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Arnold C. (Arnold Carl) Klebs.

Tuberculosis; a treatise by American authors on its etiology, pathology, frequency, semeiology, diagnosis, prognosis, prevention and treatment online

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man, and teacher. The industries thus far established or tried are



SANITATION AT HOME 481

gardening, jmultry-raising, leather work, diet kitchen, sewing and
mending, and an exchange for the sale of articles made by invalids at
their homes. Mrs. William E. D. Scott is the superintendent. The
writer of the article above referred to is Curator of the Department of
Ornithology at Princeton University, and is himself an enforced resi-
dent at Saranac Lake. At the end of nine months he had so far recov-
ered his health as to Ije able to direct actively much of the outdoor work
planned by the organization which is especially devoted at present to
truck-gardening and poultry-raising.

In Pennsylvania arrangements are being made by the Department
of Health and Charities to send a score of tuberculous patients from
the Philadelphia General Hospital to the City Tract at Byberry farm.
The change is to be in the nature of an experiment, and if it proves
beneficial a greater number of consumptive patients will be removed
to Byberry.

Sanitation at Home. — The sanitation of the home and its equipment
to prevent tuberculosis is, of course, of vital interest to the phthisiolo-
gist. The model tenement home should give to its tenants light rooms,
good ventilation, perfect plumbing, proper heating facilities, and reason-
able security from fire.

To make the air in homes as fresh, pure, and sanitary as possible
is comparatively easy in summer. The windows and doors can be left
open so as to make the air inside as fresh as that outside. The greatest
difficulty is experienced in winter. Yet physicians should not fail to
urge those in their care to renew the air at least several times a day
b}' opening the windows and doors for a few minutes. Against the
fear of night air — that nightmare of our ancestors — we should be par-
ticularly emphatic.

When there is a tuberculous invalid in the famil}' or one strongly
predisposed to the disease, and the family is in moderate circumstances,
or for some other reason the patient must be treated at home, the
ingenuity of the practitioner will be taxed to the utmost by his desire
to install the sanatorium treatment. In the Appendix (\'ll) there
will be seen a number of illustrations, such as sleeping shacks, sleeping
verandas, etc. The poorer the people the more difficult is the problem.
If the consumptive sufferer is obliged to sleep in the room which serves
as a living room for the rest of the family, there will be naturally strong
objections in winter to having the window open day and night. It is
for this reason that I devised an arrangement which I call a window
tent. A brief description may help the general practitioner to have a
window tent manufactured if the device cannot be procured in his local-
ity, or if some one in the family has ingenuity and mechanical skill
enough to make one.
32



482 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS

Window Tent for the Open-air Treatment at Home. — The window
tent is an awning which, instead of being placed outside of the window,
is attached to the inside of the room. It is so constructed that the air
from the room cannot enter or mix with the air in the tent. The
patient lying on the bed, which is placed parallel with the window, has




Fig. 137. — Window Tent in Use. Note celluloid window. (S. A. Knopf.)

his head and slioulders resting in the tent. By following the description
closely you will see that the ventilation is as nearly perfect as can be
produced with so cheap a device. The tent is placed in the lower half
of an American window, but it does not quite fill the lower half of
the frame; a space of about three inches is left for the escape of the
warm air in the room. By lowering the window the space can be re-
duced to one inch or less, according to need. On extremely cold and
windy nights there need not be left any open space at all above the
window frame. The patient's breath will rise to the top of the tent,
the form of which aids in the ventilation. The tent is constructed of
a series of four frames, made of Bessemer rod suital)ly formed and fur-
nished with hinged terminals, the hinges operating on a stout hinge
pin at each end with suitable circular washers to insure independent
and easy action in folding the same, the Bessemer rod being hardened
to make a stiff rigid frame to insure its maintaining the original form.
The frame is covered with extra-thick yacht sail twill, properly fitted,
and having elongated ends to admit of their beins tucked in under



WINDOW TENT FOR THE OPEN-AIR TREATMENT AT HOME 483

and around the bedding to prevent the cold air from entering the room.
The patient enters the bed, and then the tent is lowered over him. Or
with the aid of a cord and a little pulley attached to the upper portion
of the window, he can manipulate the lowering and raising of the tent
himself. Shutters or Venetian blinds, whether they are attached on the
inside or on the outside of the window, can be utilized in conjunction
with the window tent as a screen to intercept the gaze of the neigh-
bors, and in stormy weather as a protection. The bed can be placed
by the window to suit the patient's preference for sleeping on his right
or left side, so that he has the air most of the time in his face.

Another advantage of the window tent is that it will not attract
attention from the outside. The bed being placed alongside of the




Fig. 138.— Window Tknt Raised, Whi:n Not in Use. (S. A. Knopf.)



window will be convenient for the majority of tlie poor who have small
rooms. If, however, the bed must be placed at a right angle to the
window, this can be arranged as well. A piece of transparent celluloid
is placed in the middle portion of the tent to serve as an observation
window for the nurse or members of the family to watch the patient
if this is necessary. It also serves to make the patient feel less out-
doors and more in contact with his family. He can, if he desires, see
what is going on in the room. If the window tent must be placed at



484 Pl^BLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS



a right angle to the window, the o1jser\ation glass can he put in on the
side (see Figs. 137 to 140).

It goes without saying that, as a rule, patients should not smoke;
when, in exceptional cases, this can be allowed, the danger of the cellu-
loid window becoming ignited must be impressed upon them and the
greatest caution urged. The writer prefers celluloid to ordinary glass
for tliis jmrpose, l)ecause it can easily
assume tlie vaulted form of the rest of
the tent, and thus even the slightest
possiI)ility of an air-pocket formation
is avoided.



T:



f



Srl _v J*=





Fici. I'.'M. — Window Tknt. \'ie\v I'nua out-
side. (8. A. Knopf.)



Fig. 140. — Diagram Showing Ven-
tilation OF Window Tent.



If it is necessary to raise the bed to tlie height of the window sill,
it can be done with little expense. If the bed is of iron a few addi-
tional inches of iron piping can be attached to the legs by any plumV)er
or one handy with tools ; raising a wooden bed can be accomplished with
equal facility. If the window tent is to serve the patient only during
the night, the tent can be piilled up and the bed moved away from
the window during the day and the window closed. Or the tent can
be taken from the hooks and put out of the way.

The window tent will, of course, be of greatest value to the consump-
tive sufferer in winter. If he is feverish, or his stay in bed is advisable,
he can spend his entire time in the window tent. If the people are
poor, and the room where the consumptive sufferer lies serves as living
room for the other members of the family, the fact that the well mem-



WINDOW TENT FOR THE OPEN-AIU TREATMENT AT HOME 485

bers need not shiver and yet the patient can take his open-air treatment,
is of vital importance in many respects. While the room will not be
quite as warm as if the window was entirely closed, it will be much
warmer than if there was no tent in front of the open window. Laying
aside the economic advantages to a poor family when not being o])liged
to heat more than one room, the patient feels that lie does not deprive
his loved ones of comfort and warmth, and that lie is less a burden
and hindrance to their happiness. The other members of the family,
on the other hand, feel that they can give the patient all the air he
needs, and that he himself need not suffer for their comfort.

In winter the patient's jjed must be covered with a sufficient number
of blankets to assure his absolute comfort and warmth throughout the
night. Still, this covering should not be so heavy as to press down upon
the body and make the patient feel uncomfortable or tire him. The
tightly woven blanket is a better protection than the loosely woven one.
To the poor Avliose disposal of blankets is, alas ! often very limited, it

may be valuable advice to tell them
to put several layers of newspapers
between the coverings. Outdoor
Life (December, 1905) recommends
to have a dozen layers sewed be-
tAveen two layers of flannel. This
will certainly make a cheaj?, light,





Figs. 141 and 142.— Woolen Hoods for Outdook Sleeping.

and warm covering. In extremely cold weatlier the patient, while
sleeping in the window tent, should wear a sweater and protect his
head and ears with a wo(den cap, sliawl, or woolen hchiiet (see Figs.
141 and 14:3).

Some patients will complain that the bright light awakens them too
early in the morning, and that they have difTicuHy in going to sleep



486 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCTtLOSIS

again. In such instances I counsel the patient to have some light
weight hut dark-colored material (such as hlack lisle thread hose) to
put over his eyes. This usually suthces to obviate the inconvenience
caused hy the bright light.

In the Appendix (VII) there will also be found a number of
devices (tents, half-tents, reclining chairs, etc.) to facilitate the rest
cure outdoors during the day in the homes of the poor. When there is
no garden, no veranda, no roof, which can be utilized for outdoor sleep-
ing, the window tent can also be put into service for the rest cure during
the day. The lied is moved away and the reclining chair is put in its
place. The latter can be raised to the necessary height by wooden
blocks or a platform, and with the aid of blankets and comforters the
air from the room can be excluded, and the patient being in front of
the open window breathes only outdoor air.

Dry Air and the Danger from Overheated Dwellings. — Many Ameri-
can dwellings and public buildings are heated altogether too much. A
temperature of from 65° F. to G8° F. should be sufficient, especially
when care is taken that the heat produced by the furnace is not too
dry. The excessively dry atmos2:)here in winter in many public buildings
and in many city and country homes often gives rise to nasal catarrhs,
a condition which everybody, but especially those suffering from pulmo-
nary diseases, or prone to them, should be anxious to avoid. Besides
keeping the water pan in the furnace constantly filled, there should be
in the sitting room and sleeping rooms humidifying arrangements.

The humidifier consists of a wooden or metallic box placed with its
open side over or before the register. Layers of felt are suspended
between two metallic basins containing water; the upper one is the
smaller and is placed immediately under the cover of the humidifier,
the larger one below. By capillary attraction these layers of felt are
kept constantly moist, and the heated air coming from the furnace
passing over them is rendered more humid.

More simple evaporating devices, however, such as a vessel filled
with water and a cloth suspended above it touching the water so as to
produce capillary attraction, will answer the purpose of rendering the
atmosphere sufficiently humid.

Experience has proved that we can be perfectly comfortable in a
temperature of 65° F., and even a little lower, provided that the relative
percentage of moisture is sixty. If this moisture falls to thirty or to
twenty per cent, then the dry throat, dry nose, and dry skin are in
evidence. A single direct reading hygrometer (Fig. 42), while not over-
accurate, will answer for all practical purposes.

Danger from Dry Sweeping. — Dust must, next to the bacilli, be con-
sidered the greatest enemy to the tuberculous invalid or to the indi-



COMMON HOUSE FLY AS A PROPACJATOR OF TUBERCULOSIS 487

vidiial predisposed to the disease, for we know that even dust free from
pathogenic microorganisms, when inhaled frequently or for a long time,
will irritate the respirator}' tract and make it more susceptil)le to the
invasion of the tubercle bacillus and other microorganisms.

There is pul)lishcd an excellent little leaflet in four different lan-
guages which the Tul)erculosis Committee of the Charity Organization
Society and also the Health Department have distributed at large. It
shows how the danger arising from dusting and sweeping in the home
may be reduced to a minimum. These simple and comprehensive rules
were suggested to our committee by Prof. T. Mitchell Prudden, of
Columbia University.

The most sanitary and ideal method of cleaning any room is, of
course, the vacuum-cleaning method, which, it is to be hoped, will some
day be cheap enough to be more generally available. For schools, fac-
tories, stores, and public buildings this method should be made ol^li-
gatory.

To sweep unsprinkled streets and raise clouds of dust should be
considered a municipal crime. No sidewalks or streets should be swept
M'ithout having been thoroughly sprinkled. Surface street-car com-
panies should be compelled to sprinkle their tracks at regular intervals
in hot and dusty Aveather. This is done in several cities by cars spe-
cially devised for that purpose. Its universal adoption is an urgent
necessity.

The Common House Fly as a Propagator of Tuberculosis. — An im-
portant factor in the spread of tuberculosis is generally omitted in all
leaflets on the subject — that is, the common house fly. It would seem
that an item showing the danger of this insect as a distributor of bacilli
should be inserted. The abdominal cavities of flies caught in the rooms
of consumptives often contain the living tubercle bacilli, so also do the
fly specks scraped from the walls and windows in rooms where con-
sumptives live and particularly where their sputum receptacles do not
have any covers. The danger from these infected insects is twofold.
They die and crumble to dust, which contains the bacilli, and the
microorganisms may thus enter the system through the respiratory
tract; or the fly may infect some article of food with its feet or excre-
ment, whence the bacilli contained in the deposit iind their way into the
alimentary tract of man or animal. It is for this reason that we should
insist that all sputum receptacles should have covers and never be
allowed lo remain open.

The fly, however, may not only be a distrilmtor of pathogenic germs,
])articularly of tubercle bacilli, but it is inimical by its very presence in
the sick room. By its interference with sleep in the early morning hours
it unquestionably exerts a lowering etfect on the vitality of the tuber-



488 PITBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS

culous invalid. Thus, to any of the circulars on the prevention of tuber-
culosis one might advantageously add a paragraph relative to the de-
struction of the house fly, or it may be even better, after the example
of the New York Board of Health, to distribute a separate circular to
that effect. 1 copy here the circular relating to this subject recently
issued by the Health Department :

Keep the flies away from the sick, especially those ill with contagious
diseases. Kill every fly that strays into the sick room. His body is cov-
ered Avith disease germs.

Do not allow decaying material of any sort to accumulate on or near
your premises.

All refuse which tends in any way to fermentation, such as bedding,
straw, paper waste, and vegetable matter, should be disposed of or cov-
ered with lime or kerosene oil.

Keep all receptacles for garbage carefully covered and the cans
cleaned or sprinkled with lime or oil.

Keep all stable manure in vault or pit screened or sprinkled with lime
or kerosene or other cheap preparation.

See that your sewerage system is in good order, that it does not leak,
and is up to date and not exposed to flies.

Pour kerosene into the drains.

Cover food after a meal ; burn or bury table refuse.

Screen all food exposed for sale.

Screen all windows and doors, especially the kitchen and dining room.

Burn pyrethrum powder in the house to kill the flies.

Don't forget that if you see flies their breeding place is near-by filth.
It may be behind the door, under the table, or in the cuspidor. If there
is no dirt and filth there will be no flies.

Prevention of Tuberculosis in the School Child. — In the prevention
of tuberculosis school hygiene is most important. The writer has en-
deavored to point out the great responsibility which we all have, par-
ticularly the medical profession, in preventing tuberculosis among the
children attending the public schools. If the child has an hereditary pre-
disposition to disease l)ecause one or both of his parents has had tuber-
culosis or syphilis, been afflicted with marked nervous or mental dis-
order, or addicted to alcoholism, the strain of school life not infrequently
suffices to bring out or develop the hereditary taint.

If the home environments of the child are such that it receives either
not enough or insufficiently nutritious food, does not get enough sleep
or must sleep in an ill-ventilated room, is insufficiently clad and his
bodily hygiene generally neglected, or if, as happens too often, it must
contribute by its " child labor '' toward the support of the family, we
have additional predisposing factors to tuberculosis.



PREVENTION OF TUBERCULOSIS IN THE SCHOOL CHILD 489

As a remedy for existing conditions, the writer suggests that : First,
the necessity of giving the child more years to play ; second, more hours
of sleep throughout its school term and the abolition of " home studies " ;
third, the training of teachers in the diagnosis of diseases, especially in
the objective symptoms of early tuberculosis, to a sufficient extent to
facilitate the work of the school physician; fourth, small enough classes
to enable the teacher to come in close contact with the individual pupil,
and classes for the mentally defective and backward; fifth, the abolition
of child labor, not only in factory, workshop, and in stores, but also at
home; and sixth, the arranging of the curriculum in all schools so that
the mental development is not pushed to the detriment of the physical
welfare of tlie child.

Furthermore to be suggested is the teaching of rational hygiene —
physical, mental, and moral — including the teaching of the prevention
of tuberculosis, venereal diseases, and alcoholism, to school children
according to their age and understanding, by the regular teacher or
special teacher or the school physician.

School authorities should inaugurate a thorough course of instruc-
tion of school girls, the future wives and mothers of the nation, com-
prising sanitary and practical housekeeping, including, of course, plain
and economic cooking and the art of serving a plain meal appetizingly.

The writer also advises the building, equipment, care, and cleaning
of the schoolhouses so as to assure the best possible sanitary conditions
for teachers and children and the making of large playgrounds or roof
gardens and swimming tanks and baths as indispensable equipments in
every school.

Proper breathing exercises, such, for example, as illustrated in Figs.
143 to 146, and outdoor singing, recitation, etc., when weather per-
mits, should prove l)eneficiai, and, whenever possible, instruction in an
adjacent school farm or school gardens might form a part of the cur-
riculum.

The following respiratory exercises have, because of their simplicity,
been found most efficacious in the experience of the author:

In front of the open window or out of doors assume the position of
the military " attention," heels together, body erect, and hands on the
sides. With the mouth closed take a deep inspiration (that is, breathe in
all the air possible through the nose), and while doing so raise the arms
to a horizontal position; remain thus, holding the air inhaled from three
to five seconds, and while exhaling (breathing out) bring the arms down
to the original position. This act of exhalation, or expiration, should be
a little more rapid than the act of inspiration. When the first exercise
is thoroughly mastered and has been practiced for several days, one may
begin with the second exercise, which is like the first, except that the
33



490 PITBLIC MEASURES IN THE PROPHYLAXIS OF TITBERCULOSIS

upward movement of the arms is continued until the hands meet over
the head.

The accompanying: ilhistration shows the positions which are to be
taken during these two exercises. Take the same military i)osition of
" attention," and then stretch the arms out as in the act of swinnning,
the backs of the hands touching each other. During the inspiration move
the arms outward until they finally meet behind the back. Remain in
this position a few seconds, retaining the air, and during exhalation bring
the arms forward again. This somewhat difficidt exercise can be facili-
tated and be made more eifective by rising on the toes during the act of
inhalation, and descending during the act of expiration.

When out of doors one cainuit always take these exercises with the
movement of the arms without attracting attention; under such condi-
tions raise the shoulders, making a rotary backward movement during



yKi





Fig. 14.3. — First and Second Breath-
ing Exercise.



Fig.



144. — Third Breathing
Exercise.



the act of inhaling; remain in this position, holding the breath for a few
seconds, and then exhale while moving the shoulders forward and down-
ward, assuming again the normal position. This exercise (Fig. 145) can
be easily taken while walking, sitting, or riding in the open air.

Young girls and boys, especially those who are predisposed to con-
sumption, often acquire a habit of stooping. To overcome this the fol-



PREVENTION OF TUBERCrLOSIS IN THE SCHOOL CHILD 491

lowing exercise (Fig. 146) is to be recommended: The child makes his
best eflfort to stand straight, places his hands on his hips with the thumbs
in front, and then bends slowly backward as far as he can during the act



•::'^..;-





5c -; J



Fig. 145. — Breathing Exercise with
Rolling of Shoulders.



Fig. 146. — Exercise for Children in
THE Habit of Stooping. (Knopf
prize essay.)



of inhaling. He remains in this position for a few seconds, while holding
the breath, and then rises again, somewhat more rapidly, during the act
of exhalation.



Enough school physicians, especially trained for the work and suf-
ficiently remunerated, should be attached to every public school to assure
the exclusion of cliildren afflicted with contagious and communicable
diseases, or otlicr ])hysica] defects, including bad teeth, with a view of
curing or correcting the disease or infirmity tlii'ougli either private or
public initiative.

Tuberculous teachers sliould not be employed in public schools, but
if they have contracted tuberculosis in the performance of duty, it is
the duty of the municipality to provide for them until their earning
capacity is again established.

Tlie establishment of municipal seaside or country school sanatoria



492 PUBLIC MEASURES IN THE PROPHYLAXIS OF TUBERCULOSIS

for tuberculous children wliore some of tlie tiil)erculous teachers might
also be employed profitably is an urgent necessity.

It would also be wise to add a sufficient number of trained nurses
as school nurses, whose duty should be: first, to aid the school physi-
cian in his work ; second, to visit the homes of the physically, morally,
or mentally defective children, in order to learn if home conditions
alone are not responsible for the defects in the child. The writer is
convinced that hy such judicious cooperation of teacher, physician, nurse,
and parents, and, if the case demands it, by the help of an organized
charity society, many of the underlying causes of the child's troubles
can be lastingly remedied.

Substantial school lunches should be furnished by the numicij^al-



Online LibraryArnold C. (Arnold Carl) KlebsTuberculosis; a treatise by American authors on its etiology, pathology, frequency, semeiology, diagnosis, prognosis, prevention and treatment → online text (page 52 of 97)