patients said, "why did they lead us to believe we were 'cured' when they knew we might not be?" The final outcome of the matter was that

the term, 'apparently cured," is now applied only to patients who have been at home working under ordinary conditions of life for two years, and even then stress, much stress, must be laid upon "apparently." Today patients are said to have their disease "apparently arrested" or 'arrested," for that is all that a physician can honestly say. If a patient keeps well indefinitely he is cured; if he relapses after one, two, or three months of strenuous life, or even after a year or two, he belonged to the vast multitude of those with their disease arrested. Today as many, and in all probability more, patients are "cured" than ever before, but the writer wishes to emphasize the fact that no one can say when a patient passes from a condition of arrest into that of cure.

XXIII

ON THE HYGIENIC CARE OF THE PATIENT

"I am a man: I hold that nothing which concerns mankind can be of indifference to me."

EVERY patient with tuberculosis has certain duties and obligations that he should perform to protect his family, his friends, and all those with whom he comes in contact. On the other hand, these persons have certain obligations to such a patient, not least among which is the dissipation of foolish fear about contagion from a careful patient. He who collects and destroys his sputum, who covers his mouth when coughing, can be of no source of danger to anyone.

Many laws have been passed prohibiting spitting wherever anyone must tread. It is not sufficient, however, to pass such laws; an intelligent sympathetic public opinion should be created to enforce them. The "arrested" patient should heartily uphold all such measures, for his training has taught him that many apparently well persons who spit have tuberculosis, and a belief that one is well affords no excuse for breaking such laws. If one must spit he should always spit in some receptacle provided for the purpose or in running water. Moist

tuberculosis germs cannot leave the moist surface except under peculiar conditions, i. e., coughing, which will be mentioned later.

Every patient should know about the disposal of sputum. In the first place it is necessary for a patient who expectorates to have with him constantly some sort of receptacle to hold the sputum until it can be destroyed. While in bed or on the porch nothing is better than the ordinary individual sanitary cuspidor, constructed of a tinned iron frame, holding a thick waterproofed paper cup, folded in such manner that flanges prevent spilling if accidently overturned. Each day or oftener if necessary the filler is removed, filled with sawdust, wrapped in paper, and burned in the furnace or stove. The metal frame should be washed with a 5 per cent. solution of carbolic acid. Several types of good waterproof paper pocket cups have been devised, and a patient should never be without one. These too should be wrapped up and burned. The use of small pieces of cheesecloth or paper napkins are not so cleanly but are permissible when a patient is confined to bed. Each piece of cloth or napkin should be used but once, then folded and placed in an ordinary paper bag (obtained at the grocery), pinned on the side of the bed or mattress. This should be removed daily and burned. Such a method eliminates all handling of infected material by anyone but the patient. Much needless fear prevails among

the laity about getting a little sputum upon the hand. It can be of no possible source of danger (provided it does not get into a scratch or wound) if the hands are carefully washed with soap and

water.

To make a practice of expectorating into a handkerchief is inexcusable and dangerous. It has been said that the only dangerous germ is the dry germ, for only the dry germ can get into the air. Sputum in handkerchiefs quickly dries on account of the heat of the body, and if the handkerchief is used again some of the sputum becomes in part pulverized and when shaken in the air tends to disseminate as dust. When this soiled handkerchief is used to blow the nose upon the dried sputum may gain entrance into the lungs through the deep breath that usually precedes such an act. The Chautauqua Salute (the waving of handkerchiefs) should be abolished. If at any time the handkerchief must be used to receive sputum it should be burned.

The writer believes that colds may be disseminated by the careless use of handkerchiefs, and even by the prolonged use of a handkerchief an individual may possibly reinfect himself. Colds, grip, and influenza are all contagious, and a person suffering from one of them should not be allowed to come near a patient.

The only dangerous germ is the dry germ, but there is one exception. When a patient coughs or sneezes he may cough or sneeze out a spray

and the spray may contain the germs which have brought about the cough. This is true for grip, colds, bronchitis, influenza, diphtheria, pneumonia or tuberculosis. The little germladen droplets may go for a distance of three to four feet from the cougher and may remain suspended in the air for one-half to one or more hours. Anyone who inhales these droplets would inhale any germs they contain. Fortunately the effect of light and air is such that the germs are quickly weakened and destroyed. But it is not necessary that the germs should escape into the air. A piece of cheesecloth of two or three thicknesses held over the mouth will filter out and catch all these droplets and germs. At the end of the day or oftener the cloth may be burned. It should never be shaken and it is advisable to have a second piece to use as a handkerchief. Another practical point is that patients' chairs or beds should be at least four feet distant one from another.

The patient should, of course, exercise scrupulous cleanliness about his person, linen and clothes. As soon as a diagnosis is made it may be of value to disinfect the patient's clothes and his room, for previous to the diagnosis he may not have used sufficient care. If a patient wears a mustache or beard it should be closely cropped for sputum may get on it, dry, and so be a source of danger to him and others. Kissing must be given up. He should have whenever possible