THE FIRST SYMPTOMS OF TUBERCULOSIS.

Last month there appeared in the Bulletin an article emphasizing the value of social measures in the control of tuberculosis. We publish this month an article furnished by the Department of Health, which describes how an individual may come to know in time that he is suffering from this terrible disease. This knowledge is for the individual the essential preliminary which enables him to take advantage of the existing organizations.

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HETHER we think of the consumptive himself or of his children, threatened daily with the danger of infection, the first thing we wish for on their behalf is that they may all be looked after by doctor and nurse who understand their plight and can do much to relieve it. Though the vital importance of early treatment is recognised everywhere, it still remains true that the great majority of patients do not get any early treatment; and that is why 60, 70, 80 or sometimes 90 per cent of sanatorium patients die at last of tuberculosis in spite of their of treatment. The stable door is locked after the horse has escaped. This lamentable truth was well shown in the intensive health campaign carried out at Framingham. On Jan. 1, 1917, only 27 cases of tuberculosis were known to the health authorities. By the end of 1918, there had been recorded 242 cases. This is not to say that tuberculosis was increasing, for there were only 10 deaths in 1918 compared with 19 deaths in the previous year. Evidently", as the report says, more cases are being reported in the early stage.

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Unfortunately, intensive health campaigns, like the Framingham demonstration, cannot be carried on all over the world, at any rate, until more people are willing to invest their money in community health. But, progress is possible in two directions and without delay. First, the doctors must be more on the look-out for the early signs of tuberculosis and secondly, the public must learn to recognise the early symptoms, so that the doctor may be given a chance.

Anyone who has felt a tickling in his throat, has coughed and found his mouth full of bright red blood, will admit that this experience made his skin creep and set his heart thumping, when it happened for the first time. The very first sign of tuberculosis may be this bleeding of the lungs, either slight or profuse. It is the most fortunate start, for it frightens the patient into a doctor's consulting room, and puts the doctor at once on the alert, but it is not a very common occurrence at the beginning of the disease. There is usually a sense of tiredness and this may be the only sign at first. It comes on in the afternoon without any obvious reason and is continued from day to day. Usually it is accompanied by loss of weight, with poor appetite or indigestion. Then there is the cough. Of course every cough does not mean tuberculosis, but every cough which lasts for three weeks or more should mean a medical examination. It need not be a bad cough, the cough of early tuberculosis is nearly always a slight one, but it does not get well. After a time, a little phlegm is brought up. This means that the disease is advancing, and if the phlegm is examined under the microscope there may be bacilli to be seen or fragments of what once was lung which the disease has eaten away. The wise man will not wait until he is coughing up the bacilli and little lumps of cheesy waste. A sign, which is often found some time before the cough, is persistent pain in the chest and especially in the right shoulder. It is a

pain which is made worse by taking a deep breath, as in yawning or coughing or sneezing. If the doctor has a chance to examine his patient while the pain is still there, he can tell what is its significance. After the pain has gone, probably nobody will be able to tell whether it was pleurisy (and probably tuberculous) or rheumatism. Sweating at night and a long-continued hoarseness and shortness of breath, especially on exertion, are also signs about which the doctor ought to known..

A slight feverishness coming on at night must be due to infection of some kind. In children especially, it is a sign which should not be overlooked, and while we are thinking of children, it is well to remember that a tuberculous child, instead of losing weight, may just fail to gain weight. The following table shows the approximate amount which boys and girls should gain every month.

APPROXIMATE MONTHLY GAIN IN WEIGHT.

The following remarks on this table, made by Dr. Emmett Holt, show how the table should be used:

"Variations in the annual rate of gain of a pound or a pound and a half on either side of the average, are common in healthy boys between the ages of five and twelve years; and variations of three or four pounds on either side of the average are common from the thirteenth to the sixteenth year.

“Variations in the monthly gain in weight are even more marked than in the annual gain. Few children gain regularly every month in the year. A stationary weight for a few months is consistent with perfect health. But a prolonged period of stationary weight or a steady loss at any time is to be considered significant and demands attention. "

Children who fail to gain in weight are often anaemic. There are other causes of anaemia besides tuberculosis, but in any case the doctor should be consulted about this condition.

Probably most tuberculosis begins in childhood and intelligent care of our children with medical attention, whenever they fail to progress according to the above rules, and especially when there has been tuberculosis in the family, would do much to stamp out this disease in the next generation.

HEALTH EDUCATION AND HEALTH TRAINING.

William A. Hove, B. S., M. D., State Medical Inspector of Schools, New York State, President of the American School Hygiene Association, delivered an address on school health service in New York State before the National Education Association at Des Moines, Iowa, on July 5, 1921. From this address, which contains an outline of the programme of health education in the schools of the State of New York, we quote the following:

That normal wisdom is the result of normal health, physical and mental, is the basic principle of the programme of health education in the schools of New York State. The aim of course is the formation and development by children of automatic gcod-health habits, as well as the stimulation of normal play. The programme provides for giving school credit for health improvement as well as for mental progress. Emphasis is laid upon the need of adequately trained teachers of physical education, the education of the community to assume its own responsibility for efficient administration, and the stimulation of executives and legislators to grant necessary appropriations.

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'HE phase of Health Education and Health Training is placed last in our school health service as it is the most basic part of our whole programme is the most inclusive in its scope and exerts the greatest determining influence on results to be accomplished. Many of us have appreciated for years that the solution of most of our problems of health and of sanitation is an educational problem. We have all felt the need of better trained teachers to do this work. We have realised fully that the teacher must be qualified to do the major part of the health work in the room in which she teaches. It has been equally as evident to us that pupils must be taught practical hygiene and sanitation, and that this instruction must be of such a character as can be easily understood by chidren and easily utilised by them in the formation and development of good health habits. It is far better to teach less and to have what is taught clearly understood and properly applied to health achievements than to teach more that is poorly understood and poorly applied to the formation of health habits.

In New York State our normal schools will increase their courses from two to three years in the fall of 1922. In the re-arrangement of the instruction and training to be given to pupil teachers, 60 hours will be devoted each year, or 180 hours in three years, to practical hygiene and sanitation. The state will be insistent that matriculents to normal schools and to the State College for Teachers shall be physically as well as mentally qualified to take up the work. Every student will be given practical demonstrations in school health service. Special efforts will be made to maintain a high standard of health among our pupil teachers. They will be trained to preserve their own health and to safeguard that of pupils coming under their care after graduation. Eight of our ten normal schools are now doing more or less this special work in hygiene and sanitation. The New York State College for Teachers and the Eswego Normal School are conducting an excellent course in this work. We hope and expect in a short time to have a department of health education and sanitation established and conducted in an efficient manner in all our State institutions in which prospective teachers are trained.

1 American Journal of Public Health, Vol. XI, No 10, October 1921, page 873.

A definite programme has been adopted in our State for instruction in health and sanitation to pupils in the public schools. In its administration it will be reduced to the simplest terms in subject matter taught and training required. It will be made as interesting as possible to children and of such a character as can be utilised by them in the formation of good health habits. It will begin when the child first enters school and will continue through the high school. It will apply to every child in school. It will include daily health inspection of each pupil and will be under the direction of the teacher. It will establish a physical rating for every child on admission to school and will give school credit for health improvement as well as for mental progress. Systematic attention will be given to the correction of defects found and special emphasis will be placed on the need of keeping well. Its purpose will be to keep every child well, physically and mentally. Every community will be expected to do its best to contribute to the success of the programme for better health of teachers and pupils and better sanitary conditions in schools. The teacher in charge will be held responsible for the success of the work in her room.

A practical syllabus in the simple essentials of hygiene and sanitation, as outlined above, has been prepared for the first six grades in our public schools. This we hope to have in operation in the early part of the next school year. It is our expectation to complete the syllabus for the upper six grades during the next ten or twelve months.

TWO YEARS OF FIGHTING VENEREAL DISEASES.1 Summary of accomplishments of the Public Health Service and the State Boards of Health.

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HE United States Public Health Service, in cooperation with the various State boards of health, has made very material progress in organising a programme for combating venereal diseases. The following brief summary of the accomplishments of the Service and the State boards of health is furnished for the information of persons interested in this work.

1. Medical Measures. Four hundred and seventy-two clinics have been established. The organisation of venereal disease clinics throughout the United States is one of the most important accomplishments of the programme for combating venereal diseases.

Treatments to the number of 2,103,900 have been given to 185,200 clinic patients. The cost per treatment in the most efficient clinics is less than $ I per person. These clinics have discharged as non-infectious 41,100 patients.

Social workers follow up the infected patients in order to protect other persons. Through these social workers patients who stop treatment are persuaded to return until cured. Members of the families of the patients are brought to the clinic for examination and treatment.

Twenty-eight thousand druggists have helped in checking the sale of patent remedies.

In 16 States it is unlawful to sell such remedies.

Of 20,000 newspapers and magazines, 19,800 have agreed to take out or keep out advertisements of quack doctors.

1 From the Division of Venereal Diseases, United States Public Health Service.

Fifteen thousand placards have been posted. The placard attracts diseased persons to clinics and also has educational value.

Sixty thousand seven hundred physicians have pledged their cooperation. Seventy-three thousand nine hundred manuals of treatment have been given to physicians.

2. Educational Measures. The "Keeping Fit " exhibit has been shown to 740,000 young men and boys. The exhibit is interesting enough for college men and simple enough for older boys not yet in high school, and has done much to establish high standards of vigorous manhood.

Exhibits and lantern slides, emphasising the seriousness of the venerel menace and the importance of educational measures, have been shown to 13,000 audiences.

Motion pictures have been shown to 3,600 audiences, reaching 1,458,000 persons.

Various industries have purchased and used a million pieces of printed matter. Many firms have printed their own pamphlets.

Five thousand industrial establishments have undertaken venereal disease control.

More than 20,500 lectures have been held for business men's organisations, women's clubs, fraternal orders, and other organisations, and were attended by 3,306,000 persons.

Pamphlets to the number of 22,221,000 on the subject of venereal diseases and their control have been distributed.

Thirty-one conferences of educators have been held in order that sex education could be given in schools in case of failure to receive such instruction in the home.

Coloured lecturers have held 600 meetings for coloured people and have reached 145,000 persons.

Magazines and newspapers have cooperated. In one State full page advertisements were published in newspapers of nine cities.

3. Legal Measures. Many houses of prostitution have been closed. (Particular attention is given to prostitutes, because they constitute dangerous foci of infection.)

Men are now being prosecuted as well as women. (Men caught with women in an act of prostitution are equally guilty.)

Newspapers have supported venereal disease legislation proposed by State boards of health. Three hundred and fifty ordinances dealing with the control of venereal diseases have been passed.

Drastic measures are now taken to safeguard the public. Several States have quarantine houses in which to harbour persons with a venereal disease when necessary for the protection of the public health.

Mental tests of persons infected with venereal diseases have been extended through the agency of municipal and juvenile courts.

Thousands of dollars have been appropriated for institutions for the feebleminded. These institutions will take care of persons who would inevitably become spreaders of venereal disease were they not adequately cared for. Increasing number of social workers are being employed. More intelligent and effective handling of women infected with venereal disease is assured by the growth of social work.