Chapter 36

THE LAST DAYS OF TUBERCULOSIS

If the historian Lecky was right in saying that the greatest triumphs of the nineteenth century were its sanitary achievements, the Lecky of the twenty-first century will probably honor our generation not for its electricity, its trusts, and its scientific research, but for its crusade against the white plague and for its recognition of health rights. Thanks to committees for the prevention of tuberculosis,--local, state, national, international,--we are fast approaching the time when every parent, teacher, employer, landlord, worker, will see in tuberculosis a personal enemy,--a menace to his fireside, his income, and his freedom. Just as this nation could not exist half slave, half free, we of one mind now affirm that equal opportunity cannot exist where one death in ten is from a single preventable disease.[13]

Of no obstacle to efficient living is it more true than of tuberculosis, that the remedy depends upon enforcing rather than upon making law, upon practice rather than upon precept, upon health habits rather than upon medical remedies, upon coöperation of lay citizens rather than upon medical science or isolated individual effort. Without learning another fact about tuberculosis, we can stamp it out if we will but apply, and see that officers of health apply, lessons of cleanliness and natural living already known to us.

Perhaps the most striking results yet obtained in combating tuberculosis are those of the Massachusetts General Hospital in Boston. To visit its tuberculosis classes reminds one more of the sociable than the clinic. In fact, one wonders whether the milk diet and the rest cure or the effervescing optimism and good cheer of the physicians and nurses should be credited with the marvelous cures. The first part of the hour is given to writing on the blackboard the number of hours that the class members spent out of doors the preceding week. So great was the rivalry for first place that the nurse protested that a certain boy in the front row gave himself indigestion by trying to eat his meals in ten or fifteen minutes. It was then suggested that twenty hours a day would be enough for any one to stay out of doors, and that plenty of time should be taken for meals with the family and for cold baths, keeping clean, etc. Interesting facts gathered by personal interviews of two physicians with individual patients are explained to the whole class. Next to the number of hours out of doors, the most interesting fact is the number of hours of exercise permitted. A man of forty, the head of a family, beamed like a school child when told that, after nearly a year of absolute rest, he might during the next week exercise ten minutes a day. A graduate drops in, the very picture of health, weighing two hundred pounds. An apparently hopeless case would brighten up and have confidence when told that this strong, handsome man has gained fifty pounds by rest, good cheer, fresh air, all on his own porch. One young man, just back from a California sanatorium where he progressively lost strength in spite of change of climate, is now returning to work and is back at normal weight.

Every patient keeps a daily record, called for by the following instructions:

Make notes of temperature and pulse at 8, 12, 4, and 8 o'clock, daily; movements of bowels; hours in open air; all food taken; total amount of milk; total amount of oil and butter; appetite; digestion; spirits; cough (amount, chief time); expectoration (amount in 24 hours, color, nature); exercise (if allowed), with temperature and pulse 15 minutes after exercise; sweats; visitors.

The following simple instructions can be followed in any home, even where open windows must take the place of porches:

Rest out of doors is the medicine that cures consumption. Absolute rest for mind and body brings speedy improvement. It stops the cough and promotes the appetite. The lungs heal more quickly when the body is at rest. Lie with the chest low, so the blood flow in the lungs will aid to the uttermost the work of healing. The rest habit is soon acquired. Each day of rest makes the next day of rest easier, and shortens the time necessary to regain health. The more time spent in bed out of doors the better. Do not dress if the temperature is above 99 degrees, or if there is blood in the sputum. It is life in the open air, not exercise, that brings health and strength. Just a few minutes daily exercise during the active stage of the disease may delay recovery weeks or months. Rest favors digestion, exercise frequently disturbs digestion. When possible have meals served in bed. Never think the rest treatment can be taken in a rocking-chair. If tired of the cot, shift to the reclining chair, but sit with head low and feet elevated. Do not write letters. Dictate to a friend. Do not read much and do not hold heavy books. While reading remain in the recumbent posture.

Once having learned the simple facts that must be noted and the simple laws that must be followed, once having placed oneself in a position to secure the rest, the fresh air, and the health diet, no better next steps can be taken than to observe the closing injunction in the rules for rest:

There are few medicines better than clouds, and you have not to swallow them or wear them as plasters,--only to watch them. Keeping your eyes aloft, your thoughts will shortly clamber after them, or, if they don't do that, the sun gets into them, and the bad ones go a-dozing like bats and owls.

+--------------------------------------------------------------------+ | CONSUMPTION IN EARLY STAGES CAN BE CURED | | | | Take your case in time to a good physician or to a dispensary and | | you may be cured--DO NOT WAIT. | | | | Consumption is "caught" mainly through the spit of consumptives. | | | | Friends of Consumption--Dampness, Dirt, Darkness, Drink. | | | | Enemies of Consumption--Sun, Air, Good Food, Cleanliness. | | | | If you have tuberculosis do not give it to others by spitting; | | even if you have not, set a good example by refraining from a | | habit always dirty and often dangerous. | | | | _The Committee on the Prevention of Tuberculosis_ | | _Of the Charity Organization Society_ | | | | (By Courtesy of Siegel Cooper Co.) | +--------------------------------------------------------------------+

Important as are sanatoriums in mountain and desert, day or night camps within and near cities, milk and egg clinics, home visiting, change of air and rest for those who are known to be tuberculous, their importance is infinitesimal compared with the protection that comes from clean, healthy environment and natural living for those not known to be tuberculous. This great fact has been recognized by the various bodies now engaged in popularizing the truth about tuberculosis by means of stationary and traveling exhibits, illustrated lectures, street-car transfers, advertisements, farmers' institutes, anti-spitting signs in public vehicles and public buildings, board of health instructions in many languages, magazine stories, and press reports of conferences. This brilliant campaign of education shows what can be done by national, state, and county superintendents of schools, if they will make the most of school hygiene and civics.

+-------------------------------------------------------------------+ | CIRCULAR ISSUED BY | | | | The Committee of Sanitation of the Central Federated Union of | | New York | | | | The Committee on the Prevention of Tuberculosis of the Charity | | Organization Society | | | | 105 East 22d Street, New York City | | | | * * * * * | | | | Don't Give Consumption to Others | | | | Don't Let Others Give It to You | | | | * * * * * | | | | =How to Prevent Consumption= | | | | =The spit and the small particles coughed up and sneezed out by | | consumptives, and by many who do not know that they have | | consumption, are full of living germs too small to be seen. THESE | | GERMS ARE THE CAUSE OF CONSUMPTION.= | | | | | | =DON'T SPIT on the sidewalks--it spreads disease, and it is | | against the law.= | | | | =DON'T SPIT on the floors of your rooms or hallways.= | | | | =DON'T SPIT on the floors of your shop.= | | | | =WHEN YOU SPIT, spit in the gutters or into a spittoon.= | | | | =Have your own spittoons half full of water, and clean them | | out at least once a day with hot water.= | | | | =DON'T cough without holding a handkerchief or your hand | | over your mouth.= | | | | =DON'T live in rooms where there is no fresh air.= | | | | =DON'T work in rooms where there is no fresh air.= | | | | =DON'T sleep in rooms where there is no fresh air.= | | | | =Keep at least one window open in your bedroom day and | | night.= | | | | =Fresh air helps to kill the consumption germ.= | | | | =Fresh air helps to keep you strong and healthy.= | | | | =DON'T eat with soiled hands--wash them first.= | | | | =DON'T NEGLECT A COLD or a cough.= | | | | | | =How to Cure Consumption= | | | | =DON'T WASTE YOUR MONEY on patent medicines or advertised | | cures for consumption, but go to a doctor or a | | dispensary. If you go in time YOU CAN BE CURED; if you | | wait until you are so sick that you cannot work any | | longer, or until you are very weak, it may be too late; | | at any rate it will in the end mean more time out of work | | and more wages lost than if you had taken care of | | yourself at the start.= | | | | =DON'T DRINK WHISKY, beer, or other intoxicating drinks; | | they will do you no good, but will make it harder for you | | to get well.= | | | | =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 in | | the sunshine as much as possible, and KEEP YOUR WINDOWS | | OPEN, winter and summer, night and day. Fresh air, night | | and day, is good for you.= | | | | =GO TO A HOSPITAL WHILE YOU CAN AND BEFORE IT IS TOO LATE. | | There you can get the best treatment, all the rest, all | | the fresh air, and all the food which you need.= | | | | =THE CAREFUL AND CLEAN CONSUMPTIVE IS NOT DANGEROUS TO THOSE | | WITH WHOM HE LIVES AND WORKS= | +-------------------------------------------------------------------+

Is it not significant that America's national movement is due primarily to the organizing capacity of laymen in the New York Charity Organization Society rather than to schools or hospitals? Most of the local secretaries are men whose inspiration came from contact with the non-medical relief of the poor in city tenements. The secretary of the national association is a university professor of anthropology, who has also a medical degree. The child victim's plea--Little Jo's Smile--was nationalized by an association of laymen, aided by the advertising managers of forty magazines. The smaller cities of New York state are being aroused by a state voluntary association that for years has visited almshouses, insane asylums, and hospitals. These facts I emphasize, for they illustrate the opportunity and the duty of the lay educator, whether parent, teacher, labor leader, or trustee of hospital, orphanage, or relief society.

Three fundamental rules of action should be established as firmly as religious principles:

1. The public health authorities should be told of every known and every suspected case of tuberculosis.

2. For each case proved by examination of sputum to be tuberculous, the public-health officers should know that the germs are destroyed before being allowed to contaminate air or food.

3. Sick and not yet sick should practice habits of health that build up vitality to resist the tubercle bacilli and that abhor uncleanliness as nature abhors a vacuum.

All laws, customs, and environmental conditions opposed to the enforcement of these three principles must be modified or abolished. If the teachers of America will list for educational use in their own communities the local obstacles to these rules of action, they will see exactly where their local problem lies. The illustrations that are given in this book show in how many ways these rules of action are now being universalized. Three or four important steps deserve especial comment:

1. Compulsory notification of all tuberculous cases.

2. Compulsory removal to hospital of those not able at home to destroy the bacilli, or compulsory supervision of home care.

3. Examination of all members of a family where one member is discovered to be tuberculous.

4. Special provision for tuberculous teachers.

5. Protection of children about to enter industry but predisposed to tuberculosis.

6. Prohibition of dry cleaning of schools, offices, and streets.

7. Tax provision for educational and preventive work.

Compulsory notification was introduced first in New York City by Hermann M. Biggs, M.D., chief medical officer: 1893, partially voluntary, partially compulsory; 1897, compulsory for all. Physicians who now hail Dr. Biggs as a statesman called him persecutor, autocrat, and violator of personal freedom fifteen years ago. Foreign sanitarians vied with American colleagues in upbraiding him for his exaggeration of the transmissibility of consumption and for his injustice to its victims. As late as 1899 one British expert particularly resented the rejection of tuberculous immigrants at Ellis Island, and said to me, "Perhaps if you should open a man's mouth and pour in tubercle bacilli he might get phthisis, but compulsory notification is preposterous." In 1906 the International Congress on Tuberculosis met in Paris and congratulated New York upon its leadership in securing at health headquarters a list of the known disease centers within its borders; in 1906 more than twenty thousand individual cases were reported, ten thousand of these being reported more than once. To know the nature and location of twenty thousand germ factories is a long step toward judging their strength and their probable product. To compulsory notification in New York City is largely due the educational movements of the last decade against the white plague, more particularly the growing ability among physicians to recognize and to treat conditions predisposing to the disease. As in New York City, the public should provide free of cost bacteriological analysis of sputum to learn positively whether tuberculosis is present. Simpler still is the tuberculin test of the eyes, with which experiments are now being made on a large scale in New York City, and which bids fair to become cheap enough to be generally used wherever physical examinations are made. This test is known as Calmette's Eye Test. Inside the eyelid is placed a drop of a solution--95 per cent alcohol and tuberculin. If conjunctivitis develops in twenty-four hours, the patient is proved to have tuberculosis. Some physicians still fear to use this test. Others question its proof. The "skin test" is also being thoroughly tried in several American cities and, if finally found trustworthy, will greatly simplify examination for tuberculosis. Dr. John W. Brannan, president of Bellevue and Allied Hospitals, New York City, is to report on skin and eye tuberculin tests for children at the International Congress on Tuberculosis, mentioned later.

Compulsory removal of careless consumptives is yet rare. One obstacle is the lack of hospitals. In New York ten thousand die annually from tuberculosis and fifty thousand are known to have it, yet there are only about two thousand beds available. So long as the patients anxious for hospital care exceed the number of beds, it does not seem fair to give a bed to some one who does not want it. On the other hand, it should not be forgotten that patients are taken forcibly to smallpox and scarlet-fever hospitals, not for their own good, but for the protection of others. The last person who should be permitted to stay at home is the tuberculous person who is unable, unwilling, or too ignorant to take the necessary precautions for others' protection. A rigid educational test should be applied as a condition of remaining at home without supervision.

The objections to compulsory removal are two: (1) it is desired to make sanatorium care so attractive that patients will go at the earliest stage of the disease; (2) an unwilling patient can defeat the sanitarian's effort to help him and others. The alternative for compulsory removal is gratuitous, and, if need be, compulsory, supervision of home care, such as is now given in New York City. In Brighton, England, Dr. Newsholme treats his municipal sanatorium as a vacation school, giving each patient one month only. Thus one bed helps twelve patients each year. Almost any worker can spare one month and in that time can be made into a missionary of healthy living.

Family examining parties were begun in New York by Dr. Linsly R. Williams, for the relief agency that started the seaside treatment of bone tuberculosis. Many of the crippled children at Sea Breeze were found to have consumptive fathers or mothers. In one instance the father had died before Charlie had "hip trouble." Long after we had known Charlie his mother began to fail. She too had consumption. Family parties were planned for 290 families. Weights were taken and careful examination made, the physician explaining that predisposition means defective lung capacity or deficient vitality. Of 379 members, supposedly free from tuberculosis, sixteen were found to have well-marked cases. (Of twenty Boston children whose parents were in a tuberculosis class, four had tuberculosis.) In one instance the father was astonished to learn not only that he was tuberculous, but that he had probably given the disease to the mother, for whom he was tenderly concerned. Of special benefit were the talks about teeth and nourishment, and about fresh air and water as germ killers. One examination of this kind will organize a family crusade against carelessness.

Tuberculous teachers ought to be excluded from schoolrooms not merely because they may spread tuberculosis, but because they cannot do justice to school work without sacrifices that society ought not to accept. A tuberculous teacher ought to be generous enough to permit public hospitals to restore her strength or enterprising enough to join tuberculosis classes. It is selfish to demand independence at the price which is paid by schools that employ tuberculous teachers.

Predisposition to tuberculosis should be understood by every child before he is accepted as an industrial soldier. Many trades now dangerous would be made safe if workers knew the risk they run, and if society forbade such trades needlessly to exhaust their employees. A perfectly sound man is predisposed to tuberculosis if he elects to work in stale, dust-laden air. Ill-ventilated rooms, cramped positions, lack of exercise in the open air, prepare lungs to give a cordial reception to tubercle bacilli. Rooms as well as persons become infected. Fortunately, opportunities to work are so varied in most localities that workers predisposed to tuberculosis may be sure of a livelihood in an occupation suited to their vitality. Destruction of germs in the air, in carpets, on walls, on streets, is quite as important as destruction of germs in lungs. Why should not tenants and workers require health certificates stating that neither house nor working place is infected with tubercle bacilli? Some cities now compel the disinfection of premises occupied by tuberculous persons _after_ their removal. Landlords, employers, tenants, and employees can easily be taught to see the advantage of disinfecting premises occupied by tuberculous cases _before_ detection.

Dry cleaning, feather dusters, dust-laden air, will disappear from schoolrooms within twenty-four hours after school-teachers declare that they shall disappear. We have no right to expect street cleaners, tenement and shop janitors, or overworked mothers to be more careful than school-teachers. Last year I said to a janitress, "Don't you realize that you may get consumption if you use that feather duster?" Her reply caused us to realize our carelessness: "I don't want any more than I've got now." Shall we some day have compulsory examination and instruction of all cleaners, starting with school cleaners?

Taxing is swift to follow teaching in matters of health. Teachers can easily compute what their community loses from tuberculosis. The totals will for some time prove a convincing argument for cleanliness of air, of body, and of building wherever the community is responsible for air, building, and body. The annual cost of tuberculosis to New York City is estimated at $23,000,000 and to the United States at $330,000,000. The cost of exterminating it will be but a drop in the bucket if school-teachers do their part this next generation with the twenty million children whose day environment they control for three fourths of the year, and whose habits they can determine.

The first meeting in America of the International Congress on Tuberculosis was held at Washington, D.C., September 21 to October 12, 1908. For many years the proceedings of this congress will undoubtedly be the chief reference book on the conquest of tuberculosis.[14]

How many aspects there are to this problem, and how many kinds of people may be enlisted, may be seen from the seven section names: I. Pathology and Bacteriology; II. Sanatoriums, Hospitals, and Dispensaries; III. Surgery and Orthopedics; IV. Tuberculosis in Children--Etiology, Prevention, and Treatment; V. Hygienic, Social, Industrial, and Economic Aspects; VI. State and Municipal Control of Tuberculosis; VII. Tuberculosis in Animals and Its Relation to Man.

How many-sided is the responsibility of each of us for stamping out tuberculosis is shown by the preliminary programme of the eight sessions of Section V. These topics suggest an interesting and instructive year's study for clubs of women, mothers, or teachers, or for advanced pupils.

I. ECONOMIC ASPECTS OF TUBERCULOSIS

1. The burdens entailed by tuberculosis:

a. On individuals and families. b. On the medical profession. c. On industry. d. On relief agencies. e. On the community. f. On social progress.

2. The cost of securing effective control of tuberculosis:

a. In large cities. b. In smaller towns. c. In rural communities.

II. ADVERSE INDUSTRIAL CONDITIONS

1. Incidence of tuberculosis according to occupation.

2. Overwork and nervous strain as factors in tuberculosis.

3. Effect of improvements in factory conditions on the health of employees.

4. Legitimate exercise of police power in protecting the life and health of employees.

III. THE SOCIAL CONTROL OF TUBERCULOSIS

1. Outline of a comprehensive programme for:

a. National, state, and municipal governments. b. Departments of health and departments of public relief. c. Private endowments. d. Voluntary associations for educational propaganda. e. Institutions, such as schools and relief agencies, which exist primarily for other purposes.

2. A symposium on the relative value of each of the features in an aggressive campaign against tuberculosis:

a. Compulsory registration. b. Free sputum examination. c. Compulsory removal of unteachable and dangerous cases. d. Laboratory research. e. Hospital. f. Sanatorium. g. Dispensary. h. The tuberculosis class. i. Day camp. j. Private physician. k. Visiting nurse. l. After-care of arrested cases. m. Relief fund. n. Climate. o. Hygienic instruction,--personal and in class. p. Inspection of schools and factories. q. Educational propaganda.

IV. EARLY RECOGNITION AND PREVENTION

1. Importance of discovering the persons who have tuberculosis before the disease has passed the incipient stage.

2. Examination of persons known to have been exposed or presumably predisposed.

3. Systematic examination of school children during their course and on leaving school to go to work.

4. Professional advice as to choice of occupation in cases where there is apparent predisposition to disease.

V. AFTER-CARE OF ARRESTED CASES

1. Instruction in healthful trades in the sanatorium.

2. Training for professional nursing in institutions for the care of tuberculous patients.

3. Farm colonies.

4. Convalescent homes or cottages.

5. Aid in securing suitable employment on leaving the sanatorium.

6. How to deal with the danger of a return to unfavorable home conditions.

VI. EDUCATIONAL METHODS AND AGENCIES

1. Special literature for general distribution.

2. Exhibits and lectures.

3. The press.

4. Educational work of the nurse.

5. Labor organizations.

6. Instruction in schools of all grades.

7. Presentation and discussion of leaflets awarded prizes by the congress.

VII. PROMOTION OF IMMUNITY

1. Development of the conception of physical well-being.

2. Measures for increasing resistance to disease:

a. Parks and playgrounds. b. Outdoor sports. c. Physical education.