upon the orthodox 
 method of circumcision, is the suction by the aid 
 of a glass tube, as practiced in France and Ger- 
 many. 
 
 The common communion cup in Protestant 
 churches should be replaced by individual com- 
 munion cups. This practice, while accepted by 
 many liberal churches, is not looked upon with 
 
CHURCH HYGIENE 287 
 
 favor by those confessing the more orthodox creeds. 
 For these a cup has been devised which has the 
 advantage over the ordinary cup that the secretions 
 of any one mouth do not come in contact with an- 
 other. The device consists of an ordinary chahce 
 about five inches across the opening, with an attach- 
 ment of metal which each communicant may have 
 and place upon the rim of the chalice. If any of 
 the fluid remains after the communicant has im- 
 bibed, it flows into a false cup and into a reservoir 
 at the bottom of the chalice. The supply cup is 
 separate in the center of the chalice, and is so ar- 
 ranged that it automatically fills every time that it 
 is used, the amount being regulated at will. When 
 they do not have the individual metallic mouth 
 clips to attach to the rim of the chalice, a number 
 of layers of thin waxed paper, cut and formed to 
 fit tightly as a pad, are attached to the rim. After 
 the communicant has used the cup, by a sweep of 
 the thumb and forefinger the individual wax 
 paper which has been used is removed from the 
 pad and a clean one is revealed. (Fig. 74.) This 
 device is the invention of a Swedish clergyman. 
 Rev. C. J. Ljunggren, of Providence, R. I., whose 
 need for a device of this kind led him to invent 
 this ingenious substitute for the ordinary cup. 
 
 While one now less frequently sees patent medi- 
 cines and sure consumption cures recommended 
 
288 
 
 TUBERCULOSIS 
 
 or endorsed by thoughtless ministers, such rec- 
 ommendations still appear now and then in the 
 
 public press. It is self-evi- 
 dent that no minister, true 
 to his calling, should ever 
 do this, nor should religious 
 newspapers lend their col- 
 umns to advertise remedies, 
 the action of which on the 
 invalid is harmful ninety- 
 nine times out of a hundred 
 Fig. 74. Rev. Ljung- g^^d is perhaps never help- 
 
 gren's Hygienic Chalice. - , 
 
 ful. 
 Besides practicing the preventive measures 
 just enumerated, the ministers of the various 
 creeds can be helpful by cooperating with physi- 
 cians in the anti-tuberculosis crusade. Thus very 
 recently, interesting pamphlets on the prevention 
 of tuberculosis were written by the Rt. Rev. James 
 A. McFaul, Bishop of Trenton, and the Rev. 
 Dr. Joseph Krauskopf, a distinguished rabbi of 
 Philadelphia. In Rochester, N. Y., the Rev. Paul 
 Moore Strayer honors the medical profession by 
 inviting physicians, now and then, to occupy the 
 pulpit on Sundays to preach on health topics, and 
 particularly on tuberculosis. My friend, the 
 Rev. John Haynes Holmes, honored me recently 
 by an invitation to speak on tuberculosis on two 
 
CHURCH HYGIENE 289 
 
 successive Sundays before the Good Citizenship 
 Class of the Unitarian Church of the Messiah of 
 New York. 
 
 Nearly all leading denominations in the United 
 States have now either sanatoria or hospitals for 
 the care of tuberculous patients. It is interesting 
 to note that the Philadelphia Protestant Episcopal 
 City Mission opened a hospital for consumptives 
 as early as 1877. This institution has grown to 
 be one of the most important in the United States. 
 As will be seen from the accompanying picture 
 (Fig. 75), it now occupies a large tract of land 
 with numerous buildings and cottages, on Chest- 
 nut Hill, Philadelphia. 
 
 Under the auspices of the Roman Catholic 
 Church there are numerous sanatoria throughout 
 the United States, and in New York City this 
 church renders particular service to the tuber- 
 culosis cause by admitting to the St. Joseph and 
 the Seton Hospitals (Figs. 76 and 77) not only 
 early but also advanced cases, thus removing 
 centers of infection from many homes. 
 
 The National Jewish Hospital, which was 
 founded by the Jewish people as a contribution 
 to the world's battle against the white plague, is 
 entirely free and for destitute consumptives only — 
 no paying patients are received. It was started 
 some ten years ago, and is accomplishing a great 
 
ANTI-TUBERCULOSIS SERMONS 
 
 291 
 
 
 r^:^ 
 
 
 Fig. 76. St. Joseph Hospital for Consumptives in All Stages of the 
 Disease, New York City. 
 
 deal of good by curing many cases and reestab- 
 lishing the earning capacity of pulmonary in- 
 valids. This institution receives incipient cases 
 only. (Figs. 78 and 79.) 
 
 What is most interesting and gratifying from a 
 humanitarian point of view is that, while all these 
 institutions are nominally under Protestant, Ro- 
 man Catholic, or Jewish direction, all of them are 
 non-sectarian in their work, and patients of all 
 creeds and color are received and cared for. It 
 must not be forgotten, however, that all these 
 hospitals are taking care of the consumptive poor, 
 
292 
 
 TUBERCULOSIS 
 
 Fig. 77. Nazareth Branch of Seton Hospital for Consumptive Women 
 and Children, in Charge of the Roman Catholic Sisters of Charity. 
 
 and in order that their good work shall continue 
 and enlarge they must receive the generous finan- 
 cial support of all those able to help their suffer- 
 ing fellow-men. 
 
 There is one more field in which the clergyman 
 who is in sympathy with physicians and who 
 earnestly desires to diminish diseases of all kinds, 
 and at the same time diminish social misery, can 
 be helpful. Both disease and social misery are 
 oftentimes increased by custom and tradition, and 
 the method of burial of the dead has no little to do 
 with the welfare of the living. Medical history is 
 full of incidents showing that contagious and in- 
 fectious diseases have been propagated from su- 
 perficially buried bodies which had succumbed to 
 
DENOMINATIONAL HOSPITALS 
 
 ■9^ 
 
 Fig. 78. The National Jewish Hospital for Consumptives at Denver, 
 Colo. Men's Pavilion. Only Incipent Cases Are Admitted. 
 
 infectious diseases. This may happen through a 
 washing away of the soil of cemeteries, through 
 disinterment of the individual graves, or the re- 
 moval of the burial ofround. JNIen and beasts alike 
 have been known to become diseased and die 
 from such causes. 
 
 But it would seem that neither floods nor dis- 
 interments are necessary in order that the patho- 
 genic microorganisms may work their way to the 
 surface and then be the cause of dangerous in- 
 fectious diseases. Pasteur's experiments in regard 
 to splenic fever of cattle (charbon) are suflicient 
 evidence of this. It would seem that the burying 
 
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 1 
 
 ' 
 
 -J 
 
 - J 
 
 
 1 
 
 ^m 
 
 Mtosll 
 
 ^^xrw 
 
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 Fig. 79. The National Jewish Hosfjital for Consumptives at Denver, 
 Colo. The Balconies of the Circular Pavilion for Women. 
 
CREMATION 295 
 
 of any body when the cause of death was an in- 
 fectious disease, such as cholera, yellow fever, 
 typhoid fever, diphtheria, tuberculosis, etc., may 
 endanger the Hving. According to Pasteur and the 
 more recent experiments of Lortet and Despeignes, 
 the seemingly innocent earthworm plays a very 
 important part as an intermediary in bringing to 
 the surface living pathogenic (disease-producing) 
 microorganisms. The observations of Lortet and 
 Despeignes refer particularly to Koch's bacillus of 
 tuberculosis. These microorganisms are capable 
 of being ingested and ejected by the earthworm 
 without losing their virulence. The worms swal- 
 low earthy matters, and after separating the di- 
 gestible and serviceable portion they reject the 
 remainder in little coils or heaps at the mouths of 
 their burrows. In dry weather the worm descends 
 to a considerable depth and brings up to the surface 
 particles which it ejects. It would thus seem that 
 even the deeper burial of the bodies is no guarantee 
 that living infectious microorganisms will not be 
 brought to the surface. 
 
 Cremation has often been advocated, by any 
 number of physicians and sanitarians, in all cases 
 of death from infectious diseases, l)ut it is only 
 since the experiments of Lortet, Galtier, Gartner, 
 and Schottelius that tuberculosis has been included 
 among them, These experiments have demon- 
 
296 TUBERCULOSIS 
 
 strated conclusively that the tubercle bacillus can 
 resist putrefaction for years and be brought to the 
 surface by the earthworm. 
 
 But it is not only because it is a sanitary measure 
 that I plead for cremation. I claim that this sim- 
 pler and more expedient way of disposing of the 
 dead would be an economic advantage to many in- 
 dividuals and to every community at large. 
 
 In an address to the Chicago Medical Society, 
 advocating cremation, Dr. Charles W. Purdy made 
 some striking comparisons to show what a burden 
 is laid on society by the burial of the dead. Accord- 
 ing to his carefully prepared estimate, one and one- 
 fourth times more money is expended annually in 
 funerals in the United States than the government 
 expends for public school purposes. Hundreds of 
 acres of land are annually consecrated to the burial 
 of our dead. In many instances, and particularly 
 in the vicinities of large cities, burial lots are at a 
 premium. In some of our fashionable cemeteries 
 in New York one can not buy the few feet of ground 
 needed for the slow, loathsome decomposition of 
 his body for less than Si, 000; while cremation, 
 which means a rapid and sanitary decomposition, 
 need not cost more than $25.00. 
 
 In my work in tuberculosis I have been led to 
 become an ardent advocate of cremation, especially 
 in our large communities, and particularly for peo- 
 
CREMATION 297 
 
 pie of moderate means or the really poor. Perhaps 
 the danger of propagation of tuberculosis through 
 the graveyard, as compared with other diseases, is 
 relatively small; but the thousands of acres which, 
 near large cities, are devoted to the dead and are 
 thus useless, we need for the living. 
 
 According to statistics kindly furnished me by 
 Dr. W. H. Guilfoy, Registrar of Records of the 
 City of New York, there are 200 funerals a day, 
 which means 73,000 a year, out of which only the 
 small number of 1,000 are cremated. Many a 
 model tenement house, where people might get 
 light and air, could be built if the dozen or more 
 graveyards of many of our large cities were laid out 
 in building lots surrounded by little parks and 
 playgrounds. There the living children could play 
 and the living mothers and wives of our laboring 
 men could get a breath of air, which it is so difficult 
 to get in the present crowded conditions of the 
 average tenement districts. Would not this mean 
 prevention of tuberculosis and other diseases due 
 to overcrowding, among old and young alike ? 
 
 In my labors among the consumptive poor I 
 have always been painfully impressed by the ex- 
 pense which the ordinary funeral, including the 
 buying of a burying lot, entails. Consumption is 
 a costly disease. If the patient does not get well 
 within a year, if the disease becomes chronic and 
 
298 TUBERCULOSIS 
 
 incurable there is invalidism and loss of earning ca- 
 pacity often for two, three, and more years. When 
 the end comes, there is no end to the expense. A 
 costly coffin, expensive ceremonies, and a costly 
 burial lot sap, in many cases, every resource of the 
 relatives. I have known poor people to go into 
 debt for the sake of a decent funeral, for which 
 it took years to pay. In view of such experience, 
 which all physicians practicing among the poor 
 must have had, are we not justified, is it not our 
 duty, to plead for the relatively inexpensive dis- 
 position of the dead by cremation, and for simple 
 funerals ? 
 
 I am fully aware that there are valid objections, 
 first on medico-legal grounds, and second on re- 
 ligious grounds to which a plea for cremation must 
 give due consideration. The medico-legal objec- 
 tions could be met with by permitting no cremation 
 of any person, the causes of whose death was not 
 perfectly known, without a thorough post-mortem 
 inspection of the entire body and chemical ex- 
 amination of the stomach and intestines. I would 
 suggest a law that a complete report of the post- 
 mortem findings be handed to the proper officials 
 before a certificate for cremation is granted. 
 
 To the objection of cremation on religious 
 grounds, it is not my province to reply. Religious 
 and ethical sentiments must be honored and re- 
 
EMMANUEL CHURCH MOVEMENT 299 
 
 spected, but I am quite sure that the clergy of any 
 denomination, even those opposing cremation, will 
 agree with my plea for more simple and less costly 
 funerals which, in the families of the consumptive 
 poor, are so often productive of great hardship. 
 
 In a modern book on tuberculosis, a chapter 
 on the duties of the clergy in this great problem 
 can not be considered up to date without taking 
 cognizance of the anti-tuberculosis work of what 
 is now known as the Emmanuel Church movement. 
 While this work in its relation to tuberculosis has 
 already found numerous imitators, it originated 
 with Dr. Joseph H. Pratt and the Rev. Dr. Elwood 
 Worcester of Boston. It was the thorough scien- 
 tific training of the physician, the broad humanity 
 of the clergyman, and the cooperation of sympa- 
 thetic, devoted, and philanthropic friends which 
 made it possible to obtain most surprising results 
 in the treatment of cases in all stages of the disease 
 at their homes. To stimulate similar work where 
 it is not yet sufficiently understood, I will explain 
 the methods whereby Dr. Pratt and his co-workers 
 obtained such unusually good results. Of twenty- 
 eight patients in all stages of the disease no less 
 than eighty per cent were reported cured. 
 
 These patients were treated according to their 
 condition, some as long as two years, in "groups" 
 in or near their homes, after the most approved 
 
3oo TUBERCULOSIS 
 
 hygienic and dietetic methods with rest in the 
 open air, and constant supervision by nurses or 
 friendly visitors, under the direction of an ex- 
 perienced phthisiotherapeutist. Dr. Pratt has 
 given this method of treating a number of pa- 
 tients in their homes the name ''class method." 
 He emphasizes that in order for it to be successful 
 the classes should be small and the doctor, the 
 friendly visitors, the nurses, and the patients should 
 establish close relations with each other. It is 
 generally understood that when there are more 
 than twenty-five patients, a second class should be 
 established. 
 
 From Dr. Pratt's own writings on this subject 
 I quote the following: 
 
 ''The record book is an essential part of the class 
 method. The patient records his temperature, his 
 pulse-rate, the food he eats, and every other detail of the 
 daily life. He is required to enter in this diary the num- 
 her of hours he is out-of-doors and the amount of milk 
 he drinks. The book is inspected by the friendly visitor 
 at every visit and by the physician at the weekly meet- 
 ing. In my expjerience I have never found that keeping 
 the records leads to introspection or depression of spirits. 
 It is a great aid in carrying out the details of treatment. 
 The members take pride in keeping neat records. It 
 encourages the members to persevere. 
 
 "The weekly meeting is the distinct feature of the 
 
CO-OPERATION 301 
 
 class system. It is held in a large cheerful room at the 
 Massachusetts General Hospital. The class meeting is 
 a pleasant social hour for the members. One confided 
 to the friendly visitor that the meeting was her weekly 
 picnic. ]\Iade up as our membership is of widely differ- 
 ent races and different sects, thev have a common bond 
 in a common disease. A fine spirit of camaraderie has 
 been developed. They never discuss their symptoms, 
 and are almost invariably in good spirits. Frequently 
 our graduates (cured patients) drop in at the meeting to 
 get weighed and to greet their old associates. The mem- 
 bers are weighed each week and their pulse and tem- 
 perature taken by the friendly visitors, assisted by one 
 of the senior members. The greatest gains in weight 
 are posted conspicuously each wT€k on the blackboard, 
 and the member who remains out-of-doors the greatest 
 number of hours in the month has his record exhibited. 
 This stimulates a spirit of healthy emulation. One 
 patient was out-of-doors seven hundred and six hours 
 in a month, an average of nearly twenty-three out of the 
 twenty-four. Some of the sickest members gain this 
 distinction. The favorable cases that are making rapid 
 progress toward recovery infuse a spirit of hope in all. 
 
 "After the strength of the member has been tested 
 and increased by carefully prescribed amounts he is 
 graduated and allowed to work. Home treatment has 
 one advantage over the sanatorium in the fact that if 
 health has been regamed by leading the out-of-door 
 life at home, it is easy to keep up the hygienic habits 
 after recovery. A place for sleeping out-of-doors and a 
 
302 
 
 TUBERCULOSIS 
 
 Fig. 8o. An Emmanuel Church Class Patient Taking the Open 
 Air Treatment in a Back Yard of a Boston Tenement. 
 
 reclining chair for resting in the recumbent posture are 
 still available. Our graduates continue to sleep out-of- 
 doors or with their heads in open windows." 
 
 We reproduce here a very interesting illustration 
 (Fig. 80) showing how, under seemingly adverse 
 circumstances, it has been possible for an Emman- 
 uel Church class patient to have his outdoor sleep- 
 ing at night and open air treatment during the 
 day. As will be seen the tent has been erected in 
 the back yard of one of the poorest districts of 
 Boston. Nevertheless, the patient has what he 
 
EMMANUEL CHURCH WORK 303 
 
 needs — fresh air day and night, good food, and 
 medical supervision. But he has something more 
 which the Emmanuel people have known how to 
 provide and which accounts in no small degree 
 for the admirable results which they have obtained. 
 Without imposing their religious convictions upon 
 any one, the doctors of divinity went among 
 these patients and, assisted by friendly visitors, in- 
 spired them with hope and comfort ; talked to them 
 of home, children, wives, and husbands. Then the 
 friendly visitors looked after the wives or children, 
 mothers or sisters in the home. In all instances 
 w^hen the breadwinner was the invalid, these good 
 women took it upon themselves to see that there 
 was nothing w^anting in that home that was with- 
 out a breadwinner. In other words, the invalids 
 and their families were taken care of bv the Em- 
 manuel Church people as long as there was need 
 for it. Perhaps, never before in their lives had 
 these individuals so much peace of mind, happi- 
 ness, and contentment as when lying on their re- 
 clining chairs taking the rest-cure in the open air, 
 thinking of their well-provided family and their 
 prospective recovery; and having at the same time 
 the assurance given to them that employment 
 would be provided when they were again able 
 to work — and all this without being away from 
 home. The element of homesickness, so distress- 
 
304 TUBERCULOSIS 
 
 ing to many sanatorium patients, as well as the 
 element of worry and anxiety, did not exist. All 
 these psychological factors are responsible for the 
 success of the Emmanuel Church movement as 
 far as tuberculosis is concerned, as well as tha 
 hyo^ienic, dietetic, and fresh air treatment. 
 
 I approve most highly of such humanitarian 
 work as this, inaugurated on the one hand by a 
 doctor of medicine and on the other by a doctor 
 of divinity. There is but one word of warning 
 which I feel in duty bound to express in all 
 frankness : the seemingly little medicinal treatment 
 which is needed in many tuberculosis cases may 
 tempt the clergyman or layman to undertake the 
 treating of tuberculous patients without any, or 
 without a very thorough supervision or guidance 
 by medical men. If in any disease the physician 
 is needed, it is certainly in tuberculosis in no mat- 
 ter what stage. 
 
 In the preceding chapter we have spoken of the 
 duties of public officials, of municipal boards of 
 health, and of physicians; but no matter how great 
 their efforts may be, it will be difficult to solve the 
 problem without the cooperation of private phi- 
 lanthropy. One of the most successful ways to 
 work together is doubtless to form a special tu- 
 berculosis committee composed of representatives 
 of the local health board and other municipal 
 
CO-OPERATION 305 
 
 departments, the clergy, physicians particularly 
 interested in the tuberculosis problem, philan- 
 thropic men and women, and the representatives 
 of charitable organizations. Such a committee the 
 author was privileged to help form for the City 
 of New York in the year 1902. The following 
 is in brief the purpose of this Committee: 
 
 1. Research: Into the social, as distinct from the 
 medical, aspect of tuberculosis. The study of the 
 relation between the disease and overcrowding, 
 infected tenements, and unhealthful occupations. 
 
 2. Education: The publication of leaflets and 
 pamphlets ; the giving of lectures with and without 
 stereopticon views ; the use of a travelling tubercu- 
 losis exhibit designed to emphasize the fact that 
 tuberculosis is a communicable, preventable, and 
 curable disease; the dissemination of knowledge 
 concerning the means and methods to be adopted 
 for the prevention and cure of tuberculosis. 
 
 3. Treatment: The encouragement of move- 
 ments for suitable public and private sanatoria; 
 both for advanced and for incipient cases, for 
 adults and for children, for free care, and also for 
 the care of those who are able to pay moderate 
 fees. 
 
 4. Lef!^islation: An effort to secure the enactment 
 of legislation looking toward the control of such 
 recognized causes of contagion as spitting in pub- 
 
3o6 TUBERCULOSIS 
 
 lie places, the dry sweeping of streets, the use of 
 dark rooms in tenements for sleeping purposes, etc. 
 After seven years of existence, the Committee 
 on the Prevention of Tuberculosis of the Charity 
 Organization Society of the City of New York 
 could point to the following accomplishments, 
 which were summarized by Mr. Lawrence Veiller 
 for a report for the International Congress on 
 Tuberculosis which convened in Washington, D. 
 C, in the fall of 1908. This Committee 
 
 1. Made the first comprehensive study of the social 
 
 aspect of tuberculosis. 
 
 2. Formtilated standard schedules for recording the 
 
 social history of tuberculosis cases. 
 
 3. Made a comprehensive study of institutions and 
 
 societies for the treatment of tuberculosis in the 
 United States and Canada — publishing a Di- 
 rectory of same in 270 pages. 
 
 4. Made a careful study of tuberculosis among Ne- 
 
 groes in New York City. 
 
 5. Made a comprehensive investigation of conditions 
 
 in New York City lodging houses with reference 
 to tuberculosis. 
 
 6. Made an investigation of conditions in the New 
 
 York Federal Post-Office building with reference 
 to tuberculosis. 
 
 7. Made an investigation of country employment for 
 
 city consumptives. 
 
CHARITY ORGANIZATION SOCIETY 307 
 
 8. Made a comprehensive inquiry into the whole mat- 
 
 ter of the reUef and care of tuberculosis in New 
 York City. 
 
 9. Made a thorough study of the possibilities of home 
 
 treatment of the tuberculous sick in New York's 
 tenement houses. 
 
 10. In cooperation with the New York Milk Commit- 
 
 tee, made a comprehensive study of bovine tu- 
 berculosis in New York State and its methods of 
 regulation; and lastly, 
 
 11. Made a study in New York City of the prevalence 
 
 of tuberculosis among workers in certain in- 
 dustries — based on medical examinations. 
 
 In the educational line, this Committee 
 
 1. Originated the plan for pubhshin^ tuberculosis 
 
 maxims on the back of street car transfers — 
 50 milHon a year circulated this way. 
 
 2. Distributes 250,000 Circulars of Advice regarding 
 
 tuberculosis each year to the public, through 
 Labor Unions, Factories, Department Stores, 
 Settlements, Churches, etc. 
 
 3. Has given 733 popular lectures on tuberculosis to 
 
 audiences of 148,125 people — in Enghsh, Yid- 
 dish, ItaHan, Bohemian, French, and German — 
 228 lectures to 78,640 persons this year. 
 
 4. Originated the permanent traveling Tuberculosis 
 
 Exhibition as a means of educating the com- 
 munity.— Exhibit shown throughout each year 
 in Settlements, Churches, Clubs, etc., and in 
 
3o8 TUBERCULOSIS 
 
 stores on crowded thoroughfares — viewed by 
 150,000 people in six weeks at one place this year. 
 
 5. Established a weekly press service to 200 news- 
 
 papers in New York State — furnishing news mat- 
 ter about tuberculosis prevention and treatment. 
 
 6. Carried on the first active educational campaign 
 
 among Labor Unions — securing the cooperation 
 of the United Garment Workers of America, 
 Central Eederated Union, and American Fed- 
 eration of Labor, etc. 
 
 7. Organized a Committee on the Prevention of Tuber- 
 
 culosis among Negroes in New York City. 
 
 8. Issued a circular to 8,000 physicians against sending 
 
 consumptives out West or to the country except 
 under proper conditions. 
 
 9. Issued a strong pronouncement against ''Con- 
 
 sumption Cures." 
 
 10. Published a comprehensive book on the prevention 
 
 of tuberculosis — 388 pages. 
 
 11. Published and distributed 1,000 copies of a report 
 
 on Bovine Tuberculosis in New York State. 
 
 12. PubHshed the first Directory of Institutions for the 
 
 treatment of tuberculosis in the United States — 
 270 f)ages. 
 
 13. Published and distributed to physicians and others 
 
 6,000 copies of a report on Home Treatment of 
 Tuberculosis in New York City. 
 
 14. Originated a plan of distributing art posters, with 
 
 tuberculosis advice in them, in tenement homes — ■ 
 10,000 distributed to Italians. 
 
CHARITY ORGANIZATION SOCIETY 309 
 Furthermore, 
 
 1. It took steps to bring about formation of more 
 
 special tuberculosis clinics in the dispensaries of 
 New York City. 
 
 2. It was also an agency in New York City to advocate 
 
 formation of special tuberculosis clinics for chil- 
 dren. 
 
 3. It took active part in urging and bringing about the 
 
 building of a Municipal Sanatorium — prepared 
 and published architects' plans, which formed 
 basis of official report to the Mayor. 
 
 4. It secured funds for special relief of consumptives in 
 
 their homes — for special diet, payment of rent, 
 wage loss, clothing, bedding, pensions, etc. — 
 $33,496 thus expended in 20 months. 
 
 5. It brought about special visitation by physicians, of 
 
 Russian and Polish famihes in their homes. 
 
 6. It secured opening at night of special tuberculosis 
 
 clinic for Negroes. Colored nurses' services 
 furnished by Committee. 
 
 7. It sent a selected number of consumptives out of 
 
 the city for country treatment, and defrayed 
 their board and exoenses. 
 
 8. It brought about examination at special clinics of 
 
 children in tuberculous families — defrayed cost 
 of medical examinations of same. 
 
 9. It established First Day Camp for tuberculous 
 
 patients in New York City on abandoned ferry- 
 boat "Southfield." 
 
3IO TUBERCULOSIS 
 
 10. It has medical examinations made of workers in 
 
 different trades to determine extent of tubercu- 
 losis — cost defrayed by Committee. 
 
 11. It brought about establishment of District System 
 
 of Tuberculosis Clinics in New York City and 
 union of existing agencies in new association of 
 tuberculosis clinics. 
 
 12. It formulated comprehensive plan of hospital, sana- 
 
 torium, and dispensary treatment for the tuber- 
 culous sick in New York City. 
 
 13. From time to time it has investigated adequacy of 
 
 existing hospital provision for tuberculous sick 
 and urged the authorities to meet it more ade- 
 quately. 
 
 Regarding legislation, this Committee has shown 
 the very important part such a group of men and 
 women can play by promoting just laws and fur- 
 thering the interest of consumptives and the pub- 
 lic in general, and by opposing unjust and inhu- 
 mane laws: 
 
 1. It took active part in the legislative campaign for 
 
 appropriation for completion of the Free State 
 Hospital at Ray Brook. 
 
 2. It took active part in opposing law, making difficult 
 
 the establishment of tuberculosis sanatoria in the 
 State. 
 
 3. It has repeatedly protested against legislation weak- 
 
 ening the Tenement House Laws. 
 
CHARITY ORGANIZATION SOCIETY 311 
 
 4. It supported legislation authorizing State Commis- 
 
 sioner of Labor to require adequate ventilation 
 in factories. 
 
 5. It supported legislation authorizing appointment of 
 
 Medical Inspector in the State Department of 
 Labor. 
 
 6. It formulated Bill for the Regulation of Bovine 
 
 Tuberculosis, which served as the basis for an 
 important amendment to the Agricultural Law. 
 
 The New York Charity Organization Society has 
 a committee under the chairmanship of Professor 
 Theodore C. Janeway, M. D., which is for the purpose 
 of finding employment for the handicapped, including 
 tuberculous invalids able to do some work. The value 
 of such a committee must be obvious when one con- 
 siders how frequent tuberculosis is among the laboring 
 population. 
 
 Diet kitchens which provide good, pure milk, free 
 of charge to the destitute sick, are valuable aids in 
 the treatment and care of the tuberculous poor. The 
 milk is given to the patients upon the written recom- 
 mendation of the attending physician. The New 
 York Diet Kitchen Association, under the presi- 
 dency of Mrs. Henry Willard, has now eight branches 
 throughout the city. The Association docs magnifi- 
 cent work and deserves the support of all those able 
 to give it. 
 
 The Russell Sage Foundation, by substantial money 
 contributions, has been helpful in aiding the various 
 
312 TUBERCULOSIS 
 
 national, state, and local anti-tuberculosis agencies in 
 their educational propaganda. 
 
 It was reserved to three philanthropists of our own 
 country to found institutions for the specific purpose 
 of teaching physicians and training them in tubercu- 
 losis science. Mr. Henry Phipps of New York is the 
 founder of the Phipps Institute for the Study and 
 Prevention of Tuberculosis in Philadelphia, and, 
 furthermore, he established the Phipps Dispensary in 
 connection with the Johns Hopkins Medical School 
 at Baltimore. Mr. John D. Rockefeller established a 
 special tuberculosis hospital in connection with the 
 Rockefeller Institute in New York; and Mr. Andrew 
 Carnegie gave toward the establishment of the Robert 
 Koch Institute of Berhn for the Study of Tuberculosis, 
 the magnificent sum of $250,000 (1,000,000 marks). 
 May the examples given by these three generous philan- 
 thropists find emulation everywhere. To create op- 
 portunities to study tuberculosis in all its aspects, and 
 to send out well-trained physicians, is, indeed, indis- 
 pensable if we would wish to master the disease. 
 
 In this connection it should be said that the scien- 
 tific research work regarding tuberculosis must be 
 encouraged, and careful and humane animal experi- 
 mentation should not be opposed. It is, thanks to 
 animal experimentation that many of our infectious 
 diseases have now become, not only less frequent, but 
 more surely and rapidly cured. Anti-vivisectionists 
 should remember that scientific experimenters never 
 purposely torture animals and that, for example, the 
 
VIVISECTION 313 
 
 horses from which antitoxinc for diphtheria is produced, 
 do not suffer. Let these good people, furthermore, re- 
 call that it is to the experiments on a few hundred 
 guinea pigs and rabbits that the discovery of antitoxinc 
 is due, and that the consequence is that the mortality 
 from diphtheria has been reduced from seventy or 
 seventy-five per cent to five or six per cent. This means 
 that ninety-four to ninety-five diphtheritic children are 
 saved out of every hundred, instead of twenty-five or 
 thirty as formerly. Let every American mother re- 
 member these facts when she is asked to aid in the 
 protests against scientific vivisection. 
 
 It may seem ungracious to suggest to a philan- 
 thropist what it might be best for him to do in his 
 desire to help his fellow-men; but when one pe- 
 ruses the varied activities of a charity organization 
 society, such as those enumerated above, one can 
 not help thinking that from a concerted action of 
 the philanthropists and such a society, the greatest 
 benefit for the tuberculosis cause must be derived. 
 
 The ofificers of an organized charity organization 
 society will know where model tenement houses 
 are most needed, and what kind of tuberculosis 
 institution is best fitted to meet existing demands. 
 Thus, for example, at the time of writing this book 
 there is in the City of New York the greatest need 
 of taking care of advanced cases of tuberculo- 
 sis who constitute centers of infection in the ten- 
 
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SANATORIUM TREATAIENT 31^ 
 
 ement houses; and an urgent, crying need of the es- 
 tabhshment of sanatoria for tuberculous children 
 for whom, with the exception of Sea Breeze, there 
 is now almost no provision. I am convinced that 
 philanthropists can not render greater service to 
 the anti-tuberculosis cause at this time than by 
 helping the New York Tuberculosis Committee in 
 its efforts to suppress centers of infection, and in 
 its endeavors to prevent the tuberculous child of 
 to-day from becoming the consumptive adult of 
 to-morrow. 
 
 With the help of the clergy, of philanthropists, 
 of charitable individuals, and charity organizations, 
 a great deal, of course, can be done in the direction 
 of establishing sanatoria for tuberculous adults and 
 children, hospitals for the advanced cases, day 
 camps, night camps, and tuberculosis classes. Of 
 the economic value of sanatorium treatment in 
 tuberculosis we have spoken in Chapter VH. By 
 means of the sanatorium treatment, that is to say, 
 the treatment of the tuberculous in institutions es- 
 pecially established and equipped for the purpose, 
 eighty to ninety per cent of incipient cases are 
 cured, or their disease sufficiently arrested so that 
 they can again become breadwinners. It has been 
 demonstrated that with the aid of the sanatorium 
 treatment patients can be cured in all climates; and 
 this is very important when we consider that tuber- 
 
3i6 
 
 TUBERCULOSIS 
 
 Fig. 82. Adirondack Cottage Sanatorium. Piazza of the New 
 Medical and Reception Pavilion. 
 
 culosis is a disease which is prevalent everywhere, 
 and that it would be inexpedient and unwise to 
 send every patient to what was formerly known as 
 a ^'specific climate" particularly effective in the 
 treatment of tuberculosis. 
 
 There are now throughout the civilized world any 
 number of private and public sanatoria situated 
 in various altitudes and latitudes. The United 
 States has not been behind in establishing insti- 
 tutions of this kind. In Chapter VII we gave a 
 complete list of existing state sanatoria. The num- 
 
SANATORIUM TREATMENT 
 
 317 
 
 Fig. 83. Manila C. Wheeler Cottage of the Adirondack Cottage 
 Sanatorium, Trudeau, New York. 
 
 ber of private institutions in the United States as 
 well as in other countries is, of course, many 
 times greater, and their number, I am happy to 
 state, is constantly on the increase. According to 
 the records of Professor Livingston Farrand, the 
 Secretary of our National Association for the 
 Study and Prevention of Tuberculosis, before the 
 year 1905 there existed throughout the United 
 States 115 sanatoria and special tuberculosis hos- 
 pitals. In the year 1905, 15 of such institutions 
 were established; in 1906, 17; in 1907, 35; in 1908, 
 71; and during the first three months of 1909, 39; 
 so that we have to-day in the United States all 
 told 289 institutions where patients arc housed, 
 
31^ 
 
 TUBERCULOSIS 
 
 |s/9/XUF=if^ C o -r -r >K C3- El 
 
 — ^- O- P?OLjrvi CD 
 
 OnC i^ooT. 
 
 Fig. 84. Adirondack Cottage Sanatorium, Ground Plan of 
 McAlpin Cottage. 
 
 boarded, and kept under constant medical super- 
 vision. These institutions are justly called closed 
 establishments, that is to say, they are exclusively 
 consecrated to tuberculosis cases, and no other 
 class of patients are received there. 
 
 I can only reproduce here a fcv^ illustrations of 
 the many useful private, philanthropic, and semi- 
 
SANATORIUM TREATMENT 321 
 
 philanthropic institutions in this and many foreign 
 countries; all of them are doing a vast amount of 
 good, not only as curative but also as educational 
 agencies. (Figs. 81 to 104.) ^ 
 
 I wish it to be distinctly understood that in 
 selecting the institutions for illustration I was not 
 guided by any preference for one or the other, 
 but simply by a desire to give an idea of the 
 various types of construction now in use for the 
 treatment and care of consumptives in the various 
 climes and sections of our own and other coun- 
 tries. It may be said that in Europe the one- 
 house system is in favor, while in the United 
 States the cottage system with from four to five 
 patients is more universally adopted for private 
 institutions. The larger private sanatoria have, 
 as a rule, also an infirmary where patients who 
 need special care or supervision are temporarily 
 housed. 
 
 It is the constant outdoor life in pure air, the 
 abundant but carefully regulated diet, and the con- 
 stant medical guidance and supervision which the 
 patient receives in the sanatorium that has achieved 
 
 1 For complete and detailed information concerning other philan- 
 thropic, semi-philanthropic, and private sanatoria, the reader is re- 
 ferred to the directory of institutions of the United States and 
 Canada, compiled under the direction of the National Association 
 for the Study and Prevention of Tuberculosis by means of the 
 Russell Sage Foundation. 
 
SANATORIUM TREATMENT 323 
 
 such wonderful results. The patient sleeps out- 
 doors at night; he rests in the rechning chair tak- 
 ing what is known as the ''cure" during the day; 
 the amount of exercise is prescribed by the physi- 
 cian so that it will do him good and not harm; the 
 slightest intercurrent trouble is reported to the phy- 
 sician. 
 
 In the sanatorium the precautions, concerning 
 the expectoration and all that appertains to the 
 prevention of infection, are so thorough that it may 
 be said one is more secure from contracting tuber- 
 culosis within its precincts than anyw^here else. 
 The contracting of tuberculosis by physicians and 
 attendants in the sanatorium is of the rarest oc- 
 currence. 
 
 This brings us to the very interesting topic of the 
 medical and social mission of the sanatorium for 
 consumptives. Of its curative mission we have 
 already spoken. The educational mission of san- 
 atoria for consumptives is so important that, ac- 
 cording to some authorities, it overshadows all 
 others. In the sanatorium the patient is taught 
 how to dispose of his sputum and how to guard 
 against drop infection. He is taught how to cough, 
 when to cough, and when not to cough. He learns 
 to live in fresh, pure air by day and by night. He 
 learns w^hen to eat, how to cat, and ^^•hat to eat. 
 He learns how to breathe, how to exercise, and when 
 
324 
 
 TUBERCULOSIS 
 
 Fig. 88. Edward Sanatorium at Naperville, Near Chicago. For In- 
 cipient Cases Only. Dr. Sachs Is the Visiting Physician, a Nurse 
 Is in Charge of the Institution. Ten Beds Are Maintained by the 
 Nurses' Association. Rates $10.00 per Week. 
 
 to exercise, and what to do in order not to catch 
 cold. He learns not to be unduly alarmed at the 
 sight of ])lood in the sputum. He learns to be 
 hopeful and cheerful, and that he must labor to get 
 well. When he returns home cured or improved, 
 he will impart all his knowledge to his family, 
 friends, and neighbors, and become a hygienic fac- 
 tor in the community. 
 
 To the public at large the well-equipped sana- 
 torium teaches that phthisiophobia is as unjust as 
 
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SANATORIUM TREATMENT 
 
 327 
 
 it is cruel, and that a patient who takes care of 
 his expectoration and guards against droplet in- 
 fection is as safe an individual to associate with 
 as any one. It, furthermore, teaches that sanatoria 
 for consumptives are no danger to the neighbor- 
 hood. The statistics of the two villages Goerbers- 
 dorf and Falkenstein, where five of the largest Ger- 
 man sanatoria have been located for many years, 
 show that the mortality from tuberculosis has been 
 reduced by one-third from what it was before the 
 estabhshment of these institutions. 
 
 In Rutland, Alass., w^here the ^Massachusetts 
 State Sanatorium is located, during the six years 
 after the opening of the sanatorium there have been 
 only eight deaths from tuberculosis annually with 
 an increased population, while prior to the estab- 
 lishment of the sanatorium, among a smaller num- 
 ber of people, they had fourteen deaths annually 
 from this disease. Almost as marked a reduction 
 has been reported by Dr. Elliott of Gravenhurst, 
 Canada, where sanatoria for early as well as for 
 advanced cases of tuberculosis have been estab- 
 lished for nearly ten years. 
 
 Besides educating individual patients and the 
 community at large, the sanatorium offers excel- 
 lent opportunities for young physicians who enter 
 there as assistants to become expert diagnosticians 
 ^.nd experienced phthisiotherapeutists. The knowl- 
 
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SANATORIUM TREATMENT 329 
 
 edge gained by a year or two of service in a san- 
 atorium for consumptives will make the young 
 practitioner, if he does not wish to continue in in- 
 stitutional work, an ideal family physician, well 
 equipped to treat the most frequent and prevalent 
 of all chronic diseases. 
 
 The trained nurse, taking a post-graduate course 
 in a sanatorium for consumptives, will gain val- 
 uable experience which she can utilize advanta- 
 geously after she returns to her private work as a 
 general nurse. 
 
 The last mission of the sanatorium is to help, to 
 better, to uplift, and to harmonize social differences. 
 
 There is no denying the sad fact that the exces- 
 sive use of alcohol is to be found among the rich as 
 well as among the poor of nearly all nations. In 
 a sanatorium, the regular mode of hfe, the strict 
 prohibition of alcoholic drinks, except in rare in- 
 stances for medicinal purposes, may therefore wtII 
 be considered an important social factor in help- 
 ing to reduce that curse of so many civilized na- 
 tions — alcoholism. The belief that alcohol is a 
 preventive, or a sure cure for consumption, is not 
 confined to any one country. I have met with this 
 erroneous conception among the people of Europe 
 as well as of America, and it is not always exclu- 
 sively to be found among the so-called submerged 
 or ignorant poor. 
 
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SANATORIUM TREATAIENT 331 
 
 The regularity of life in a well-conducted san- 
 atorium also tends to make the careless individual 
 a careful one, the thoughtless a more thoughtful. 
 In a people's sanatorium the uneducated patient 
 is given an opportunity to increase his knowl- 
 edge, and the one who has had no opportu- 
 nity of acquiring good manners will be taught 
 them. 
 
 Nearly all the European and American sanatoria 
 offer intellectual and educational advantages to 
 their inmates. The sanatorium often confers bene- 
 fits even ethically and morally. A prolonged so- 
 journ in such an institution will probably always 
 leave a deep impression on the social views of the 
 consumptive individual. Be he ever so rich, aristo- 
 cratic, or even indifferent to his fellow-men, he will 
 become more democratic and more benevolent; he 
 will feel more for his comrades than he has prob- 
 ably ever felt before. There often appears a spirit 
 of the truest charity among sanatorium inmates, 
 and it was my good fortune to witness such a man- 
 ifestation among well-to-do and aristocratic tuber- 
 culous patients at Falkenstein while I had the 
 honor of serving as assistant to my regretted and 
 immortal teacher, Geheimrath Dettweiler. As a 
 result of the deep feeling for the suffering of the 
 consumptive poor outside of the sanatorium, who 
 were deprived of the care and comfort of institu- 
 
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SANATORIUM TREATMENT 
 
 333 
 
 Fig. 94. New Mexico Cottage Sanatorium, Silver City, N. M. 
 Private. For Pulmonary and Laryngeal Tuberculosis at Curable 
 Stage. Rate: $83.00 per Month. 
 
 tional treatment, these well-to-do patients contrib- 
 uted largely to the estabhshment 3f the first people's 
 sanatorium in Germany, now located at Rupperts- 
 hain. Later, this institution was largely bene- 
 fited by the generous bequest of a patient who, 
 during his last few months, had received the tender 
 care of the physicians and devoted nurses at Fal- 
 kenstein. Our own beloved Trudeau who, twenty- 
 five years ago, in the wilderness of the Adirondack 
 Mountains, started with one little cottage and two 
 poor patients, owes the existence of the now great 
 and justly celebrated Adirondack Cottage Sana- 
 torium (Fig. 78), comprising about thirty cottages, 
 with a large administration building, infirmary, 
 library, and church, to liberal contril^utions from 
 rich and grateful tuberculous patients. 
 
334 
 
 TUBERCULOSIS 
 
 Fig. 95. Nordrach Ranch, Colorado Springs, Colo. For First and 
 Second Stages. Private. Rates: $60.00 to $65.00 per Month. 
 
 Besides the sanatorium, the special hospital, and 
 the dispensary, there are other methods which of 
 late years have proved efficacious in the care of 
 tuberculous patients, and particularly of the con- 
 sumptive poor. We refer to the day camp, the 
 night camp, and the class method already de- 
 scribed in connection with the Emmanuel Church 
 work. 
 
 The day camp idea originated in Germany in 
 1900, under the name of ''Walderholungsstatte," 
 which might be freely translated as a health station 
 in the forest. The first day camp for consump- 
 
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 TUBERCULOSIS 
 
 Fig. 97. A Two Room Compartment Tent of the Star Ranch, 
 Colorado Springs, Colo. 
 
 tives in the United States was, I believe, estab- 
 lished by the Boston Association for the Rehef and 
 Control of Tuberculosis. 
 
 The purpose of such a day camp, which is 
 usually located in the healthiest locahty of a city, 
 preferably in wooded regions, is to receive patients 
 during the daytime, to provide the consumptive 
 patient with a comfortable chair for the rest-cure 
 in a pleasant and sheltered spot, and to provide him 
 with one or two substantial meals and milk and 
 eggs between times. The patients are, of course, 
 taught to be exceedingly careful with their expecT 
 toration and instructed in all other hygienic meas- 
 ures essential for their own and their associates' 
 
SANATORIUM TREATMENT 
 
 337 
 
 Fig. 98. Muskoka Cottage Sanatorium, Gravenhurst, Canada. 
 
 well-being. A physician and nurse supervise the 
 treatment and care. 
 
 It was not only in Boston that the first day camp 
 was estabhshed, but to the city of Boston also be- 
 longs the credit of having established the first mu- 
 nicipal day camp. 
 
 Under the auspices of the Red Cross a number 
 of day camps for the tuberculous have since been 
 established in Washington, Schenectady, Albany, 
 New York, etc. Of one of them, located on the 
 roof of the Vanderbilt Clinic, we take pleasure in 
 reproducing an interesting photograph. (Fig. 99.) 
 
33^ 
 
 TUBERCULOSIS 
 
 Fig. 9y. Red Cross Day Camp on the Roof of the Vanderhilt 
 
 Clinic. 
 
 Of the educational value of such a day camp 
 there can be no doubt. For cases for which no 
 places in sanatoria can be found, it offers, at least, 
 a temporary substitute for sanatorium treatment. 
 Of equally great value is it as a temporary sojourn 
 for a patient discharged from a sanatorium, but in 
 need of after-treatment. 
 
 To the best of my knowledge, the credit of the 
 night camp idea belongs to Dr. William Charles 
 White, medical director of the Tuberculosis League 
 in Pittsburg, who first proposed it to the profession. 
 Of these latter institutions we have as yet but very 
 
340 
 
 TUBERCULOSIS 
 
 Fig. ioi. Sanatorium Falkenstein near Frankfort on the Main, with 
 Ruin of Falkenstein Castle in the Background. Private. 
 
 few in this country; still, it is my firm conviction 
 that night camps do as much good as day camps. 
 Many a tuberculous patient is obliged to work for 
 his own maintenance or the support of his family. 
 Upon the advice of his physician he may have 
 changed his indoor work for an outdoor occu- 
 pation, yet what good does it do him if he is 
 obliged to sleep in an unsanitary tenement or lodg- 
 ing house ? And to what danger is not his family 
 exposed when they are numerous and obliged to 
 live in close proximity with the sufferer? 
 
 I am convinced that the greatest number of in- 
 fections originate in the sleeping rooms of our con- 
 sumptive tenement house dwellers, and at night- 
 
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342 TUBERCULOSIS 
 
 time. It is then that the consumptive member of 
 the family unconsciously expels the bacilliferous 
 droplets during the cough, which render the at- 
 mosphere infectious. Fearing to have the other 
 members of the family feel uncomfortable or cold, 
 he will consent to have the windows closed at 
 night, or close them himself in spite of the doctor's 
 injunction to keep them open. 
 
 Through the night camp, the family of the 
 consumptive will be protected and he himself 
 assured of a good bed in a well-aired room or 
 shack. 
 
 In Canada there exists, under the management 
 of Dr. Arthur J. Richer, an institution in which 
 individuals who for one reason or another are not 
 strong, either because they are just recovering from 
 pleurisy, pneumonia, or grippe, overworked or 
 predisposed by heredity, are received and treated 
 with a view of preventing a possible development 
 of tuberculosis. I have given to that institution 
 the name preventorium and it would seem to me 
 an admirable idea if these preventoria were to be 
 multiplied throughout the world. They certainly 
 would constitute a mighty factor in the crusade 
 against tuberculosis. 
 
 It must be evident that to carry out, in a city like 
 New York, such class methods as have been de- 
 scribed in this chapter, one will encounter a great 
 
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344 TUBERCULOSIS 
 
 many difficulties which are easily surmountable 
 in a smaller community. Outdoor sleeping on 
 a veranda, or in a yard, or even on the roof under 
 present conditions, is practically impossible in a 
 large city. After much experimenting I succeeded 
 in getting a fair substitute in the window-tent, 
 illustrated in Chapter V (Fig. 21); but a window- 
 tent is, of course, not quite equal to actual out- 
 door sleeping, as the window itself may not always 
 have access to the best of fresh air, and the tent 
 does not provide sufficient circulation in hot 
 weather. 
 
 The class method, furthermore, can only be 
 successful when the patients comprising "a class" 
 do not live too far apart, and when they can be 
 visited and supervised by a nurse, and whenever 
 necessary, by a physician. Thus, the ideal for 
 class method treatment w^ould be a house espe- 
 cially built and constructed for the purpose; in 
 other words, a house where tuberculous patients 
 could have the best sanitary arrangements, with 
 balconies for outdoor sleeping, and the building be 
 constructed in every way to answer the particular 
 purpose of caring for families with tul)erculous 
 invalids. My distinguished colleague. Dr. Henry 
 L. Shively, had the good fortune to find, in 
 Mrs. Wm. K. Vanderl^ilt, Sen., a philanthropic 
 lady willing to carry out the plans for such sani- 
 
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346 
 
 TUBERCULOSIS 
 
 Fig. 105. The Proposed Shively Sanitary Tenements; Street View. 
 
 Built by Mrs. Wm. K. Vanderbilt, Sr. 
 
 Henry Atterbury Smith, Architect. 
 
 tary tenements, which will soon be erected in this 
 city. 
 
 I am indebted to him for the accompanying 
 photographs (P'igs. 105, 106) of what will be known 
 as the Shively Sanitary Tenements, and which will 
 occupy the center of the block on Avenue A, be- 
 tween 78th and 79th Streets. 
 
 Each of these four tenements will be built in the 
 form of a hollow square, with a court 30 by 31 feet 
 
SANITARY APARTMENTS 347 
 
 in the center, which will be decorated with turf and 
 flowers. To enter an apartment the tenants will 
 have to go through the archw^ay leading into the 
 court, and then up one of the four staircases built 
 in the corners of the court. The staircases will 
 be open to the air and will run to the roof, and 
 every apartment w^ill open directly off the staircase. 
 This will give each of them a separate front door. 
 
 On the roofs will be erected comfortable loggias. 
 Wind-breaks of glass will be set up on the north 
 side. The floors will be tiled. Shrubs will make 
 the place bright and steamer chairs will be set ready 
 for the tenants. Toilets will also be provided for 
 men, women, and children. 
 
 It is hoped by this means to encourage the open 
 air life of the people to the utmost extent. They 
 will be able to enjoy fresh air without going to 
 institutions, and a great deal of expense will be 
 thereby saved to them. 
 
 Every apartment is to be provided with a bal- 
 cony. The tenements are to be six stories high, and 
 a row of balconies is to be erected for each story. 
 To give access to them, the windows will be built 
 in three sections, so as to open from the floor to the 
 ceiling. Tenants may sleep out on them, or, if the 
 windows are thrown open to the top, the room will 
 be practically part of the balcony. 
 
 To secure the proper ventilation of the courts 
 
Fig, ig6. The Proposed Shively Sanitary Tenements; Court View, 
 Showing Open Staircases. 
 
SANITARY APARTMENTS 349 
 
 inside the tenement houses, a passage will be cut 
 through. For the ventilation of the rooms, it is 
 planned that every apartment shall have windows 
 opening on to both the interior court and the exte- 
 rior of the tenement house. By this means it will 
 be possible to obtain a regular stream of air through 
 an apartment at any time. The apartments will be 
 from two to five rooms each. They will conform 
 with the tenement house regulations and contain 
 from 70 to 120 square feet each. It is hoped that 
 it will be possible in every case to install a bath. 
 Gas rather than coal ranges will be provided in 
 order to get rid of the trouble in handling ashes. 
 
 With the aid of the Shively tenement homes, it 
 seems certain to me that the class method of treat- 
 ment as conceived and so successfully carried out 
 by Dr. Pratt, can very well be imitated in New 
 York. It was suggested to me by another philan- 
 thropic lady, interested in tuberculosis work, that 
 it would be a good idea to have in each tu- 
 berculosis dispensary district of a great city one 
 or two of such sanitary tenements, and to in- 
 duce as many as possible of the dispensary pa- 
 tients to reside in these ideal homes. If the 
 rent in these sanitary tenements should be higher 
 than in the average tenement house, it would 
 probably be a judicious expenditure on the part 
 of charitable institutions and charitable indi- 
 
350 TUBERCULOSIS 
 
 viduals to pay the difference as an inducement 
 for tuberculous patients to occupy these apart- 
 ments. The tuberculous inhabitants of each open 
 air tenement house could constitute a class, and 
 the supervision of physician and nurse, when all 
 the patients are under one roof, would certainly be 
 easy and at the same time most efficacious. 
 
 It would seem that these open air tenements 
 might almost solve the problem for the early 
 cases among workers in cities, if we could only 
 have enough of them; but we must not forget the 
 advanced cases. The incurable and refractory 
 patients must be segregated, else they are a 
 menace to their families and the community as 
 well. Institutions for them are urgently needed 
 in our country at present. Professor Edward T. 
 Devine, in his new book "Misery and its Causes," 
 pleads eloquently for them, and in recent addresses 
 before our National Anti-tuberculosis Association 
 the Hon. Homer Folks, Ex-Commissioner of Chari- 
 ties, and Professor Wm, H. Welch stated that the 
 greatest need in America at this time was for such 
 institutions. Dr. Welch said that in the opinion 
 of Professor Koch and Professor Newsholme the 
 marvelous reduction in tuberculosis in England 
 and Scotland (Glasgow 42%) was largely due to 
 the institutional segregation of advanced tubercu- 
 lous cases. 
 
CHAPTER XI 
 
 THE DUTIES OF THE PEOPLE IN THE COMBAT 
 AGAINST TUBERCULOSIS 
 
 ''The people have recognized their true foe in 
 tuberculosis and are stirring to the combat through- 
 out the civilized world." These significant words 
 recently spoken in an address before a large anti- 
 tuberculosis gathering, by the foremost authority 
 in American pathological science, Professor Wil- 
 liam H. Welch of Johns Hopkins University of 
 Baltimore, are indeed encouraging. 
 
 The opportunities for every layman to learn 
 something of what he should know about tubercu- 
 losis are certainly not lacking. Literature abounds, 
 daily papers often speak of it, and lectures are 
 given under the auspices of tuberculosis commit- 
 tees, boards of education, and health boards. 
 These lectures are always free, and upon a request 
 addressed to any board of health, it is not difficult 
 to get Hterature and information. 
 
 The one thing which the people at large should 
 realize above all others is, that it is necessary to 
 seek the advice of a physician at the earliest possi- 
 
 351 
 
352 TUBERCULOSIS 
 
 ble moment in a tuberculous affection. If he is 
 too poor to pay for a private consultation, there 
 are in every city, or if not there ought to be, tu- 
 berculosis dispensaries for the poor to which the 
 patient should apply. 
 
 To enable even a layman to recognize the early 
 signs of the disease, I would say that any or all of 
 the following symptoms may be present in the be- 
 ginning of a pulmonary tuberculosis: A long con- 
 tinued cough or hoarseness ; loss of flesh ; flushes or 
 pallor in the face; feverish sensation in the after- 
 noon; occasional night-sweats; a chilly sensation 
 every morning; a loss of appetite; sometimes a 
 little streak of blood in the expectoration ; loss of 
 strength manifesting itself in getting tired easily; 
 frequent colds; a perceptible quickening of the 
 heart-beats after slight exertion; a little change in 
 disposition, at times an increased irritability or a 
 feeling of depression; a disinclination to pursue 
 certain work which the individual formerly loved 
 to do, or even a disinclination to pleasures which 
 were formerly enjoyed. I do not mean that any 
 one should be frightened on discovering any of 
 these symptoms and imagine that he has the rest 
 of them. wSome of them may be present, and on 
 examination no tuberculosis may be found. It is 
 then all the better for the patient; but when any 
 of these svmptoms are present, or persist at all, 
 
SYMPTOMS OF TUBERCULOSIS 353 
 
 they should be considered a warning sign, and it 
 is always best in such a case to consult a physi- 
 cian. It can not be said too often that the earlier 
 the tuberculous patient submits himself to proper 
 treatment, the greater are his chances for recovery. 
 One more point regarding early symptoms must 
 be mentioned; namely, that cough is not, as is 
 often considered by laymen, an ever present symp- 
 tom in early tuberculosis. It may be entirely ab- 
 sent in the beginning. 
 
 The public at large should know that the disease 
 is preventable and curable. What we have en- 
 deavored to teach in Chapter II to those living 
 with the patient, should really be known by all peo- 
 ple, for we can never tell how soon we may have a 
 tuberculous patient in our midst. In spite of the 
 reduction in mortality since the recent active work 
 against this disease, still out of every seven deaths 
 one is due to tuberculosis, which means that in 
 the United States about 200,000 individuals die 
 annually from the white plague. In the world at 
 large, one individual dies every three seconds of 
 one form of tuberculosis or another. The most 
 frequent is, of course, the pulmonary type, or 
 consumption. 
 
 In Chapter II we have emphasized the fact that 
 tuberculosis is very rarely directly hereditary; 
 but that what is often transmitted by tuberculous 
 
354 TUBERCULOSIS 
 
 parents is a weakened system or physiological 
 poverty. We have already stated that by proper 
 training a child born under such conditions may 
 grow up to become a strong, healthy man or 
 woman. Nevertheless, it is evident that tubercu- 
 lous individuals ought not to marry, and when 
 tuberculosis develops in a married couple it is best 
 that they should have no children. The child con- 
 ceived and born while the mother is suffering from 
 pulmonary tuberculosis in the advanced stages, has 
 little chance for life ; or, at least, a great deal less 
 than in a case where the mother has been afflicted 
 with the disease only in the incipient stage. The 
 same is perhaps true even when the father is the 
 tuberculous parent. But whichever it may be, the 
 father or the mother, the work to overcome the 
 predisposition to tuberculosis in infancy and child- 
 hood must begin before the child is born. The 
 mother who fears the transmission of a tuberculous 
 predisposition to her child must, throughout the 
 child-bearing period, live in the best possible hy- 
 gienic environment, in the purest air obtainable 
 and, from the earliest recognition of her condition, 
 refrain from wearing restricting garments. She 
 should often breathe deeply and, in fact, she 
 should take regular breathing exercises until the 
 desire for deep breathing becomes natural to her. 
 The kind of breathing exercise which a pregnant 
 
PREVENTION OF TUBERCULOSIS 355 
 
 woman can take without fear of harm in her con- 
 dition, but which on the contrary will benefit her, 
 is the following: She takes a deep inhalation and 
 during this act raises the shoulders, rolls them 
 backward and holds the breath for three to five 
 seconds while in this position. (See Fig. 66.) Then 
 she exhales while moving the shoulders forward 
 and downward. This exercise which she should 
 take frequently every day she should, of course, 
 only practice in pure air, preferably near the open 
 window or when outdoors. It is evident that not 
 only the respiratory, but also the circulatory, in 
 fact the whole system, must be benefited by such 
 a practice of deep breathing. 
 
 The living and the sleeping room of the preg- 
 nant woman should always be well ventilated and 
 at least one window should be kept open in the 
 bedroom even in cold weather. While it is hard 
 to demonstrate that the fear so many people have of 
 night air is indirectly responsible for a good deal 
 of tuberculosis, I nevertheless believe this to be 
 the case. Some people will sleep in a small bed- 
 room, often several individuals together, with 
 windows tightly closed, breathing the same air over 
 and over again, and thus each surely poisoning 
 himself with the toxic products of his own exhala- 
 tion and that of the other sleepers. 
 
 The newly born child is as much in need of pure 
 
356 TUBERCULOSIS 
 
 air as the grown up person, and while in early in- 
 fant life the system requires more warmth, the air 
 the child is to breathe must be free from dust and 
 other impurities. The lying-in room and nursery 
 should be well ventilated and their temperature 
 well regulated. The atmosphere in such rooms 
 should be warm enough, but never be too hot or 
 too dry. 
 
 As the young child grows, it should gradually be- 
 come accustomed to cooler air. The habit of en- 
 veloping the child's face in a thick veil when it is 
 taken out for an airing is absurd, and if veiling is 
 used at all, it should be thin, permitting the air to 
 have access to the face. As the child grows up, at- 
 tention should be paid to its breathing. It should 
 be noted whether it breathes through the nose as 
 it should, or whether the nose seems obstructed 
 and it breathes with its mouth open. It must be 
 remembered that mouth breathing in children is 
 a predisposing cause to frequent colds, to bron- 
 chitis and similar affections, all of which in many 
 instances must be considered fore-runners of con- 
 sumption. Mouth breathing in children is caused, 
 as a rule, by certain growths in the throat (adenoid 
 vegetation) and sometimes by enlarged tonsils, or 
 by polypi in the nose. Besides its deleterious in- 
 fluence on the child's respiratory system, adenoid 
 vegetation may also result in difficulty of hearing, 
 
iPREVENTiON OF TUBERCULOSIS 357 
 
 consequent impairment of the intellect, and even 
 in actual deformities of the jaw. Adenoids and 
 all other obstructions to free breathing should be 
 promptly removed by timely operations. 
 
 When a child, because of its delicate constitution, 
 is susceptible to frequent colds, so that one may 
 hesitate to take it much outdoors, it should be 
 borne in mind that fresh, pure air really does not 
 give colds. What are commonly known as colds 
 are often an infectious disease due to a specific 
 microorganism which fastens itself more readily 
 on a delicate system. To overcome such a sus- 
 ceptibility to colds, one should resort to the ju- 
 dicious use of cold water. 
 
 From the tenth to the twelfth month one should 
 accustom the child gradually to cold baths. The 
 best time to begin is after its daily warm bath. 
 Rub the child a few times with the hands dipped 
 in cold water, and then wipe it rapidly. By and 
 by one may begin with cold sponging, and later 
 with a little douche. In the use of cold water it is 
 absolutely necessary that the reaction should fol- 
 low rapidly. This reaction, as is well known, is 
 manifested by a pleasant warmth perceived by the 
 child, and is made visible externally by a reddish 
 appearance of the skin. Whenever cold water is 
 applied to the skin, one will notice at first a certain 
 whiteness or pallor which is caused by the contrac- 
 
358 TUBERCULOSIS 
 
 tion of the external blood vessels. The return of 
 the blood to the. surface causes a reddening of the 
 skin. Whenever reaction is lacking or tardy, the 
 advice of the physician should be sought. 
 
 Of course, it goes without saying that a child 
 should always be properly dressed. In order that 
 its lungs may develop to the fullest extent it must 
 not be hindered by restricting garments, partic- 
 ularly by tight neckwear, collars, or bands. Fur- 
 thermore, it must be remembered that to dress the 
 neck too warmly lessens the power to resist taking 
 cold when there happens to be a change in the 
 atmosphere. The less one is accustomed to bundle 
 up the neck, the more freely will one breathe and 
 the less will one be likely to take cold. 
 
 When a girl develops into a young woman, one 
 should bear in mind that the tightly laced corset 
 is one of the most injurious garments that can be 
 worn. Not only is free and natural breathing in- 
 terfered with by this article of dress, but indi- 
 gestion and disturbances in the circulation follow 
 excessively tight lacing. Anaemia, or poverty of 
 blood, so often observed in young girls, can very 
 frequently be ascribed to this unnatural mode of 
 dress which does not permit either a free circu- 
 lation or sufficient oxygenation of the blood. 
 
 We reproduce here three pictures to better illus- 
 trate the results of excessive lacing. Figure 107 
 
PREVENTION OF TUBERCULOSIS 
 
 359 
 
 Fig. 107. Situation 
 of Vital Organs in 
 a Normal Chest. 
 
 Fig. 108. Situation 
 of Vital Organs in 
 Constricted Chest. 
 
 Fig. 109. Skeleton 
 of Chest, Perma- 
 nently Constricted 
 by too Tight Lacing. 
 
 shows the situation of the organs in the chest and 
 abdomen in a normal thorax. Figure 108 shows 
 lungs, liver, and intestines as they appear in a 
 thorax constricted by wearing a tightly laced corset 
 for a number of years. Figure 109 show^s the skele- 
 ton of a chest deformed by tight lacing. 
 
 In the preceding chapters we have spoken of 
 child labor in factories and workshops, and of too 
 much work at school; but there is another way in 
 which the child's constitution may be injured and 
 for which the parents are responsible. I refer to 
 child labor at home. Often, thoughtlessly, parents 
 make little girls in their teens take care of the 
 smaller brothers and sisters and force them to 
 help cook and to wash, and I know of families in 
 which the same duties are imposed upon the young 
 boys who, in addition, have to do all the errands of 
 the family. When one considers that these chil- 
 dren must also go to school, one can fully realize 
 
36o TUBERCULOSIS 
 
 how dreary their httle hves must be, how httle 
 play they have, and how their health must become 
 undermined because of the great physical strain 
 which is put on their growing organisms and be- 
 cause of the lack of healthful outdoor exercises. 
 Particularly pathetic is the lot of little "boys and 
 girls between the ages of ten and fourteen who, 
 because of the loss of one parent, father or mother, 
 must fill the vacant place while the remaining par- 
 ent is absent to earn a living for the family. In 
 such instances the older girl or boy must often be 
 the servant of the family. I have seen '' little 
 mothers " in the tenement homes whose lives were 
 virtually sacrificed, they having developed tuber- 
 culosis because of the physical strain put upon 
 them. 
 
 It does not require much for the tubercle bacil- 
 lus to get the best of such an enfeebled child's or- 
 ganism. Parents should bear this in mind, and 
 everybody who can help to prevent such conditions 
 should do his utmost to save the lives of the little 
 children. 
 
 As soon as the intelligence of the growing child 
 will permit, it should be taught to breathe deeply, 
 and later on be taught the exercises which we have 
 described in full in Chapter IX, when speaking of 
 prevention of tuberculosis during school life. 
 
 In speaking of the social mission of the 3ana- 
 
PREVENTION OF TUBERCULOSIS 361 
 
 torium, we have mentioned the fact that alcohol- 
 ism must be prevented in order that tuberculosis 
 may be cured, and here we wish to say that the 
 excessive and injudicious use of alcoholic drinks, 
 particularly whiskey and the stronger liquors, is a 
 very pronounced predisposing factor to tubercu- 
 losis. I am of the opinion that as long as there is 
 excess and intemperance in the use of alcohol as 
 a beverage, so long v/ill it be impossible to stamp 
 out tuberculosis. 
 
 It is not only well known that alcoholism pre- 
 disposes to tuberculosis, but it has also been sta- 
 tistically demonstrated that the children of al- 
 coholic parents contract tuberculosis more readily 
 than children of temperate parents. In my labors 
 among the poor I have often sought to convince 
 tuberculous patients of the folly of spending money 
 for alcohol as a means to cure the disease. If they 
 would spend the same amount of money for nu- 
 tritious food, they themselves would probably have 
 been cured, much more readily, and their families 
 could have lived in greater comfort. 
 
 There are sometimes cases of consumption in 
 which the judicious administration of alcohol as a 
 medicine is indicated, and I would therefore re- 
 gret if ever a law should be enacted which would 
 prevent a physician from prescribing alcohol in 
 the treatment of disease, 
 
362 TUBERCULOSIS 
 
 Since the alcohol problem is one of the factors 
 of the tuberculosis problem, I feel justified in 
 giving a few suggestions on this great question. 
 While I believe that excessive use of alcohol is re- 
 sponsible for more disease, more tuberculosis in 
 particular, and also more crime than any other 
 one cause, I still question the wisdom of absolute 
 prohibition in our present state of civilization. 
 
 Could the Gothenburg system be carried out in 
 the United States, I would certainly favor it as a 
 means of decreasing intemperance, and conse- 
 quently crime and disease. This system consists 
 in the manufacture and sale of alcohol by the gov- 
 ernment, and giving the dispenser of alcohol a 
 salary, so that no benefit shall accrue to him from 
 the amount of alcohol he sells. The law strictly 
 prohibits the sale of liquor to the intoxicated, the 
 habitual drunkard, and to minors. I am almost 
 tempted to suggest this method to some of our 
 prohibition states — it would probably tend more 
 to decrease intemperance than prohibition laws do 
 now as they have worked in some places. How- 
 ever, with a heterogeneous population like ours, 
 the same laws are perhaps not applicable to every 
 state. Prohibition has decreased crime in the 
 South among the Negroes, while, if I am correctly 
 informed, crime and arrests for intoxication are 
 on the increase in Maine. 
 
I^REVENTION OF TUBERCULOSIS 1,62, 
 
 It is the same with individual states as it is with 
 individual men and women. They have their 
 idiosyncrasies, peculiarities, and different constitu- 
 tions. Some people can not take a teaspoonful of 
 liquor without feeling the intoxicating effect ; others 
 can not drink the smallest quantity without a de- 
 sire being aroused for more than is good for them. 
 It must be self-evident that these t}^es of people 
 with peculiar constitutions should religiously re- 
 frain from taking alcoholic drinks. 
 
 That a low type of saloon is injurious to any 
 community every one will admit. It would seem 
 that in most of our states it will be difficult to en- 
 force strict prohibition laws. To create by a higher 
 license a higher type of saloon and diminish their 
 numbers, must surely have a good effect. 
 
 What in my humble opinion is injurious to the 
 individual as well as to society, causing many a 
 man to become intemperate is, on the one hand, 
 the American treating habit, and on the other, the 
 habit of taking alcoholic drinks on an empty 
 stomach and between meals. For all this I have 
 but one remedy — education. The treating habit, 
 so far as liquor is concerned, must be abolished by 
 teaching the young through the practice and ex- 
 ample of the adults, that the custom is wrong and 
 should be discountenanced. 
 
 There should be institutions for the cure of the 
 
364 TUBERCULOSIS 
 
 habitual drunkard to which he may go himself or 
 be committed by the court, if his conduct is such 
 as to make such a procedure justifiable. 
 
 There are few men, and, perhaps, not one 
 v.'oman in this country who would not be willing 
 to do something toward the decrease of alcoholism 
 and its concomitant social misery. If well-meaning 
 men and women would unite in their efforts to sup- 
 press the treating habit by practice and example, 
 and would pledge themselves never to partake of 
 alcohol except in moderate quantities with their 
 meals and in diluted form, I am convinced that a 
 greater step toward temperance would be made 
 than by any other means heretofore employed. 
 
 Aside from this, I believe that the building of 
 model tenement houses by private or municipal 
 enterprise, the creation of more parks and play- 
 grounds and healthful places of amusement open 
 Sundays and week-days, where the laborer can par- 
 take of non-alcoholic drinks and enjoy the society 
 of his friends, will do more to do away with alco- 
 holism than many a more strict measure. 
 
 In short, let us not forget that to combat al- 
 coholism we must combat social conditions creat- 
 ing misery and want. If there was more social 
 justice, we would need to have fewer charitable 
 institutions. While it is true that alcoholism be- 
 gets crime, misery, and unhappiness, it is equally 
 
PREVENTION OF TUBERCULOSIS 365 
 
 true that much misery and suffering begets al- 
 cohoHsm. In a civihzed country like ours there 
 should never be such a condition as a man willing 
 to labor, but obliged to suffer misery and want 
 for want of labor. 
 
 There is, indeed, a great opportunity in this 
 respect for practical statesmanship and practical 
 philanthropy. I am convinced that in a com- 
 munity which provides labor and just pay for all 
 those willing to labor, there will be need of fewer 
 pohce, fewer prisons, penal institutions, and in- 
 sane asylums, while the commonwealth will, in 
 the end, gain in all respects morally, sanitarily, 
 and financially. 
 
 Where it is feasible for laborers working in the 
 open, and also for those working indoors, cool, non- 
 alcoholic drinks should be dispensed in summer 
 and warm ones in winter, at reasonable rates. 
 
 Lastly, I would suggest that well-kept comfort 
 stations should be more numerous throughout our 
 large cities than they are at the present time. A 
 municipality which will do its duty in this respect 
 will prevent the necessity of men going into saloons 
 for calls of nature, and then feeling called upon or 
 being tempted to spend money there for drink. 
 
 We have already referred to the proper housing 
 of the masses, and would emphasize here that un- 
 sanitary housing and lack of sunlight and air in 
 
v) 
 
 66 TUBERCULOSIS 
 
 the home must be considered a strong predispos- 
 ing factor to disease. It brings about the acquired 
 t\^e of predisposition to tuberculosis. While the 
 individual laborer and employee may not always 
 be able to procure the necessary ventilation he 
 would wish to have while at work, he ought 
 to be able to have it at his home. He should 
 practice and teach his family the love of fresh air, 
 deep breathing, and particularly keeping the bed- 
 room windows open at night. During the warmer 
 seasons, outdoor eating, outdoor concerts, out- 
 door theatres, etc., should be encouraged. We 
 can learn much in this respect from European 
 cities. 
 
 In the preceding chapters we have spoken of 
 the value of cooking-schools for children and 
 adults, and also of the value of housekeeping cen- 
 ters. It is a well-known fact that there is a great 
 deal of waste of food substances in the homes of 
 the poor because of ignorance, and much of the 
 bad feeding and underfeeding of the masses is due 
 to lack of knowledge. It can not be urged strongly 
 enough upon married women and girls, the future 
 mothers of the nation, to avail themselves of all 
 possible opportunities to learn practical, economic, 
 and healthful cooking, and practical and sanitary 
 housekeeping. 
 
 People in general should embrace all opportuni- 
 
PREVENTION OF TUBERCULOSIS 367 
 
 ties to learn what they can about the prevention 
 of disease. They themselves should practice all 
 they know concerning these important matters; 
 lead sober, regular lives; be temperate in all 
 things. They should practice clean living, plain 
 cooking, and clean housekeeping, the utilization of 
 fresh air and sunlight. Everybody should make 
 it his rule, whether tuberculous or not, never to 
 expectorate when indoors except in a proper re- 
 ceptacle (spittoon or cloth); and when outdoors, 
 if he must spit, to spit into the gutter but never on 
 the sidewalk. 
 
 In cases where prohibitions against expectora- 
 tion are posted, or other health notices, the pub- 
 lic should take particular pains to heed them and 
 not act in a spirit of opposition. When an em- 
 ployer is trying to do his best to look out for the 
 sanitary condition of his employees, they should 
 cooperate with him in every way possible in order 
 to reduce the sources of infection or causes of 
 predisposition. 
 
 The public should attend the popular lectures 
 on health and sanitation, not neglecting those on 
 the prevention of tuberculosis. They should re- 
 member that the knowledge thus gained is power 
 and will help in preventing disease, misery, and 
 death. Every individual, in no matter what walk 
 of life, can help to prevent tuberculosis, and to do 
 
36S TUBERCULOSIS 
 
 this means happiness for others and happiness for 
 himself. 
 
 When speaking of the care to be taken in the 
 disposal of sputum (Chapter I), we mentioned 
 how the housefly can become a conveyor of infec- 
 tion. It can spread tuberculosis and other dis- 
 eases. How^ easily can nearly every one help in 
 the extermination of this insect! 
 
 It should be the duty of every one to remember 
 this and do what he can to prevent this source 
 of infection. Every fly in the sick room, no mat- 
 ter of what disease a patient may suffer, should 
 be killed. Since the fly breeds in manure in pref- 
 erence to all other places, we must concentrate 
 our attention to the destruction of this insect in 
 its early stages. To this end all vaults and pits 
 containing stable manure should be screened or 
 sprinkled with lime or kerosene. All garbage, 
 vegetable matter, or other decaying material 
 tending to attract flies should be covered. Some 
 municipal ordinance concerning stable hygiene 
 with a view of preventing the breeding of flies 
 and the screening of all articles of food exposed 
 for sale, would be most timely. However, the 
 individual also must do his duty by screening 
 windows and doors, especially those of the kitchen 
 and dining room, and the covering of all food 
 suVjstances. 
 
PREVENTION OF TUBERCULOSIS 369 
 
 Another method whereby every individual, no 
 matter in what station of hfe, can be helpful in 
 preventing tuberculosis in himself, his friends and 
 neighbors, is by his example of love for fresh air. 
 We have spoken of this a number of times in refer- 
 ence to the cure as well as to the prevention of 
 tuberculosis, but it can hardly be emphasized too 
 much. If one can not sleep in the open air, he can 
 certainly have his window open at night. If his 
 occupation demands a great deal of indoor life, or 
 perhaps makes inhalation of dust unavoidable, he 
 should be all the more eager to spend his leisure 
 hours in the fresh air, to breathe deeply often when 
 in pure air, to avoid places of amusement where 
 the air is impure, smoky, and dusty, and to keep 
 regular hours, and be moderate and temperate in 
 all things. He will thus be doing all he can to 
 counteract whatever bad effect his occupation may 
 have on his health. 
 
 It is not only in the prevention of tuberculosis 
 that any individual may be able to help by spread- 
 ing the knowledge he may have, through the prac- 
 tice of it or by imparting it to his neighbor or 
 friend in a tactful manner where it is most needed, 
 that is to say, to an untrained consumptive; but 
 every well meaning citizen, young or old, even in 
 the most moderate circumstances, will also have 
 opportunity to help in the cure of tuberculosis. 
 
370 TUBERCULOSIS 
 
 There is an excellent movement now on foot 
 known as the Red Cross anti-tuberculosis work. 
 The American National Red 
 Cross issued last year, before 
 Christmas, a beautiful stamp 
 which bore a wreath of holly with 
 the words "Merry Christmas" 
 and ''Happy New Year." (Fig. 
 no.) The stamps were sold in 
 
 Fig. iio. American i . ti t . j 
 
 J. , n c. sheets like an ordmary stamp and 
 
 Red Cross Stamp «' ^ 
 
 for the Year 1908. also in Small books (nine for ten 
 (Original Printed ^^^^^ twcnty-four for twcnty-five 
 
 in Red.) ' \ ^ 
 
 cents, forty-eight for fifty cents), 
 like the Government postage stamps. The Christ- 
 mas stamp was not good for postage. It did not 
 carry any kind of mail, but any kind of mail 
 carried it. Some eleven million stamps were sold 
 in the United States, which means that more than 
 $100,000 were contributed to the Red Cross anti- 
 tuberculosis work throughout the country during 
 Christmas tide of 1908. The New York County 
 branch alone netted $11,000, and one of the imme- 
 diate results of this gratifying help from the people 
 of the City of New York was the establishment of 
 the Red Cross Tuberculosis Camp on the roof of 
 the Vanderbilt Clinic of which we gave an illustra- 
 tion. (Fig. 99.) 
 
 In the preceding chapter we have spoken of the 
 
PREVENTION OF TUBERCULOSIS 371 
 
 activities of the Tuberculosis Committee of the 
 City of New York. While, of course, it can not be 
 expected that such a vast activity can be carried 
 out by every committee, much useful work can 
 be done even on a smaller scale, and such com- 
 mittees should always be composed not only of 
 physicians but also of laymen. Here again is an 
 opportunity for helpfulness by the layman who 
 is willing. By becoming a member of such a 
 committee or a member of an association for the 
 study and prevention of tuberculosis, he can show 
 his interest and participate in the crusade against 
 tuberculosis. Labor organizations, trades un- 
 ions, workingmen's mutual relief societies, etc., 
 should make it a point to have all their members 
 educated in the prevention of tuberculosis, and no 
 such organizations should exist without its com- 
 mittee on tuberculosis. Life insurance companies 
 can also be helpful by distributing anti-tubercu- 
 losis literature among their policy holders, and 
 thus help in the general campaign education. A 
 good example in this respect was recently given 
 by the Metropolitan Life Insurance Company 
 through its Industrial Department at New York 
 under the management of Dr. Lee K. Frankel. 
 
 No fair-sized community should be without its 
 anti-tuberculosis association or committee. Of the 
 steady growth in number and strength of such 
 
372 TUBERCULOSIS 
 
 associations, the following statistics are the best 
 evidence. 
 
 About four years ago, in February, I made a care- 
 ful inquiry concerning existing anti-tuberculosis 
 committees and associations in the United States, 
 and I could then only count forty-nine anti- 
 tuberculosis bodies calling themselves associations, 
 societies, committees, or leagues. In May, 1905, 
 in Washington, there was held the first meeting of 
 the National Association for the Study and Pre- 
 vention of Tuberculosis under the presidency of 
 Dr. Edward L. Trudeau. Dr. William Osier, now 
 of Oxford, and Dr. Hermann M. Biggs, of New 
 York, were the vice-presidents. Dr. Henry Barton 
 Jacobs was the Secretary, and Surgeon-General 
 George ]\I. Sternberg, the Treasurer. Soon after 
 this, an Executive Secretary in the person of Pro- 
 fessor Livingston Farrand was appointed, and it is 
 largely owing to his energy that at the end of 1906 
 there existed as many as sixty-tw^o anti-tuberculosis 
 associations. The year 1907 added forty-nine, and, 
 at the time of writing the closing chapter of this 
 book (March 15, 1909), there was a total of 273 
 anti-tuberculosis associations in the United States. 
 
 As has Ijcen already stated, these associations 
 are composed of lay and medical men and women. 
 This speaks well for the growing interest in the 
 anti-tuberculosis cause. The present membership 
 
PREVENTION OF TUBERCULOSIS 
 
 373 
 
 Fig. III. Proposed Quarters of National Pythian Sanatorium, Las 
 Vegas, N. M. 1300 Acres Have Been Donated to this Institution. 
 
 of the National Association is about i,6oo. Much 
 is done, but there is more to do. 
 
 For masonic and other fraternal societies, also 
 for mutual benefit associations of all kinds, the 
 solution of the tuberculosis problem offers an 
 unusual field for most humane activities ; and it is 
 encouraging to note the progress being made in 
 this direction. The Grand Lodge of Free and 
 Accepted Masons of the State of New York has 
 already collected a good-sized fund and owns a 
 tract of land on which it expects to build a tuber- 
 culosis sanatorium. The Knights of Pythias 
 fraternity has a National Pythian Sanatorium of 
 which they expect to make a model institution. 
 It is located at Las Vegas, N. M. (Fig. iii.) 
 
374 
 
 TUBERCULOSIS 
 
 Fig. 112. Union Printers' Home for Consumptives. Established 
 and Maintained by the International Typographical Union. 
 
 The Modern Woodmen have a sanatorium for 
 their tuberculous members at Colorado Springs, 
 and in the same place the Union Printers have a 
 beautiful consumptives' home for their afflicted 
 brethren, which has been erected and is main- 
 tained by the International Typographical Union. 
 In its prospectus it very appropriately says: ''Its 
 bounty is unpurchasable ; its charity without 
 price." (Fig. 112.) At the recent meeting of the 
 Supreme Council of the Royal Arcanum, resolu- 
 tions urging the establishment of a tuberculosis 
 sanatorium by that order were presented and 
 
376 TUBERCULOSIS 
 
 passed. At Black Mountain, N. C, there has 
 existed for a number of years a sanatorium es- 
 tablished by the Royal League. 
 
 There is one more very important field of in- 
 terest to the populace at large in the direction of 
 prevention as well as of the cure of tuberculosis. 
 I refer to what might be accomplished in the 
 United States by insurance against tuberculosis. 
 This has been done in other countries, especially 
 in Germany, with unqualified success. In the 
 latter country insurance is obligatory against ac- 
 cident, old age, and disease for all laborers and 
 employees not earning enough wages to provide, 
 under ordinary circumstances, for any of the three 
 mentioned emergencies. The beneficial results of 
 such an insurance in reducing the morbidity 
 (number of sick) and mortality from tuberculosis 
 must be evident when one considers the following 
 points. At the slightest indisposition or other 
 apprehension of developing tuberculosis, the policy 
 holder may apply for examination at the office 
 of some of the insurance company's physicians. 
 Thus, an early diagnosis, if tuberculosis is present, 
 is assured. The insurance companies in Germany 
 soon learned that when one of their policy holders 
 was afflicted with early tuberculosis, it would be 
 to their financial advantage to immediately in- 
 stitute the best possible treatment for such an in- 
 
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 X 
 
 
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 L- r^ 
 
 
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378 TUBERCULOSIS 
 
 dividual, which was for the majority of this class of 
 cases — the sanatorium treatment. They made ar- 
 rangements with private sanatoria (Fig. 113) for im- 
 mediate reception of their patients who being in the 
 earlier stages were, of course, much sooner cured 
 than had they been allowed to go on until the disease 
 had reached a more advanced and less curable stage. 
 
 In time, these insurance companies found out 
 that it would pay them to own and maintain san- 
 atoria themselves. The result is that there exist 
 now in Germany a number of this kind of sana- 
 toria owned by insurance companies, and in flour- 
 ishing condition. (Fig. 114.) While on the surface 
 these companies have entered into this sanatorium 
 building and managing as a business proposition, 
 it must, nevertheless, be acknowledged that such 
 enterprises have a very large humanitarian aspect, 
 for many valuable lives are thus saved and a great 
 deal of sorrow and misery spared to the masses. 
 
 It is for this reason that I most heartily recom- 
 mend to our life insurance companies to imitate 
 the German insurance against accident, old age, 
 and disease, and not to exclude early cases of tuber- 
 culosis, nor predisposed individuals from becom- 
 ing policy holders. I also recommend the build- 
 ing of their own sanatoria for employees and policy 
 holders, as contemplated by the Metropolitan Life 
 Insurance Company. 
 
CHAPTER XII 
 
 PROSPECT OF THE ULTI^IATE ERADICATION OF 
 TUBERCULOSIS 
 
 One of the greatest scientists of the nineteenth 
 century, a man who through his studies and the dis- 
 coveries which he gave to the world, has, perhaps, 
 done more to save human beings than any other 
 man, was Louis Pasteur of France. (Fig. 115.) 
 Among his writings one can find two sentences 
 which to my mind are well fitted to inspire man- 
 kind, that is to say, every one, rich and poor, young 
 and old, the statesman and the ordinary citizen, the 
 physician and the tuberculous patient, to do all 
 he can to be helpful in this world crusade against 
 tuberculosis. The first of these inspiring sentences 
 reads, "II est au pouvoir de I'homme de faire dis- 
 paraitre toutes les maladies parasitaires " (It is in 
 the power of man to cause all parasitic diseases to 
 disappear from the world). 
 
 The bacillus of tuberculosis is a parasite — it need 
 not exist. Outside of the animal organism it re- 
 tains its virulence in darkness and filth, and in the 
 human body it thrives when health is undermined 
 
 379 
 
H* <*>>- #•*• ^'^ 0'» Ck Y7»*»««'>* i«»#^\"* 
 
 Fig. 115. Louis Pasteur in His Laboratory. 
 
ULTIMATE ERADICATION 381 
 
 by misery, want, ignorance, or excesses. Through 
 the education of young and old in the prevention 
 of tuberculosis and in sanitation in general, filth, 
 darkness, and ignorance, as causes of tuberculosis 
 among the masses, will be removed. To convince 
 employers of men and women that to guard the 
 toilers against disease will be of mutual benefit, 
 and to teach employees to share in the work, will 
 cause tuberculosis as a disease of the masses to 
 disappear among the laboring population. States- 
 men and city fathers will learn that to take care 
 of the consumptive poor at the right time and at 
 the right place tends to the moral, financial, and 
 sanitary gain of every community; and then they 
 will not hesitate to establish sanatoria and special 
 hospitals for the cure of all those in need of in- 
 stitutional treatment. By the enactment of wise 
 and humane laws they will diminish social misery, 
 suffering, and want. 
 
 The second of the two immortal phrases of the 
 great Pasteur above referred to reads, ''En fait du 
 bien a repandre, le devoir ne cesse que la oii le 
 pouvoir manque," which might be interpreted into 
 English as follows: "Our duty to do good only 
 ends where our power to do good fails." 
 
 If the lover of his kind, the rich philanthropist, 
 would follow this precept, do good and spread 
 the good, help to build model tenements, open air 
 
382 TUBERCULOSIS 
 
 schools, preventoria for the prevention, and san- 
 atoria for the cure of patients, and provide health- 
 ful recreations for the poor; and if the lover of his 
 kind, the poor philanthropist, rich in heart but 
 poor in worldly goods, would bring his knowledge, 
 his good will, his labor, and his mite towards the 
 prevention of this as yet the most prevalent and 
 fatal of all diseases, the ultimate eradication of 
 tuberculosis would seem to be in sight. 
 
 It is not safe to make a prophecy as to when this 
 time will come, but it may safely be said that 
 w^hatever we do in the direction of preventing the 
 development of tuberculosis, will prevent social 
 misery and social ills. Inasmuch as we diminish 
 tuberculosis among the masses, we will diminish 
 suffering, misery, and social discontent; and when 
 the problem of tuberculosis will have been solved, 
 this disease so graphically described as ''the great 
 white plague" forever eradicated, then will we be 
 nearer the millennium than we have ever been be- 
 fore, and Peace, Health, and Happiness will be our 
 lot on earth. 
 
INDEX 
 
 PAGE 
 Adaptation of Sanatorium Methods at Home . . . -57 
 Adirondack Cottage Sanatorium . .314, 316, 317, 318, $33 
 Aerarium, Bull's . . . . . . . . -75 
 
 Aerotherapy 57, 80 
 
 Agnes Memorial Sanatorium . . . . . . 319, 320 
 
 Air in its Relation to Tuberculosis . . . .84, 356, 369 
 
 Alabama State Sanatorium ....... 196 
 
 Alcoholism 329, 361 
 
 Almhouses .......... 157 
 
 Alphabet in Tuberculosis ........ 265 
 
 Antagonism, Unjustified ........ 283 
 
 Anti-spitting Ordinances .... 133, 165, 218, 367 
 
 Anti tuberculosis Associations in the United States . . -372 
 Atmosphere, Pollution of ...... . 84, 131 
 
 Bacillus of Tuberculosis . . . 4, 5, 17, 164, 285, 296, 379 
 
 Baker, Dr. Josephine ........ 283 
 
 Barlow's Sanatorium ........ 322 
 
 Barnes, Dr. H. L 193 
 
 Baths 12, 53, 248 
 
 Bed Linen, Care of . . . . . . . . .20 
 
 Beds, Klondike 77j 78 
 
 Bement, Mr., Chicago, 111. 127 
 
 Bensel, Dr. Walter 283 
 
 Berck-sur-Mer, School Sanatorium and Hospital . . 277 
 
 Biggs, Professor Hermann M. . . . -23, 133, 139, 372 
 
 Billings, Dr. John S., Jr. . . . . . . . . 149 
 
 Bird, Mr., Chicago, 111 127 
 
 Bishop of Fano .......... 285 
 
 Bonney, Dr. S. G 23 
 
 Boston Association for the Relief and Control of Tuberculosis . 336 
 
 Bovine Tuberculosis . . . . . , . .216, 239 
 
 Bowditch, Dr. Vincent Y 24 
 
 Brannan, Dr. John W 273 
 
 3^3 
 
384 
 
 INDEX 
 
 Breathing Exercises 
 
 Bull, Dr. T. M. 
 
 Busse, Mayor of Chicago . 
 
 Carnegie, Mr. Andrew 
 
 Carolina Rest for Education of Mothers 
 
 Chalice, Hygienic 
 
 Childlabor 
 
 Childlabor at Home . 
 
 Children's Sanatoria . 
 
 Children, Tuberculosis in . 
 
 Charity Organizations, Duties of 
 
 Church Hygiene 
 
 Circumcision, Ritual . 
 
 Cities, Buildings of 
 
 City Employees, Examination of 
 
 Class Methods . 
 
 Cleaning of Rooms 
 
 3i» 33, 43 
 
 171 
 
 Work of 
 
 Cleaning of Streets 
 
 Clergy, Duties of 
 
 Climate .... 
 
 Climatolog}', Maxims in 
 Clinic for Tuberculosis 
 Colds .... 
 
 Cold Water 
 
 Committee, N. Y. Tuberculosis, 
 
 Communion Cup, Hygienic 
 
 Communion Cup, Individual 
 
 Conclusions 
 
 Concrete, Reinforced, for Sanitary Home 
 
 Confessional Chairs and Grates 
 
 Connecticut State Sanatorium . 
 
 Cooking, Instruction in . . . 
 
 Cooperation of Federal, State, and Municipal Authorities 
 
 Cough ...... 
 
 Country Sanatorium at Otisville, N. Y 
 Cremation ..... 
 
 Cronin, Dr. John J. . 
 
 18 
 
 157 
 
 300. 
 
 PAGE 
 
 252, 354 
 
 • 74 
 . 127 
 
 . 312 
 
 . 281 
 
 . 288 
 
 . 212 
 
 • 359 
 . 276 
 
 276, 354 
 . 284 
 . 284 
 . 28s 
 . 88 
 . 165 
 
 344, 349 
 . 21 
 . 132 
 . 284 
 
 172, 316 
 
 • 33 
 149, 153 
 
 • 357 
 53, 357 
 
 • 306 
 . 288 
 . 286 
 . 382 
 
 • 125 
 . 285 
 
 196, 325 
 
 . 280 
 
 . 171 
 
 I, 22, 50 
 
 . 160 
 
 • 295 
 . 283 
 
INDEX 
 
 38s 
 
 PAGE 
 
 Curability . 
 
 
 
 
 
 14 
 
 . 30 
 
 Gushing, Mr. Geo. H. 
 
 
 
 
 128 
 
 Guspidors 
 
 
 
 . 6 
 
 7 
 
 Darlington, Commissioner Thomas , 
 
 
 
 139 
 
 167 
 
 Davosplatz, Switzerland 
 
 
 
 
 339 
 
 Day Camps 
 
 
 
 
 
 
 334 
 
 Dedication 
 
 
 
 
 
 
 2 
 
 Despergnes 
 
 
 
 
 
 
 295 
 
 Dettweiler, Geheimrath P 
 
 
 
 
 
 28 
 
 33^ 
 
 Devine, Professor Edw. T 
 
 
 
 
 
 
 350 
 
 Diet Kitchen 
 
 
 
 
 
 
 3" 
 
 Disinfection 
 
 
 
 
 . 45, 
 
 159 
 
 220 
 
 Dispensaries 
 
 
 
 
 . 148, 
 
 151 
 
 156 
 
 District of Columbia, Sanatorium of . 
 
 
 
 
 179 
 
 Dixon, Commissioner Samuel G. 
 
 
 
 
 192 
 
 Domestic Animals, Tuberculosis in . 
 
 
 • • . 
 
 
 244 
 
 Douches 
 
 
 
 82, 
 
 357 
 
 Dress. .... 
 
 
 
 
 13. 
 
 49 
 
 Dress for Predisposed Children 
 
 
 
 
 
 358 
 
 Droplet Infection 
 
 
 
 5, 10, 20, 203 
 
 231, 
 
 342 
 
 Dryness of Air in Homes . 
 
 
 
 
 
 121 
 
 Dublin Tuberculosis Exhibition 
 
 
 
 
 
 146 
 
 Dust 
 
 
 
 5, 17, 122, 
 
 131 
 
 238 
 
 Duties of Those Living with Patients 
 
 
 16 
 
 135 
 
 Edison, Mr. Thomas A. . 
 
 
 
 125 
 
 Education, Anti-tuberculosis 
 
 . 146, 166 
 
 232 
 
 280 
 
 Educators, Duties of . 
 
 
 
 246 
 
 Edward Sanatorium .... 
 
 
 
 324 
 
 Elevated Spittoons, Self-flushing 
 
 
 8, 9 
 
 132 
 
 Elliott, Dr. J. H 
 
 
 
 327 
 
 Emmanuel Church Class Patient 
 
 
 
 302 
 
 Emmanuel Movement and Tuberculosis 
 
 
 
 299 
 
 Employees, Examination of 
 
 
 
 232 
 
 Employers, Duties of ... 
 
 
 
 228 
 
 Eradication, Prospect of . 
 
 
 
 379 
 
 Evans, Commissioner W. '. 
 
 E. 
 
 
 
 
 
 167 
 
386 
 
 INDEX 
 
 Evening Lectures to Adults in Public Schools 
 
 Examination for Tuberculosis 
 
 Exercises for Patients 
 
 Exercises for Prisoners 
 
 Exhibition .... 
 
 Expectoration 
 
 Expenses and Maintenance 
 
 Factories and Tuberculosis 
 
 Falkenstein Sanatorium, Germany 
 
 Farmers' Duties in Prevention of Tuberculosis 
 
 Farming Made Attractive .... 
 
 Farrand, Professor Livingston . 
 
 Federal Authorities, Duties of . 
 
 Federal Department of Health . 
 
 Federal Sanatorium at Fort Bayard, N. M. 
 
 Federal Sanatorium at Fort Stanton, N. M. 
 
 Federal Sanatorium at New Fort Lyon, Colo. 
 
 Financial Gain from Timely Treatment 
 
 Fisher, Dr. E. D 
 
 Flies and Tuberculosis 
 
 Folks, Hon. Homer .... 
 
 Food and Tuberculosis 
 
 Forestry Schools 
 
 Fowler, Dr. 
 
 Frankel, Professor B. 
 
 Frankel, Dr. Lee K. 
 
 Fraternal Sanatoria 
 
 Free State Hospital at Ray Brook, N. Y. 
 
 Funerals, Cost of ... . 
 
 Galtier, Dr 
 
 Garden City Association of America . 
 Garden City Association of Great Britain 
 Gartner, Dr. ..... 
 
 Gaylord Farm Sanatorium 
 
 Goler, Dr. Geo. W., Health OlTicer . 
 
 Gothenburg System .... 
 
 PAGE 
 
 . 279 
 
 i57» iqSj 231, 269 
 
 . 49 
 
 . 208 
 
 143, 144, 145 
 
 5, 201, 367 
 
 . 161 
 
 215, 228 
 340 
 238 
 226 
 
 372 
 171 
 227 
 217 
 217 
 217 
 161 
 24 
 
 9, ID, 368 
 
 52, 169 
 226 
 211 
 206 
 371 
 
 373 
 310 
 296 
 
 295 
 93 
 94 
 295 
 325 
 167 
 
 362 
 
INDEX 
 
 387 
 
 Grancher, Professor J. J. 
 Greene, Mr. Frederick D. 
 Guilfoy, Dr. W. H. . 
 
 134, 
 
 Half-tent, Knopf's .... 
 Handicapped, Employment for the . 
 Handkerchiefs ..... 
 Health Department's Work 
 Heating ........ 
 
 Height of Buildings 
 
 Hereditary Tuberculosis ..... 
 
 History of Patients After Having Left Sanatorium 
 Holmes, Rev. John H. . . . . . 
 
 Home Sickness ....... 
 
 Home Treatment ...... 
 
 Horses, Tuberculosis in .... . 
 
 Hopital pour les Enfayits Tubercnleux a Berck-sicr-Mer 
 Hospitals ........ 
 
 Housekeeping Centers ..... 
 
 Houses, Construction of . . . . -9 
 
 Housing Laboring Population .... 
 
 Huggard, Dr. . 
 
 Humidifier ........ 
 
 Hydrotherapy . ...... 
 
 Hygiene, Factory ....... 
 
 Hygiene, Personal 
 
 Hygrometer ........ 
 
 Indiana State Sanatorium ...... 
 
 Indoor Occupations, Number of People Employed in 
 
 Infant, Newborn, Care of . 
 
 Infection by Close Contact .... 
 
 Infection by Ingestion ...... 
 
 Infection by Inhalation ...... 
 
 Infection by Inoculation ...... 
 
 Information for All ....... 
 
 Inland Sanatorium of N. Y. Orthopaedic Hospital 
 Insane Asylum and Tuberculosis . . . . 
 
 Instruction Leaflets 30, 47) 
 
 PAGE 
 
 28 
 103 
 297 
 
 8, 9, II 
 160, 166 
 
 119 
 
 276 
 156 
 
 95, 107 
 85> 92 
 
 53 
 
 134, 139 
 
 58 
 
 311 
 
 20 
 168 
 230 
 
 91 
 353 
 178 
 288 
 
 31 
 
 301 
 
 243 
 277 
 
 158 
 282 
 116 
 
 365 
 
 85 
 122 
 
 81 
 228 
 
 12 
 123 
 
 196 
 90 
 
 357 
 169 
 
 5 
 5 
 6 
 
 54 
 159 
 197 
 218 
 
388 
 
 INDEX 
 
 Insurance Against Tuberculosis . 
 International Tuberculosis Exhibit 
 Iowa State Sanatorium 
 
 Jacobi, Professor A. . 
 Jacobs, Dr. Henry Barton . 
 Janeway, Professor Edw. G. 
 Janeway, Professor Theodore C. 
 Jewish Hospital, National . 
 Justice to Consumptives 
 
 Kelly, Mrs. Florence . 
 Kentucky State Sanatorium 
 King, Dr. Herbert M. 
 Kissing Animal Pets . 
 Kissing Articles of Adoration 
 Kissing, Infection through 
 Kissing the Bible 
 Klebs, Dr. Arnold C. 
 Knopf's Cuspidors 
 Koch Institute .... 
 Koch, Professor Robert 
 Krankenheim, Weicker's . 
 Krauskopf, Rev. Joseph, D. D. . 
 
 Lacing, Tight .... 
 
 Laryngeal Tuberculosis 
 
 Lectures ..... 
 
 Lectures to Employees 
 
 Leipziger, Dr. Henry M. 
 
 Life in Fresh Air 
 
 Life Insurance Companies Helpful in 
 
 Linen, Care of . 
 
 Littlejohn, Professor Harvey 
 
 Ljunggren, Rev. C. J. . 
 
 Locke, Dr. Edwin A. . 
 
 Lodge, Sir Oliver 
 
 Lodging Houses and Tuberculosis 
 
 London Open Air School . 
 
 Propaganda 
 
 P.\GE 
 
 • 376 
 . 144 
 . 180 
 
 24, 128 
 
 • 372 
 
 24, 27 
 
 • 311 
 
 • 293 
 
 • 23 
 
 . 282 
 . 196 
 
 • 330 
 
 • 244 
 . 284 
 
 244, 267 
 . 284 
 
 • 24 
 
 7, 9, 132 
 . 312 
 
 241, 350 
 
 • 375 
 . 288 
 
 • 358 
 
 . 36 
 
 35i> 367 
 . 232 
 
 • 279 
 
 • 369 
 
 • 371 
 , 20 
 . 128 
 . 287 
 . 278 
 . 129 
 . 117 
 . 270 
 
INDEX 
 
 3^9 
 
 Loomis Sanatorium . 
 
 Lortet, Dr. 
 
 Lyman, Dr. David R. 
 
 Mailbags, Infection through 
 Marriage of the Tuberculous 
 Maryland State Sanatorium 
 Massachusetts State Sanatorium 
 McFaul, Rt. Rev. James A. 
 Meat, Tuberculous 
 Medical Guidance, Necessity of 
 Medical Supervision of Patients 
 Metchnikoff, Professor E. . 
 Metropolitan Life Insurance Company 
 Michigan State Sanatorium 
 Milk and Tuberculosis 
 Miller, Dr. James Alexander 
 Millet, Dr. C. S. 
 Miner's Tuberculosis 
 Minnesota State Sanatorium 
 Misery, Social, and Tuberculosis 
 Missouri State Sanatorium 
 Mothers' Education in Tuberculosis 
 Mothers, Tuberculous 
 Mouth Breathing 
 Mouthmask, Frankel's 
 Municipal Authorities, Duties of 
 Muskoka Cottage Sanatorium . 
 
 National Association . 
 
 National Jewish Hospital 
 
 National Pythian Sanatorium 
 
 Natural Defense, Means of 
 
 New Hampshire State Sanatorium 
 
 New Jersey State Sanatorium . 
 
 New Mexico Cottage Sanatorium 
 
 Newsholme, Dr. 
 
 New York City Open Air School 
 
 New York C. O. S. Tuberculosis Work 
 
 PAGE 
 
 326, 328, 330, 332 
 295 
 325 
 
 220, 
 
 174, 
 
 350, 
 
 37i> 
 
 6: 
 
 364, 
 281, 
 
 289, 
 
 293. 
 
 224 
 
 354 
 181 
 176 
 288 
 216 
 
 15 
 173 
 
 18 
 
 378 
 182 
 166 
 274 
 ', 74 
 233 
 184 
 382 
 186 
 
 354 
 18 
 
 356 
 205 
 126 
 337 
 
 372 
 294 
 373 
 17 
 196 
 
 187 
 333 
 350 
 272 
 
 305 
 
390 
 
 INDEX 
 
 New York Milk Committee 
 
 New York State Sanatorium 
 
 New York Tuberculosis Clinics 
 
 Night Air, Fear of . 
 
 Night Camps .... 
 
 Non-Alcoholic Drinks 
 
 Nordrach Ranch Sanatorium 
 
 North Carolina State Sanatorium 
 
 Notification .... 
 
 Number of Institutions in the United States 
 
 Number of Associations in the United States 
 
 Nurses . ...... 
 
 Occupations Suited for the Tuberculous . 
 
 Occupations Unsuited for the Tuberculous 
 
 Oderberg Sanatorium for Tuberculous Policy 
 
 Offices, Tuberculosis in 
 
 Ohio State Sanatorium 
 
 Open Air Schools 
 
 Open Air School "Southfield" 
 
 Open Air Model Tenements 
 
 Open Air Private Dwellings 
 
 Osier, Professor William , 
 
 Otis, Professor Edw. O. 
 
 Outdoor Sleeping 
 
 Outdoor Sleeping, Dress for 
 
 Overwork in Prisons 
 
 Overwork in Schools . 
 
 Parsons, Mrs. Henry 
 
 Pasteur, Louis 293, 295, 379 
 
 Pasteurization 19 
 
 Patients at Work 
 
 Patients' Duty . 
 
 Pennsylvania State South Mountain Sanatorium 
 
 People, Duties of the 
 
 Perkins, Dr. J. . 
 
 Philadelphia Protst. Epi.sc. City Mission House for Consumptives 
 
 Philanthropists, Duties of 
 
 138 
 
 149 
 
 42, 156, 
 Holders 
 
 270. 
 
 24, 2 
 59, 98 
 
 5, 
 
 324 
 
 201 
 42 
 
 271 
 
 97 
 
 108 
 
 27 
 103 
 
 PAGE 
 
 307 
 188 
 
 119 
 338 
 364 
 
 334 
 189 
 
 43 
 317 
 372 
 329 
 
 226 
 169 
 
 377 
 229 
 
 190 
 
 272 
 
 272 
 
 99 
 
 109 
 
 372 
 24 
 
 344 
 76 
 
 209 
 
 251 
 
 262 
 380 
 167 
 332 
 4 
 191 
 
 351 
 270 
 290 
 284 
 
INDEX 
 
 391 
 
 at Seabreeze 
 
 PAGE 
 
 Phipps, Mr. Henry 3^2 
 
 Phipps Institute for the Study and Prevention of Tuberculosis 312 
 
 Phthisiophobia .... 
 
 Physicians' Duties 
 
 Physicians, General Advice from 
 
 Physicians, Special Advice from 
 
 Physiological Poverty 
 
 Plan for Disinfecting Mailbags . 
 
 Plan, Prize, for Tenements 
 
 Playground for Tuberculous Children 
 
 Playgrounds .... 
 
 Playgrounds for Public Schools . 
 
 Pocket Flasks .... 
 
 Police Power of Health Department 
 
 Postmaster-General . 
 
 Post-natal Infection . 
 
 Post Offices, Tuberculosis in 
 
 Pratt, Dr. Joseph H. . 
 
 Precautions, Anti-tuberculosis . 
 
 Predisposition, Overcoming of . 
 
 Pregnant Woman, Care of . 
 
 Prevention by Insurance of the Peopl 
 
 Preventorium .... 
 
 Printers' Union Home for Consumptives 
 
 Prisons, Tuberculosis in 
 
 Probst, Dr. Charles O. 
 
 Proctor, Senator Redfield . 
 
 Proedohl's Spittoon . 
 
 Prohibition .... 
 
 Protestant Episcopal Home for Consumptives 
 
 Providence Open Air School 
 
 Prudden, Professor T. IMitchell 
 
 Public Press, Duties of the 
 
 Purdy, Dr. Charles W. 
 
 Pythian Sanatorium . 
 
 Railroads and Tuberculosis 
 Ransom, Dr. J. B. . 
 
 S> 21 
 
 e Against Tuberculosis 
 
 i97> 
 
 168, 
 
 22 
 
 274 
 
 28 
 
 43 
 
 
 47 
 
 
 54 
 
 
 18 
 
 
 224 
 
 
 95 
 
 
 278 
 
 91 
 
 164 
 
 246 
 
 247 
 
 
 8 
 
 
 160 
 
 
 218 
 
 20 
 
 41 
 
 218 
 
 220 
 
 299 
 
 349 
 
 203 
 
 323 
 
 
 354 
 
 
 354 
 
 5 
 
 378 
 
 157 
 
 342 
 
 
 374 
 
 199 
 
 210 
 
 
 190 
 
 
 190 
 
 202 
 
 , 215 
 
 
 362 
 
 
 290 
 
 
 270 
 
 
 123 
 
 246 
 
 280 
 
 
 296 
 
 
 373 
 
 
 235 
 
 24 
 
 207 
 
392 
 
 INDEX 
 
 Death Rate in Glasgow 
 
 Reaction . 
 
 Recitations 
 
 R^d Cross Camp 
 
 Red Cross Society 
 
 Red Cross Stamp 
 
 Reduction in Tuberculosis 
 
 Registration 
 
 Research . 
 
 Respirator)' Exercises 
 
 Rest-cure . 
 
 Richer, Dr. Arthur J. 
 
 Riverside Hospital Sanatorium 
 
 Rhode Island State Sanatorium 
 
 Rockefeller Institute, New York. 
 
 Rockefeller, Mr. John D . 
 
 Rogers, Dr. Oscar H. 
 
 Roof Camping . 
 
 Roof Gardens 
 
 Room, Consumptive's 
 
 Rosenau, Dr. J. N. . 
 
 Rothrock, Dr. A. N. . 
 
 Royal Hospital for Consumptives at Ventnor 
 
 Royal League Sanatorium . 
 
 Sachs, Dr. Theodore B. . 
 
 Sage, Russell, Foundation 
 
 Sailors, Tuberculous 
 
 Sanatoria . . • 3i> 156, 158, 160, 172 
 
 Sanatoria as Educators 
 
 Sanatorium, Its Medical Mission 
 
 Sanatorium, Its Social Mission 
 
 Sanitary Private House for Laborers 
 
 Sanitary Tenements for Tuberculous Families 
 
 School Age of Pupil Entering 
 
 School Farms 
 
 School Hygiene. 
 
 SchcK)l Lunches . 
 
 Schools and Tuberculosis . 
 
 289 
 
 si6 
 
 
 PAGE 
 
 
 357 
 
 
 260 
 
 338 
 
 370 
 
 
 370 
 
 
 370 
 
 
 350 
 
 
 43 
 
 
 312 
 
 
 253 
 
 59 
 
 79 
 
 
 342 
 
 
 162 
 
 
 192 
 
 
 312 
 
 
 158 
 
 
 146 
 
 
 105 
 
 91 
 
 347 
 
 
 56 
 
 
 167 
 
 
 191 
 
 
 345 
 
 
 376 
 
 
 324 
 
 3ii> 
 
 321 
 
 217, 
 
 244 
 
 33^, 
 
 378 
 
 
 33^ 
 
 
 323 
 
 
 329 
 
 
 112 
 
 
 346 
 
 
 251 
 
 
 262 
 
 
 248 
 
 
 263 
 
 41, 
 
 246 
 
INDEX 
 
 393 
 
 PAGE 
 
 vanced Cases, 
 
 Schottelius, Dr. . 
 
 Schrader, Mr. Geo. H. F. . 
 
 Sea Breeze Sanatorium 
 
 Seaside Sanatorium . 
 
 Segregation, Institutional, for Ad 
 
 Sermons, Anti-tuberculous 
 
 Servants, Tuberculous 
 
 Seton Hospital 
 
 Sharon Sanatorium 
 
 Shively, Dr. Henry L. 
 
 Shively Sanitary Tenement 
 
 Shack, Millet's . 
 
 Short, Mr. R. Thomas . 
 
 Singing .... 
 
 Sleeping Porch or Balcony. 
 
 Smith, Mr. Henry Atterbury, 
 
 Smoke Nuisance 
 
 Soldiers, Tuberculous 
 
 Spittoons .... 
 
 Star Ranch, Colorado Springs 
 
 State Authorities, Duties of 
 
 State Sanatorium, Location of 
 
 Statistics .... 
 
 Sterilization 
 
 Sternberg, Surgeon-General Geo 
 
 Stimulants 
 
 St. Joseph's Hospital 
 
 Street Sprinkling 
 
 Sunday Tuberculosis in Churches 
 
 Surgeon-General Marine Hospital Service 
 
 Sweatshops .... 
 
 Sweeping ..... 
 
 Swimming Lessons in School 
 
 Swine, Tuberculosis in 
 
 Symptoms, Early, of Tuberculosis 
 
 Taft, Hon. Wm. H. . . . 
 Teachers' Duties 
 
 -/ / 
 
 M, 
 
 211 
 
 158, 
 
 7, 
 
 297> 
 
 
 . 295 
 
 
 . 281 
 
 ), 276 
 
 , 278, 315 
 
 
 . 276, 278 
 
 
 • 350 
 
 
 . 289 
 
 
 • 233 
 
 
 . 289, 292 
 
 
 • 335 
 
 
 • 344, 346 
 
 
 • 346, 348 
 
 
 . 62, 63 
 
 
 • 94 
 
 
 . 260 
 
 
 60, 62 
 
 
 . 346 
 
 
 . 128 
 
 
 . 217 
 
 8, 16 
 
 132, 201 
 
 
 • 336 
 
 
 . 171 
 
 
 . 172 
 
 , 327 
 
 353, 372 
 
 
 • 19 
 
 
 • 372 
 
 
 • 52 
 
 
 289, 291 
 
 
 • 131 
 
 
 • 245 
 
 
 . 227 
 
 
 . 214 
 
 
 21, 123 
 
 
 . 248 
 
 
 . 242 
 
 
 268, 352 
 
 
 . 227 
 
 
 . 246 
 
394 
 
 INDEX 
 
 PAGE 
 
 Telephones, Protection from Possible Infection 
 
 Tenement Houses 
 
 Tents 
 
 Topography for State Sanatorium 
 
 Treating Habit . 
 
 Treatment at Home 
 
 Trudeau, Dr. Edw. L 
 
 TubercuHn Tests 
 
 Tuberculosis, Pulmonary, Definition of 
 
 Tuberculous Teachers 
 
 Tucker 
 
 Tyson, Professor James 
 
 Underwear, Sanitary 
 
 Union Printers' Home for Consumptives 
 
 Vanderbilt, Mrs. "Wm. K., Sen. 
 
 Van Pelt, Professor John V. 
 
 Veiller, Mr. Lawrence 
 
 Ventilation, Proper . . . . .in 
 
 Vermont State Sanatorium 
 
 Vivisection, Scientific 
 
 Wald, Miss Lillian D. 
 Watchfulness for Early Symptoms 
 Waters, Dr. Bertram H. 
 Wehrawald Sanatorium, Germany 
 Weicker's Sanatorium at Goerbersdorf 
 Welch, Professor Wm. H. 
 West Virginia State Sanatorium 
 Whitewash Scales 
 White, Dr. Wm. Charles . 
 Willard, Mrs. Henry , 
 Windows, French 
 Window-tent, Knopf's 
 Wisconsin State Sanatorium 
 Woman Labor . 
 Worcester, Rev. Dr. Elwood 
 Workshops in Prisons 
 W^nne State Farm, Texas 
 
 24, 2 
 
 5, 27 
 
 229 
 
 98 
 238 
 
 lOI 
 
 
 234 
 
 95, 98, 215 
 
 
 66 
 
 . 
 
 172 
 
 
 3(>3 
 
 • 57> 
 
 301 
 
 > 333} 
 
 372 
 
 
 241 
 
 
 3 
 
 
 278 
 
 
 66 
 
 
 24 
 
 
 12 
 
 
 374 
 
 ■ 344, 
 
 346 
 
 , 107, 
 
 112 
 
 
 306 
 
 , 347, 
 
 355 
 
 
 195 
 
 
 312 
 
 
 282 
 
 
 352 
 
 
 283 
 
 
 341 
 
 • 343, 
 
 375 
 
 • 350, 
 
 351 
 
 
 196 
 
 
 206 
 
 
 338 
 
 
 311 
 
 107, 
 
 248 
 
 
 67 
 
 
 194 
 
 
 212 
 
 
 299 
 
 
 210 
 
 
 2H 
 
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