_TUBERCULOSIS AND PNEUMONIA_
These two common widespread diseases affecting the lungs may be
discussed together, although they are not closely related in origin or
effects.
_Tuberculosis._
That form of tuberculosis known as consumption is at present the most
prevalent and the most dreaded of all infectious diseases. In 1908, in
the Registration Area of the United States (about one half of the whole
country), it caused 67,376 deaths. Deaths from other infectious diseases
are shown in the following table, together with the population:--
TABLE XVIII. SHOWING DEATHS FROM VARIOUS INFECTIOUS DISEASES IN THE
UNITED STATES, 1908
Population of Registration Area 45,028,767
Deaths in Registration Area 691,574
Deaths from tuberculosis 67,376
Deaths from pneumonia 61,259
Deaths from diarrhoea (chiefly of babies) 52,213
Deaths from cancer 33,465
Deaths from typhoid fever 11,375
Deaths from diphtheria and croup 10,052
Deaths from scarlet fever 5,577
Deaths from whooping cough 4,969
Deaths from measles 4,611
Deaths from smallpox 92
Deaths from hydrophobia 82
Deaths from leprosy 11
Deaths from bubonic plague 5
Deaths from yellow fever 2
Pneumonia is second in fatality, the two diseases of pneumonia and
tuberculosis carrying off 128,635 persons, or about one fifth of all
persons dying in the year. While these have both been great plagues to
humanity from the very earliest days, it is only within the last ten
years that their ravages have been appreciated and, especially with
tuberculosis, their causes actively combated. There are two phases to be
considered in discussing tuberculosis or consumption, namely, first, the
method of prevention and second, the method of cure. It follows also
that, since the cure of advanced cases is impossible and since every
case which exists is a menace to the health of the community on account
of the danger of the spread of the disease, the prevention is far more
important than the cure.
Until the discovery by Robert Koch, in 1882, of the germ causing
consumption, little could be done in the way of prevention, but since
that time, only one quarter of a century ago, we have learned and
applied the knowledge that, in the vast majority of cases, the disease
is spread by the sputum of consumptive patients, which becomes dry,
forms dust, and so is carried into the air to be breathed by persons not
otherwise affected. It seems so simple a method, then, to prevent the
spread of consumption. All that need be done is to take care of the
expectorations of persons suffering with the disease. It is thoroughly
believed by experts that if this were done carefully and faithfully, the
disease would be stamped out within a few years, and the slogan of a
certain sanitary organization is "Complete Control of Tuberculosis in
1915." Too much emphasis cannot be placed on the direct and simple
method of infection, and while other factors enter, as will be shown
later, a thorough recognition and control of tuberculosis sputum would
practically stamp out the disease.
The following circular, issued by the Committee on the Prevention of
Tuberculosis of the Charity Organization Society of New York City,
indicates the procedures advised by them to prevent the spread of the
disease and, as will be seen, the essence of the axioms there expressed
are summed in the words "Don't spit!":--
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 your 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.
To be sure, the precept of "Don't spit," as applied in cities, has other
reasons for enactment than to prevent tuberculosis. Spitting is a filthy
habit, and its practice should be decried on the score of cleanliness
whether on the streets or in any public place, so that the signs now
seen in street cars and railroad trains, in halls and office buildings,
are intended not altogether for consumptive patients, but also for those
who need laws to force them to observe ordinary rules of cleanliness and
decency. It is, however, the main step towards doing away with
consumption, and the faithful observance of the injunction ought to be
insisted upon quite as much in the individual home as in a city street
or public building. Case after case has been cited of instances where
one consumptive patient in a family has spread the disease through the
household, and, at intervals of a year or so, one after another of the
family has succumbed to the attacks of the consumptive germ, when by
proper precautions and suitable care of the sputum of the first sick
person, the other deaths might have been prevented.
_Individual resistance to tuberculosis._
There is a remarkable difference in the ability of individuals to
withstand the attacks of this disease, and it will be found always that
the first to succumb are those whose vitality has been in some way
depleted. The women of the family, who are generally confined to the
house, who do not have their lungs reenforced by a continual influx of
fresh air, who are tired and worn out with their household duties, give
themselves an easy prey to the attacks of the bacteria, while the men
and boys, who are more outdoors, who are vigorous and strong, throw off
the attack and are not affected.
It is a significant fact that by examination, dead bodies, so far as was
known, not afflicted with tuberculosis in life, have, to the extent of
60 per cent, been found to have evidences of consumption in their lungs;
that is, the edges of the lungs have been found affected, although the
vitality of the individual was such that the action of the germ had been
stayed before any serious injury was done. Most of us, at one time or
another, have had, unknowingly, mild cases of consumption. It would be
strange, indeed, if we did not, in view of all the tuberculous infection
flying around in the air. But most of us are able to successfully combat
the disease, so that the germs are destroyed before they are able to
affect the entire body.
The other part of prevention consists in building up and holding up the
vitality of the individual to a point where the vital forces can
successfully oppose the attacks of the germs. Probably the decrease in
the number of cases of consumption in the last quarter of a century has
been due quite as much to the improved sanitary conditions of living,
whereby the germs have been unable to secure a foothold in the
individual, as to any precautionary measures taken against the germ
itself.
_Precautions by the consumptive._
But the chief factor in the future restriction of the disease, as in the
past, must be the disinfection of the germs immediately after they are
thrown off from the consumptive patient, and it is well worth while to
emphasize just what the consumptive should do or have done for him in
order that he may not be responsible for the further spread of the
disease. In the first place, when he spits, he must appreciate and act
on the fact that the sputum is alive with consumptive germs, each one of
which may possibly transmit the disease to whoever may come in contact
with it. The patient must keep in mind continually that this sputum is
poison, a deadly poison, and that it is his duty to see that every
particle of it is disinfected or destroyed by one of the methods already
indicated. He may expectorate into a vessel filled with a carbolic acid
solution or he may expectorate into a vessel filled with water which may
afterwards be boiled. He may use a cloth or paper, like a Japanese
napkin, which may later be burned in the fire. But, above all things, he
must not expectorate anywhere and everywhere, regardless of the
consequences.
The consumptive patient must not cough without holding a handkerchief
over his mouth, since small particles of sputum may become dislodged and
distributed in this way.
The eating utensils used by a consumptive patient must not in any way be
allowed to infect other people. The consumptive must have his own dishes
reserved exclusively for him, and they must be, after each meal,
carefully disinfected. With these precautions and with avoidance of such
practices as kissing or otherwise directly infecting others, there is no
reason why a consumptive patient should be in any way an object of
dread or why he should not live with his family in as much comfort as he
can obtain, in perfect safety to himself and to them.
_Cure of consumption._
The chief factor in the cure of consumption is the time at which the
attempt at cure is started. Consumption is not an incurable disease, as
was once thought, and there is no reason for so considering it. There is
no such thing as galloping or quick consumption as distinguished from
slow or lingering consumption, since the consumptive germ is the same in
all people. The same germ may act differently in different people, and
if one's power of resistance, as happens with those accustomed to
drinking liquor, is low, the action of the germ is rapid, although the
disease is identical with the form in which death comes only after years
and years. If taken in time, that is, before the germ has so infected
the body as to be beyond all possible restraint, as large a proportion
of consumptive patients may recover as of patients from typhoid fever or
diphtheria or any other infectious disease, but the cure must be started
early. For instance, at one of the sanitariums in the Adirondacks, out
of 267 patients admitted, who had the disease in an incipient stage,
complete recovery was had in 219 cases, the disease was arrested in the
case of 42 others, and in only 6 was the treatment not effective. Where
the disease had become advanced, however, it was found that out of 192
cases, only 32 apparently recovered and 140 were improved to some
extent. These are the significant facts in an institution for incipient
cases only, where advanced cases, such as are met with by the practicing
physician, are not received.
Unfortunately, the ordinary physician does not always recognize the
disease in its first stages, and a person may suffer for months with
consumption, and even pass the time when the cure of the disease would
be possible, without its being recognized. Such sick persons are treated
for catarrh, for an obstinate cold and bronchitis, for grippe or
malaria, whereas a proper diagnosis of the disease would be a
recognition of the early stages of consumption and thus would prompt the
patient to start at once on the necessary methods for cure. Nor is it
possible to recognize the disease by any one definite indication. The
cough which was once thought to be the deciding symptom is very often
absent until the last stages of the disease. Expectoration of blood is
similarly one of the last symptoms, exhibited only when too late for
remedial measures. The presence of the tuberculosis bacillus or "T. B."
in the sputum is also not generally found until the tissue of the lungs
has become well advanced towards destruction, too late for remedy.
Experts in diagnosis attach great importance to family history, and have
learned to expect the disease in persons when exposure to contagion is
inevitable. They will recognize the disease from evidence not
discernible to regular practitioners. For instance, if one member of a
family is known to be affected, any chronic indisposition in another
member, involving, perhaps, a daily rise in the temperature of the body,
not sufficient to arouse alarm, but apparent in the listless behavior of
the person, may be enough to suggest the beginning of the disease. An
expert may detect the clogging up of the lung tissue by an examination
of the lungs themselves, and probably this direct examination, with a
record of the daily rise and fall of temperature, particularly if the
suspected patient has a listless feeling and a gradual loss of weight,
would be sufficient to suggest the ordinary remedies.
The three remedies, which are nature's own methods, are good food, fresh
air, and rest. It is difficult to say which of these three items is the
most important. Certainly no hope of building up the resistance of the
patient against the inroads of the disease can be expected unless the
patient is thoroughly nourished. One of the sad facts in connection with
those unfortunates whose fight against tuberculosis is nearly over and
who in desperation have fled to Arizona, hoping that the dry air might
afford relief, is that the lack of nourishing food, inevitable in those
deserts, hastens on the disease, so that the expected benefits from the
dry air are entirely offset. Likewise, in tenement-house districts in
cities, the fight against consumption is practically useless because of
the impossibility of securing for those starved or underfed helpless
ones the nourishing food necessary. In the country, this part of the
treatment ought to be the simplest, and yet one fears that the habit of
eating through nine months of the year only salted and dried foods has
not furnished patients in the country with the kind of nourishment
necessary. Experience indicates that eggs and milk should be the bulwark
on which the patient must depend for food, and in the sanitariums of New
York State it is not uncommon for patients to be stuffed with two dozen
raw eggs every day in addition to other food.
The next important factor is rest, since the effect of tuberculosis is
to break down lung tissue, and for the prevention of this it is
necessary to give the forces of the body every aid in preventing this
destruction. All exercise taken by a tuberculous patient means the
withdrawing of that much blood from the lungs, where is the strategic
point of the disease, to the part of the body being exercised, and one
of the most striking features of sanitarium treatment is the absolute
rest enjoined on the patients. Flat on their backs, day and night for
months, without so much exercise as walking across the room, is the
ordinary treatment, and the effect of disobedience is plainly seen in
the rise in temperature or increase in fever which follows a violation
of these rules. Even when the patients are allowed to sit up, they do
not sit straight, but rest on couches or reclining chairs, so that their
heads are down and their feet up, making the passage of the blood to the
lungs easier. Even where the patient, determined to recover, is not able
to place himself in the hands of a hospital physician, he can adopt this
important method of arresting the disease by strictly avoiding exercise
and exertion of every sort. The Massachusetts General Hospital in Boston
has tuberculosis clinics, where patients who are not far enough advanced
in the disease to require absolute rest are inspected daily, their
condition noted, and advice given for the following twenty-four hours.
One of the most common violations of the prescriptions given is
overexertion, and yet the rest condition is essential for building up
the diseased lung.
The third method of treatment involves fresh air, in order to improve
the oxygenating character of the blood. If one remembers that the oxygen
in the blood is the chief scavenger of the body and that the vitality of
the red corpuscles and their abundance is an essential factor in curing
the disease, it will be seen why fresh air is so important. The tendency
to-day is to insist on fresh air and to lay less stress on the climate
than was formerly done.
It was not uncommon a few years ago for a physician, recognizing
consumption, to send his patient away, partly because he honestly
believed the climate of Arizona or Colorado or the Sandwich Islands was
better than that where the patient lived, and partly, without doubt,
because he was glad to get rid of a disease which he knew it was not in
his power to cure. To-day, unless the patient can go to a properly
equipped and maintained sanitarium, physicians recognize that conditions
may be as beneficial at home as elsewhere and, provided the three
factors mentioned--good food, rest, and fresh air--can be obtained, the
chances for recovery are better because of better care at home than
elsewhere.
But fresh air is essential, and this means that the patient must spend
twenty-four hours a day in the open. He must eat and sleep out of doors.
He must not go into the house when it rains, nor when it snows, and even
with the thermometer at zero he must still stay out, wrapping himself
up, to be sure, so that his body is not cold, but breathing into his
lungs the life-giving, vitalizing, oxygen-bearing air. The side porch of
a house may be very easily transformed into a room with a cot bed and an
easy chair, where the consumptive may stay continually, and while it is
convenient to have a window or a door opening from the porch into a room
where the patient may be dressed and bathed, this is not essential,
although customary in sanitariums. If no side porch exists, it is
possible to build such a porch, and the picture shows how such a
construction may be added to even a small house in the city (Fig. 75).
If this is out of the question, the windows of a room may be left open
all the time, or the patient may lie on a bed, the head of which either
extends through the window or is arranged to admit fresh air by a
specially devised window tent.
Educational campaigns have been vigorously prosecuted for the past ten
years, and gradually through the world is spreading a growing
appreciation of the dangers of this disease. The effect of this
increasing knowledge is reflected by a continually decreasing number of
deaths in proportion to the population. The following diagram (Fig. 76)
shows how this law is obeyed in New York State, the downward tendency of
the line since 1890 being very plainly marked.
[Illustration: FIG. 75.--Outdoor sleeping porch for tuberculosis
patients.]
The results being so manifest, the prophecy of Dr. Biggs of New York,
written in 1907, is certainly justified:--
"In no other direction can such large results be achieved so certainly
and at such relatively small cost. The time is not far distant when
those states and municipalities which have not adopted a comprehensive
plan for dealing with tuberculosis will be regarded as almost criminally
negligent in their administration of sanitary affairs and inexcusably
blind to their own best economic interests."
[Illustration: FIG. 76.--Mortality from pulmonary tuberculosis. Deaths
per 100,000 population.]
_Pneumonia.--The germ._
In New York State in the year 1908, the largest number of deaths from
any specific disease was due to consumption, the number of deaths in the
rural population alone being 2906. The next largest number of deaths in
the rural communities, and always a close second to consumption, was
from pneumonia, the number being 2191; so that pneumonia justly ranks as
highly important in the list of diseases which are at present most
deadly in their effect on the human race and against which a vigorous
fight should be made.
While pneumonia, like tuberculosis, is due to the action of a specific
organism, the germ itself is not so generally infectious; that is, the
germ has not the power of remaining vigorous when out of the human body
in the same way as has the germ of consumption. Like tuberculosis, the
germ is expectorated and remains virulent when dried into dust, but the
germ is much more sensitive to temperature changes and does not live
longer than two or three hours when dried and exposed to the sun. It is,
very curiously, a normal resident in the mouths of at least one third of
all healthy persons, and it is only necessary for the body of these
persons to become weakened for the germ to be able to secure a foothold
and produce the disease. Unlike tuberculosis, which attacks chiefly
those in the vigor of life, from fifteen to forty-five years of age,
pneumonia attacks generally the very young and the very old; those under
five and those over forty-five, the time of life when the vital
resistance is the least.
_Weather not the cause of pneumonia._
One of the sources formerly believed to be largely responsible for
pneumonia, that is, exposure to severe weather, is curiously negatived
by the fact that children and old people are not those generally exposed
to weather. Perhaps no fallacy in any disease has been more prevalent
than that pneumonia is usually contracted by exposure to wet or to cold.
It has, indeed, been noticed that the disease has been practically
non-existent under conditions where it would be prevalent if exposure
alone were the cause. For instance, in the Arctic zone, where the
temperatures are very low and where no adequate provision against the
rigors of a severe climate are possible, pneumonia is practically
unknown. During Napoleon's retreat from Moscow, when thousands of
soldiers died from physical exposure, from frost bite and starvation,
where if exposure were the predisposing cause of pneumonia, it would
have raged as an epidemic, it seldom appeared, proving this opinion.
Perhaps one reason why the disease has been supposed to result from
exposure is the undoubted fact that it is chiefly prevalent in the
winter and spring rather than in the summer. This argument is, however,
modified by the fact that the majority of cases do not occur in January
or February when the temperature is lowest, but in March, when the
opening of spring is in sight. The reason for this is evident when we
remember that the cause of the disease is a germ, generally present in
the body and needing only a reduced vitality for its successful inroad
on the human system. When, therefore, a person shuts himself up in an
overheated house, without ventilation, takes insufficient exercise, and
lives with an apparently determined effort to do everything possible to
reduce his bodily vigor, then it is no wonder that the germ, almost in
exultation, finds an opportunity for successful development.
_Preventives in pneumonia._
Much as in tuberculosis, then, the best remedy and the best prevention
for pneumonia is a careful attention to the needs of the body in order
that it may preserve its normal vigor. Regular hours, sufficient sleep,
and good food will, in most cases, keep the body in such a condition
that pneumonia need not be dreaded, no matter what the exposure or what
the temperature. Further than this, if the disease does once start and
gain a foothold in the lungs, the best cure is, as with tuberculosis, a
plentiful supply of oxygen or fresh air in order to remove the toxins
formed by the disease and give the lung tissue an opportunity to
recover.
Formerly medical men treated pneumonia by confining the patient in an
overheated room in which steam was generated, with the idea that the
lungs would be most helped by an atmosphere of moist heat. Now, a
pneumonia patient is supplied with all the fresh air possible, the
windows of the sick room, even in winter, being kept continually open,
and every effort being made to give the patient fresh air even when
every breath means a shooting pain, and apparently untold suffering. In
some of the New York City hospitals, the ward for pneumonia patients is
on the roof, and children and babies suffering with pneumonia are at
once taken there, even with snow piled all around the tent in which they
are kept. The nurses and physicians are obliged to don fur coats, and
heavy blankets must be provided to keep the patients from freezing to
death; but the pneumonia germ, under these conditions, is worsted almost
as if by magic, and within a few hours after leaving the warm wards of
the hospital the patients start on the road to recovery.
The remedy, then, for the 2000 cases of pneumonia which occur in New
York State each year, is an improved regulation of the health conditions
of the separate families throughout the state--a better hygienic
regulation of the everyday life. Care must be taken to provide better
ventilation in the houses, more fresh air in the sitting room and in the
sleeping rooms, more outdoor life in the winter time, and more exercise
by which the blood circulation will be kept active. Then more varied and
more suitable food must be consumed, food which will be capable of
absorption by the tissues and not clog the intestines and poison the
system. More bathing, by which the pores of the skin can be relieved of
the organic matter which otherwise clogs them and prevents their
effective action in the removal of waste products, must be indulged in.
With these three factors properly evaluated, with more fresh air, with
better food, with ample bathing, pneumonia need not be dreaded, since
then it would attack only those few whose constitutional vigor was
impaired, and in the course of a generation or two the number of these
would be so decidedly diminished that pneumonia would find no one
susceptible.
_Infection of pneumonia._
It must not be forgotten that a pneumonia patient is a source of
infection quite as much as is a tuberculous patient, and the same
precautions against infection should be followed. The nurse should be
particularly careful not to infect herself. She should be careful to
exercise enough self-control always to get daily exercise and fresh air
and must, as a matter of self-protection, avoid overfatigue. The eating
utensils, food refuse, and soiled clothing may all be infectious and
must be sterilized by boiling as soon as removed from the sick room. The
severe epidemics which have occurred from pneumonia have occurred in
camps where sanitary conditions are grossly violated. Under such
conditions pneumonia has become a most alarming epidemic, sometimes
called the black death. In a single house, however, disinfection of the
wastes of the patient and a proper care of the personal hygiene of the
rest of the family will avoid the spread of the disease, and if the
patient has sufficient vitality, sustained by good food and fresh air,
he will recover without serious after affects.