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

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!":—

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 reËnforced 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.

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."

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.