Announcement 
NATIONAL HEALTH SERIES 
In order to provide the general public with authoritative 
books on health at low cost, the National Health Council has 
arranged with the Funk & Wagnails Company for the publi- 
cation of The National Health Series. This series will 
contain twenty books on all phases of human health, written 
by the leading authorities in the United States. 
Man and the Microbe; How 
Communicable Diseases are Con- 
trolled. By C.-E. A. Winslow, 
Dr. P. H.; Professor of Public 
Health, Yale School of Medicine. 
A description of germs and 
germ diseases and how they are 
spread, together with practical 
methods of disease prevention by 
means of sanitation. 
The Baby's Health. By Richard 
A. Bolt, M.D., Gr. P. H.; Di- 
rector, Medical Service, Ameri- 
can Child Health Association. 
How to care for the baby so 
that it will be healthy, will de- 
velop properly, and be strong and 
free from disease. 
Personal Hygiene; The Rules 
for Right Living. By Allan J. 
McLaughlin, M.D.; Surgeon 
United States Public Health 
Service. 
Practical suggestions as to how 
to apply personal hygiene to pro- 
mote health and get the most out 
of life. 
Community Health; How to 
Obtain and Preserve It By D. 
B. Armstrong, M.D.; Sc.D.; Ex- 
ecutive Officer of the National 
Health Council. 
An outline of what the com- 
munity should do for the health 
of its citizens and what each 
person should do to make his 
community a healthy place. 
Cancer: Nature, Diagnosis, and 
Cure. By Francis Carter Wood, 
M.D.; Director, Institute for 
Cancer Research, Columbia Uni- 
versity. 
The best statement about can- 
cer ever written for the laity. 
It tells what it is and how to 
know it and have it cured. 
The Human Machine; How the 
Body Functions. By W. H. 
Howell, Ph.D., M.D., LL.D., 
Sc.D.; Associate Director, School 
of Hygiene and Public Health, 
Johns Hopkins University. 
A non-technlcal, literary de- 
scription of the anatomy and 
physiology of the human body, 
the most wonderful machine of 
all. 
The Young Child's Health. By 
Henry L. K. Shaw, M.D.; Clin- 
ical Professor, Diseases of Chil- 
dren, Albany Medical College. 
How to care for the health of 
the runabout child from two to 
six years of age. 
The Child in School; Care of 
Its Health. By Thomas D. Wood, 
M.D.; Professor of Physical Edu- 
cation, Teachers College, Colum- 
bia University. 
Promotion of health habits in 
chl'dren of school age and ex- 
actly how to go about it 
Tuberculosis; Nature, Treat- 
ment, and Prevention, by Linsly 
R. Williams, M.D.; Managing 
Director, National Tuberculosis 
Association. 
Covers the whole field of tuber- 
culosis, the cause, spread, treat- 
ment, prevention and duties of 
citizens, patients, and the com- 
munity. 
The Quest for Health: Where 
It is and Who can Help Secure 
It. By James A. Tobey, M.S.; 
Administrative Secretary, Nation- 
al Health Council 
A statement of what health is, 
how it may be obtained, and a 
description of the actual help 
which the government. States, 
municipalities, physicians, and 
voluntary health agencies can 
give to individuals. NATIONAL HEALTH SERIES 
(Continued) 
Love and Marriage; Normal 
Sex Relations; By T. W. Gallo- 
way, Ph.D., LittD.: Associate 
Director of Educational Measures. 
American Social Hygiene Asso- 
ciation. 
The various elements, biologi- 
cal, social, and sexual, which 
make up a successful and happy 
married life. 
Food for Health's Sake; What 
to Eat By Lucy H. Gillett, 
M.A., Superintendent of Nutri- 
tion, Association for Improving 
the Condition of the Poor. New 
York. 
An outline of what and how to 
eat for maximum efficiency and 
health building. 
Health of the Worker; How to 
Safeguard It By Lee K. Frankel 
Ph.D.; Chairman, National Health 
Council. 
Hygiene and sanitation in 
factory and shop and how in- 
dustrial workers can protect and 
promote their health. 
Exercises for Health. By Lenna 
L. Meanes, M.D., Medical Direc- 
tor, Women's Foundation for 
Health. 
Illustrative material giving to 
individuals the type of exercise 
best suited to each one's per- 
sonal needs. 
Venereal Diseases; Their Med- 
ical, Nursing, and Community 
Aspects. By W. F. Snow, M.D., 
General Director, American So- 
cial Hygiene Association. 
A non-technical discussion of 
cause, spread, treatment, cure, 
and prevention of each of these 
diseases and related social hy- 
giene questions. 
Your Mind and You; Mental 
Health. By Frankwood E. Wil- 
liams, M.D., Medical Director, 
National Committee for Mental 
Hygiene, and GeorgeK. Pratt, M.D. 
Describes how your mind can 
be a friend or enemy and how 
it can ba enlisted as your ally. 
Taking Care of Your Heart. 
By T. Stuart Hart, M.D., Presi- 
dent, Association for the Preven- 
tion and Relief of Heart Disease, 
New York. 
How to avoid and prevent heart 
troubles, which form the lead- 
ing cause of death in this 
country. 
The Expectant Mother: Care of 
Her Health. By R. L. DeNor- 
mandie, M.D.; Specialist, Bos- 
ton, Mass. 
The health care needed during 
pregnancy in order that both 
mother and baby may be healthy 
and well. 
Home Care of the Sick; By 
Clara D. Noyes, R. N. ; Director 
of Nursing, American Red Cross. 
What to do in the home when 
illness is present. Practical sug- 
gestions for the care of the sick. 
Adolescence; Educational and 
Hygienic Problems. By Maurice 
A. Bigelow, PhD.; Professor of 
Biology and Director School of 
Practical Arts, Teachers College, 
Columbia University. 
The scientific and sociological 
aspects of adolescence to explain 
the proper transition from child- 
hood to adult life. 
THE NATIONAL HEALTH SERIES 
20 Volumes. I8mo. Flexible Fabrikoid. Average number of pages, 70. 
Price per set, $6.00 net; per volume, 30c. net. 
FUNK & WAGNALLS COMPANY, Publishers 
NEW YORK and LONDON National health Council 
Direct Members 
American Child Health Association, 
370 Seventh Avenue, New York City. 
American Public Health Association, 
370 Seventh Avenue, New York City. 
American Red Cross, 
17th Street between D and E, Washington, D. C. 
American Social Hygiene Association, 
370 Seventh Avenue, New York City. 
American Society for the Control of Cancer, 
370 Seventh Avenue, New York City. 
Conference of State and Provincial Health Authorities of 
North America, 
Care of State Department of Health, Lansing, Mich. 
National Committee for Mental Hygiene, 
370 Seventh Avenue, New York City. 
National Committee for the Prevention of Blindness, 
130 East 22d Street, New York City. 
National Organization for Public Health Nursing, 
370 Seventh Avenue, New York City. 
National Tuberculosis Association, 
370 Seventh Avenue, New York City. 
Conference Members 
United States Public Health Service, 
Washington, D. C. 
United States Children's Bureau, 
Washington, D. C. 
Associate Members 
American Association of Industrial Physicians and Surgeons, 
Care of Dr. W. A. Sawyer, Eastman Kodak Co., 
Rochester, N. Y. 
Women's Foundation for Health, 
370 Seventh Avenue, New York City. 
OFFICERS 
Lee K. Frankel, Chairman, 
William F. Snow, M.D., Vice-Chairman. 
James L, Fieser, Recording Secretary. 
Linsly R. Williams, M.D., Treasurer. 
STAFF 
A. J. Lanza, M.D., Executive Officer. 
James A. Tobey; Administrative Secretary. 
Thomas C. Edwards, Business Manager. 
Elizabeth G. Fox, Washington Representative. 
Offices of the National Health Council 
Administrative:-370 Seventh Avenue. New York City. 
Washington:-17th and D Streets, N. W., Washington, D. C. TUBERCULOSIS 
NATURE, TREATMENT, AND 
PREVENTION 
BY 
LINSLY R. WILLIAMS, M.D. 
Managing Director, National Tuberculosis Association 
THE NATIONAL HEALTH SERIES 
EDITED BY 
THE NATIONAL HEALTH COUNCIL 
FUNK & WAGNALLS COMPANY 
NEW YORK AND LONDON 
1924 Copyright, 1924, by 
FUNK & WAGNALLS COMPANY 
Printed in the United States of America 
Published, May, 1924 
Copyright Under the Articles of the Copyright Convention 
of the Pan-American Republics and the 
United States, August 11,1910 INTRODUCTION 
The printed works on tuberculosis outnumber those 
on any other disease. Not a few follow the great- 
est names in medical history and remain, for all 
time, models of their kind. But, highly technical 
or devoted to matters in dispute, they will always 
be sealed books to the general public. 
During the last twenty years no one has denied 
that, if every man and woman possessed the privi- 
leged information of the doctors and would act upon 
it, tuberculosis would release its hold before the close 
of the present century. Education has therefore been 
the foundation and driving force of all organized 
measures to combat the disease; and since these "mass 
efforts" have got well under way the deaths from 
tuberculosis in the United States have diminished 
almost two-thirds. 
The problem of telling the public about tubercu- 
losis has always lain in the difficulty of presenting 
authentic information about it in a simple and read- 
able manner. The writer's task has been almost 
insuperable:-to be comprehensive yet concise; to be 
plain and definite, yet fair and judicial, about many 
important features in controversy; to keep in proper 
perspective a uniquely large and complex body of 
data of variable weight and value; yet never carry 
the reader beyond his depth. 
Readers differ widely in their capacity to take in 
and make use of details that are, by nature, dry 
and matter of fact, and do not appeal to the imagi- 
nation. Every one will therefore form his own 
opinion of how well Dr. Williams has accomplished INTRODUCTION 
the formidable effort to cover practically the entire 
subject of tuberculosis in not much more space than 
would ordinarily be devoted to a single lecture. But, 
whatever may be individual opinions, it may well be 
doubted whether any work now in existence will 
convey to the average mind, in less time and with 
less tax on the attention, as well balanced and as 
accurate a view of tuberculosis as will this little 
volume. 
Behind it is a rich and versatile experience with 
the greatest of diseases. For ten years Dr. Williams 
met tuberculosis at first hand in the dispensaries and 
hospitals of New York City. From observing and 
combating it in the patient he stepped into the 
broader field of public-health administration in the 
Health Department of New York State, which he 
helped to bring to the eminence that it now enjoys 
and where his duties took him into the study and 
control of tuberculosis as a community disease. 
Then followed five years of devising methods to stay 
the scourge in France, a period of organizing and 
directing effective antituberculosis machinery under 
the auspices of the Rockefeller Tuberculosis Com- 
mission in France. This labor done, he returned to 
the United States to become Managing Director of 
the National Tuberculosis Association. 
The clear and simple account of the causes, symp- 
toms, and treatment, so important for all who would 
detect and take hold of tuberculosis at its first 
awakening, rests, therefore, on the authority of one 
who has had practical acquaintance with what he 
relates. It would be difficult also to think of any 
one more competent than Dr. Williams to write 
about the prevention of the disease. 
Allen K. Krause, M. D., 
Editor, American Review of Tuberculosis. 
Johns Hopkins Hospital, February, 1924. CONTENTS 
I-Extent of Tuberculosis I 
II-What Tuberculosis Is 4 
The tubercle-bacillus-Source of the bacilli- 
Entrance into the body-How the bacilli grow 
within the body-The production of a tubercle 
-What happens to the bacilli within the body. 
III- Infection-Immunity and Resist- 
ance 15 
IV- Pulmonary Tuberculosis 21 
Symptoms: Local symptoms-Cough-Hemor- 
rhage-Constitutional symptoms-The more 
common modes of onset--Other modes of on$et 
-Pleurisy-Symptoms of pleurisy-Pneumo- 
thorax-Arrest of symptoms-Progressive 
symptoms. 
Physical Signs: Percussion-Auscultation-X- 
ray-Examination of sputum-Blood test- 
Tuberculin test. 
V-Non-pulmonary Tuberculosis . . 34 
Lymph-nodes-Meninges-Tuberculous adeni- 
tis-Tuberculous adenitis of bronchial nodes. 
VI-Treatment 38 
Pulmonary Tuberculosis: The sanatorium-Ap- 
parent cure-Specific treatment-Sanatorium 
treatment-Rest-Food-Fresh air-Drugs- 
Climate-Aids in treatment: Artificial pneu- 
mothorax; operation. 
Non-pulmonary tuberculosis: Sunlight treat- 
ment. 
VII-Outcome 52 VIII-Prevention of Tuberculosis ... 54 
Specific Measures: Disinfection-Isolation. 
General Measures: The curative method: Sana- 
torium, hospital, dispensary-Educational value 
of curative measures-The dispensary method 
of treatment. 
Community Measures: The tuberculosis-nurse 
-The preventorium-The open-air school- 
Popular education. 
Official Measures: The health department- 
Supervision. 
IX-Relation of the Standard of Liv- 
ing to Tuberculosis 66 
Influence of poverty on death-rate^-Isolation- 
Effect of nutrition-European conditions-The 
death-rates during the war. 
X-The Antituberculosis Campaign 70 
Leadership in the movement-Results of anti- 
tuberculosis campaign: Diminution in death- 
rate-Causes of diminution. 
XI-The Ideal to be Obtained. ... 77 
CONTENTS TUBERCULOSIS 
CHAPTER I 
EXTENT OF TUBERCULOSIS 
A LITTLE knowledge is a dangerous thing, yet 
knowledge in itself is of the greatest usefulness. 
The knowledge that the germs which cause an abscess 
can be killed by boiling in water is a useful piece of 
information, but to boil an arm in water in order 
to cure an abscess is a foolish thing to do. Knowl- 
edge of the story of the tuberculosis germ and what 
influence this germ has had upon the human race 
may similarly be dangerous, but if that knowledge 
be applied with judgment, it will render to humanity 
one of the most important services that can be per- 
formed for mankind. 
Why should one have any knowledge or informa- 
tion regarding tuberculosis? Isn't it sufficient for 
the doctors to know about it? On the contrary, 
every one should be interested, not only in tuber- 
culosis, but in other diseases which greatly influence 
the lives, happiness, and conduct of so many people. 
Since 1900 tuberculosis has destroyed more than 
2,000,000 people in the United States, and the loss of 
earning power and the cost and care of the sick has 
amounted to $10,000,000,000, at least. Every person 
now living in the United States has one chance out 
Author's Note: It has not been possible to cover the entire 
subject of tuberculosis within the limits of this book. Chapters 
on after-care, occupational therapy, sanatorium sites, dispensary 
and sanatorium management, and others have been omitted pur- 
posely. 
1 2 
TUBERCULOSIS 
of fourteen of dying of tuberculosis and one chance 
in fifty of becoming affected with this disease. These 
facts are so important that every one should know 
something of the disease. It can not be'left to the 
doctors because it is frequently too late for the 
patient when the doctor is first consulted. 
Approximately 100,000 persons die from tuber- 
culosis in the United States each year. Nearly 
1,000,000 are sick with tuberculosis part of the time, 
and at least 500,000 are under constant treatment for 
the disease. The amount of suffering is incalculable, 
and the economic cost of caring for this enormous 
number of patients runs into hundreds of millions 
of dollars annually. 
Tuberculosis is just as prevalent in other civilized 
countries, altho it does not exist among aboriginal 
races. In this country tuberculosis seems to be as 
prevalent among the Italians and Hebrews as in 
other races, but is less fatal. In a population of 
100,000 in the United States about 100 persons die 
each year of the disease. Health officials commonly 
speak of this, the ratio of deaths to population, as the 
tuberculosis death-rate. For example, if in a city 
of 50,000 inhabitants there were 62 deaths from 
tuberculosis in a year, it would be said that the death- 
rate from tuberculosis was 124 per 100,000. 
The disease is far more common in early adult 
life, and the death-rates are higher from this disease 
between the ages of 30 and 50 than they are at earlier 
and later periods of life. The most common form 
of tuberculosis is tuberculosis of the lungs and this 
is responsible for about 90 per cent, of the deaths 
from the disease. Children are more commonly 
affected with tuberculosis of the lymph nodes, bones, 
and joints than they are with pulmonary or lung 
tuberculosis and these particular types are far less 
fatal than the pulmonary. However, tuberculosis of EXTENT OF TUBERCULOSIS 
3 
the lungs is by no means uncommon in childhood. 
Tuberculosis of the membranes lining the brain or 
tuberculous meningitis is comparatively rare, yet most 
young children who die of tuberculosis die from this 
form. It is always fatal. CHAPTER II 
WHAT TUBERCULOSIS IS 
TUBERCULOSIS is a disease caused by the 
presence and growth in the body of a small germ, 
called the tubercle-bacillus, which was discovered by 
a German scientist, Robert Koch, in 1882. The name 
is derived from the Latin word tuberculum or nodule, 
for there are found in the bodies of persons dying 
of tuberculosis many small nodules about the size of 
a pea, which were called tubercles by the older 
medical writers. It was found by Koch that the little 
germs were constantly present in these tubercles, and 
as each germ was rod-like in shape he called it a 
bacillus, the Greek word for a rod. They are very 
small and can not be seen without the aid of a. high- 
powered microscope. 
How do we know that tuberculosis is caused by 
the tubercle-bacillus ? We know this to be a fact 
because at some time during the progress of the 
disease, tubercle-bacilli can be found in the body 
of the diseased person and, if an examination of 
the body is made after death, certain definite changes 
in the body-tissues are always found and the tubercle- 
bacilli are always found in these diseased portions. 
When these bacilli are found, they can be grown 
artificially outside of the body on certain materials, 
such as the potato and some kinds of broths, pro- 
vided these materials are kept at body heat. The 
evidence is not conclusive unless it is known that the 
tubercle-bacilli may be grown artificially outside of 
the body and entirely free from any other forms of 
The Tubercle-bacillus 
4 microscopic life. When the bacilli are only of the 
one kind, scientists speak of this growth as a pure 
culture. 
We have now shown that the tubercle-bacillus is 
always found in the body that has tuberculosis and 
that it may be grown in pure culture. How do we 
know that this pure culture will cause tuberculosis? 
This has been proved by introducing the bacilli of 
this pure culture into the bodies of small susceptible 
animals and in these animals the infection of tuber- 
culosis, identical to that which occurs in man, has 
been reproduced. These facts in regard to the 
causation of the disease by bacteria have been proved 
true for a considerable group of diseases, now called 
communicable or transferable diseases.1 These dis- 
eases were commonly called "contagious" a genera- 
tion ago because it was assumed that the disease 
was contracted by contact with an individual who 
had the disease. We know now that what is meant 
by contact is the transference of the germ from one 
individual to another in sufficient quantity to repro- 
duce the disease in others. These facts were dis- 
covered and proved by the same Dr. Koch, who was 
the founder of the science of bacteriology. 
Tubercle-bacilli are not all of exactly the same 
race. We know that the different races of humans 
vary as to their physique, intelligence, and warlike 
habits. Bacteria also show differences, and the 
tubercle-bacilli vary in type. They are so small, one 
could not say often that there were differences in 
physique, but there are certainly differences in their 
habits and in their warlike manifestations. There 
is a type of tubercle-bacilli which grows chiefly in 
the human body, another type which grows chiefly 
in the bodies of cattle, and a third which grows 
WHAT TUBERCULOSIS IS 
5 
1 See also "Man and the Microbe," by C.-E. A. Winslow. Dr. 
P.H., in the National Health Series. 6 
TUBERCULOSIS 
chiefly in birds. The type which is most commonly 
found in man is called the human bacillus. It is 
the one which is the most warlike in its efforts to 
destroy man and is one of the commonest parasites 
of the human body. Because this bacillus is active 
and warlike and is a dangerous germ to have lodged 
in one's body, it is said to be virulent. The tubercle- 
bacillus which is common among cattle is also dan- 
gerous to man but less virulent for him. Of all the 
persons affected with tuberculosis, a relatively small 
proportion are affected with the cattle-bacillus, and 
the effect of the bird-bacillus in man is an unim- 
portant factor. 
It is known that if the bacilli taken from a human 
being who is diseased are grown over long periods 
of time outside of the body they become less virulent, 
particularly if they are grown upon certain materials. 
We know that if certain races of man feed upon 
certain foods, they will lose in strength. The same 
is true in growing the tubercle-bacillus artificially. 
The tubercle-bacillus consists of a single cell and 
belongs to the vegetable kingdom. It does not possess 
powers of motion and is reproduced by division, that 
is, each individual germ divides in half to make 
two germs. When present in the body of men, the 
tubercle-bacillus is known as a parasite because it 
lives ia and receives its food supply at the expense 
of the individual in whom it is lodged. 
S0URCE OF THE BACILLI 
Where do the tubercle-bacilli come from? We 
know from history and from the descriptions of 
diseased conditions that tuberculosis has been a 
disease of mankind for thousands of years, and we 
know that the tubercle-bacillus comes from the bodies 
of persons affected with the disease and from the 
bodies of diseased animals. The most common dis- WHAT TUBERCULOSIS IS 
7 
eased condition caused by the tubercle-bacillus is 
a chronic inflammation of the lungs, known as pul- 
monary tuberculosis, and the most characteristic 
symptom of this disease is cough. The causes of the 
cough and the expectoration which may accompany 
it will be explained later, but in the expectoration 
of a person affected with pulmonary tuberculosis 
there are commonly found millions of virulent tuber- 
cle-bacilli. The expectoration, sputum, or spit, is 
deposited by diseased persons on the ground, side- 
walks, and streets, on the floors of public buildings 
and conveyances, on the floors of the home, and less 
frequently in the toilet, sink, spittoon, and on cloths, 
gauze, and handkerchief. If a person with pul- 
monary tuberculosis coughs, there is almost always 
a fine spray coughed out and very frequently this 
spray contains tubercle-bacilli. In the course of the 
disease, tubercle-bacilli are frequently found in other 
body discharges either from the intestinal or urinary 
tract and in much smaller numbers in the pus which 
comes from tuberculous abscesses. These discharges, 
however, are more apt to be deposited in places 
which are less likely to do harm than is the case 
with the sputum. The tubercle-bacillus belongs to a 
hardy race and will live for weeks and months 
provided it is kept moist and away from sunlight. 
Sputum no longer recognizable as such may be col- 
lected on shoes and skirts and on the fingers of 
children playing on the floor or picking up objects 
in the street, and the soiled fingers of children readily 
find access to their mouths. During preparation food 
may become soiled with tubercle-bacilli from the 
fingers of the person preparing it. In other words, 
there is a hand to mouth contact which is not appre- 
ciated by the individual, and is quite likely an im- 
portant mode of infection. 
Many persons suffer from a chronic cough or an 8 
TUBERCULOSIS 
occasional cough, with or without sputum, and many 
such persons are not conscious of the fact that the 
cause of their cough is tuberculosis. These persons 
carry in their bodies millions of tubercle-bacilli and 
they are less careful of the places where they deposit 
their sputum than are persons who have knowledge 
of the fact that they have tuberculosis and that the 
disease may be communicated to others. 
Cows are frequently affected with tuberculosis and 
the disease may become far advanced and generalized 
before the owner of the cow realizes that the cow 
is sick. The tubercle-bacilli may be present in the 
milk or may be deposited from the intestinal tract. 
It is very common for the flank and tail of the cow 
to be soiled with discharges which, when dried, 
readily fall into the pail of the milker, thus con- 
taminating the milk with tubercle-bacilli. There is 
relatively less danger, however, if the udder of the 
cow is not diseased and less likelihood then of the 
milk being contaminated with the tubercle-bacilli. 
We may say briefly, therefore, that the chief sources 
of tubercle-bacilli are human patients affected with 
pulmonary tuberculosis and cows affected with tuber- 
culosis, but the human patient is a far more im- 
portant source than the diseased cow. 
Entrance into Body 
How do the bacilli gain entrance into the body? 
The tubercle-bacilli may enter the body of a human 
being through the respiratory tract. That is, they 
may be inhaled down the windpipe and into the 
lungs, or they may be swallowed and taken into the 
stomach and intestines, or they may be taken into 
the mouth and go to the lymph-nodes of the neck. 
Tubercle-bacilli may also gain entrance to the body 
through the skin and other exposed parts of the 
body, altho this last is very rare. WHAT TUBERCULOSIS IS 
9 
We have just told of the sources of the bacilli 
and it is easy to tell how the bacilli enter the body 
when one considers the sources. The most dangerous 
and common sources are from the constant coughing 
of persons who have pulmonary tuberculosis, from 
the deposit of sputum upon the floor or other parts 
of the home and upon the sidewalks and streets, and 
from the drinking of cow's milk which contains 
tubercle-bacilli. 
What happens when the bacilli have entered the 
body? If the bacilli are inhaled, they pass down 
through the windpipe and smaller bronchial tubes 
and are washed along by the moist material which 
lies upon the surface of the fine bronchial tubes 
until they finally adhere to a certain spot, when one 
of two things happens. They either die from lack 
of nourishment or they pass into the tiny lymph- 
channels. Here they find some nourishment for a 
time, but nature brings her forces into play and new 
body-cells are formed or old body-cells are called 
from a distance and build a small wall around the 
bacilli. This small wall eventually shuts off the 
tubercle-bacilli from the rest of the body and the 
tubercle-bacilli are unable to obtain suitable nourish- 
ment. As a result they die, or they may remain 
alive but dormant for months or years without doing 
any harm to the individual. 
If, however, the bacilli be sufficient in number 
and virulence, and if they receive enough nourish- 
ment to multiply while the body is forming the wall 
about them, the materials developed by the growth 
of the bacilli act as poisons, eating away the inner 
part of the newly formed wall. If they continue to 
form their poisons the wall will ultimately be eaten 
away or dissolved so that the bacilli may pass on 
Method of Development 10 
TUBERCULOSIS 
to a lymph-node or to other points in the lung. 
Here again this same process is repeated and a new 
effort is made by the body to throw a wall around 
this new point of growth. 
Some of the bacilli may gain entrance into a tiny 
blood-vessel or lymph-duct and may again be carried 
along to still other parts of the lung or even to more 
distant parts of the body. We usually find that if 
the bacilli have once gained entrance to the lung 
they begin after a time to grow in various places, 
usually at the top of the lung, and one will find 
that these places are in various stages of develop- 
ment. In one we may find that the tubercle-bacilli 
have been successfully defeated by the body, that 
the wall thrown around them is tight and firm, that 
new body-cells have formed and that a small hard 
pea-like nodule is developed, which is known as 
a tubercle. These tubercles may be as small as a 
pin-head and in the earlier stages of their develop- 
ment can not be seen with the naked eye. This 
development of the tubercle is caused by what is 
known as proliferation or new growth of body-tissue. 
If the tubercle-bacilli are successful in their combat 
and cause the wall of one of these tubercles to soften, 
a curious material is formed consisting of the dead 
bodies of the new cells formed by the body and the 
dead bodies of the tubercle-bacilli themselves. This 
material is cheesy in character and this process of 
death and disintegration of cells is known as casea- 
tion. As this process continues, the wall of the 
tubercle is eventually broken down and the contents 
of the tubercle have greater access to the lung-tissue. 
The presence of this foreign substance in the tiny 
air-boxes of the lung or in the terminal passages 
of the bronchi causes an irritation which brings 
about a spasmodic contraction of the diaphragm and 
chest muscles that diminishes quickly the size of the WHAT TUBERCULOSIS IS 
11 
entire lung and brings about a sudden forcible ex- 
piration known as a cough. Almost any foreign 
body deposited in any of the small air-passages or 
in the small air-boxes of the lung will cause such 
an irritation and cough. Coughing gradually forces 
up the material from the smaller passages to the 
larger and to this foreign substance is added the 
normal secretion of the bronchi. The entire mass 
finally reaches the windpipe from which it is thrown 
out of the body by a cough; the mass thus expec- 
torated from the body is called expectoration or 
sputum. 
In this sputum one finds the tubercle-bacilli and 
particles of cells, living or dead, which have come 
all the way from the tubercle in the lung. If a 
number of small tubercles, pin-head or pea-sized, 
are in close proximity to each other, they may finally 
grow to such an extent that they may be combined 
to form a diseased spot as large as an olive or 
walnut. At such stage they are called agglomerated 
tubercles. If the growth of the tubercle-bacillus con- 
tinues in an agglomerated tubercle and the diseased 
tissue undergoes this process of proliferation and 
caseation, the involved lung-tissue will first be re- 
placed with this new so-called tuberculous tissue. 
When this tissue has softened and broken down, it 
may be liquified and the semifluid material dis- 
charged into a bronchus. There will then remain a 
space where nothing exists, and this will be known 
as a cavity. 
During all this period of proliferation, caseation, 
and cavitation, nature always continues its efforts 
of protection and even after a cavity has been 
formed, new cells are formed around the cavity. If 
the wall around the cavity becomes practically com- 
plete and solid, there will still remain an exit from 
the cavity to one of the small air-passages. After 12 
TUBERCULOSIS 
the wall has been formed the liquids of the body may 
deposit in the newly formed wall a chalklike material 
which gradually becomes of almost stony hardness 
and the entire wall of the cavity becomes one firm 
chalklike mass a quarter of an inch, more or less, 
in thickness and a cure may be effected. 
It is very rare to find a single tubercle or any part 
of this process going on at only one point. One 
usually finds all the processes going on together if 
a person has been diseased for a long period of time. 
Attempts have been made to define the different 
anatomical changes which take place in the lung 
or other parts of the body and to classify the 
disease in accordance with what is found after death 
or what is assumed to occur during life. This has 
not been found practicable on account of the variety 
of conditions which may occur at one and the same 
time. It is easy, however, at the outset of the 
disease to find a small number of tubercles at the 
upper part or apex of the lung and in a large 
number of cases a small number of tubercles develop 
at the apex. Some of these may be close together 
slowly forming one larger tubercle, and healing will 
take place without the development of caseation or 
the formation of a cavity. In other cases the tuber- 
cles will continue to develop in different parts of 
the lung, usually extending from the top toward the 
bottom, and as the new tubercles are formed at a 
lower level, the agglomerated tubercles above un- 
dergo caseation, so that we find at the same time 
caseation or destruction of tissue above and develop- 
ing tubercles at a lower level. 
As the disease progresses, the caseous area at the 
top continues to evolve, and the tissue breaks down, 
forming a small cavity, while the tubercles at the 
next lower level undergo caseation and at a third 
level new tubercles have begun to develop. When WHAT TUBERCULOSIS IS 
13 
the process has reached this development, many 
lymphatics and small blood-vessels have been entered 
by the bacilli and have begun to travel to other 
parts of the body; or when the sputum is coughed 
up constantly from these many diseased areas, the 
vocal cords and larynx, which are situated at the 
top of the windpipe, are constantly smeared with 
the sputum containing tubercle-bacilli, which may 
adhere to the vocal cords and larynx and cause them 
to be diseased also. 
It is very difficult also to avoid swallowing sputum 
occasionally or to avoid having some particles of 
sputum containing bacilli left in the mouth while 
eating, so that the bacilli gain entrance to the 
stomach. While a person is in good health the 
normal juices of the stomach will kill large numbers 
of the bacilli. If the disease has existed for a long 
time, the stomach-juices are less able to destroy the 
bacilli, for the bacilli may be enveloped in a mass 
of material brought up from the lung and which 
may not be destroyed by the stomach-juices. Accord- 
ingly, the bacilli pass through into the intestine and 
may lodge there sufficiently long to cause a disease 
of the wall of the intestine. 
If tubercle-bacilli are swallowed frequently over 
long periods of time, they will ultimately cause a 
diseased condition in the wall of the intestines. In 
adults the wall of the intestines is usually so con- 
stituted that it remains impervious to the tubercle- 
bacilli and they do not enter into the body through 
the wall of the intestines. In children and young 
animals, however, the wall of the intestine is much 
more susceptible. 
A curious condition in small children is that 
tubercle-bacilli, if lodged on the wall of the intestine, 
may pass through the lymphatics of the intestinal 
wall without doing any injury to the intestine itself. 14 
TUBERCULOSIS 
These bacilli may be carried by the lymphatics to 
the nearest lymph-gland and may be lodged there 
for an indefinite period of time, or the same process 
of proliferation, caseation, and destruction of tissue 
may take place in the lymphatic glands of the ab- 
domen as has been described for the lymphatic 
glands of the lung. If this condition takes place 
and the process extends, it results in an adenitis or 
inflammation of the lymph-nodes along the spinal 
column. If this tuberculous inflammation continues, 
it may extend into the lung or into the peritoneum 
(the lining of the abdominal cavity), in the latter 
case causing peritonitis. CHAPTER HI 
INFECTION, IMMUNITY, AND RESISTANCE 
WHEN the tubercle-bacilli enter the body of a 
normal individual for the first time and find 
lodgment there, the number of bacilli may be so 
small and the normal defenses of the body so effec- 
tive that the bacilli are entirely walled off and no 
evidence of disease occurs, but the individual who 
harbors these bacilli is said to be infected. Such 
an individual may at any time develop the disease 
tuberculosis if the bacilli continue to grow and 
produce poisons. There is a difference, then, be- 
tween infection and disease which should always 
be remembered. 
What is the extent of the disease tuberculosis 
among civilized people and what is the extent of 
infection? It has been known for many years that 
when the bodies of persons dying during adult life 
were carefully examined after death by means of 
autopsy, nearly all showed evidence of the growth of 
the tubercle-bacilli in some part of the body, more 
commonly in the lungs. It was not known until 
fifteen years ago and not generally accepted until 
ten years ago that tubercle-bacilli were so prevalent 
that almost every individual received some of the 
bacilli at some time before he attained the age of 
twenty. To determine this, a simple test, known 
as the tuberculin skin reaction, was devised which 
is both harmless and painless. 
The tuberculin skin reaction consists of the fol- 
lowing procedure: "If tubercle-bacilli are grown in 
pure culture on broth, the broth comes to contain 
15 16 
TUBERCULOSIS 
products of the bacilli and this broth with the 
dissolved materials of the bacilli may now be filtered 
free from the mass of germs that have been growing 
on it. The clear, filtered broth is now known as 
tubercrdin, which then is the liquid food on which 
the bacilli have grown and which now contains in 
solution substances from the bodies of the germs." 
If a single drop of this liquid be placed upon the 
surface of the skin and a very tiny abrasion made 
in the skin underneath the drop of tuberculin and 
the tuberculin be allowed to dry, a certain reaction 
will take place if the person is infected with tubercle- 
bacilli. A small reddened of inflammation is 
produced at the site of this abrasion within twenty- 
four hours, but if the person is not infected with 
tuberculosis, no reaction whatever takes place. 
By the application of this test to thousands and 
thousands of people, it has been found that the 
proportion of apparently normal healthy persons who 
show this reaction increases steadily with each year 
of life. In some large congested cities it has been 
found that 90 per cent, of children at the age of 
fifteen show that they have already been infected. 
Studies made with this test in the United States 
show that about one-half to two-thirds of children 
show this reaction at the age of fifteen. From a 
study of all the evidence which has been submitted 
up to the present time, it is the conclusion of many 
that nine out of ten adults in this country have 
been infected with tuberculosis. Fortunately the 
vast majority never become diseased. 
Immunity and Resistance 
When one begins to study the nature of com- 
municable diseases one soon discovers that there are 
certain animals entirely immune from, insusceptible 
to, or entirely free from communicable diseases INFECTION, IMMUNITY, RESISTANCE 
17 
which occur in man. It is also found that man is 
entirely free from, insusceptible to, or immune from 
certain diseases of animals. One of the present dif- 
ficulties in the progress of medical science is due 
to the fact that it is impossible to make any ex- 
perimental studies on many small animals because 
they are entirely immune to certain diseases. By 
immunity is meant that the individual has a power 
to resist a certain disease. The immunity may be 
racial, a family trait, or individual, and may be 
partial or complete. In the study of tuberculosis 
certain animals are found to be entirely immune to 
the disease even when large doses of bacilli are 
injected. For example, if the tubercle-bacilli of 
warm-blooded animals are introduced into the body 
of cold-blooded animals, these bacilli do not produce 
progressive disease in the cold-blooded animal, but 
they may remain alive and intact for a considerable 
time. This is real immunity which is natural. 
In the warm-blooded animals, particularly in man, 
no such complete immunity exists. It is known that 
the Jews have a lower mortality rate from tuber- 
culosis than persons of other races living under 
identical conditions. It is also known that among 
the aboriginal races of Africa the mortality is very 
high and the disease takes a very severe and acute 
course. 
A number of interesting discoveries have been 
made which give some idea of the reasons for these 
conditions. It has been known for years that in 
persons who have had tuberculous glands of the 
neck during childhood which have been completely 
cured before the age of fifteen, less than the aver- 
age amount of pulmonary tuberculosis develops 
later in life. In other words, the existence of a 
tuberculous infection in a gland has conferred upon 
the individual a certain amount of immunity. This 18 
TUBERCULOSIS 
definite statement was first made by Marfan in 
France in 1886. Robert Koch also noted a most 
remarkable fact, that if a small animal is inoculated 
with tuberculosis and several weeks later is re- 
inoculated, healing takes place much more rapidly 
at the site of the second inoculation than it did in 
the original case. As a result of the first inocula- 
tion, infection occurs not only at the site of the 
inoculation but also in the neighboring glands and 
then throughout the body, while after the second 
inoculation the entire process remains more localized. 
Therefore, it can now be said definitely that tuber- 
culous animals are more resistant to tuberculosis 
than are normal animals. 
This experiment induced Koch to make further 
studies of the products of tubercle-bacilli, particularly 
with tuberculin, with the hope that the products of 
the bacilli when inoculated into the body would 
bring about a cure of the individual who is already 
tuberculous or prevent infection where it had not 
existed before. Unfortunately these efforts have 
failed. Individuals who have been infected by tuber- 
cle-bacilli during their childhood have a relative 
immunity against the disease to the extent that the 
disease is not so likely to occur in these individuals 
unless they receive repeated doses of tubercle-bacilli 
or an extremely large dose at one time. On the 
other hand, we know that susceptible small animals 
having little immunity that have not been inoculated, 
when given a large dose become severely ill with a 
progressive type of the disease which is very com- 
monly fatal. 
As a result of the studies which have brought this 
knowledge to light, it is now believed that those 
races which for generations have been exposed to 
tubercle-bacilli, have gradually acquired a resistance 
to infection because the children in the race receive INFECTION, IMMUNITY, RESISTANCE 
19 
small infections, which are sufficient to prevent the 
development of the disease from new infections from 
without unless a later dose of the bacilli be very 
large. On the other hand, races such as the aborig- 
inal negro which have never been exposed to tuber- 
culosis, when exposed to large doses develop an 
acute and severe disease; but if the same exposure 
is experienced by the Hebrew, who has already been 
infected and partly protected, only a mildly progres- 
sive disease is brought about. In other words, a 
small amount of infection confers a certain amount 
of immunity and a complete absence of infection 
leaves the individual highly susceptible to the disease. 
It is also noticeable in certain families that for 
generations there has been no case of tuberculosis, 
but what is not known in such cases is whether 
the children have been infected during childhood 
or whether they have been entirely free from any 
infection during a period of several generations. 
It is a matter of common knowledge that tuber- 
culosis is more prevalent in early adult life than 
at any other period, and the development of the 
disease usually occurs after the individual has suf- 
fered from some acute disease or has been under- 
going hardships, privations, overwork, lack of food, 
and such other conditions as are frequently found 
among the poorer classes. It seems conclusive from 
the observations of thousands of physicians that if 
the vitality of the body is impaired by acute disease 
or hardship, the individual is likely to develop tuber- 
culosis because his resistance to the tuberculosis 
that has lain dormant in his body has been impaired. 
This resistance is nothing more or less than a diminu- 
tion of the relative immunity which that individual 
usually enjoys when in good health. As has been 
shown under the description of what happens when 
bacilli enter the body, the tubercle-bacilli become 20 
TUBERCULOSIS 
walled in by a new growth of cells, but in many 
instances the enclosed tubercle-bacilli remain for 
months or years living and virulent within the wall. 
If the resistance of the body is lowered it seems 
true that certain changes take place in the body-cells 
which permit the tubercle-bacilli to grow more 
rapidly, to bring about a destruction of the defensive 
wall, and to cause a new infection or what is called 
a reinfection. That is to say, no new bacilli need 
be brought in from outside of the individual, but 
those that are already harbored in his body are 
responsible for an extension of the infection and 
the production of a diseased condition. We may, 
therefore, say definitely that altho immunity is 
acquired by infection, good health and no additional 
doses of bacilli will prevent the disease from oc- 
curring. But if immunity and resistance are lowered 
by improper habits of life, there is every likelihood 
that the infection will spread and cause the disease 
tuberculosis. CHAPTER IV 
PULMONARY TUBERCULOSIS 
Symptoms 
THE SYMPTOMS of pulmonary tuberculosis 
are caused by the presence and growth of the 
tubercle-bacilli in the lung which bring about definite 
changes in the lung-tissues. Symptoms are also 
caused by the products of the tubercle-bacilli at the 
place of growth and the absorption of these products 
by the blood. Symptoms then are of two kinds, local 
symptoms, due to changes in the lung, and constitu- 
tional symptoms, due to the entrance of products 
from the diseased area into the blood stream. 
Local Symptoms 
As already pointed out, the tubercle-bacilli cause 
the formation of new tissue or tubercles. At first 
these tubercles are of microscopic size and as a rule 
do not cause any local symptoms, nor in the early 
stage do they cause any constitutional symptoms. 
If, in the individual already infected, the bacilli 
continue to grow and the tubercles become larger, 
there is a gradual change from infection without 
symptoms to active disease with symptoms. The 
transition from the condition of infection to the 
condition of disease is generally gradual but may be 
sudden, and the symptoms of the disease depend upon 
the way in which this takes place. 
The onset of the disease and the beginning of 
symptoms occur in a number of different ways. Tl»e 
first symptoms may be referable to the lung only, 
21 22 
TUBERCULOSIS 
or the symptoms may be those of a general disease, 
or they may be both, which is more often the case. 
COUGH 
If the symptoms are only those caused by the 
presence and growth of the tubercle-bacilli and 
tubercles in the lung, cough is the most characteristic 
symptom at the onset of the disease. Cough is pro- 
duced by irritation of the lung and is not severe at 
the onset. It is most frequent in the morning, and 
at first there may be no expectoration of sputum. 
If ulceration takes place, there is destruction of 
tubercles and the waste products brought about by 
this destruction enter into the smaller air-passages 
and are coughed up. 
There is also an increased amount of secretion due 
to a localized bronchitis in a small area of the lung 
surrounding the diseased area. As the waste prod- 
ucts collect in the area of localized bronchitis during 
the night, the expectoration is most frequent upon 
rising in the morning. Cough and expectoration are 
the two cardinal symptoms of tuberculosis of the 
lungs. 
If a tubercle develops adjacent to a blood-vessel 
and ulcerates through the wall of the blood-vessel, 
bleeding takes place-the blood is then coughed out 
from the lung and a hemorrhage or hemoptysis 
■occurs. This may be the first symptom, and it is 
such a definite sign of danger that persons who 
have a hemorrhage as the first symptom are im- 
mediately warned and most commonly seek and 
accept medical advice. More frequently hemorrhage 
does not take place until after the disease has been 
present for months and when hundreds of tubercles 
have been formed and ulceration has taken place in 
HEMORRHAGE PULMONARY TUBERCULOSIS 
23 
many places. The possibility of hemorrhage occurs 
only when tubercles develop close to blood-vessels. 
In other words, the chance of hemorrhage depends 
upon the accidental location of a tubercle near a 
blood-vessel. 
When the onset of the disease is demonstrated only 
by cough and expectoration, medical advice is fre- 
quently not sought at once because there is little 
difference between these symptoms and those of an 
ordinary bronchial cold. The possibility of tuber- 
culosis remaining undiagnosed for weeks or months 
has caused physicians and health workers to urge 
that no cold be neglected and that a person who 
has had a bronchial cold for three weeks or more 
should seek competent medical advice and have a 
physical examination of the lungs. 
Constitutional Symptoms 
If the tubercles develop slowly in the lung and 
have not yet reached the ulcerated stage there may 
be no symptoms referable to the lung, but the 
products caused by the growth of the tubercle-bacilli 
being absorbed into the blood cause definite consti- 
tutional symptoms. The commonest symptoms are 
loss of energy, a continued tired feeling, and lack 
of desire to make any effort either mental or physical. 
This latter is most noticeable in persons who have 
generally expressed a sense of well-being, and must 
not be confused by persons who have always some 
anxiety as to their physical condition and who con- 
stantly complain of "that tired feeling." Very com- 
monly there is a loss of appetite and a mild indiges- 
tion which continues over a period of weeks or 
months before other symptoms occur, and this makes 
one suspicious that tuberculosis is the cause of the 
indigestion. Loss of weight is also a common symp- 
tom which is gradual and generally not noticed until 24 
TUBERCULOSIS 
other symptoms call the patient's attention to the 
fact that he is not well; but when he is weighed, 
he notices that he has lost quite a few pounds. It 
is very common to have all three of the above symp- 
toms combined in the early stage of the disease. 
By far the commonest constitutional symptoms are 
fever and fatigue. The fever is so mild at first 
that it may not be noticed, but if the temperature 
be taken morning and afternoon it is found that 
there is a definite rise of temperature in the late 
afternoon or evening and that this occurs day after 
day. This afternoon temperature frequently rises 
to only half a degree or so above normal and the 
morning temperature is usually a little less than the 
normal morning temperature. A morning temper- 
ature by mouth of 97.50 Fahrenheit, and an evening 
temperature of 99.50 Fahrenheit would be suspicious. 
The More Common Modes of Onset 
The average patient when consulting a physician 
for the first time usually complains of a cough with 
expectoration in the morning, loss of appetite, loss 
of weight, and some afternoon fever. These symp- 
toms generally have been present for a number of 
weeks or even months before the patient seeks 
medical advice. 
Altho the above symptoms are the most common, 
other types of onset occur, which tho unusual must 
be recognized by the physician. It is not uncommon 
to find a sudden onset of cough, expectoration, high 
fever, and all the symptoms of pneumonia, and on 
first examination it is almost impossible to differen- 
tiate the disease from pneumonia. The process in 
the lung is that of tuberculosis of a pneumonic type. 
When the apparent pneumonia has been treated for 
OTHER MODES OF ONSET PULMONARY TUBERCULOSIS 
25 
several days or a week, the ordinary crisis which 
usually occurs in pneumonia does not take place, 
but there is a gradual diminution of the acute symp- 
toms and the disease then begins to take a chronic 
course. 
In other cases the onset is very similar to an 
attack of typhoid fever. The onset is gradual, the 
fever becomes higher, the cough is slight or does not 
exist, it is very difficult to secure any expectoration, 
and the patient has all the characteristic symptoms 
of a severe febrile disease. As time goes on the 
pulmonary symptoms begin to develop and become 
more pronounced and the disease may take a chronic 
course as in other severe types of the disease. In 
these two latter types of onset the amount of lung- 
tissue involved is usually large and the amount of 
damage ultimately done is great and, when the 
disease becomes chronic, it has a far graver outlook 
than if the onset had been slow. In both of these 
types there is the very grave danger of the disease 
becoming generalized throughout the body and death 
resulting from the growth of tubercles in almost 
all parts of the body. 
The lungs are composed of tissues which are very 
elastic in character and kept in a state of distention 
or expansion by atmospheric pressure. They are 
surrounded by a double layer of very thin tissue, 
known as the pleura, one of which covers the outside 
of the lung and the other lines the chest wall. 
During respiration the lungs expand and contract as 
a result of the enlargement or diminution of the 
size of the chest cavity. The enlargement of the 
chest cavity is caused by lifting the bones of the 
chest or, as is commonly said, by expanding the 
chest, and also by the contraction of the diaphragm 
PLEURISY 26 
TUBERCULOSIS 
which enlarges the chest space downwards. The 
lungs are situated in the chest, which is a closed 
cavity, the only opening being through the trachea or 
windpipe. There is no space between the two layers 
of the pleura and, as these two layers are smooth and 
moist, the pleura which covers the lung slides up 
and down against the pleura which lines the chest 
wall.1 If air or fluid enters in between these two 
layers of the pleura, the size of the chest cavity 
diminishes and the size of the lung consequently 
diminishes. If an inflammation occurs in the pleura, 
one is then said to have pleurisy. 
One of the commonest forms of inflammation 
of the pleura is caused by the growth of a tubercle 
in the lung close to the pleural covering. The 
tubercle may gradually enlarge and cause an inflam- 
mation of the pleura. The inflammation may then 
extend from the pleura lining the lung to the pleura 
lining the chest wall. When this takes place, move- 
ments of the lung in respiration will cause pain, 
and frequently when a physician makes an examina- 
tion over the area of pain and adjacent to it, certain 
abnormal sounds are heard. This condition is known 
as tuberculous pleurisy. If the condition progresses 
it is commonly associated with the pouring out or 
exudation of serum from the blood, which may 
amount to a few ounces or even to as much as 
several quarts. This will largely diminish the 
capacity of the chest and interfere with respiration, 
causing shortness of breath. The fluid pressing 
against the heart may also cause some impairment 
to the heart's action. 
If there be simply an inflammation without the 
pouring out of blood-serum it is called a dry pleurisy. 
The new inflammatory tissue becomes gradually 
1 See also "The Human Machine," by W. H. Howell, M. D., in 
the National Health Series. changed into scar-tissue and the inflammatory prod- 
ucts are removed by the white blood-cells, leaving a 
scar which causes the pleura covering the lung to 
adhere to the pleura lining the chest-wall. These 
scars are very commonly found at post-mortem 
examinations, not only in the bodies of persons who 
have died of tuberculosis, but also of other persons 
who evidently have had tuberculosis without ever 
having had symptoms other than that of an occasional 
pain in the chest. 
If an exudate or pouring out of blood-serum has 
taken place, the condition is then known as a 
pleurisy with effusion. This may last for weeks or 
even months and the fluid will gradually be absorbed. 
While this process has been going on the pleura 
covering the lungs and the pleura lining the chest- 
wall may be gradually covered with scar-tissue. 
When all fluid has disappeared these two layers of 
the pleura may adhere together, causing what is 
known as an adherent pleura and this condition will 
permanently limit the complete expansion of the 
chest on the side in which the process took place. 
PULMONARY TUBERCULOSIS 
27 
SYMPTOMS OF PLEURISY 
A mild or dry pleurisy is characterized by the 
presence of a sharp stabbing pain in the chest, usually 
accentuated during breathing in (inspiration), and 
almost always accompanied by an irritable cough 
without any expectoration. Not infrequently the 
pleurisy occurs after the symptoms of tuberculosis 
of the lungs have already shown themselves. There 
may have been a cough with expectoration caused 
by the disease in the lung, and to this cough there 
is added the pain just described. There may be a 
rise of temperature at this time and also an in- 
creased pulse-rate. 
If the pleurisy is complicated with the pouring out 28 
of serum in between the layers of the pleura in any 
quantity, the patient almost always suffers from 
shortness of breath, weakness, extreme prostration 
at times, sweating profusely after the slightest exer- 
tion, and a rapid and feeble pulse. As the fluid 
becomes absorbed, the interference with respiration 
and heart-action lessens and the patient shows a 
gradual return toward normal. If, however, the 
two layers of the pleura adhere, complete respiratory 
action is not restored on that side. In many cases, 
however, if the lung on the other side remains 
normal, there may be no serious interference with 
respiration, as the normal lung may be sufficient to 
provide enough air without the patient's realizing 
that there is anything wrong with his respiratory 
apparatus. 
TUBERCULOSIS 
If the lungs of a normal animal are removed 
from the body, they will collapse to about one-half 
the size that they had when they were normally 
situated inside of the chest cavity. This collapse is 
due to the fact that the lungs are elastic and that 
the pressure of the atmosphere is applied on the 
outside of the lungs as well as on the inside of the 
lungs through the windpipe. This collapse of the 
lung never takes place in health, but may take place 
if air or gas enters between the two layers of the 
pleura. The so-called pleural cavity, or the theoret- 
ical space between the two layers of the lung, is 
normally in a state of vacuum, so that its pressure 
is less than atmospheric pressure. If a tubercle 
situated in the lung just beneath the pleura should 
ulcerate, so that there would be a communication 
from a small air-passage within the lung to the 
pleural cavity, air would then enter the space between 
the two layers of the pleura and the lung on that side 
PNEUMOTHORAX would collapse just as if it had been removed from 
the body. When the lung collapses, it is of no value 
in respiration, and the individual has recourse only 
to the lung on the opposite side. 
Pneumothorax is a relatively rare condition and 
occurs usually in one of two ways. Occasionally 
there is a person who is in good health, but who 
has had a mild tuberculous process in the upper part 
of one lung, which has extended to the pleura, and 
there is a scar between the two layers of the pleura. 
Perhaps all this process has taken place without his 
knowledge. Then from a sudden muscular effort 
with the arms extended high above the head, and 
with a sudden forced inspiration, the scar on the 
lung may be torn in such a way that air is permitted 
to pass from one of the smaller air passages into the 
space between the two layers of the pleura. This 
condition is usually associated with a sharp pain, 
extreme shortness of breath and almost complete 
collapse, from which the patient ordinarily recovers. 
When placed at rest, the lung usually heals over 
while in the state of collapse and then gradually 
reexpands, for the air in the pleural cavity is rapidly 
absorbed and the condition becomes entirely abated. 
Very rare instances are known where this condition 
has occurred without the patient's realizing that any- 
thing unusual had happened. More commonly, how- 
ever, pneumothorax occurs in the later stages of 
tuberculosis when the lungs have become riddled 
with tubercles. By the time this condition occurs, 
the pleura is frequently adherent and hence the 
extent of the lung collapse is limited. 
When the rupture takes place and air passes into 
the pleural space, the inflammation or tuberculous 
process which exists close to the pleura extends into 
it. Pus containing tubercle-bacilli may pass through 
the tiny hole in the pleura from the lung into the 
PULMONARY TUBERCULOSIS 
29 30 
pleural space. The pleural space is then filled not 
only with air, but also with the serum from the 
blood and the micro-organisms which cause inflam- 
mation, so that the fluid becomes purulent or pus. 
When this condition occurs it is known as tuberculous 
empyema. The symptoms of this latter condition 
vary but little from that of an ordinary pneumo- 
thorax, with the exception that if there is much pus, 
the fever will take on what is known as a hectic 
type, possibly associated with chills, the temperature 
rising to 103°, 104°, or 105° Fahrenheit in the 
afternoon or evening and being subnormal in the 
morning. This particular condition rarely occurs 
except in the course of a far advanced and progres- 
sive case of tuberculosis. 
TUBERCULOSIS 
It frequently happens that when the onset of the 
disease is mild, with cough, expectoration, and slight 
fever, the disease process in the lung may subside at 
any time; the defenses of the body overcome the 
action of the tubercle-bacilli, they cease to multiply 
and, as the poisons produced by their growth diminish 
and finally cease, the constitutional and local symp- 
toms also gradually diminish and disappear. An 
"arrest" is then said to have taken place. This term 
is used in contradistinction to the word "cure" for, 
altho the patient may be apparently cured, there is 
a definite disease process in his lung, there has been 
a growth of new tissue, and there is a permanent 
scar in the lung which will persist throughout life. 
Tubercle-bacilli remain in the lung encased within 
a wall of new tissue, and these bacilli remain alive 
and virulent tho they may be dormant throughout 
life. They may also renew their activity at any 
time, so that there is always possibility of relapse. 
Arrest of Symptoms PULMONARY TUBERCULOSIS 
31 
After the onset of the disease, whether it be 
gradual or sudden, whether accompanied by marked 
local or marked constitutional symptoms or both, it 
very frequently happens that these symptoms con- 
tinue, the disease process in the lung continuing to 
develop, and a constant growth of new tubercles and 
ulceration of old ones. This condition continues 
for months and even years and is known as chronic 
pulmonary tuberculosis. The cough and expectora- 
tion continue as the most prominent local symptoms. 
There may be progressive loss of weight and constant 
fever, hemorrhages may occur from time to time 
and, accompanied with the loss of weight and fever, 
there are violent sweats which usually take place 
at night. If the process in the lung continues, there 
is more and more destruction of lung-tissue with 
cavity formation, the patient becomes more and more 
feeble, and death finally ensues from hemorrhage or 
exhaustion. 
Progressive Symptoms 
Physical Signs 
The symptoms which have just been described are 
called subjective symptoms, or those symptoms of 
which the patient is conscious. There is another 
group of symptoms known as objective symptoms, or 
those which are detected by the physician upon 
examination by the use of various methods. 
PERCUSSION 
The physician makes use of the sense of sight, 
hearing, and touch and, in addition to these three 
senses, he also makes use of the method of examina~ 
tion known as percussion. Percussion is a method 
of examination which consists of tapping the surface 
of the body to elicit a definite sound or, as it is 
called, a percussion note. This is usually performed 32 
by placing the hand flat against the chest and tapping 
with one of the fingers of the other hand lightly 
upon a finger of the hand which is flat against the 
chest-wall. This tapping elicits a definite musical 
note which varies according to the density of the 
tissue lying underneath it. 
TUBERCULOSIS 
The physician also uses an instrument known as 
the stethoscope, which is placed against the chest- 
wall and connected with the ear by means of a hollow 
tube, so that he may determine from the nature of 
the sound transmitted to the ear any changes from 
the normal sounds caused by the rush of air through 
the trachea and bronchi to the lung and also such new 
sounds as 'may be present due to the existence of 
the inflammatory process. 
AUSCULTATION 
X-RAY 
The X-ray is also used because of its value in 
detecting changes from the normal. It is known 
that with the X-ray the normal lung has a definite 
appearance, and a new growth of tissue taking place 
in the growth of tubercles or any destruction of 
lung-tissue will show changes in the shadow of an 
X-ray picture. These changes may also be seen 
when the lung is looked at through a fluoroscope, 
which is simply an apparatus which permits the eye 
to see through the lung if the X-rays are at the 
same time allowed to pass through the lung. 
The most certain method of diagnosing tuberculosis 
is the examination of the sputum in order to deter- 
mine the presence of tubercle-bacilli. This is per- 
formed by selecting from the sputum a small mass 
of material, which is spread thin on a glass slide, 
EXAMINATION OF SPUTUM PULMONARY TUBERCULOSIS 
33 
then stained in a certain way and examined under 
the microscope. 
There is a rare possibility of making an error in 
diagnosis, as the bacilli of leprosy are similar, 
but as leprosy is such a rare disease and as its 
symptoms are so different from those of tuberculosis, 
the danger of error practically does not exist. 
BLOOD TEST 
During the past few years it has been found 
helpful in the diagnosis of a certain percentage of 
cases of tuberculosis to examine the blood-serum, 
employing a serological test. This test is not gen- 
erally used, is at present of only limited value and 
of a highly technical nature, and is employed only 
in certain sanatoriums and laboratories with' the hope 
that it may become so perfected that it will be useful 
as a means of diagnosis when other tests and exam- 
inations fail. 
TUBERCULIN TEST 
The use of tuberculin, whether employed by sub- 
cutaneous injection underneath the skin, by injection 
into the skin, or by application upon a small abrasion 
on the surface of the skin, gives a definite reaction 
when tubercle-bacilli have been lodged in the body. 
At the present time tuberculin is of considerable 
value as a diagnostic test, but need not be tried in 
cases where the diagnosis may be made by other 
methods. It is useful because a positive tuberculin 
reaction is of aid in making a diagnosis of tuber- 
culosis, especially in young children where it is so 
difficult to secure sputum for examination, and in 
other cases where the tubercle-bacilli have not been 
found. It must be remembered, however, that the 
presence of a positive tuberculin test only demon- 
strates the fact that infection has taken place but it 
does not tell that disease is present. CHAPTER V 
NON-PULMONARY TUBERCULOSIS 
TUBERCULOSIS is far more common in the 
lungs than elsewhere, but when the disease 
occurs in any other part of the body it is character- 
ized by special symptoms, depending upon the situa- 
tion of the disease process. When the tubercle- 
bacilli first enter the body they have to pass through 
the lymph-nodes (erroneously called glands) and 
frequently remain lodged in these lymph-nodes with- 
out passing on to any other part of the body. If the 
bacilli cause a disease of the node it is called tuber- 
culous adenitis. If the bacilli pass on to other parts 
of the body, they most commonly become lodged in 
the lung, but they may extend by the blood-vessels 
to the meninges, the thin membranes which cover the 
brain, giving rise to the disease known as tuber- 
culous meningitis. They may enter into bones of 
the spine or joints from the blood, or they may 
extend from the lymph-nodes of the abdomen to 
the membranous lining which covers the intestines 
and cause an inflammation of this lining, known as 
the peritoneum, the inflammation of which is known 
as peritonitis. If the inflammation spreads down to 
the spinal cord, causing an inflammation of the 
membrane or meninges which cover the cord, the 
disease is known as a spinal meningitis. If the 
disease affects the spinal column, its occurrence is 
in the bony disks of the vertebrae, the bones which 
make up the spinal column. This condition is known 
as tuberculosis of the spine or Pott's disease. The 
Lymph-nodes 
34 disease may affect one of the long bones of the 
arm or leg, most commonly that part of the bone 
within or adjacent to a joint, and the disease is 
named according to the joint or bone affected. For 
example, an inflammation of the head of the femur, 
the long bone of the thigh, is known as hip-disease. 
If the disease affects one of the other joints, it is 
commonly referred to as a tuberculous joint or white 
swelling. The disease rarely affects the bones away 
from the joints, but if it does the disease is called 
tuberculous osteitis. If the small bones of the fingers 
be affected, it is called a tuberculous dactylitis. 
In all of the conditions mentioned above exactly 
the same process takes place as has been described 
in the lung. There is first a growth of tubercles, 
and if these tubercles extend so that a lining mem- 
brane of any part of the body be involved in the 
inflammation, there follows an exudate of serum 
which becomes purulent. This formation of pus, 
however, is different from pus which is ordinarily 
formed in the course of an acute inflammation. In 
the formation of an ordinary acute boil or abscess, 
one is quite familiar with the swelling, redness, and 
heat which occur during the development and before 
the formation of pus. When tubercle-bacilli are 
responsible for the formation of pus, there is usually 
less acute inflammation of the adjacent tissues and, 
as a result, there is little swelling except that pro- 
duced by the pus itself and comparatively little 
heat or redness. This relative absence of heat, swell- 
ing, and redness is so characteristic that an abscess 
caused by the tubercle-bacillus is commonly referred 
to as a cold abscess. 
NON-PULMONARY TUBERCULOSIS 
35 
Tuberculous Adenitis 
The most common site for a tuberculous process 
of the lymph-nodes to begin is in the nodes of the 36 
TUBERCULOSIS 
neck. This condition is characterized by the inflam- 
mation of one or more of these nodes and they can 
then be readily felt under the skin. One must not 
assume that every node in the neck which becomes 
enlarged is due to tuberculosis. In children from six 
to fifteen years of age an enlarged lymph-node in 
the neck is one of the most ordinary abnormal con- 
ditions found at that period of life. A cavity in a 
tooth, a gum boil, a small canker sore in the mouth, 
or an inflammation of the tonsils is very commonly 
associated with an enlargement of the lymph-node 
which drains the lymph from the particular area 
that is inflamed. If there be a tuberculous inflam- 
mation of one of these lymph-nodes, accompanied 
with pus formation, and the pus has passed out of 
the node into the adjacent tissue, the condition is 
known as a cold abscess in the neck. 
Tuberculous Adenitis of Bronchial Nodes 
In children one of the sites where tubercle-bacilli 
frequently become lodged is in the chain of lymph- 
nodes which lie in front of the spinal column at the 
place where the windpipe divides and where the 
small bronchi radiate out in a fanlike way to the 
right and left lung. As the bronchi begin to divide 
in a manner somewhat similar to the roots of the 
tree, this part of the lung is generally called the root 
of the lung, and a number of lymph-nodes are 
normally situated in between the root of either lung. 
When infection takes place in childhood, the tubercle- 
bacilli frequently set up an infection in this chain 
of lymph-nodes and the usual process of growth and 
caseation takes place, frequently followed by calci- 
fication and complete healing. Occasionally the heal- 
ing is not complete and sometimes constitutional 
symptoms are caused by the growth of bacilli. Fre- 
quently there is cough, caused by the enlargement NON-PULMONARY TUBERCULOSIS 
37 
of the lymph-nodes pressing on the root of the lung. 
Children who have this condition often present the 
aspect of a child affected with pulmonary tuber- 
culosis, but there may be no involvement of the 
lung. Such children are frequently spoken of as 
pretuberculous, altho they show evidence of infec- 
tion by the presence of the tuberculin reaction, and 
occasionally the enlarged glands can be seen by means 
of the X-ray. If such a condition continues, the 
infection may spread to the lung and pulmonary 
tuberculosis develops. The condition may become 
entirely healed. CHAPTER VI 
TREATMENT 
Pulmonary Tuberculosis 
THE MODERN treatment of tuberculosis was 
begun by Brehmer at Goerbersdorf, Germany, 
in 1849. The treatment outlined by him consisted 
of graduated exercise in the open-air for a prescribed 
number of hours a day, accompanied by a sanatorium 
regimen in providing regulated periods of rest and 
exercise, with a substantial amount of food and but 
a limited amount of medicine. Some years later 
Peter Dettweiler, who had been a patient in Breh- 
mer's sanatorium, established a second institution at 
Falkenstein, Germany, in which he made rest a much 
more important element of treatment than Brehmer 
had done. Altho Coddington in England, in the early 
part of the nineteenth century, had endeavored to 
launch the fresh-air treatment for tuberculosis, it 
was not pushed systematically until Brehmer opened 
his sanatorium in Germany. 
This method of treating tuberculosis was not com- 
menced in the United States until 1885, when the 
Adirondack Cottage Sanatorium at Saranac Lake 
was opened as a result of the efforts of the late 
Dr. Edward L. Trudeau. Dr. Trudeau had already 
been endeavoring to cure himself in the Adirondack 
wilderness for a number of years and had found 
from personal experience that rest in the open-air 
was the most satisfactory type of treatment. This 
The Sanatorium 
38 TREATMENT 
39 
was the beginning of the sanatorium movement in 
this country, which has been steadily extended so 
that there are now over 600 institutions known as 
sanatoriums, hospitals, camps, etc., which provide 
treatment for persons affected with tuberculosis. 
The results of sanatorium treatment are very suc- 
cessful and many persons are apparently entirely 
cured after three to six months of treatment. It 
has been learned that many of the patients whd were 
discharged as cured relapsed some months or years 
after they had returned to their normal occupations. 
With the information gained, the sanatorium experts 
somewhat changed their terminology and defined 
cases that were discharged from the sanatorium in 
perfect health as "apparently cured" instead of cured. 
During the last two decades there has been a 
steady increase in the amount of knowledge of the 
life history of the tubercle-bacillus and it is now 
fairly generally appreciated that when the tubercle- 
bacillus has once gained a foothold in the body, 
even tho the diseased area may be walled off and 
the tubercle-bacilli encased within a fibrous area, 
the disease is cured, but the infection remains. 
Many physicians, tuberculosis experts, representa- 
tives of voluntary health associations, and tuber- 
culosis organizations have constantly stated that 
tuberculosis is curable and if curable, why not cure 
it? This statement is a little extravagant, but in 
the main it is true and nearly all patients can for 
all practical purposes be cured provided the disease 
is recognized in time and the patient put under 
appropriate treatment. 
The treatment of tuberculosis depends on a large 
number of factors, but may be summed up in the 
statement that it consists of rest, good food, and 
Apparent Cure 40 
TUBERCULOSIS 
fresh air under the guidance of a well-trained 
physician. 
In order to understand fully what the treatment 
means, some more complete description must be given. 
The most important thing of all is to secure the 
services of a well-trained, sympathetic physician who 
fully understands how to manage patients affected 
with this disease. It is only the rare individual who 
can work out his own salvation without medical ad- 
vice. This has been done, however, and occasionally 
occurs, because some diseases are so mild in their 
character that the individual will recover without 
any guidance whatsoever. Those who endeavor to 
cure themselves by the use of knowledge obtained 
from the study of text-books or tracts published 
by various health departments and voluntary asso- 
ciations take a dangerous risk if they avoid proper 
medical supervision. 
Specific Treatment 
Ever since Koch discovered the tubercle-bacillus 
in 1882 there has been a constant quest for the 
discovery of some drug or animal product, some 
antitoxin or vaccine which would cure patients 
affected with this disease. Indeed, before the dis- 
covery of the bacillus, many attempts had been made 
to cure the disease by various methods of treatment. 
During the past thirty years efforts have been made 
to cure the disease with Koch's tuberculin and many 
other types of tuberculin, with Maragliano's serum, 
Friedmann's turtle-bacillus vaccine, and countless 
others. Efforts have been made to cure the disease 
with various drugs, with arsenical compounds, copper 
salts, various concoctions and decoctions of herbs 
and chemicals. New methods of treatment are being 
suggested daily, and we hear now of Dreyer's treat- TREATMENT 
41 
ment, Spahlinger's treatment, Nolan's treatment, and 
a host of others. 
It is a common psychological fact known to every 
practising physician that in every chronic disease 
any physician who offers any prospect of cure fills 
the patient with hope, and nearly every patient may 
persuade himself for a temporary period that he is 
improving. It is true also that in a number of such 
cases actual improvement does take place, and those 
who are expert in caring for tuberculosis sufferers 
know how important the psychological condition of 
the patient is. They know that the patient who is 
free from financial worry, free from the burden of 
his family, free from worry about the support of 
his wife and children, who has made up his mind 
that he will devote as much time to the cure as may 
be necessary, and who has the character and deter- 
mination to carry out the cure, is the individual 
who makes the best progress. The despondent, care- 
less, and reckless patient falls by the wayside and 
the cure is only rarely effected in persons of this 
type, but many persons are cured of tuberculosis 
and restored to lives of economic usefulness, or to 
other walks of life. 
Sanatorium Treatment 
Sanatorium treatment offers to the patient the best 
opportunity of acquiring the habit of living an 
orderly, well regulated existence, which is so neces- 
sary for his cure. The sanatorium offers all of the 
four factors so necessary-the skilled physician, rest, 
good food, and fresh air. 
The patient with a moderate amount of disease 
should be admitted to a receiving ward or wing of 
the sanatorium and placed at complete rest for at 
least twenty-four hours. After this a careful ex- 
amination is made, a complete history is taken, the 42 
TUBERCULOSIS 
sputum is examined, an X-ray picture is taken, and 
the sanatorium physician outlines a plan of treat- 
ment. The plan of treatment consists of determin- 
ing the amount of rest which is necessary for the 
patient. This can not be definitely stated in advance 
and the usual beginning is rest in a recumbent posi- 
tion for the full twenty-four hours of each day, as 
many hours as possible being passed in the open- 
air on a covered porch. In many sections of the 
country the climatic conditions are such that the 
patient can not remain wholly out of doors, and the 
porch is frequently not only covered but protected 
from the wind on one or two sides. In some sections 
flies and mosquitoes are such a nuisance that it is 
necessary to screen the porches, but this unfor- 
tunately reduces the free circulation of air by about 
10 per cent. 
Rest 
Rest is particularly important, for the disease 
consists of an ulcer in the lung and that is a part 
of the body which is definitely injured. Every one 
realizes that an injured part is more nearly restored 
to normal when complete rest is obtained. A broken 
leg, a smashed finger, a swollen knee, a bruised 
thigh, all heal more rapidly and with less pain when 
completely set at rest. If the body remains in a 
recumbent position with no muscular effort, respira- 
tion is reduced ten times a minute or about 15,000 
in twenty-four hours. The respirations are counted 
only with difficulty if the patient realizes that they 
are being counted. If one watches an individual 
who has been walking about or working at his 
ordinary occupation, one finds that his respirations 
are about twenty-four to the minute. If one could 
see this same individual lying quietly in his bed 
in the early morning just before he awakes, it would TREATMENT 
43 
be found that his respirations were about fourteen 
or sixteen. This is the effect of rest on the normal 
individual and it is the same on the individual who 
has pulmonary tuberculosis. Exercise, walking, and 
running increase the respirations and sometimes cause 
rapid, long, and forced respiratory movements which 
may at any time do serious damage to the ulcer in 
the lung. As the rest is continued, the ulcer shows 
a disposition to heal. The discharge from the ulcer 
begins to lessen and consequently the cough and 
expectoration lessen too. The products which cir- 
culate in the body, called toxins, come from the 
diseased area and cause fever, prostration, and loss 
of appetite. As these diminish during the healing 
of the ulcer, the temperature subsides, the appetite 
improves, and the patient begins to feel better. 
Food 
There have been many fads and fancies in the 
feeding of persons who have tuberculosis. At times 
an excessive amount of meat has been given to 
patients, and at others an excessive amount of milk 
or eggs. It must not be forgotten, however, that 
tuberculosis is a febrile disease and that during the 
febrile period patients can not eat as much or as 
hearty foods as when their temperature is normal, 
The food should be simply prepared, served in a 
manner pleasing to the patient and in such quantity 
as may be determined by the desire of the patient 
and the wisdom of the physician. 
Twenty years ago when it was realized that nearly 
every patient with tuberculosis was underweight, 
recourse was had to forced feeding and many patients 
were literally stuffed like a Strassburg goose. If 
their stomachs digested the food and it was assimi- 
lated by the body, the patient became very fat and, 
when he began to get well and to go about again, 44 
TUBERCULOSIS 
the additional weight only increased his heart action, 
made his breathing more rapid, and made him gen- 
erally uncomfortable. This discomfort was relieved 
only when he had lost weight. An individual who 
ordinarily weighs 150 pounds when in normal health 
may lose 20 or 30 pounds as a result of tuberculosis 
before he is placed under proper treatment. The 
weight which has been lost consists of a loss of 
fat and a loss of muscle. If forced feeding is begun 
and the patient gains weight while lying still in bed, 
he will gain in fat but not in muscle, and when he 
gets out of bed the ratio of fat to muscle will be 
entirely out of its proper proportion. 
Ten years ago there was a tendency on the part 
of some to feed the tuberculosis patient with an 
excess of meat. This was in accordance with the 
recommendations of Dr. Richet of Paris, who had 
followed out a number of experiments which led 
him to the conclusion that if patients ate meat three 
or four times a day they would be less likely to 
have tuberculosis. Other observers have attempted 
to prove that tuberculosis was less common in races 
which ate large quantities of meat than in those 
which had a relatively small amount of meat. This 
is now known not to be the case. The best method 
to follow is to have the diet considered as a prescrip- 
tion to be ordered by the doctor in the same way as 
rest is prescribed by him. 
Fresh Air 
Of the trinity of factors necessary for the treat- 
ment of tuberculosis, fresh air was the one which 
was first exploited. It was believed that fresh air 
alone might cure patients affected with tuberculosis. 
Patients were told to go to the country, to take a 
sea voyage, and to sleep with windows open, but 
this treatment was found to be of little value, except TREATMENT 
45 
in very occasional instances, unless it was accom- 
panied by a proper amount of food and rest. Fresh 
air, however, plays a most important part in the 
treatment of tuberculosis and has most beneficial 
effects. Fresh air improves the appetite and diges- 
tion, diminishes fever, increases oxidation from the 
skin, and has apparently other virtues which are not 
as vet fully understood. 
Drugs 
From time immemorial cod-liver oil has been 
recommended for the treatment of tuberculosis, but, 
as far as can be learned in the last decade, it has 
no special advantage in tuberculosis except that it 
supplies a high amount of vitamin which is normally 
found in other foods. It is a good nourishing food, 
but no more valuable than butter, cream, or other 
animal fats. Various drugs are commonly used in 
the treatment of pulmonary tuberculosis, but usually 
they are of the variety known as symptomatic, that 
is, medicines which are given to relieve symptoms. 
For example, drugs are given to relieve cough, pain, 
hoarseness, night sweats, and other conditions which 
occur from time to time. Drugs are given to im- 
prove the appetite, to relieve constipation, diarrhea, 
etc. 
Of the various drug-cures, none has yet stood 
the test of time, nor have results been obtained 
with any one of these so-called cures which are 
any better in the long run than the prescription of 
proper amounts of fresh air, good food, and rest. 
We may say, then, that as yet there is no* cure 
for tuberculosis that is known as a specific. There 
is no special drug or other product which will in 
a few or numerous doses cure tuberculosis. There 
are, however, large numbers of unfortunate persons, 
many of whom are in the most reduced circumstances, 46 
who are ready to grasp at the last straw and who 
pay one hundred, two hundred, or five hundred dollars 
for a new drug or series of drugs to an inexperienced 
physician with the hope that some relief may be 
obtained. Most of this money has been wasted on 
false hopes and no cure has as yet appeared. There 
are many who feel that the medical profession is 
hostile to a cure. This is not true. It is longed 
for, hoped for, and searched for, but as each new 
cure is heralded, physicians take careful account of 
what has been done before and, having been dis- 
appointed so many times, they become skeptical. 
There are specific methods of treating malaria, 
there are specific methods of treating diphtheria, 
syphilis, and several other diseases, and there are 
at least forty new cures for tuberculosis widely 
advertised each year. It can not be that all are sure 
cures, and after a careful test, which so many of 
them have received, our hopes are dashed to the 
ground once more. When a cure which gives 
promise of success does come, it will undoubtedly 
obtain little recognition at first, but when it is 
announced to the public, its use will be carefully 
explained and the production will be placed in com- 
petent hands where it will be carefully guarded. 
It will be distributed or sold to the public at a fair 
price and the individual who discovered it will 
neither ask nor seek profit from it. One can not 
refrain from praising the work and manner of 
Banting, the discoverer of insulin, especially when 
he so safeguarded its production and made sure of 
no profit to himself. 
TUBERCULOSIS 
Climate, or a change of air and scene, may offer 
advantages that are serviceable in treatment. But 
climate is not necessary for the improvement and 
Climate TREATMENT 
47 
arrest of the ordinary case of pulmonary tuber- 
culosis ; and since it usually entails considerable added 
expense it is better for the average patient to seek 
prompt attention in institutions, like sanatoriums, 
which may be available nearer home. Nevertheless, 
those patients who are able to make the change with- 
out undue financial, physical, and psychic strain will 
often hasten their recovery by seeking treatment at 
the hands of competent physicians of well managed 
sanatoriums in so-called tuberculosis climatic regions. 
Aids in Treatment 
The entrance of air into the pleural space causes 
collapse of the lung, a condition already described 
as pneumothorax. When pneumothorax takes place, 
for a temporary period the lung is completely at 
rest. 
Artificial pneumothorax is performed by thrusting 
a hollow needle through the chest wall and allowing 
a definite amount of nitrogen gas to enter into the 
pleural space very gradually; this brings about a 
complete collapse of the lung, thus giving the diseased 
organ complete rest. The gas is absorbed within a 
week and, in order to continue the rest of the lung, 
the operation has to be repeated. Many physicians 
use this treatment with varying results, altho those 
who have had the greatest experience with it and 
who have used it in properly selected patients have 
seen most happy results. It must be remembered 
that if the lung on one side is collapsed, the remain- 
ing lung must be healthy or comparatively healthy 
or else the patient will not have sufficient lung space 
for ordinary breathing. 
Artificial Pneumothorax 
Artificial pneumothorax is now used as a treatment 
in patients where the disease is limited to one side 48 
TUBERCULOSIS 
if ordinary methods of treatment are not sufficient. 
It is used to stop or control hemorrhage from the 
lung, and also in cases which are progressive and 
unilateral. The use of artificial pneumothorax is 
perfectly logical and gives rest to the lung just as 
the application of a plaster cast does to a broken 
leg. It is not particularly difficult to perform and 
is relatively free from danger. 
It is a great advantage to the patient and physician 
if the physician knows the condition of the lung prior 
to the operation, for he can then be reasonably sure 
whether or not the pleura is adherent and can know 
whether one or both lungs are affected. The opera- 
tion is frequently repeated every week, and then at 
longer intervals. Many patients may be kept in 
good health by this method. Most physicians now 
use ordinary air instead of nitrogen, for the results 
are found to be as satisfactory as when nitrogen 
is used. The amount of air injected varies from 
200 to 800 cubic centimeters. Absorption of this 
air or gas from the pleura begins at once, and the 
lung will reexpand to its normal size within varying 
limits of time. 
Operation 
In a small number of chronic cases where the 
pneumothorax can not be induced because of a 
markedly adherent pleura, or if the pneumothorax 
has been continued without relief to the symptoms 
and the disease is limited to one side, a very radical 
surgical operation is sometimes performed. It is 
possible to remove part of a number of the ribs 
and to diminish the size of the chest wall, reducing 
the size of the space available for the lung and 
making it much smaller than normal. This opera- 
tion is attended with great danger and is used only 
in extreme cases. TREATMENT 
49 
A few surgeons have also endeavored to remove 
the diseased portion of the lung by operation, but 
this is attended with such great danger that it has 
been used rarely and unless new methods are dis- 
covered for performing such an operation, it should 
not be done. 
Non-pulmonary Tuberculosis 
The treatment of any tuberculous process is car- 
ried on by using the same principles employed in 
the treatment of tuberculosis of the lungs. Rest 
for the body, rest for the diseased area, fresh air, 
and careful feeding all play a most important part. 
Here again rest is essential. If a lymph-node of the 
neck becomes diseased with tuberculosis and the node 
becomes enlarged, the patient is frequently treated 
with general measures. If the node continues to 
enlarge and ulceration takes place, with the formation 
of a cold abscess, the abscess is sometimes opened 
and may heal after months of treatment. It is a 
wiser procedure to remove entirely the diseased 
lymph-nodes before ulceration takes place and be- 
fore the formation of an abscess. 
A far better method of treatment and one which 
offers better hopes of complete cure is that devised 
by Rollier of Switzerland and consists of the ex- 
posure of the diseased part and the entire body to 
the direct rays of the sun. This treatment has only 
one disadvantage and that is that it takes a long 
period of time In disease of the joints or of the 
vertebrae of the spine, an approved method of treat- 
ment is to give the diseased area complete rest by 
means of special apparatus in the way of splints, 
braces, or plaster casts, but by far the best method 
is to compromise a little with the type of apparatus 
Sunlight Treatment 50 
TUBERCULOSIS 
used, so that a considerable amount of rest to the 
diseased part may be obtained allowing sunlight to 
be employed directly upon the diseased area. 
Rollier has developed the use of sunlight in a 
remarkable manner. The patient is placed com- 
pletely at rest and by use of braces, sand-bags, and 
other apparatus, the diseased area is given as much 
rest as possible. The patient is exposed to sunlight 
in the following manner: On the first day of treat- 
ment, the feet alone are exposed to the sun for five 
minutes. On the second day the feet are exposed 
for five minutes, then the covering is pulled up so 
that the legs are exposed for five minutes and the 
feet for an additional five minutes. Each succeed- 
ing day an additional part of the body is exposed 
for five minutes and the parts previously exposed 
have five minutes of additional exposure, so that 
in time the entire body will be exposed for a half- 
hour or more. The period of exposure is increased 
daily until the patient rests nude in the sunlight 
for several hours a day. This treatment can be 
applied in the coldest weather, provided the sunlight 
is direct and no clouds or mist interfere and provided 
the body is protected from wind. The method is 
also being employed in various parts of the United 
States with great success. 
The duration of the treatment is long, taking from 
six months to several years, but in many cases the 
joint or diseased part becomes entirely healed and 
the function of the joint entirely saved, which is 
far better than to have a stiff joint or to have had 
the joint cut out by a surgical operation. It is 
astonishing to see children, who are more commonly 
the sufferers from this type of disease than adults, 
during their convalescent period, when they play in 
the snow or skate entirely nude except for shoes 
and breech-cloth. TREATMENT 
51 
Just how the action of sunlight produces such 
a remarkable effect is not known, but no one who 
has seen the results obtained in Switzerland and 
in this country from this method of treatment can 
fail to be convinced of its enormous value. As a 
result of this treatment, many physicians are now 
using an artificial light passing through quartz in 
an endeavor to reproduce sunlight in localities where 
a smaller number of clear days occur and when 
sunlight can not be used. CHAPTER VII 
THE OUTCOME 
WHEN a patient presents himself to a physician 
for the first time and a diagnosis of tuber- 
culosis is made, it is most natural that the patient 
should ask, "What are my chances ? Shall I get well ?" 
There is no definite rule that the physician can use 
which will enable him to say positively that the 
patient will entirely recover or that he will not get 
well. The physician can say that if the patient 
has a disease which is not far advanced and if he 
will and can take the proper treatment, the probabili- 
ties of his recovery are excellent. 
The prognosis or outcome, however, depends upon 
a number of important factors. It depends very 
largely upon the temperament of the individual and 
his willingness to undergo the treatment in every 
detail. Patients who oppose every restriction and 
who constantly say, "Why can't I?" and, "Could 
I do this or that?" show their mental response to 
accepting advice. Other patients are not intelligent 
enough to see the necessity of carrying out all the 
recommendations. It has been aptly said, "No fool 
is ever cured of tuberculosis of the lungs." On the 
other hand, if the patient has character and is firmly 
convinced of the necessity of following out directions 
and persists in his attempt to be cured, a large part 
in his recovery is accomplished. After several weeks 
of observation and a study by the physician of the 
extent of the involvement of the lung, coupled with 
a study of the temperature chart and the patient's 
general condition, the physician can come to a fairly 
52 THE OUTCOME 
53 
definite conclusion as to whether or not the patient 
will get well. There are always accidents in a 
chronic disease of this type, however, and nothing 
that is said can be positive. The prognosis, altho 
usually hopeful, may change as a result of new con- 
ditions which affect the condition of the patient. 
But there are several things which are perfectly 
definite. If the patient does not enjoy sufficient 
financial ability to undertake his cure with great 
thoroughness, his chances for recovery are immedi- 
ately limited; and further, if the length of cure is 
shortened and the patient returns to his former 
occupation too soon, the prognosis is less satisfactory. 
In order to give a satisfactory result, it should be 
assumed that the patient is able to undertake a cure 
for the length of time necessary, and this length of 
time depends upon the condition of the patient and 
the progress which he makes and can not be definitely 
stated in advance. Further, if the patient is able to 
return to his work gradually or after his cure is able 
to take up a new occupation that is less onerous his 
chances of complete recovery are improved. 
Results of Sanatorium Treatment 
Patients treated in sanatoriums who have been ad- 
mitted during the incipient stage become apparently 
cured or arrested in 75 per cent, of the cases. If 
the disease is moderately advanced when the treat- 
ment is begun a cure is effected in 63 per cent, of 
cases. If the disease has progressed and is far ad- 
vanced there are even then 25 per cent, of recoveries. 
Results as favorable as these are obtained in many 
sanatoriums both public and private,-even in the 
heart of New York City. 
Every one who becomes affected with the disease 
in this country should have the advantage of sana- 
torium treatment; the outlook is far more favorable 
than was dreamed of forty years ago. CHAPTER VIII 
PREVENTION OF TUBERCULOSIS 
WHENEVER a physician discovers that a 
patient has tuberculosis it is then his specific 
duty to prevent the patient from becoming a danger 
to others. The responsibility also rests very largely 
upon the patient and his family. The following 
procedure must be carried out in detail: The patient 
must always cover his nose and mouth while cough- 
ing or sneezing. His hands and face must always 
be kept cleansed. His washing utensils, dishes, and 
other implements employed in eating should not be 
used by any one else and should be thoroughly 
disinfected after use. All expectoration should be 
received in cloths, gauze, or paper, and placed in 
a bag which can be burned. The patient may also 
use a sputum cup or flask in which there has been 
placed a 5 per cent solution of carbolic acid or other 
suitable disinfectant prescribed by the physician. 
The cup or flask must be emptied regularly and 
disinfected before using again. Paper or paste- 
board sputum cups may be employed provided they 
can be completely destroyed by burning. The pa- 
tient's nurse, attendant, or the member of the family 
who cares for him should not come in too close or 
prolonged contact with the patient and should wash 
the hands thoroughly after nursing, feeding, or 
handling the patient in any way. The clothing and 
bed linen should be washed separately and should 
first be soaked in a disinfectant solution and kept 
Specific Measures : Disinfection 
54 PREVENTION OF TUBERCULOSIS 
55 
in a carbolized sheet or sack before being sent to the 
laundry. 
One of the most difficult situations is that which 
occurs when the mother is tuberculous and there 
are small children in the family. Such a parent 
should be instructed not to kiss any infant, nor 
fondle it nor hold it in her arms. If the child is 
too small to be cared for by other members of the 
family, the child should be nursed outside of the 
family. It is particularly important that mothers 
who have developed tuberculosis and who have a 
nursing infant should discontinue the nursing of 
the child. 
Isolation 
The patient should sleep in a bed by himself and 
preferably in a separate room if he has to be treated 
at home. Detailed precautions of this kind are now 
printed and published by nearly every health depart- 
ment and voluntary health association and may be 
secured on application by any physician or individual 
in need of them. 
General Measures 
The methods employed for the prevention of 
tuberculosis have been developed as a result of the 
scientific knowledge of the tubercle-bacillus, of the 
disease tuberculosis, and of the methods by which 
tubercle-bacilli are conveyed from one individual to 
another. The long painstaking researches that have 
been carried on by many scientific workers in dif- 
ferent parts of the world have added to our knowl- 
edge, so that one can now make certain definite 
statements about tuberculosis which are now used 
as the underlying principles in the prevention of 
tuberculosis, as follows: 
Tuberculosis is caused by the tubercle-bacillus. 56 
It is not hereditary. 
Tuberculosis is a communicable disease. 
Tuberculous infection usually occurs during child- 
hood and less commonly during adult life. 
Infection takes place usually through the respira- 
tory and digestive tract. 
Infection may take place during the first year of 
life, and the proportion of persons infected in civil- 
ized communities increases with each year of life. 
The percentage of children already infected at 
the age of 15 varies from 50 to 90 per cent. 
Infection does not mean disease. Nearly all adults 
are infected but few become diseased. 
Human tuberculosis may be caused by bacilli 
usually of human origin, much less frequently of the 
bovine type. 
Tuberculous infection may develop commonly into 
tuberculous disease without the individual so diseased 
becoming conscious of it. 
Spontaneous cures occasionally take place. 
Tuberculosis is curable, and the earlier treatment 
is undertaken the greater is the probability of the 
diseased process becoming arrested. 
In general it may be stated that the methods em- 
ployed for the eradication of tuberculosis have been 
curative, preventive, and educational. In describing 
each of the methods used, it will be found difficult 
to limit certain activities employed to any one of 
the three divisions, for the curative methods are 
sometimes preventive, the preventive sometimes cura- 
tive, and educational activities are carried on when 
either of the two are employed. 
TUBERCULOSIS 
In 1883, Dr. Trudeau of Saranac Lake treated 
patients having tuberculosis by the sanatorium 
method, and in 1885 the Adirondack Cottage Sana- 
The Curative Methods: Sanatorium PREVENTION OF TUBERCULOSIS 
57 
torium was opened. This was the initial step in 
the curative method of prevention which is also 
distinctly educational and preventive. During the 
stay in the sanatorium, the patient is taught not only 
how to care for himself but how to prevent infecting 
other members of his family and his associates and 
is instructed in the proper method of disposing of 
his expectoration. In addition, lectures, illustrated 
talks, and pamphlets are frequently given to patients 
in sanatoriums so that many of them acquire some 
definite knowledge about the disease and its methods 
of prevention. 
The sanatorium is distinctly preventive in that it 
provides isolation facilities for the patient in an 
active stage of the disease when he is discharging 
millions of tubercle-bacilli, thereby removing him 
from his family and associates and diminishing the 
likelihood of infection and disease among them. One 
should remember that tuberculosis is not catching 
in the ordinary sense, but that persons who are un- 
taught as to the care of their sputum may, by their 
intimate association with other members of the 
family, constantly expose them to repeated receptions 
of tubercle-bacilli, not only infecting them, but also 
bringing about a diseased condition by the repeated 
introduction of large doses of bacilli. 
Hospitals 
It is true that the earlier that treatment is com- 
menced, the better the prognosis, but many unfor- 
tunate people, largely of the working class, do not 
have their condition diagnosed until the disease is 
well advanced and there is little hope of a complete 
arrest of their condition. Such patients continue 
for years, securing occasional treatment from hos- 
pital, dispensary, or private physician, and, when 
their disease becomes more severe and they are no 58 
TUBERCULOSIS 
longer able to work, they have recourse to the public 
hospitals. 
Forty years ago one found in the general wards 
of our larger hospitals many advanced and hopeless 
cases of tuberculosis. Some health officials and 
physicians interested in the tuberculosis problem 
brought about the provision, by municipalities or 
private agencies, of special pavilions or hospitals for 
the care of these sufferers. Such patients are now 
treated in special tuberculosis hospitals and are 
sometimes restored to partial or complete working 
capacity. 
The hospital is, therefore, curative, but it is also 
largely preventive in that it isolates patients in the 
advanced stages of the disease when they are fre- 
quently less able properly to dispose of their sputum 
or other discharges and when they are far more of 
a menace to their family and associates than in the 
earlier stages of tuberculosis. 
Hospitals have also been provided in many sections 
for the treatment of non-pulmonary tuberculosis. 
This type of institution is more commonly found in 
Europe than in this country and, altho it is primarily 
curative, it does have some preventive value from 
the sociological point of view. That is, it relieves 
the adult members of the family of the burden of 
care caused in the household by the presence of a 
chronic invalid who requires a great deal of atten- 
tion. The child or adult as a patient is also taught 
to adapt himself to the well-ordered routine of the 
sanatorium life. 
The Dispensary 
Prior to the discovery of the tubercle-bacillus the 
impoverished consumptives, who were not so ill as 
to be continually in a hospital, were treated in the 
out-patient departments of general hospitals or in PREVENTION OF TUBERCULOSIS 
59 
dispensaries. They mingled with other indigent pa- 
tients and were commonly treated with cough-syrups, 
sedatives, and cod-liver oil. In the latter part of 
the nineteenth century some beginnings were made 
to separate these tubercular patients from other pa- 
tients in the dispensary by the organization of a 
special class or clinic of tubercular patients in the 
same manner as special classes of patients had been 
organized for women's diseases, children's diseases, 
and so on. These classes were almost always or- 
ganized by some physician who was particularly 
interested in the subject and who saw that the 
patients were receiving inadequate treatment. As 
time went on, more and more classes of this type 
were organized and also special dispensaries for 
diseases of the chest or for tuberculosis alone. In 
the larger cities a number of classes or dispensaries 
of this nature were organized. The physician in 
charge endeavored to secure a more adequate history 
of the patient and to record it upon special charts 
prepared for the purpose. He made a more careful 
physical examination and recorded it together with 
the patient's pulse, temperature, and weight. 
This dispensary class served several distinct pur- 
poses. First, it acted as a center for sending patients 
to hospitals or sanatoriums; second, it acted as an 
educational center where it was possible to advise 
patients more definitely as to the measures to be 
taken to prevent the infection of others; and third, 
it gave the physician an opportunity to secure special 
relief measures for patients who were in need. Phy- 
sicians who were rendering their services free soon 
found it impossible to continue to do everything that 
should be done for the patients without practically 
giving their entire time to the work. A trained 
nurse was then employed who engaged in all the 
work necessary to secure the admission of patients to 60 
hospitals and sanatoriums, assisted the physician in 
the dispensary in the taking and recording of the 
patient's weight, pulse, and temperature, and in the 
examination, and secured relief for those who were 
needy. In addition, a new function developed for 
the trained nurse which consisted in the making of 
visits to the homes of the patients and there instruct- 
ing them and other members of their family as to the 
dangers of the disease, the methods of preventing 
infection, and the care necessary for the patient. 
It was possible in some instances to secure outdoor 
sleeping porches, facilities on roof or in yard, or 
window tents, so that the patients could secure rest 
in the open air as much as possible. 
TUBERCULOSIS 
Community Measures 
The addition of the trained nurse to this type of 
work was the inauguration of the public-health nurs- 
ing movement, which has become such a large factor 
in the reduction of disease and mortality. The tuber- 
culosis-dispensary or tuberculosis-class, altho pri- 
marily curative in its constitution, has become a most 
useful educational and preventive measure. It is 
educational, because of the information given directly 
to the patient by the physician and to the patient and 
members of his family by the nurse, as well as by 
the distribution of educational leaflets and printed 
directions on the precautions to be taken by the 
patient and members of his family. The home visits 
by the nurse are perhaps the most important single 
measure employed in the prevention of tuberculosis. 
The Tuberculosis-nurse 
First employed in the dispensary or tuberculosis- 
class for aiding the physician, the nurse has played 
a more and more important part in disseminating 
information among the families which she visits. PREVENTION OF TUBERCULOSIS 
61 
Whether the nurse be employed by the health depart- 
ment, the visiting nursing association, the voluntary 
health agency, or the factory, her function is similar 
and it has been described in connection with the 
dispensary. 
The Preventorium 
The preventorium is an institution designed pri- 
marily for the care of children suspected of having 
tuberculosis or members of families in which tuber- 
culosis exists. Such children are commonly spoken 
of as "contacts," that is, children who are living 
in a home with a tuberculosis patient. The preven- 
torium was designed also for the care of children 
who were undernourished or underweight for their 
age and in whom no definite evidence of disease 
could be detected. The preventorium is, in fact, 
a year-round country boarding-school for children, 
with the expectation that more emphasis is placed 
upon the physical care of the children, and that 
children who are evidently ill are not admitted. 
Open-air School 
The open-air school also is an important factor in 
the prevention of tuberculosis. It consists of a 
school-building so devised that the classrooms are 
out of doors, but shelter is provided from wind and 
weather. Children admitted to these schools are of 
the same type as those admitted to the preventorium, 
if preventorium care is not available. 
In our large crowded cities it has not been found 
feasible to establish open-air schools, and a com- 
promise has been made by the creation of open-air 
classrooms in some of the schools. In both the open- 
air school and open-air class additional clothing is 
frequently provided by philanthropic societies or by 
the school authorities themselves, and facilities are 62 
TUBERCULOSIS 
provided for a rest-period either upon a cot, couch, 
reclining chair, or even a mattress on the floor, and 
for the giving of a mid-morning lunch. The children 
are under the supervision of a special teacher and 
trained nurse and every effort is made to build up 
their health. Observations are also made as to their 
gain in weight and strength. 
Popular Education 
Before the discovery of the tubercle-bacillus in 
1882, very little was known about the disease tuber- 
culosis by the masses of the population, who learned 
of the disease only when a member of the family 
became ill with "consumption." When the diagnosis 
of this disease was known to the family, all looked 
forward to a fatal ending and to the fact that the 
disease would be a menace to the family and its 
descendants for years to come. During the past 
thirty years increasing efforts have been made to 
instruct the mass of the population on the subject, so 
that the average family would have sufficient infor- 
mation to seek an early diagnosis and secure proper 
treatment. Advice has been given by tract, pam- 
phlet, leaflet, spoken word, lantern slide, film, news- 
paper article, magazine, special journals, and, in 
fact, by every means devised for spreading informa- 
tion throughout all parts of the country to reach 
every citizen. For the benefit of the foreign popula- 
tion much of this literature and information has 
been prepared in various languages. The population 
has been considered by groups and special efforts 
have been made to increase the knowledge of physi- 
cians, medical students, hospital authorities, and par- 
ticularly to inform patients and their families, and 
to advise employers of labor and members of labor 
unions and various other special groups of the 
population. PREVENTION OF TUBERCULOSIS 
63 
This educational propaganda has been carried on 
by the official health agencies, by the federal, State, 
and local governments, by various social-welfare 
agencies, and in particular by the National Tuber- 
culosis Association and its affiliated associations. 
Official Measures: The Health Department 
The tuberculosis-nurse is the most important in- 
dividual factor in the prevention of tuberculosis, and 
a large number are employed by health departments. 
Yet the supervisory machinery used by the health 
department for the prevention and control of tuber- 
culosis stands first in efficacy in the prevention of 
the disease. Certain definite procedures are now 
carried out by every properly organized health de- 
partment. It is not necessary to describe at length 
the machinery of this department nor the desirability 
of its being officered by well-trained, reliable physi- 
cians and aids who are earnest in their efforts to 
control and prevent disease and who are adequately 
remunerated for their services. In the larger State 
and city health departments, there is usually a special 
bureau for the handling of tubercular cases, but in 
the smaller health departments these cases are usually 
handled by either the health officer himself or by 
one of his assistants. 
The chief function of the health-department work 
is the execution of the laws enacted by the State and 
the local ordinances which may have been enacted 
by the health department. This legislation in our 
field is usually of the following type: legislation 
providing for the care of tubercular patients in 
sanatoriums, hospitals, or other institutions created 
by the State or the local administrations; legislation 
which permits the construction and maintenance of 
dispensaries and the employment of tuberculosis- 
nurses-in other words, legislation which directs the 64 
TUBERCULOSIS 
health department to provide curative measures for 
tubercular patients. Legislation for the prevention 
of tuberculosis has been enacted in most of the States 
by requiring physicians to report their tubercular 
patients. Legislation which prohibits expectoration 
in the street and public places has also been enacted. 
In many States the boards of health have power 
to enact local ordinances which have the force of 
law. These ordinances relate largely to the ma- 
chinery or method to be employed in the prevention 
of different diseases. Since tuberculosis is a com- 
municable disease and is a danger to the public, many 
State laws and local ordinances require the health 
departments to offer free treatment to any individual 
regardless of his financial situation in the same 
manner as they would compel isolation or offer free 
treatment to other more acute types of communicable 
disease. Nearly every health department now pro- 
vides facilities for the laboratory diagnosis of sputum 
which may be sent by physicians to the laboratory 
where an examination of the sputum is made free 
of charge.1 
Supervision 
The theory of the supervision of tuberculosis by 
health departments is that the health department 
shall be notified of the presence of a tubercular case, 
that instructions shall be given to this individual by 
the health department and to the physician attending 
such patient, that treatment shall be provided for the 
patient if he has no family physician, and that the 
health department shall receive notification upon 
the removal or death of the patient. It is further 
the duty of the department to see that sanitary pre- 
cautions are taken by the patient, whether in the 
1 See also "Community Health,'' by D, B. Armstrong M D 
in the National Health Series. 81 " PREVENTION OF TUBERCULOSIS 
65 
home, the hospital, or outside of either, to see that 
cleansing, disinfection, or renovation is performed 
after the removal or death of the patient before other 
persons live in the premises vacated by the patient, 
to receive notification of the discharge of the patient 
from hospital, sanatorium, or other institution-in 
other words, to maintain a supervision of the patient 
during his entire life and to provide facilities for 
his care when that may be necessary. Unfortunately, 
the public is not as yet educated to the necessity of 
this supervision. In many places it is resisted, for 
there is an unnecessary fear of danger to others by 
close association with an individual who has or has 
had tuberculosis, and health departments are not as 
yet adequately staffed to provide such supervision 
for all tubercular patients. CHAPTER IX 
RELATION OF THE STANDARD OF LIVING 
TO TUBERCULOSIS 
Influence of Poverty on Death-rate 
IT HAS been recognized since the inception of 
any activity for the prevention of tuberculosis 
that those general conditions of life summed up in 
the term "standard of living" play a most important 
part in the tuberculosis-problem. It has been a 
matter of common observation for generations that 
tuberculosis was more prevalent in the slum than 
in the palace, and that where large families were 
congregated together in small quarters with the 
resulting overcrowding, there was usually an in- 
sufficient income, overwork, worry, and privation, 
whereas good health was far more common where 
the reverse was the case. 
In 1903, the Committee on Tuberculosis of the 
Charity Organization Society of New York City 
published a "Handbook on the Prevention of Con- 
sumption." In this handbook great stress was placed 
upon the evil influence of bad housing and lowered 
standards of living. Since the inception of the anti- 
tuberculosis campaign, ever-y effort has been made to 
improve the standard of living of the laboring 
classes. Individuals who have been leaders at one 
time or another in the antituberculosis movement 
have also been leaders in the movement for better 
housing, shorter hours of work, better wages, and, in 
general, for an increase in the standard of living. 
This phase of the antituberculosis movement has 
been carried on very largely by the lay social worker 
66 STANDARD OF LIVING 
67 
to whose attention has been brought the daily knowl- 
edge of dependent families in which there were one 
or more cases of tuberculosis. One medical writer 
has referred to tuberculosis as "a disease of the 
masses." 
One became accustomed, when studying mortality 
figures, to note that in a large city the annual death- 
rate from tuberculosis was 250 to 100,000 living 
population. Little thought was given to the distri- 
bution of these deaths in various parts of the city 
and no real study of this subject was made until that 
by Drolet of the New York Tuberculosis Associa- 
tion in 1920. This study covered the borough of 
Manhattan of the City of New York, comprising a 
population of two millions and covering 219 sanitary 
areas, most of which varied in population from eight 
thousand to fifteen thousand. The differences in the 
death-rates in these sanitary areas were most aston- 
ishing. The study showed that in 25 sanitary dis- 
tricts, there was a death-rate of over 400 per 100,000, 
and that in 44 sanitary districts the death-rate was 
under 75. No intensive investigation is necessary 
to convince oneself that in the areas which showed 
a death rate of over 400 (running in some places up 
to over 1,000) there were marked economic or racial 
conditions which provided a very low standard of 
living, and that in the areas where the death-rate 
was under 75, the economic and racial conditions 
were most favorable. 
From the chart accompanying the survey one notes 
that the favorable areas are in the highest-class resi- 
dential districts near Central Park and along River- 
side Drive, and that the highest death-rates occur 
in the most populous and poorest districts. There 
is a notable exception, however; for in the lower 
East side, a very congested area of the city where 
the standards of living are low, there are two sanitary 68 
TUBERCULOSIS 
areas with an extremely low death-rate. This entire 
section is largely populated by Hebrews in whom 
there is an apparent racial immunity to tuberculosis. 
Guilfoy of the New York Health Department in 
a similar series of charts has shown that tuber- 
culosis is not the exception in varying death-rates, 
that similar variations occur in almost these identical 
areas for pneumonia, measles, scarlet fever, and 
Bright's disease. Does not a high standard of living 
mean a great many more things than a bed with 
at least 60 square feet of floor space, 600 cubic feet 
of air, at least 2,500 calories of nutritious food, 
and at least 8 hours of rest a day? It means far 
more in the favored areas, for there we have in 
addition to this minimum standard of living, oppor- 
tunities for healthful recreation, shorter hours of 
work-as a rule not exceeding 7 out of the 24- 
fairly long annual vacations, freedom from economic 
worries, opportunity to wear appropriate clothing 
and change it if wet, the best of medical advice and 
nursing care, and above all the intelligence which 
is so necessary to enable people to earn an income 
sufficient to enjoy a high standard of living.1 
It is definitely true that tuberculosis is far more 
common among people who maintain a low standard 
of living than among those who maintain a high 
standard. Does this not mean also that where a 
high standard is maintained, the possibilities of in- 
fection are largely diminished? Children play in 
a nursery where adults do not expectorate on the 
floor. Children who live in the tenements play on 
the floor or on the streets which are constantly 
soiled with expectoration which may contain tuber- 
cle-bacilli. Children and adults living on a high 
standard also have separate beds and rarely sleep 
1 See also "Personal Hygiene," by A. J. McLaughlin, M.D., in 
the National Health Series. with more than two in a room. At the slightest 
illness of adult or child, isolation is attained at 
once before it is instituted by the physician, who 
is usually called at the first moment of discomfort. 
Quite the reverse is true among people living on 
a low standard where three, four, five, or more 
persons live in the same room and may sleep in 
the same bed, perhaps in their clothes, and with no 
facilities for isolation. A physician is rarely called 
until the patient is severely ill, and if the disease is 
found communicable there is no suitable isolation 
except that which may be maintained at the city 
isolation hospital. 
STANDARD OF LIVING 
69 
Effects of Nutrition 
During and after the Great War, there was a 
marked increase in the death-rates from tuberculosis 
in those countries where the normal food-supply was 
diminished. As food became scarce death-rates went 
up, and when food became plentiful the death-rates 
soon began to come down. These changes were so 
marked that there is undoubtedly a definite relation- 
ship between the amount of food-supply in a country 
and the amount of tuberculosis. There were un- 
doubtedly other forces at work, but the food factor 
was the most important in causing this increased 
amount of tuberculosis. CHAPTER X 
THE ANTITUBERCULOSIS CAMPAIGN 
A NUMBER of antituberculosis measures have 
been introduced which not only have a bearing 
on tuberculosis but on other public-health problems. 
The pasteurization of milk supplies was urged to 
prevent tuberculosis in childhood. This had a defi- 
nite bearing on the diarrheal diseases of infancy 
and certain communicable diseases. The physical 
examination of all school-children was urged in order 
to detect early cases of tuberculosis. It was soon 
found that there were many abnormal conditions 
which needed attention and the physical examination 
of school-children was found to be more of a general 
public-health problem than a specific tuberculosis- 
problem. In some quarters it was urged that school- 
lunches be provided for school-children in order to 
increase their resistance against tuberculosis, and 
it was found that many children were undernourished 
from causes which had no relation to tuberculosis. 
Through the antituberculosis work, the public- 
health nurse has become one of the most useful and 
popular agencies in the modern public-health move- 
ment, and here again an activity which was designed 
primarily for combating tuberculosis became part 
of a generalized public-health function. The open- 
air school and the open-air class were designed 
primarily to benefit such children as were exposed 
to tuberculosis or who were supposed to be in a 
pretuberculous stage. It has since been found that 
children affected with many other weaknesses or 
abnormalities were much benefited by having their 
70 THE ANTITUBERCULOSIS CAMPAIGN 
71 
schooling in the open air. So here again the tuber- 
culosis movement became a part of a general-health 
movement. 
In more recent years it has been felt that the 
chief hope of the future lay in the possibilities of 
educating the child on the subject of tuberculosis 
so that he would be trained to live in such a manner 
as to prevent him from developing tuberculosis. 
Here again it has been found impossible to divorce 
the subject of tuberculosis from general health-train- 
ing and there has sprung up throughout the entire 
country an extremely popular movement for the 
training of children in the formation of health 
habits. 
The most important and useful work of McCollum 
and others on nutrition has stimulated a deep interest 
in the subject of undernourishment or malnutrition 
in children. The results of the investigations, 
coupled with the war-nutrition experience, has stimu- 
lated the formation of special groups of children into 
what is known as nutrition classes. These classes 
are handled in a way comparable to a tuberculosis 
class in a dispensary, that is, by careful examination 
and record, and home visits. Large numbers of 
children are said to be undernourished and the 
results of intensive treatment of small groups of un- 
dernourished children by this class method have 
given remarkable results, as evidenced by their gain 
in weight and general improvement. 
This antituberculosis work has been brought about, 
first, through the effective leadership of a small 
group of individuals who have been firmly convinced 
that tuberculosis is a menace to civilization and 
that, if considered as a communicable disease and its 
dangers made known to the public at large, appro- 
priate methods would be taken which would ulti- 
mately eradicate the disease. These leaders in the 72 
antituberculosis movement have sometimes been 
identified with health departments and sometimes 
have had no direct relation with the official health 
authorities. They have been physicians and laymen, 
physicians in charge of sanatoriums, in hospitals, and 
in general practise, laymen who have been associated 
with social-welfare agencies or who have seen the 
ravages of tuberculosis in their own families. Many 
of the steps mentioned have been taken by health 
departments entirely independent of lay support and 
in opposition to the views of the medical profession 
at large. 
TUBERCULOSIS 
A small group of these leaders discussed the 
tuberculosis problem in the early part of this century 
and believed it useful to organize private associations 
for the purpose of informing the public and stimulat- 
ing and supporting the official authorities for the 
control of the disease. The first association organ- 
ized was the result of the efforts of Dr. Lawrence 
F. Flick of Philadelphia, who organized the Penn- 
sylvania Tuberculosis Society in 1892. The next 
association was organized in 1902 by Dr. Hermann 
M. Biggs and others, and was known as the Tuber- 
culosis Committee of the Charity Organization So- 
ciety of the City of New York. Other local asso- 
ciations were organized during the next few years. 
In 1904, at a meeting of an important representa- 
tive group held in Baltimore, the chairman, Dr. 
William H. Welch, appointed a committee to discuss 
the organization of a national tuberculosis associa- 
tion. On March 28, 1904, the following resolution 
was passed by this committee: "RESOLVED, That 
we here assembled do now organize ourselves into 
a United States Society for the Study and Preven- 
tion of Tuberculosis." In June, 1904, the Associa- 
Leadership in the Movement THE ANTITUBERCULOSIS CAMPAIGN 
73 
tion was organized, with Dr. Edward L. Trudeau as 
President and Dr. William Osler and Dr. Hermann 
M. Biggs as Vice-presidents. From this time for- 
ward the antituberculosis activities in the United 
States have been advanced through the efforts of 
this Association, now known as the National Tuber- 
culosis Association, which has caused the organiza- 
tion, either directly or indirectly, of nearly all of the 
48 State associations and of the 1,300 or more local 
associations. 
The creation of all the institutions and the de- 
velopment of the official antituberculosis work car- 
ried on by health departments is not due to any one 
movement alone. There has been marked progress 
during the last twenty years in all phases of public- 
health activity, and the antituberculosis associations 
have played a large part in the expansion of these 
activities and have, without a shadow of a doubt, had 
a most marked influence in the development of gen- 
eral public-health work. 
Results of the Antituberculosis Campaign 
What are the results of all this activity, and the 
results of the expenditure of large sums of money 
for the maintenance of institutions, for the relief 
of tuberculosis sufferers and their families in their 
homes, for the study of tuberculosis in laboratories, 
for the propaganda work which has been maintained, 
and for the salaries of official and non-official workers 
in this field? In our modern complex social organ- 
ization it is very difficult to specify definite causes 
and definite results. Many of us are apt to assume 
that because such and such a thing was done at one 
period and something else occurred thereafter, the 
first was the direct cause of the second. One should 
be sure of his ground when possible and should 
remember that post hoc propter hoc is not always 74 
TUBERCULOSIS 
true. One can, however, state the facts in regard 
to the tuberculosis-problem and point out the various 
steps that have been taken to diminish tuberculosis 
and then point to the amount of disease and death 
which existed forty years ago and the amount of 
disease and the death-rates of today. One can not 
assume that the handling of the tuberculosis problem 
as a communicable disease and the increased standard 
of living are either one the direct cause of the 
diminution which has taken place in tuberculosis. 
Neither can one specifically say that the two are 
the sole causes-but the facts are strikingly sig- 
nificant. 
Diminution in Death-rate 
What was the extent of tuberculosis twenty- 
three years ago and what is the situation to-day? 
The death-rate from tuberculosis in the United 
States in the year 1900 was 201 per 100,000, 
and during the years 1900 to 1921 there has been a 
constant decline in the mortality rate from tuber- 
culosis. The last published figures for 1921 were 
99 deaths per 100,000 living inhabitants. It has 
been assumed for years that there were at least five 
living cases of tuberculosis for each annual death 
and it has been shown by some observers, notably 
by Armstrong at Framingham, that there are at least 
ten living cases of tuberculosis in a community to 
each annual death from this disease. This means 
that in the year 1900 when the mortality rate was 
201 per 100,000 there were 152,760 deaths and 
1,527,000 living cases, or 2 per cent of the entire 
population, actively affected with tuberculosis at 
some period of the year. At the present time, with 
a death-rate of approximately 100, there are 105,000 
deaths annually in the United States, and on this 
proportion it may be assumed that there are over THE ANTITUBERCULOSIS CAMPAIGN 
75 
1,000,000 persons in the United States affected with 
tuberculosis, which is active at some period of the 
year, or less than i per cent. If the rates which 
obtained in 1900 had continued, there would be 
to-day over 2,000,000 cases and over 200,000 deaths 
annually. It is only by figures such as these that 
one can obtain a definite idea that tuberculosis as 
a problem has not yet been solved. When one con- 
siders that there are 66,000 available beds in hospitals 
and sanatoriums, we know that the vast majority 
of patients, seriously ill or in a stage permitting 
complete arrest, do not receive either hospital or 
sanatorium care. 
The fall in the mortality is more significant in 
our larger cities than it is in the country as a whole, 
for the diminution in mortality in the rural districts 
has been more gradual. In New York City, how- 
ever, the death-rate has been constantly declining 
since 1900, and the mortality has been reduced from 
280 per 100,000 to 103 per 100,000 in 1921. In 
nearly every city a similar diminution has been noted. 
A certain number of enthusiastic health workers 
have stated that this marked diminution in mortality 
is the result of the active antituberculosis campaign 
which has been carried on in various parts of the 
country with more or less intensity and to the efforts 
of the antituberculosis workers and official health 
agencies. There are others who view the subject 
solely from the point of view of evidence and state 
that the death-rate from tuberculosis had been dimin- 
ished in various parts of the world prior to the 
efforts of official and voluntary health agencies, and 
that their continued diminution was due to unknown 
causes. Both of these views are extreme. There 
is no doubt but that with the increasing intelligence 
of the mass of the people, an opportunity for main- 
taining a higher standard of living would have 76 
TUBERCULOSIS 
occurred without any conscious effort to diminish 
tuberculosis and that this increased intelligence and 
increased standard of living would undoubtedly have 
played a part in diminishing tuberculosis mortality. 
During the past thirty years, there has been a deter- 
mined and conscious effort to diminish the total 
amount of tubercle-bacilli in the civilized world, an 
effort to isolate and educate large numbers of per- 
sons affected with tuberculosis, and to educate many 
who might be menaced with the disease, and this 
effort has contributed largely to the splendid results 
obtained. 
Causes of This Diminution 
There are undoubtedly definite factors which have 
produced a diminution in this disease and without 
attempting to place them in their order of relative 
importance, they can be stated as follows: 
Isolation of patients in the advanced stage of the 
disease; 
Education of patients in institutions or attending dis- 
pensaries, and of private physicians in the method of 
preventing the disease; 
The destruction of sputum containing tubercle-bacilli 
or the disposition of sputum in such places that will less 
readily infect others; 
The dissemination of information to adults on the 
nature of tuberculosis and its methods of prevention; 
The health instruction given to children and their 
training in health habits. CHAPTER XI 
THE IDEAL TO BE OBTAINED 
TO ERADICATE tuberculosis completely from 
the country it will be necessary for each indi- 
vidual or head of the family to be sufficiently in- 
formed on the subject of tuberculosis as to seek 
competent medical advice as soon as symptoms sus- 
picious of the disease occur. It will be necessary 
for physicians to be sufficiently well-trained as to 
diagnose properly and treat accurately such patients. 
It will be necessary to provide a sufficient number 
of hospital or sanatorium beds for those that require 
this type of treatment and a sufficient number of 
properly trained nurses to supervise patients who 
must be treated in their homes. Employers of labor 
should be advised of the importance of employing 
persons who have had tuberculosis for a shorter day 
than that required for the normal individual. Em- 
ployees should appreciate that there is no danger 
in associating with a patient who has had tuber- 
culosis, provided the former patient and employees 
are both familiar with the precautions necessary to 
prevent the spread of the disease. All children must 
be trained so that they may acquire health habits. 
If the general public, physicians, and nurses are 
sufficiently well-informed as to the need of early 
diagnosis, the importance of early treatment, and 
the necessity of complete supervision, there is no 
reason why tuberculosis should not be completely 
eradicated from the human race. The results al- 
ready obtained give much promise, and those who 
are active in carrying on the work are most optimistic 
77 78 
in their belief that death-rates will constantly di- 
minish and the number of persons diseased will 
become fewen and fewer so that in a few decades 
tuberculosis will no longer be as it has been and 
still is in many countries the captain of the agents 
of death. 
TUBERCULOSIS