at once and set aside until cleansed in the manner to be described for all linen. In the absence of suitable material upon which to gather the droplet emanations from the mouth while coughing, the patient should be instructed to hold the hand before the lips and wash it at once. The lips should be carefully wiped with paper napkins or gauze, although in some cases preference is given to washing with a mild disinfecting solution. In this event the advantage accrues not so much from the nature of the solution, as from the thoroughness of cleansing. No handkerchief, gauze, or cloth should be used more than once for wiping the lips.

As a rule, the consumptive should be advised to dispense with his beard, especially if at all luxuriant. Nothing is more unsightly or unclean than an overhanging growth upon the upper lip of pulmonary invalids, unless it is the time-honored chin-whisker of our countrymen upon which may adhere particles of bacilli-laden sputum. If objection be made to the removal of the beard, it at least should be cropped very closely.

A proper receptacle for the sputum is of the utmost importance. It is essential that the expectoration should not be permitted to dry exposed to the air of the room, nor to soil by accident any article for which it was not intended. It should be deposited, without going astray, in earthen cups partly filled with water, in paper spit-cups, or upon pieces of gauze. Old-fashioned cuspidors upon the floor are an abomination not to be tolerated. In all instances the patient should deposit the sputum with the cup or other receptacle held closely to the mouth, in order to avoid scattering the agents of infection. Earthen cups used for this purpose should be cylindric in shape and provided with a cover. It is important that some means be taken to conceal the unsightly expectoration and prevent the entrance of flies, thus avoiding consequent distribution of bacilli to articles of food, as has been described. Under no circumstances should there be used hand cuspidors with an inclined upper surface terminating in a small aperture at the center, as it is inevitable that particles of adherent sputum will become dried upon the presenting upper portion. Caution should be exercised to prevent the retention of sputum in a similar manner upon the sides or edges of earthen cylindric cups. If paper spit-cups are used, they should be destroyed by fire, and if these are contained within a square tin box, the latter should be boiled daily. If pieces of cheese-cloth or gauze are employed, they should be folded immediately after expectoration, and deposited temporarily in a proper receptacle, as has been explained, and subsequently burned. If an ordinary earthen cup is used as a receptacle for the sputum, it is important that it should have a handle and be partly filled with water. It is unnecessary to employ disinfectants, provided proper attention is given to emptying and refilling the cup at frequent intervals. If a receptacle of this sort is used, the primary essential is that the sputum should be kept moist and covered. In cities with modern sewerage facilities the cup may be emptied into the water-closet. In other cases the sputum should either be boiled or exposed to a strong phenol solution for several hours.

An elaborate method for the sterilization of tuberculous sputum has been described by Kirkland and Patterson. The sputum is poured into an iron vessel, which is provided with a movable lid and has at the bottom

two steam jets which, in operation, give a circular motion to the contents. After the sputum has been emptied into the iron receptacle and the lid screwed down, the steam is introduced through the jets at the bottom to a pressure of fifteen pounds. After the sputum has boiled for twenty minutes it is allowed to cool, and is then drained into the sewer by the opening of a valve at the bottom of the sterilizer. The sputum-cups are cleaned in a somewhat similar manner. They are first suspended by their handles upon a series of horizontal brass tubes, which form the essential feature of a cage which, in turn, is lowered into the iron tank. Into this are admitted water and steam, the boiling being permitted for twenty minutes. The advantages of this method appear to be marked economy of time, greater safety in the handling of the cups, and more thoroughness than if washed by hand.

It is of the utmost importance that proper provision be made for the cleansing and sterilization of the linen. In the later stages of consumption, when the patient is completely bedridden, the danger of soiling the linen with infected sputum becomes exceedingly great on account of the physical exhaustion. In many cases the intellect is impaired more or less and the patient is totally unable to appreciate his status as a source of danger to others. The responsibility for a proper hygiene of the sick-room then devolves entirely upon the attendant. At such a time it is better that the sputum should be deposited upon pieces of cheese-cloth or gauze, rather than in sputum-cups, as these are often upset if permitted in the hands of the patient. The paramount consideration relates to the observance of the utmost cleanliness as regards the clothing, hands of the invalid, bed-clothes, floor, and rugs. The hands of the attendant, as well as the patient, should be kept absolutely clean at all hazards. All articles of soiled linen which are not to be destroyed, should be brought into immediate contact with a 5 per cent. solution of phenol or immersed for several hours in a solution of corrosive sublimate and subsequently boiled. The solution may be made by dissolving a dram each of corrosive sublimate and ammonium muriate in a gallon of water contained within a wooden bowl or tub. This solution may also be used for washing floors, walls, or wooden furniture. In institutions sterilization. plants are essential for a proper cleansing of the linen.

The furniture of the sick-room should be as simple as possible. Draperies, lace curtains, velvet or plush furniture, and all articles likely to retain dust should be excluded. It is desirable to clean the room, if possible, only when the patient is out-of-doors. Care should be taken not to dust with feather-dusters or to sweep vigorously with a dry broom. The rugs should be cleaned in the open air, and dusting should be performed only with a moist cloth. There should be no carpet in the room occupied by a consumptive.

It is properly one of the prerogatives of health officials to supervise effective methods of disinfection of apartments, after the death or removal of the consumptive. Much has been written of late concerning the necessity of disinfecting such rooms and the contained furniture at public expense. The movement relative to the destruction or disinfection of all articles with which the invalid has come in contact has extended sufficiently to inspire on the part of certain students and educators an advocacy of cremation. It is well in this connection to call attention to the fact that the administrative control of tuberculosis pertains far

more to the supervision of the consumptive, and his immediate environment while he is yet alive, and disseminating innumerable agents of injection, than to the disposal of his body after the potent source of danger has ceased to exist. As a matter of fact, an insistence upon strict precautionary measures relating to personal cleanliness and the hygiene of the sick-room during life is of infinitely more importance than the disinfection of apartments and the destruction of their contained articles after death. It would appear, however, that both the profession and the public are educated more or less to a belief in the wisdom of rigid disinfection of apartments occupied by consumptives. Frequently, however, no particular concern is manifested as to their immediate presence in the family for prolonged periods. Disinfection of apartments by no means is to be deprecated, but the thought is suggested that in some instances the importance of this procedure is exaggerated. As suggested by Chapin, disinfection should not be regarded as an expiatory atonement for previous unsanitary sins. It is particularly to be recommended in crowded tenements exhibiting a sad deficiency of sunlight or fresh air, and occupied by the ignorant, impoverished, and sometimes the vicious. Disinfection, when done at all, should be practised in a most thorough manner, and may be performed by the burning of sulphur or formaldehyd. Formaldehyd disinfection is the more modern, and probably the more efficient, method. The key-holes, window-cracks, fire-places, door apertures, and all other crevices should be tightly sealed. Articles of clothing or bedding should be spread or suspended in the room in order that the disinfection may be as thorough as possible.

The most convenient manner of formaldehyd disinfection results from the use of the generator. As commonly employed, however, the formaldehyd is sprinkled upon a sheet and suspended upon a clothesline. There should be used one pint of formaldehyd to every 1000 cubic feet of air, and the room tightly closed for at least twelve hours in order to make fumigation as thorough as possible. Much of the clothing, bedding, and sometimes the rugs may be disinfected. by placing in a steam sterilizer. If sulphur is used, it should be placed in an iron vessel, which in turn is put into a tub partly filled with water. The iron kettle should stand upon bricks placed in the bottom of the tub. About three pounds of powdered sulphur should be used for every 1000 cubic feet of air. After the sulphur has been ignited, the room should be tightly closed, and remain unopened for from ten to twelve hours. If sulphur candles are employed, there is considerable danger that the disinfection will be incomplete unless several candles are burned at the same time in a small room. The walls, window-frames, and other wooden portions of the room should be thoroughly washed with the disinfecting solution previously described.

Further considerations relating to the care of the consumptive, the hygiene of the room, and the importance of detailed instructions in the interests of the invalid will be discussed in connection with the following subdivision.

CHAPTER LXXXV

THE EXTENSION OF MATERIAL AID ACCORDING TO THE VARYING NEEDS AND REQUIREMENTS OF DIFFERING CLASSES

AN organized effort toward the suppression of consumption, to be effective, must take cognizance of the obligation imposed upon society to render, when needed, substantial assistance to sufferers from the disease. The movement for the restriction of tuberculosis must not be permitted to assume the characteristics of a "crusade" against the individual consumptive, but rather against the conditions which make possible the existence of the scourge. There must be a campaign against tuberculosis rather than the tuberculous. Both for the attainment of the best results in prophylaxis and for humanitarian reasons the attitude of society, as directed largely by the medical profession, must not partake of oppression and persecution. Arbitrary measures are demanded only by the exigencies of unusual cases. Upon the other hand, the predominating spirit actuating all attempts of administrative control should be that of benignancy, supervisory helpfulness, and material aid.

The first appeal for assistance arises from the great mass of needy consumptives who are confined to their homes. To such a class, instructions as to the sanitary disposal of sputum and the hygiene of the room are of but slight value unless means are provided to permit their proper execution. In other words, practical aid to the ignorant and impoverished constitute an essential factor in the general scheme of supervision surely no less important than the distribution of educational leaflets. and the periodic visits of nurses and inspectresses. The benefits derived as a result of the visiting nurses' association and similar organizations, though manifold, can be greatly augmented by the disbursement, under their direction, of sputum-cups, gauze, disinfectants, or other material used for the purposes of prevention. The cost is utterly insignificant in comparison with the results to be obtained, and the same is true of the expense necessary to supply deficiencies in the way of food or clothing in individual cases. At least fresh eggs and milk should be freely furnished to the very poor. By this means not only are there afforded additional opportunities for the restoration of working power and subsequent maintenance of families, but also greater assurances of compliance with precautionary rules. Among the destitute the probability of faithful coöperation on the part of invalid or family is much enhanced if there are sustained relations of mutual reciprocity. The advanced consumptive who, in ignorance and poverty, is destined to succumb to prolonged illness at home represents by all odds the greatest source of danger as regards the transmission of the disease to others. Assuredly no investment can yield a more substantial return than the extension of material aid to such a class, in the hope of thereby diminishing the possibilities of contagion.

Assistance to these people should also include the distribution of needful articles of clothing and such medicines as are demanded under the sanction of the visiting nurse or other official representatives. Provision should be made for the proper cleansing of rooms and cloth

ing, the cost of frequent scrubbings of the floor and washing of the linen being defrayed at public expense.

Not the least important province of the nurse or inspectress in the interest of the patient is a supervision of the immediate environment. Although often a matter of tedious detail, the advantages of a proper attention to the surroundings are almost incalculable. An intelligent and resourceful inspection of apartments often affords means for an out-of-door existence which would at first be considered as impossible of attainment. Recourse may be taken to back porches, roofs of tenement houses, tents, and improvised aëraria, by means of which simple contrivances the invalid is permitted to partake of the benefits of fresh air and sunshine. If the patient is unable to stay out-of-doors, the mere supervision of the sick-room is sometimes fraught with important benefits. The selection of a room containing the greatest facilities for ventilation, and with a sunny exposure, falls entirely within the scope of visiting supervision, as does even the arrangement of the furniture, the situation of the bed near an open window, the adjustment of temperature, and the regulation of the amount and character of bedcovering. Attention to the foregoing considerations involves but slight expense, while a devotion to detail adds immeasurably to the material comfort of the sufferer and insures, as a rule, conformity to precautionary instructions. An important advantage of systematic periodic visitation is the opportunity permitted to acquire accurate data as to the sanitary conditions and the probable dangers of infection to others. Upon this evidence may be based any action leading to the forcible removal of the patient to special institutions.

INSTITUTIONS FOR CONSUMPTIVES

From the aspect of prophylaxis, institutional care and supervision are demanded by three fairly distinct classes of pulmonary invalids: (a) The hopelessly ill and impoverished.

(b) The vicious, who refuse to conform to established rules.

(c) The consumptive poor, who, with suitable assistance, offer a reasonable prospect of recovery.

No inclusion is made of the non-indigent incipient class, for whom especially sanatorium provision has been provided. Without the slightest reflection upon the usefulness of institutions open only to patients with slight infection and in comfortable circumstances, the fact remains that from the standpoint of prevention such patients do not comprise a group constituting important elements of danger to others. The construction of sanatoria for incipient non-charity cases in the interests of prophylaxis does not represent a legitimate obligation upon society. The proper scope of such institutions will not be considered at this time, but will be reserved for later discussion in connection with Treatment.

The Hopelessly Ill and Impoverished. For the very advanced cases, it is clearly incumbent upon society to provide segregation hospitals where the last comforts of life can be administered without the slightest danger to families or the community, and where death may be robbed of a portion of its horrors through judicious nursing and medical care. The destitute and dying consumptive who is not granted a welcome in municipal hospitals open to other classes of suffering