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Copyright, 1906 
Hv J. l'>. LipiMNcoTT Company 







This book has from its inception to its end been intended to ])e 
exactly what its title denotes, — a comprehensive exposition of the 
effect whicli consumption has liad upon civilization, and a considera- 
tion of its relation to liuman affairs. Its scope is wider tlian that of 
a medical treatise, although I believe it will be found an adecpiate, if 
not an exhaustive, text-book upon this disease, which is so destruc- 
tive to the human race. Indeed, it is quite essential to view the 
subject very broadly. Manifestly, medical science cannot cope alone 
and unaided witli this difficult and prodigious world-problem : many 
forces — economic, legislative, sociological, humanihirian — nuist be 
enlisted. This essay, then, is addressed both to the physician and 
to the layman. I should not wish the latter, while reading it, to be 
imaginiug vain things concerning himself; and so I have put matters 
of a purely technical nature, except where otherwise indicated, in 

I tliank the publishers and their efficient and exceedingly hel])ful 
staff for the manner in which they have put my work into the form 
and substance of a book. 

The gist, at least, of some of these cliapters has ap[)eared in 
various journals ; and I beg to express my sense of obligation to the 
editors of The New York Medical Journal, The New York 3Iedical 
Neivs, The New York 3fedical Record, The Medical Times, The Boston 
Medical and Si(r(/ic(d Joiinial. American Medicine, and Tin' Popular 

Science Monthly. 

J. B. II. 





I. Introductoi y 17 

II. Evolution and CunHUiuplion 21 

III. Ancestry — The Present Life— Posterity 2.'! 

IV. Tlie Psychic Element 29 

\'. Literature and the Arts 32 

\1. Historical 40 


The Si'ECii-ic Cause of Tuberctlosis. 

I. (ienns 51 

II. The Germ of Tuberculosis 54 

III. The Koch Bacillus and the Tubercle 5B 

IV . Avenues of Infection 61 

V. Human and Bovine Tuberculosis (18 

VI. Latency 06 

Vn. Iiinnunity (58 



I. Preliminary 7o 

II. Hereditary Influences ... 74 

III. Prenatal Influences 7(j 

IV. Intrinsic Postnatal Factors 78 

\. Environment 82 

\' I . Rural Districts 85 



I . Economics 89 

II. Races and Peoples 100 

III. Overcrowding lOS 

I V. Occupations 112 

V. Habits and Social Customs 1 20 

VI. Tlip " Lunger "in the West 124 



I. The House 131 

II . Poverty . . . : 1 85 

III. Alcoholism 143 

IV. The " Lung Block " 147 

V. Preventable Conditions 153 


r.vRT vr. 


rilAlTKR Pagk 

I. rieliniinarv • 159 

II. Iiilialatioii 160 

III. Ingestion 168 

IV. Tnoculation 169 

V. Marriage and (he Offspring 171 

VT. The School-Child 17() 

VII. The Adolescent and the Adult 1815 

VI 1 1. Vaccination and Tuberculosis 18U 

The CiKK. 

I. The Pliysician and the Patient 197 

II. Fundamental Principles 199 

1 1 T. ( >ther Considerations 207 

The Mi;.\ns of Ci uk. 

1. Tents and ( )thcr ( >iitiloor Stnictures 21H 

II. I)ispen.«aries 224 

III. The Visiting Nurse 280 

IV. Hospitals for Tuberculous Cliildren 236 

American Sanatoria. 

I. Preliminary 245 

II. Saranac Lake 247 

III. ( )ther Sanati iria in New York State 255 

I \'. The rMassachuselts State Sanatorium 262 

V. Sanatr)ria ^Maintained by the United States Government 265 

\'I. DeiKjminatioual Institutions 270 

^"I I. Canadian Sanatoria 275 



I. England 2«1 

II . I-'rance ■ 286 

III. Austria 287 

IV. Switzerland 288 

V. ( iermany 290 


The Sanatorium and its Ad.h'ncts. 

I . The Sanatorium Idea 299 

II. Hospitals and Homes for Advanced Consumptives 308 

III. Farm and (>pen-Air Colonies 312 

IV. Tuberculosis in Insane Asyluuis .■)](> 

V. Tuberculosis in Prisons 321 

YI. The Financing of the Tuberculosis Situation 326 

YII. State Insurance for Workmen in (iermany 331 


Administrative ^Measures. 

Chapter Page 

I. Laissez-Faire — Paternal i^iiu :i"59 

II. The Health Department of ^'ew York City lUl 

III. The Tenement House Department of New York City ."547 

IV. Administrative Work in Other Municipalities 857 

V. Communities without Health Boards :]t]?, 

VI. State Jurisdiction .")H5 

VII. Federal Jurisdiction .j67 

Xox-Governmental Activities. 

I. The Family Physician o7o 

II. Educational ;)76 

III. :Model Tenements .",78 

IV. Individual and Associational Enterprises :'.82 

V. The Charity Organization Society of New York City .")87 

VI. The Baltimore Exposition 890 

VII. The National Association for the Study and Prevention of Tuberculosis 394 


Scientific Resume. 

I. Early Diagnosis 399 

II. Clas.sification of Cases and Technique of Exauiinations 404 

III. Pure Milk 418 

IV. The Inspection of Milch Cattle and of Meats 420 

V. Retrospect 428 


Sociological Resujie. 

I. Untoward Factors 433 

II. Phthisiophobia 445 

III. Consumption and Christianity 448 

IV. Conclusion 451 



A. Disinfection 461 

B. Tonics and Bitters 4W) 

C. Hydrotherapy and Hardening 467 

D. Extracts from a Children's Journal 470 

fi. Tents and Temporarj' Structures 472 

F. Sanatorium Construction and Cost 490 

G. Sanatorium and Dispensary Rules and Regulations, Schedules, Circulars, 

etc 498 

H. Results of Treatment 507 

I. Societies, Committees, Sanatoria, Special Hospitals and Camps, Dispensa- 
ries and Clinics 514 

List of Illustrations 

F\G. Page 
Dr. Edward L. Tnuleaus .Sanaturiuin at Saraiiac l^ake . . . . Frotitixpierr. 

1. Robert Louis Stevenson 32 

2. Francois Frederic Chopin 34 

I). John Keats •5() 

4. Botticelh"s Venus 38 

5. The Beata Beatrice 39 

0. Louis Pasteur 50 

7. Robert Koch 50 

8. Germ multiplication 52 

9. Varieties of germs 52 

10. Diagram of normal lungs 56 

1 1 . Miliary tubercles 56 

12. Tubercles from child's lung, with bacilli 56 

13. Cavities in lung tissue 57 

14. Tubercular tissue converted into tibmus tissue 58 

15. Cells with cilia 59 

16. Consumptive father with apparently healthy infant 61 

17. Hester Street, New York 83 

18. Atmosphere in Hester Street, New Y. rk 84 

19. Atmosphere at Madison .\ venue and Sixty-sixth Street. New York 84 

20. Deaths in Illinois, 1903 90 

21. Mortality from ten princijjal causes 91 

22. Deaths from consumption in Illinois, 1903, by ages 94 

23. Proportion of mortality causi-d by consumption in New York City 95 

24. INIortality among single, married, and widowed 96 

25. Death-rates, white and colored 100 

26. Mortality by races 104 

27. Manhattan Borough, by wards 109 

28. Mortality in European states 110 

29. Mortality in principal cities of the w(irld Ill 

30. Death-rate in various occupations (Brandt ) 114 

31. Death-rate in various occupations ( Hoffman) 118 

32. Air-shaft 1-^1 

33. A " dark room " l-'"*- 

34. A basement in the " Lung Block " 13/ 

35. A tenement-house workshop 138 

36. Room in Philadelphia in which six died of consumption 140 

37. Ground-plan of the " Lung Bloe-k " 147 

38. Signs of the times ^''^ 

39. A fire-escape -00 

40. A rattan garden couch -01 

41. An aerarium -0- 

42. Side view of an aerarium -0-"5 

43. Dr. Dunham's bed -O"* 



Fig. Page 

44. A tent at Saranac Lake 21-^ 

45. A Kn.«*li Hospital tent 214 

4H. I'rof. Fisher's tent 215 

47. Ojvii-air shelter 21() 

4S. The Tuoker tent 217 

40. The Tiu-ker tent, interior 217 

50. Dr. Masten's tent 21S 

51. A Diu'ker tent-honse 21S 

52. Revolving shelter 2111 

5o. Old street-cars as living quarters 220 

.54. Interit)r of " lean-to " 220 

55. A mountain home 221 

56. The Nathan cottage 222 

57. A tuberculosis ilispensary 225 

58. Exercises at the country sanatorium of the ^lontefiore Home 240 

50. Boys at the country sanatorium of the Montefiore Home 241 

(iO. Sanatorium at Goerbersdorf 245 

fit. Tubercle bacilli, with pus-cells, in sputum 241! 

02. .Saranac Lake in winter 247 

03. I)r. Trudeau 248 

04. Porch at Saranac Lake 250 

05. The Prescott cottage 25;> 

()0. The Montefiore country sanatorium 257 

07. Women at the Montefiore country sanatorium 2-58 

08. A " lean-to " at the Loomis sanatorium 200 

OO. Block plan of the ^lassachusetts State Sanatorium 201 

70. The INIas.sachusetts State Sanatorium 202 

71. Taking the air 203 

72. Fort Stanton Sanatorium 200 

7:;. Tent at Fort Stanton 207 

74. Tents at Fort Stanton 209 

75. St. Joseph's Sanatorium 270 

7(). Shacks at ^Muskoka 275 

77. X shack at Muskcjka 277 

78. Sherwood Forest Sanatorimu 282 

79. Dr. Uettweiler. . .• 201 

80. Dr. BreliTuer as a yourg man 204 

81. The Brehmer Sanatorium 205 

82. Dr. Brehmer 200 

83. The Rhode Island Sanatorium 208 

84. The Agnes :Memorial :500 

85. The Fourth of July at Bedford 301 

80. Men at Bedford 302 

87. Sun-bath at Sharon ( winter) .30.3 

88. Camp at Sharon (summer J 304 

89. Camp at Sharon ( winter ) 304 

90. E.xercises at Bedford Sanatorium .".05 

91 . Sewing-circle at Bedford .300 

92. The Pottenger Sanatorium, ^Monrovia, California 307 

93. Inmates of liedford Sanatorium at work 312 

94. The Y. M. C. A. Health Farm, Denver. Colora<lo 313 

95. The Nordrach ranch 315 


Fig. I'AfJE 

9ti. Tents on AVard's Island 818 

i>7. Kevolvnig tent on Ward's Island 319 

9<s. Clinton Prison 322 

Vl!t. Cellar of a macaroni factory 349 

100. A hall and sink 350 

101 . A hall and sink renovated 350 

102. Advertising sign before premises 352 

10,">. Advertising sign removed 352 

104. Bottom of an air-shaft 353 

105. New law court 354 

106. A living room 355 

107. A living room improved 355 

lOS. A roof pavilion 3S3 

109. Turban's scheme 407 

110. A history blank 408 

111. A monthly summary 409 

1 12. Diagrams of the chest 409 

113. Pasteurization of milk 413 

1 14. The Walker-Gordon farms 423 

115. A healthy cow 425 

116. A consumptive cow 426 

117. The Ulrich tent 474 

118. The Gardiner tent 475 

119. The Xordrach tent 476 

120. Details of the Tucker tent 477 

121. The Tucker tent 478 

122. Pavilion tent at the Metropolitan Hospital 479 

123. Ground plan of a " lean-to " 481 

124. A "shelter," Rush Hospital 484 

125. The Lapham tent 485 

126. Dr. Biggs's tent-house 487 

127 The Natlian cottage 4S9 

12S. The Prescott cottage (first floor) 490 

129. The Prescott cottage (second floor) 491 

130. The Prescott cottage (third floor) 492 

131. The Maine Sanatorium 493 

Part I 


If thiiu. Loifl. wilt he oxtreme to mark wliat is done aiiii<<. () Lon 

Who may ahi(]e it r 
For there is mercy with thee ; therefore slialt thou he feared. 





Whilst meagre phtliisis gives a silent, blow : 
Her stroaks are sure, but her advances slow. 
No loud alarms nor fierce assaults are shown. 
She starves the fortress first, then takes the town. 


It is with a very real sense of melancholy that one contemplates 
the long death-roll of those of the Avorld's great men and women who 
have succumbed untimely to the tubercle bacillus, which is and has 
been through countless generations by far the most potent of all death- 
dealing agencies. Had it not been for this detestable parasite, Bastien 
le Page might have given us another Joan of Arc to feast our eyes 
upon ; Rachel might for many years have continued to permeate the 
spirits of her audiences with the divine fire that was in her. Our 
navy did well enough in the 1812 war, as all the world knows; but 
what a rip-roaring time there would liave been if John Paul Jones had 
lived to take a hand in it. We might be reading more of Stephen 
Crane's splendid war stories ; we might have had more of Robert 
Louis Stevenson's delicious lace-work ; Schiller might have given us 
another "Song of the Bells" ; we might have taken another "Senti- 
mental Journey" with Laurence Sterne ; Henry Cuyler Bunner might 
have continued to delight us, and to touch our hearts ; John Keats 
might have given us another " Endymion." Had the tubercle bacillus 
permitted, Nevin might have vouchsafed us another "Rosary"; von 
Weber another " Euryanthe Overture" ; Chopin might have dreamed 
another " First Polonaise" ; and the tender flute notes of Sidney Lanier 
might even now be heard. Marie Constantinova Bashkirtseff, Xavier 

2 17 

18 CONSlMl'TlOX 

Bicliat, .lolin (lodmaii, llciu' 'rhroilorr I lyaciiillu' l«i('iincc, Henry Pur- 
cell, Joliii Slcrlini;-, 1 Iciirv TiiiinKl. Arlciiiiis Ward. I lonry Kirk White, 
H(Miry David Tliorcau. Harucli Spinoza, John AthUn^lon Symonds, 
Prosjior Meriine(\ — such iianic.^ as those are l)ut a nioiely anionp: those 
of ihi' world's nobility wiiosc [irecions lives were cut ol'l' in their prime 
by the Great White Pla^^ue. 

And our sense of n^sentmiMit is l)y no means mitigated when we 
n'llert that this l)a(illus is so niinnte that it was reserved for Koeli, in 
our own time, with llu^ aid of an exipiisitely liiLih-powered microscope, 
to discover it, and to reveal its life history and its habits and properties. 
It were indeed worthy the pen of a Heine to set forth how, although 
our mastodons are extinct, although we easily destroy all other visible 
brute creation, although we hold ourselves to be world-masters and 
universe-compellers, the race has nevertheless until our generation 
been impotent in the presence of an organism measuring in length 
one ten-thousandth of an inch and in breadth one fifty-thousandth of 
an inch, — an organism which nHiltii)lies so rapidly and so invisibly and 
insidiously that tli(^ consumijtive, in coughing, emits several billions 
of it during twenty-four hours. 

There would be no excuse truly for putting such sinister details as 
these before the laity were it not that the condition of things, whicli we 
term consumption or tuberculosis, is a tremendous, much-pervading 
human factor. I have intimated that of all death-dealing agencies, 
Koch's bacillus claims the greatest nund^er of victims ; tlie cholera, 
typhus, the plague of the middle ages, smallpox, are not in the run- 
ning with consumption. The latter, although its ravages have not 
been so jjicturescpiely grewsome, has claimed many more victims than 
any of the others ; it has probably been coeval with human existence, 
and very likely has afflicted our primordial ancestors. 

To-day every third or fourth adult dies of consumption. In the 
periods between birth and senescence every seventh death is caused 
by it. The point about tliese two propositions is this : Very few of 
us die merely of old age ; almost every one dies of some disease or 
another, so that it would not seem to matter much what the particular 
disease might be that would carry us off. But, although all periods 
of life are precious — infancy and childhood and old age, as well as any 
other — it is during adult life that consumj)tion achieves its fell work, — 
in the {(oriods when young people should entertain wholesome antici- 
pations of matrimony ; when Imsbands should be strong to work for 
and maintain their families ; wdien wives should have strengtli to rear 
their children, and when men and women generally should have physi- 
cal and mental capacity so that they may accomplish the world's work. 


No one knows better than the physieian how truly h)U(hing may 
be the condition of things we are considering at the first of these 
periods, — the period of early manhood and womanliood, when poetry, 
music, flowers, sunshine, and the new-born instinct to love, and power 
to inspire love, are gloriously dominant; when sentiments ring true; 
when thoughts of compromise with unworthy factors, of subordinating 
ideals to considerations of interesi, have not yet been conceived ; when 
the love exists which welcomes sacritices and feels that if it is ever to 
manifest itself, it should do so most gladly and most abundantly when 
the beloved is sorely stricken; the love that feels bound to triumph 
over all obstacles, and which snaps its fingers contem[)tuously in the 
face of fate. One is proud for human nature when such spirit is ex- 
hibited. Nevertheless it is then that this dreadful disease demands 
with deplorable frequency to be reckoned with. And it is then that 
the mature physician discerns the practical certainty that marriage, 
in cases where consumption exists or is suspected, will be followed by 
intensified illness, and perhaps death (which might not otherwise have 
occurred) on the part of the sick one ; the possibility of infection of 
the healthy mate ; the likelihood of unhealthy offspring, or of its early 
and perhaps, under the circumstances, fortunate death ; and other 
indications suggesting disaster at the very beginning of married life, 
when all the circumstances, if any time in life ever requires it, should 
be favorable, and founded upon virility of mind and body. 

The tubercle bacillus enters the body either with the air we 
breathe, or with tuberculous food-stuffs, or rarely through wounds. 
Wherever it implants itself an inflammation may occur about it, with 
the result that a tubercle is formed {tuber is Latin for root or bulb). 
This tubercle, at first microscopic, presently attains proportions 
from that of a millet-seed to a hickory-nut, or larger. Its develop- 
ment is termed tuberculosis. If the tubercle does not undergo 
"fibrosis" or some other innocuous process, such as we \n\\\ consider, 
there is likely to become developed, through the agency of one or 
more "predisposing causes," the complex of symptoms which w^e call 
consumption. Probably no reader of this book will be fortunate 
enough not to recall among his familiars some sufferer from this dis- 
ease. Those thus afflicted become progressively very weak and very 
much emaciated. Their hearts beat rapidly and they are apt to have 
a pink flush on their cheeks, which is quite unlike the blush of 
health, but which is in reality an indication of the fever that is con- 
suming them. The rest of their faces is very pale and tliin and is 
suffused with a clammy sweat. Their cheek-bones are prominent ; 
and their eyes have a quite unnatural brilliancy, seeming large and 


beaulirul. l!ui tlicii' lustre is nut of heallli, — rather of disease, and too 
often of death. It is such eyes tliat the poet Bryant has portrayed in 
a touching and melancholy sonnet. And the consumptive spits blood 
sometimes, and is short of breath, and has a })ersislent, hacking cough, 
that harasses him dreadfully, and will not let him rest. 

The rcad(>r is now likely to wonder how, with all these teeming 
billions of bacilli about, any one ever escapes the disease. The fact 
is, the bacillus allows very few of us to die w'ithout leaving some trace 
of its activity in our syst'-ni. JciU-r mcnsrh hat dm oide elii bischcn 
Tuberciilose, as Naegali demonstrated in 98 per cent, of the bodies 
which he examined on autopsy, of jjeople who had succumbed to all 
sorts of disease, besides those dying of old age. 

As has been indicated, there are two conditions essential to the 
development of coi]suniption. In the first place, there must be the 
presence of the bacilli of Kocli as its specific or essential cause. In 
the second place, the body must be predisposed to the disease by 
various unhealthful factors, such as vicious heredity, alcoholism, 
poverty, and the like. Most of us are able to resist the bacillus 
because our bodies are sufficiently strong to resist the organism, and 
because there are in our tissues certain germicidal properties which 
are ordinarily sufficient to cope with and destroy the bacillus. The 
layman will easily get the idea from the following experiment: 
Some rabl)its were inoculated with tubercle bacilli and placed in 
relations generally deleterious to health ; these became consumptive. 
Another group, selected from these same rabbits, were likewise con- 
fined, but were not subjected to infection, and these did not develop 
the disease. Whilst among a tliird group, which were inoculated like 
the first, but which were, on the contrary, favorably located as to 
hygiene, most of the rabbits escaped the disease. 



We have as possibilities either Balance, or Elaboration, or Degeneration. — 

An exposition of the general trend of this book is here desirable 
with relation to certain tenets of the evolutionists. 

The opmion is expressed, not frequently, but often enough to be 
entitled to consideration, that after all it were better for the race in 
general if its weakUngs were left to die off; that efforts, for instance, on 
the part of the medical profession to save the lives of consumptives, 
especially of tuberculous infants, are essentially misdirected, for the 
reason that they are in violation of the natural law of the survival of 
the fittest. 

Considered upon a purely physical basis this tenet of the evolu- 
tionist would seem to require that creatures who are unfit had best be 
left to perish, because their continued existence would be an addi- 
tional and a useless burden for the strong to bear, and a handicap 
upon the development and progress of the fit. No doubt the Spartans 
thought thus when they threw their infants, unliealtliily born, to the 
wolves, and from a purely pliysical point of view they were cjuite 
right. They considered, perhaps subconsciously, that the claims of 
the individual and those of the race here involved a contradiction, 
which were sensibly to be adjusted in but one way. To save a sickly 
infant would be contrary to communal hygiene, which would have for 
its ultimate object the improvement of the race. 

Yet, we would not consider this tenet of the (physical) survival 
of the fittest to be indicative of evolution in all its phases, for it is, 
as here expressed, a tenet expressive of mere materialism. Evolu- 
tion, to be a philosophy, an all-comprehendiug system upon which 
consistent living is to be based, must consider not only the purely 
material or physical, but all other aspects of life as well — the mental, 
the moral, the emotional, the spiritual — an evolution inclusive of 
the humanities. For no doctrine in philosophy is more certain than 
that the physical, moral, mental, spiritual, and all other phases of 
existence are inseparable, and mutually affecting and affected parts 
of the individual being. The most practical Gradgrind, the coldest 
political economist, tlie most austere statesman, will grant this, as well 



as those most siisoeptiblt* to the emotional ; at least tliey will if 
they be men exjierienced in cK'nliii','- dircM-tly with human conditions. 
If this \i('\v hi' a('('e|it('d. a synipalhy lor the weak and the afflicted 
and a solicitude for their return to liealth and stren^Mh is allo^-ether 
lojrical. Otherwise the conclusion is inevitable thai civilization, the 
iri/lc zutn <piic)i. altrnisiii, (Christianity itself, liave been and are colossal 

If the broail view of evohition here set forth be accepted, who 
would presume to take it upon himself to discriminate, or to select 
from among his fellows "the llttest" for survival? Many a useful 
man. who has given substantial comfort to otliers, has been unhealthily 
born and has had his infant life hanging month after month upon a 
tliread until the scale has been turned existenceward, with results 
vastly beneficial to his kind. The biographical dictionaries furnish 
the names of many a weakling who, having triuni})hantly grown to 
maturity, has impressed himself upon his civilization to its great good 
and i)rotit. 

However, even in the materialistic evolulionist's creed it is held 
somewhere, I believe, lliat tluTe is in nature a constant struggle for the 
recovery of lost perfection, a struggle in which she much oftener suc- 
ceeds than fails, in the long run, at any rate, if not in the first attempt. 
It has been well observed that in medicine this siriving after lost per- 
fection is as much a part of nature's healing power as is the force 
making for recovery in most cases of sickness. It is a common 
observation among physicians that weakly parents not infrequently 
beget strong children. We shall see that oftentimes tuberculous i)arents 
have born to them virile offsi)ring, whose chances against consump- 
tion seem rather better than those of children of untainted parents. 
Before adolescence there are comparatively few deaths from tubercu- 
losis, — the period when it manifests itself most and during which 
most deaths occur from it being between the fifteenth and fiftieth 
years. There is, then, a long period of latency in which, if the child 
be well nurtured, and if he live hygienical ly, he will be likely to over- 
come such tendencies to disease as he may have begun life with. 
Here surely are evidences of an upi'ight and honorable offer on the 
part of nature to remedy untoward conditions. It rests with us to 
emulate her. 



For of the soul the body form doth take ; 
For soul is form, and dofh the body make. 

Edmund Spenser. 

I PURPOSE in this section the presentation of certain basic facts 
■which are scientific in the present day, and some statements of plii- 
losopliy which, when correlated, appear to me to fariiisli (confessedly 
to a distinctly limited degree) a contribution to the subject of existence 
after death. I believe that these facts and these statements will fur- 
nish a basis upon which the undoubted interest of humankind in a 
future life can be measurably accounted for. (I wish to emphasize the 
phrase "a future life." I do not purpose a consideration of the im- 
mortality of the soul of an individual after the deatli of his body. That 
momentous subject is as it may be, so far as this essay is concerned.) 
Sucli a presentation as this may not appear relevant to the trend of 
tliis work. I think, however, tliat it is ; its relevancy lies in the fact 
that (with certain exceptions, to be dwelt upon later) a tendency to 
some diseases, and particularly to tuberculosis, may be transmitted 
from generation to generation ; and that this tendency need oftentimes 
not be transmitted when there is an understanding of the physical 
agencies which foster it. The facts and statements I would set forth 
are the following : 

From the biological view point, which is scientitlcally a correct 
one, conception, birth and death are but incidents in a succession of 
life processes. As regards conception, we observe that all life lias its 
origin in a cell ; and that at conception there is in the union of the 
sperm and ovum but the transformation of older cellular elements into 
a new cellular compound. Primarily, it is with the quality and prop- 
erties of cells that we have to deal. 

Again, the growth of the organism from the initial union of tlie 
sperm and ovum is simply a process of cell multi|)lication. Tliis pro- 
cess advances in utero ; and while in utero it advances in conformity 
with the maternal environment. Biologically speaking, the birth of the 
organism means simply a change of environment, so far as it is con- 
cerned ; and not a very essential one, as we must conclude upon 



Nor is the death of tlie body an abrupt and sudden change of con- 
ditions ; in reality it is but a biological incident. For during every- 
day of sentient existence some portion of the economy dies. Daily 
dying is an integral part of daily living. During the process of metab- 
olism, by which existence is maintained, the body gives off its waste 
dead material, which returns to earth, and becomes useful — essential^ 
indeed, in the processes of cosmic chemistry, to the development of 
other life. And at death, in the colloquial sense, dust has simply 
returned to dust, to aid the dust with which it becomes mingled in the 
fructification and nourishment of other existences. 

Recognizing then that conception, birth and death are in the rela- 
tion as stated, we may next consider certain conditions of the living 
organism, the human body, in the every-day sense of the term. 
Among all the various material elements, which are combined in tiie 
human organism, there is not one which has not been appropriated 
from the universe outside it. What we consider an individual body 
is but a subtle selection from among these external elements, made 
under the control of the mysterious and inexplicable force, thus far 
comi)rehended only by the dogmatist, which we vaguely term the vital 
principle, the breath of life, and the like. 

The i)resent day philosopher, in my opinion, understands tlie first 
cause, the essential origin by which these and other cosmic activities 
are achieved, no better than it has ever been understood. Neverthe- 
less, with this limitation he has achieved a very comprehensive and 
most helpful grasp upon life. He has not explained for us why cosmic 
phenomena exist ; but he has explained in great and almost adequate 
measure lioir these phenomena react upon one another, and jDarticu- 
larly liow external phenomena react upon the human organism. It is 
certain, as the monist teaches, that life is the constant adjustment of 
internal relations to external relations ; that the body, in the various 
correlated activities of its organs and tissues, is constantly being 
affected by, and must respond to, influences from without, either 
physical or chemical in their nature. If these influences are whole- 
some, health may be expected, and a healthy body is the result ; 
when they are unwliolesome, in ways presently to be mentioned, 
disease is inevitable. 

Now this human organism is dominated by a mind. The existence 
of this mind is a fact of human experience ; to deny this is to deny that 
there is any such thing as living at all. Cogito, ergo sum, is perhaps 
the most palpable, the most absolute fact of all facts. And it is here 
where, having thanked the monist for the great help he has given us, 
we must take a different road than the one he has laid out. 


He tolls us that the iiiiiid, in its various aspects — reason, intellect, 
Avill, emotion — is but the outcome of jjurdy material conditions. The 
beginning of living, of sentient existence, he tells us, was when the sun 
iirst shone upon and vivified a morsel of })rimordial ijrotoplasm. Thus 
there was, to start with, a sort of amcrboid, a unicellular existence, 
from which has evolved step by step through various more and more 
highly developed stages, the human organism, tiie most highly devel- 
oped that w'e know of. However, this is by no means a complete 
explanation of the way in which the protoplasm became sentient. 
How did the protoplasm get there ? we are entitled to ask ; and how 
did the sun come to shine ? The nionist may answer that millions of 
years ago there existed atoms w^hich under the pressure of gravitation 
became concentrated into nebulae, whence were evolved suns, whence 
in turn w^ere evolved planets, upon which certain particles of matter, 
or accumulations of atoms, took the form of protoplasm, upon which 
the sun acted. Very well, then ; but how did the primal atoms come 
into existence ? And the monist may answer tliat these atoms were 
born or evolved out of a single space-filling ether. To this we may 
again respond, with tiresome persistence : Then how did the ether 
come into existence ? And so on, as far back as the monist wants to 
go. The monist has not, in sliort, solved for us the mystery of mind. 
And the point I want to make is tliat although the body, through envi- 
ronmental stimuli, undoubtedly reacts upon and influences tlie mind, 
the latter is, nevertheless, essentially the dominant factor in life, and 
is, on the wliole, master of the body with which it is associated. The 
l)resence of the physical brain is essential to the exhibition of mind ; 
but brain is not mind, — it is the material machinery by means of which 
mind manifests itself. 

And here the dicta of Kant concerning time and space are a 
propos. Time and space, he declares, are original intuitions of reason, 
prior to all experience ; they are a priori intuitions, with w-hich sen- 
sationalism has absolutely no connection ; tliey are intuitions of rea- 
son in nowise dependent upon sensations ; they are intuitions of 
reason absolutely unaffected by material conditions or environmental 

And are not these Kantian dicta correlated to the scientific state- 
ment that what is popularly termed the present life is but a link in a 
chain of life processes ? And if, in accordance witli the Kantian reason- 
ing, time and space are intuitions concerning which it is impossible 
to conceive limitation, or epoch, or stages, or divisions, docs not the 
same hold concerning physical manifestations in the universe? Is 
there not here a dualism of the psychic and the physical '? And is it 


possible, indeed, to dissociate the human mind in our conceptions from 
the human body ; and since we cannot do this, is it possible that the 
conditions of iliimitability and of boundlessness, which exist for the 
human mind, do not in equal degree obtain as regards the material 
human body? 

It remains now to state one other scientific fact : that heredity is 
the biological law according to which living beings tend to repeat 
themselves in the offspring and to transmit to them their properties. 
We will here emphasize, as medical facts beyond dispute, that tenden- 
cies, at least, to such diseases as syphilis, asthma, alcoholism, insanity, 
epilepsy, and tuberculosis are transmitted by parents to their offspring, 
as are also many stigmata of an unwholesome sort, such as malforma- 
tions, eye affections, deaf-nmtism, anatomical aberrations, a scrofulous 
temperament, defective development of the heart and the arteries, 
anaemias, and many like indications of a baneful condition of living. 

We are now, I think, in a position to make deductions. 

As regards perverse heredity : What offspring is there that can 
honor a parent whose vicious life, or whose careless life, if you will, 
has resulted in tlie transmission of stigmata, — a parent who has fore- 
knowingly given to his children a heritage of disease, of suffering, and 
of mortification ? And what manner of man is he who wilfully, and 
with knowledge of possiljle consecjuence to his offspring, will live 
unhealthily ? 

Even those who suffer diseases innocently acquired, such as cancer, 
tuberculosis, and the like, would not escape reproach if they Avere to 
put themselves in a position where they would be likely to transmit 
their disease to future generations. Indeed, there is an anxiety, gen- 
erally subconscious, but one nevertheless very potent, on the part of 
normal natures concerning the well-being of their posterity : and 
this anxiety we would emphasize regarding the disease with which 
we are here dealing. 

It cannot be maintained, if the statements here set forth are sound, 
that no one has occasion to be interested in any other than his own 
present existence. In fact, we find that the present life is indissolubly 
linked, biologically and physiologically, with the past and with the 
future. Therefore the past and the future cannot be said to be of no 
moment to any individual. And it is these considerations which afford, 
I think, as cogent and as logical a basis for human interest in a future 
life as any that has been conceived. 

I for one would not deny the claim of the emotional, the spiritual, 
the non-intellectual, to be authoritative. After all, what we know 
intellectuallv emanates in large measure from the unknowable. 


Knowledge is generally but a consideration of phenomena (appear- 
ances). Perhaps the emotional and the spiritual are nearer reality 
than the intellectual and the practical. I would merely submit those 
definite, tangible data upon which, without an appeal to undemon- 
strable dogma, it may be reasonably concluded that no man's life is 
circumscribed between his physical birth and death. 

It is evident these considerations are concerned only with a future 
life, not the future life of any given individual. In these times, indeed, 
there seems to be but little interest in the likelihood of such a con- 
tinued existence as is re})resented in the phrase, " the immortality of 
the soul.'" Goldwin Smith voices this trend of thought in stating that 
after all no one really has an interest in a future life ; that what is 
beyond the present is not vital to us ; that whence we have come and 
whither we go are considerations which do not, after all, very much 
affect our conduct. 

This is true, however, it seems to me, only in the sense that it is 
not the same life, not the particular soul, that is hoped to be immor- 
talized ; and certainly the biological facts here set forth do not warrant 
any belief in a perpetuation of the same individual consciousness. 
What they do warrant, however, is a vital interest in another life, 
whose welfare depends in large measure upon the condition of the 
being from which it emanates. This great humanitarian observes that 
"immortality is inconceivable. We must discard the term. The ques- 
tion is whether our hopes and responsibilities extend beyond this 
world and life. Conscience tells us that this world, its awards and its 
judgments, are not all, but that as we do well or ill in this life, it will 
be well or ill for us in the sum of things. What question can be more 
practical ? Even taking it on the lowest ground, what would our 
social state be if vice and wickedness had only to bilk human law? 
Would not self-sacrifice be folly and martyrdom insanity?" 

Do not the facts and philosophic statements here set forth reason- 
ably attest these propositions? "That physical science has nothing 
to say to this matter is true." I hope I have shown that physical 
(or biological) science has in fact furnished a distinct contribution to 
the subject. "But is physical science," continues Goldwin Smith, 
"our only sure source of knowledge?" Indeed not. For physical 
science has to do essentially with phenomena ; but when physical 
science affords us data upon which we may make reasonable deduc- 
tions, the result is distinctly contrilDutory to philosophy (the sum of 
all science, or knowing). Again : " There is in man something of 
which the materialist still owes us an account. All may be, and 
in a sense no doubt is, the outcome of physical evolution. That does 


not seem to nio to close the iiufuiry/' Surely not. And being a physi- 
cal scienlist I should say, as a deduction from the statements I have 
made, that all is by no means the outcome of merely physical evolu- 
tion. The materialistic deals with the plienomenal. The innnaterial, 
tlie psychic, the si)iritual deals, whenever it conforms with innate rea- 
son, with reality ; and is to that degree a safer guide tlian the essen- 
tially and solely materialistic. 

I may not further discuss tliis subject in its many impressive aspects : 
Teresianism, with its beautiful sentiment, " The heart hath reasons 
reason knows not off the tender Augustinian expression, which 
would suggest eternal kinship with a beneficent Creator, " I have 
come from my Father, and 1 shall not be satisfied or at rest until I 
return to him ;" the ancestor worship and the belief in reincarnation 
of Oriental peoples ; the eerie notions of little children, which would 
seem to savor of pre-existence ; the anxiety on the part of good 
parents to give to their offspring a better bringing up than they them- 
selves have liad ; and the like. 

These general speculations concerning a future life have grown out 
of a desire to present logically the course through generations of 
pathological conditions in the human organism, among which tuber- 
culosis is the one with which we have here to deal. With certain ex- 
ceptions to be dwelt upon later, a tuberculous ancestry tends to tuber- 
culosis in the living subject ; and so may this pathological state be 
transmitted to one's posterity. The moral consideration, then, is that 
wherever there is such a tendency the conscience of the existent sub- 
ject will prompt him to right living, so far as in him lies, in order that 
he may not transmit to the future life for which he is responsible a 
condition of body inviting to this dreadful disease, with all the agony 
of mind and distress of body which inheres to it. 


The spirit lias all matter to choose from. — Schopenhauer. 

"What's mind? No matter; what's matter? Never mind; 
what's spirit? It is immaterial.'* This is Pwne/i'.s system of ])hilos- 
ophy, and certainly there is none more uncontrovertible. 

The manner in which the mind influences the body has been 
nearly as old a theme for speculation, no doubt, as the nature of mind 
itself. Nowadays there is evidently a trend in the opposite direction ; 
the real, the important influence is held to be that of the body upon 
the mind, the body being itself acted upon by its environment. The 
reader has no doubt observed that in this book we by no means ac- 
cept without reservation this view. Until we have discovered the 
natiu'e of mind, and what matter is, until we have explained these 
ultimates, we cannot positively adopt either position to the complete 
exclusion of the other. However, in common sense both are intel- 
ligDDle. Evidently these two factors are conditioned upon one another 
— are essentially complemental. It is demonstrable that the mind 
impresses itself upon the body ; and the present day psychologist has 
shown that tlie body reacts upon the mind. In the ciiapter on })re- 
dispositions we sliall further consider the latter of tlicse propositions. 
In this section we shall dwell upon the former, particularly tlie influ- 
ence of psychism with regard to tuberculosis. 

It is indeed difficult to gauge such influence ; to compute the ex- 
tent to which thought can affect the development of a leucocyte, the 
making of a drop of lyiuph, or the behavior of an excretory cell. The 
process is not susceptDDle of investigation by the microscope or by 
laboratory methods. Nevertheless it is essential, notably in tuber- 
culosis, that the influence of the mind upon the body be not lost sight 
of. It is in every one's experience that mental perturbations derange 
the functions of various organs. Why may not acute shock, such as 
attends an accident, or chronic shock, such as accompanies nerve ex- 
haustion, or overwork and anxiety, or a protracted i)lay of profound 
emotions, predispose to graver affections ? Indeed, it is an altogether 
scientific, practical procedure to note that the sympathetic nerve is an 
essential part of the machinery through which tliought manifests itself; 
that passive congestion from any cause makes a tissue susceptible to 



tuberculosis; aiul lliat synipatluMic lu^rve ubdTatious constitute tlie 
likeliest fartor hi hi-iiii-- about sucb confjestion. 

Psychisni in cousunii)tioii is j)ractically similar to tbat wliich obtains 
in every disease of long duration, in all cbronic diseases. Every one 
must liave observed with sadness that among his relations or his 
friends temperaments most stable, manly, engaging and lovable, have 
undergone changes during a prolonged sickness, especially if return to 
health seems unlikely. Such changes are well typified in some dis- 
positions wliich become altered during the period when the autunni 
of life merges into old age. There is no better example of this than 
Conan Doyle's sketch of Corporal Gregory Brewster, so touchingly pre- 
sented by Henry Irving in "Waterloo," — how the old man, who had 
in his youth done an act of splendid courage, and Avho had been an 
epitome of maidiness in his prinie, wliined fretfully to be fed, cried like 
a child when his pipe fell from his hand and was broken, and exulted 
that "Brother George never had such a pipe," when a new one w^as 
presented him. Upon awakening from a dreamy sleep, however, he 
lived agahi for a moment that thrilling act of courage done in his 
youth, throwing back his bent shoulders, his emaciated form erect, his 
eyes flashing fire, shouting with a voice once again resonant: "The 
guards want powder ; the guards want powder, and they shall have 
it" — and then falling back dead. 

The pathetic fact seems to be, with regard to tuberculosis, as in all 
things else, that all phases of individual life, the physical, the moral, 
the mental, the spiritual, seem intimately blended and interdependent, 
so that the whole is affected by an abnormality in any one aspect. We 
may here note that as regards the moral nature the consumptive differs 
in no way from other chronic sufferers. 

The consumptive, however, as regards his psychism, has to con- 
tend with some factors which do not generally obtain in other chronic 
affections. It is no wonder he is sensitive, and that his sensitiveness 
makes him morbid, wdien others manifest fear because of his mere 
presence among them ; look upon him as if he had committed some 
crime ; are annoyed because of the cough and the expectoration com- 
pelled by his disease. 

"W'e might here adopt the old classification of mind (Tuke) into 
will, intellect, and emotions. The will, as all other mental aspects, is 
unstable and variable ; however, there is sometimes an extraordinary 
optimism. The intellect is often acute ; and sometimes it is oddly 
uncanny and outrP. The emotions of consumptives are very varied. 
Ecstasy, impulsiveness, obstinacy, irritability, abnormal energy, alter- 
nate witli depression, grief, disappointment because of non-improve- 


ment, such as has been hoped for; fear and aiixiely concerning their 
condition ; mortification because of the attitude toward them of people 
in health ; shock upon learning from the physician the disease from 
which they are suffering; homesickness among those in sanatoria; 
religious gloom, and perhaps terror, and the like.' 

* Cornet and Flick have notable contributions upon this important subject. 



Trockner HusIcti. todler Trdinprter.— Gf.rman Proverb. 

It's a groat chance, we find, to arrive io one's grave in this English climate, 
without a smack of a consumption, Death's direct door to most hard students, 
divines, physicians, philosophers, deep lovers, zealots in religion. — Gideon Harvey 

It appears to nif that the quality of tlie genius of a great man, if 
he be consuniplive, may be, in some cases at least, affected by his dis- 
ease ; perhaps this is due to the effect upon the nervous system of 
the toxins evolved in the body by the bacillus — a weird condition, cer- 
tainly. Robert Louis Stevenson's work would best illustrate, I think. 

1- lu. 1.— Robert Ldui.s Stevenson. 

this phase of tlie subject. Perhaps in liis case this equality of genius i 
to Avhich I refer may be temperamental, and would have appeared ^ 
equally if he had never been a consumptive. Certainly there are no 
more fascinating contributions to literature than this man's works. I 
touch upon certain passages. For instance, in the " Master of Ballan- 



trae,"the man who pretended deatli and was buried, and who, follow- 
ing an imagined Oriental custom, ''swallowed his tongue," remained 
for months beneath the ground, and, on being exhumed, manifested a 
gasp and a sound in the throat, showing tliat a spark of life still re- 

In Treasure Island, the reading of which has at least lialf a dozen 
times kept me up until well into the morning, there is the weird touch 
of the dreadful blind pirate, his quick, sharp footfalls coming nearer 
and nearer the inn in which the frightened boy lay, how he kept con- 
stantly tapping the hard pavement with his walking-stick in the clear, 
cold moonlight night, — an incident in literature similar in its ])sychology 
to Beethoven's " knocking of fate at the door" in the Fifth Symphony. 
Then again the way Long John Silver, the man witli the wooden leg, 
killed the sailor in the woods of Treasure Island, — how, as the sailor 
walked away. Long John balanced himself by grasping the branch of 
a tree overhead, on the instant got off liis wooden leg, 'et drive with 
it so that it struck the sailor square in the spine ; how then Long John 
hopped quickly to the prostrate man, and finished the job with a 
knife-plunge in the back — an uncanny incident, certainly. 

In the Bottle Imp there is that of the two men viewing the bottle, 
made of iridescent glass, within which could be seen some strange 
thing moving about, — how, his curiosity being too much for him, 
one of the men for an instant uncorked the bottle, and how, after 
a glance within, his face grew ashen and from that moment he was a 
sick and stricken man. 

Dr. Jekyll and Mr. Hyde is full of such strange touches as these, 
especially that ghastly turning of the benign face of Dr. Jekyll into 
the hideous face of his devil nature in the upper story window of 
a calm Sunday afternoon. There is surely here some sort of literary 
pathology manifested. 

In the realm of music Chopin has produced some so ravishing that 
it has been said : " It is wrong to produce music so exquisitely beau- 
tiful, of a beauty rather supernatural than of the earth." And again 
it has been truly said that after a piano concert devoted wholly to his 
compositions, the virile, normally masculine element has been found 
so lacking in them that one would wish to shout, to run, to do some 
feat of strength by way of establishing equilibrium. Much indeed of 
almost spectral beauty there is in this man's work, suggesting too in- 
sistently the white moonlight and exotic atmospheres. What mortal 
indeed will ever again, unless in a dream, liear such exquisite nmsic — 
music supernatural and not at all of the earth — as that in the trio of 
the First Polonaise ; or such plaintive melody, which sounds as if the 


compDScr were ooininuiiiiii,'' with spirit crcaluros, as is to bo found in 
the Nocturne (opus 37)? And lliat duo waltz passage (opus 42), 
^^ilich sounds as if it were the waiHug and the sighing of tlie spirit 
lovers whom Dante inunortalized. Nowhere else in music — not even 

Fig. 2.— Francois Frederic Chojjin. 

in the deaf Beethoven, nor in Tchaikowski, saturated with the dread- 
ful melancholy of the Sclavic race — appear such eerie harmonies, such 
strange phrases in sixths, such tender, heart-searching music as is 
characteristic of this composer. Nowhere else in music, perhaps, is 
there quite sucli as this. Is it in some measure because during the 
last ten years of his life — the most productive years, I suppose — 
poor Chopin was a consumptive? I have sufficiently elaborated my 
observation, however, in the examples of these two great men. I do 
not pursue tiie subject further, having no heart to mutilate the idols 
of my readers. Certainly what 1 have conceived concerning their genius 
in nowise decreases my affection and my gratitude for their works. 

Marie Bashkirtseff exhibited so many characteristics, such as are 
touched upon in the preceding section, that the disease from which 
she suffered cerlainly would appear to have im})ressed itself upon her 
temperament and her genius. Concerning her, Gladstone bade us be 


careful liow we deal with these same "abnormal beings, who seem to 
warn us common mortals, how we handle them roug-lily or lightly ; 
because they are above and beyond us, our arms do not encompass 
them." From this point of view, considers a critic, " we may perhaps 
find in her not alone that which repels, and is to be dreaded and 
shunned, but that which supremely attracts, which animates and in- 
spires us, — so glowing and redundant a vitality that our own faculties 
are intensified, our perceptions quickened, and our energies re- 
enforced. Centred in self as she was, there revolves around Marie a 
whole world of possibility and suggestion, — a world that is so often 
blank and inert to our dull sense, but that to her was luminous, 
plastic, and full of revelation ; visions of beauty beckon and invite 
her, lovely sounds woo her, and on all sides she is called out to the 
infinite. Like an .Eolian harp, her resonant nature vibrated at every 
touch. Art, music, books, nature, the whole gamut of the emotions 
swept over tlie strings that rang and finally snapped with the effort to 
express the ardent, concentrated, insatiable individuality that burned 
within her." Truly this critic had understanding. ^ In this same 
volume is set forth her affection for and kindness to Bastien le Page, 
whose death followed a few weeks after hers, and was due to the same 
disease. When he was too ill to walk he was often carried to her 
house, wiiere they lay, stretched out on two lounges, silent, dull with 
pain, letting their young lives drift away, " seeming to have no out- 
look, no hope, and at the last no apparent desire for another and a 
purer, more ideal life." This poor young woman died in her twenty- 
fourth year. 

We niay here introduce, as it were, a scherzo in a sonata other- 
wise sombre enough, — Joseph Jefferson's story in The. Cerdunj^ how he 
advised Artemus Ward, who was not in good liealth, to be careful lest 
the kindness of London should kill him. " On no account, in his 
delicate state of health, was he to expose himself after his entertain- 
ment to the pernicious etfects of a London fog. But he was weak and 
yielded to the influence of his many admirers. So his career was 
brilliant and brief. He had that unfortunate desire for the second 
round of applause, that is so fatal to the health and position of an actor." 
He died not many months after his London delnd, attended to the 
last by Tom Robertson. A strong attachment had sprung up between 
them, and the devotion of his now-found English friend was touching 
in the extreme and characteristic of Robertson's noble nature. Just 
before Ward's death, Robertson poured out some medicine in a glass 

1 The Century, May, 1890. 



and ollVrod it io liis iruMid. Ward said, " i\Iy doar Tom, I can't take 
that dreadlul slull'."' •• Coiiio, coiiio," said llobortsoii, iir^iiii^ liiiu to 
swallow llic iiausiHMis drii,>^\ "tliori''s a dear follow. Do now, for my 
sake ; you know 1 would do auy[liin<^- for you !" 

"Would you?" said A\'ard, feebly siretcliing out his hand to ^rasp 
his friend's, })erha[)s for llu' last lime. '• I would, indeed," said Rob- 

"Then you hiko ii." said Ward. The humorist passed away a 
few hours afterwards. 

Of Keats is here rejjroduced a porlrail, from a skelch made by 
Joseph Severn in 1821. It was in his last illness, and underneath it 

Fig. 3.— John Keats. 

is the legend: '• God bless you, my dear Brotlier and Sister. Your 
ever affectionate Brother, John Keats.'' Did ever a man feel the 
" W^eltschmerz"' as did Keals? Nothing can be added that would 
enhance tla? jioignant sadness inherent in his face. Severn made his 
portrait of Keats in his youth. He died fifty-eight years after his 
illustrious friend. 

'' Henry Timrod's life was so heartbreaking that one finds it hard 
to linger over it. The reader is constantly reminded of the cumula- 
tive sadness that was the lot of Keats." He had also Keats's sensi- 
bility of temperament, his sensitiveness to outward influences. Both 
these men suffered physically in tlie same way. Surely it was a sad 
time in the South. Timrod was born in Charleston in 1829. War 
was beginning to loom ominous. Timrod's muse was not for stirring 


tiling's, but for repose, for graceful love songs, for lyrics in praise of 
spring and woodland. "It was not time for music, and Timrod was 
not one to draw the gaze of busy men. Later, whon ilie fever of war 
heated his verse, men carried his stirring songs in their hearts, but 
forgot the singer. Later still, when they came ba(;k crushed and 
heartbroken, yet ready to take up manfully the struggle of life anew, 
it was still less the fortunate hour for the poet." The stress of poverty 
bore much on Timrod, and even in his sixteenth year his illness im- 
pressed itself upon hhn. He loved nature and the lonely and cloistered 
life he led in green fields and woods at this time. " He always re- 
mained a child ; yet he w^as a cliild only in his inability to cope with 
the hard conditions that beset him. In his mental attitude toward life 
he was manliness itself" ^ 

I hold always in affectionate remembrance a patient and a friend, 
originally a Marylander, — a tall, tliin, gaunt man, saturated with bon- 
homie, and with a countenance of extraordinary gentleness. He 
had been a newspaper man in New York City, and his "stuff" had 
been much in demand at one time in various papers — the sort of 
work that appears in the Sunday issues — not reporting, but the writing 
of stories and the like. His strong point was comic verses, children's 
stories, and the manifestation of much kindly, natural humor. In the 
course of time he contracted consumption, as others in his family had 
done before him. A profuse hemorrhage one night greatly frightened 
him, and he went away from New York for a time, spending most of 
his money in trying to regain his health. But he did not do well, and 
returned to New York to earn sufficient to recoup his fortunes. He 
did not succeed as well as before he went away. As is often the case 
in newspaper work, liis " stuff " did not go as well as it had formerly 
done. So week after w^eek for a number of months he was in want. 
During the visits I directed him to make to my office, his conversation 
was a most pathetic intermingling of pessimism with genial and amus- 
ing anecdotes. I happened once to touch upon the Civil War, — 
and never repeated the mistake. He was of a very old family whose 
proclivities had been warmly Southern. He became excited and spoke 
most bitterly against the North. His had been since Revolutionary 
times an honorable people, gentlemen and gentlew^omen ; their planta- 
tions had been conducted most wisely, and had yielded them great 
wealth, which they had dispensed judiciously and liberally, so that no 
human being within their ken, no dog indeed, needed any wholesome 
thing in life ; their slaves had been treated wdth the utmost humanity 

^L. F. Tuclier, in T7ie Century, February, 1881. 



and liad boon devotodly attacliod to thoni ; no man could pass through 
that country without oxporioncing, at least for a night, their kindly 
and gonorous "hospitality. But Northern carpet-baggers, unscrupulous 
men, tricksters absolutely devoid of the instincts of gentlefolk, and to 
whom the meaning of the word honor was impossible of conception — 
despicable victors, who recognized no other ri,L;lil than the might they 
ro[)resented — had come into his country, had made the fornuu* slaves 
discontented and unhapj)y, yearning again for the old order of things; 
had destroyed liis family estates, and made them devoid of fruition 
and improfitable ; so that his family, once rich and munificent, was 
now- without means. In such manner did my dear friend inveigli, 
coughing, sweating, trembling the while ; I doing my utmost to calm 
him, fearing a fatal issue even w'hile he was speaking. 

Well, he had been working upon a novel, tlie publication of which 
he felt sure would get him money and regain for liim his riglitful po- 
sition. He worked steadily at this, while I could see he was getting as 

steadily sicker and weaker. One 
day, the saddest of all, he told me 
a very good publisher had pro- 
nounced his novel excellent, and 
that it would be accepted if he 
would go over it tlioroughly once 
again, making certain changes. 
But this lie had not strength left 
to do. He vjQui South from New 
York after telling me this ; and 
there, in a few weeks, lie died. 
What has become of his novel I 
know- not ; it would have had at 
least one appreciative reader. 

Tuberculosis has exerted no 
little influence upon the plastic 
arts. Dr. Hillier gives instances 
to this effect. Consumptive models 
have inspired some great paintings. Simonetta Catanea, who sat for 
Bottic(,'lli, died of consumption at an early age. In his "Venus" the 
artist has faithfully, if not intentionally rejiroduced the sunken cheek, 
the long, slender neck, the steep, sloping shoulders. And the model 
most frequently engaged by Dante Galn'iel Rossetti, a modern disciple 
of Botticelli, was also a consumptive. j\Iany of his paintings '■ have 
that expression of suffering w^hich is undoubtedly phthisical in origin. 
A certain sweet sadness which attaches to these pictures is due to 

Fig. 4. — Botticelli's •• Venus." 



phthisis in tlie models. It is tlie appealing sadness of disease, and 
not the splendid natural beauty of health, as symbolized in the Venus 
de Milo." 

Literature and the arts have indeed given many hostages to con- 
sumption. In all the ways in which genius works — in the plastic arts, 
in verse, in romance, in poetic prose, 
on the stage, in music, both original 
and in the sympathetic faculty to in- 
terpret by song and instruments the 
outpourings of the composer's soul — 
how recklessly have such spirits de- 
spised the pains and the wants of the 
physical body, how generously and with 
what open hearts have they given to 
the world of theu* real selves, of all 
things universal the most valuable and 
the most imperishable ! One Avould 
think that in return for such precious 
gifts, the world would at least see to it 
that these benefactors should have no 

need of bread and sustenance. But how often have they perished 
for want of these things. How little, indeed, has the world, in any 
case, given them in return, — the sordid w^orld, that counts little of 
value which has not tangible form and which cannot be seen and 
eaten and put to material use. Strange irony of fate that those who 
love best the flowers, the expanding landscape, the kine in the fields, 
the pure air of heaven, the good, rich red wine of life, tlie pantheistic 
sunset — that those who love most to live and know best how to appre- 
ciate reality — must earliest succumb ! 

Fig. 5.— The Beata Beatrice. 



The most dangerous disease, and the one that proved fatal to the greatest 
number, was consumption. — Hippocrates. 

From time to time in the history of mankind some one disease or 
another has popularly been looked upon as the universal scourge. 
Thus has the Wandering Jew personified the cholera, which in various 
eras swept away enormous numbers. Dr. Hecker's book on "Epi- 
demics in the Middle Ages" reveals how like a blighting spectre the 
Black Death stalked through three continents. Before the beneficent 
discovery of Jenner smallpox had destroyed vast numbers of lives, so 
that oftentimes cities and towns were much more than decimated, 
and villages were swept entirely out of existence ; so that every other 
person met upon the thoroughfare would be a pock-marked survivor. 
The congener of such diseases as these in the present day is tuber- 
culosis ; and it is as certain as any human fact that such has been the 
case from time immemorial. It is likely to have had an existence at 
least coeval with man ; that our primordial ancestors, indeed, were 
afflicted by it in remote and nebulous ages. To-day the simian suffers 
from it probably more than does any other living thing. 

The physicians of all times, Hippocrates, twenty-five centuries ago^ 
and after him Galen, Celsus and others, had to contend with the Great 
White Plague, as we have to to-day. Its ravages have not exhibited, 
so terrible an aspect, nor have they been so grewsomely picturesc{ue ; 
nevertheless this insidious disease has always been far preeminent as 
regards the number of its victims. It has undoubtedly been more 
destructive than the sword to human life.^ It does seem odd, for 
instance, that in a city like New York an epidemic, say of smallpox, 
which may involve the deaths of a mere handful, will create a pro- 
digious panic, while consumption, which in this city destroys every 
year more than ten thousand in the most productive periods of life, 
receives com|)aratively so little attention. Only the other day it was 
reported tliat one man died in the Bronx Borough of smallpox. " There 
were three hundred or more people living in two adjoining tene- 

^Richat estimates the deatli-roll of all the wars of the nineteenth century 
at 14,000.000, and that of consumption in the same period and countries at 


ments, and they were exposed to the contagion for fifteen or twenty 
days." Our Health Department at once sent its physicians, who 
found the street in wliich the death occurred (•row(h'd with excited 
men and w^omen, many of whom dared not go home for fear of con- 
tracting tlie disease. 

Then followed a scene, the description of which is corrohorated by 
that of many a historical incident. The physicians prepared at once 
to vaccinate all within the sphere of the contagion. The tenants, 
mostly women and children, were very uneducated and w^ere of all 
nationalities, mostly Italian ; and there was generally a superstitious 
horror of tlie proceedings. Here and there frightened people fought 
fiercely and had to bo roughly handled before they could be vacci- 
nated ; many submitted only upon threat of arrest and imprisonment. 
The neighborhood was greatly excited over the news that one indi- 
vidual had died of small-pox, "and the police had to deal with a kind 
of panic." 

If a case of bubonic plague, or of yellow fever, or asiatic cholera, 
were to develop in New York City there would be newspaper '' scare- 
head" extras, and the greatest alarm Avould be felt ; and business and 
traffic to the city from the surrounding country would certainly be de- 
moralized. Yet, as we have noted, but little attention is given to con- 
sumption, a disease much more deadly than all of these put together, 
and much more inimical to human happiness. The terrible Black 
Death lived one year in London ; it killed fifty thousand. Consump- 
tion kills in the world at least 5,000,000 yearly ; in England and 
Wales alone more than sixty thousand a year. And of all deaths in 
the United Kingdom between the ages of twenty-five and thirty-five 
nearly one-half are due to this disease. 

And all this is so great a pity, because consumption is a disease so 
easily preventable ; and in most cases curable. And though death- 
rate statistics are impressive enough, still more so are the connotations 
of sufferings antecendent to death, of the periods of illness in the cases 
of the vastly greater number of the phthisical who have recovered, 
and of the hardships visited upon the families and friends of the 

Among the early Greek physicians there w^ere those who recog- 
nized the infective nature of tuberculosis. For instance, a physician 
of the time of Aristotle asked : " Why are those taken by phthisis, 
wlio are brought in contact with the sufferers, and not taken by such 
diseases as dropsy, fever and apoplexy, however close the contact with 
sufferers from tliis disease may be?" Phthisis, continues this physi- 
cian, is obviously infectious, because it si)oils the air and makes it 


heavy, and thus others become infected. That such views as these 
were g-enerally prevalent may be gathered from a speech by Isocrates, 
"who based the claim of his client to inherit his father's estate on the 
fact that he had nursed him whilst suffering from phthisis, although 
his friends had dissuaded him, saying that most of those who nurse in 
this disease themselves succumb to it. Galen clearly held that phthisis 
was an infective process, and that it was a danger to live with those 
who suffered from it. Ajihrodiseus declared that the phthisical patient 
send.^^ out during the expiration bad air, which, being rebreathed by a 
healthy person, would in turn convey tlie disease to him. 

But Aritaeus the Cappadocian (50 b. c.) left a description of the 
consumptive which cannot be improved upon in the present day. It 
is here reproduced : 

" Voice hoarse, neck slightly bent, tender, not flexible, somew^hat 
extended fingers, slender, but joints thick ; of the bones alone the 
figure remains, for the fleshy parts are wasted ; the nails of the fingers 
crooked ; the pulps are shriveled and flat, for, owing to the loss of 
flesh, they neither retain their tension nor rotundity ; and, owing to 
the same cause, the nails are bent, namely, because it is the compact 
flesli at their points wdiich is intended as a support to them ; and the 
tension thereof is like that of the solids. Nose sharp, slender ; cheeks 
prominent and red ; eyes hollow, brilliant and glittering ; swollen, 
pale or livid is the countenance ; the slender parts of the jaws rest on 
the teeth, as if smiling, otherwise of a cadaverous aspect. So also, in 
all other respects, slender without flesh ; the muscles of the arms 
imperceptible ; not a vestige of the mammae ; the nipples only to be 
seen ; one may not only count the ribs themselves, but easily trace 
them to their terminations, for even the articulations of the vertebras 
are quite visible ; and their connections with the sternum are also 
manifest ; the intercostal spaces are hollow and rhornboidal, agreeably 
to the configuration of the bone; hypochondriac region lank and 
retracted ; the abdomen and flanks contiguous to the spine ; joints 
clearly developed, prominent, devoid of flesh ; so also with the tibia, 
ischium and liumerus ; the spine of the vertebrae, formerly hollow, 
now protrudes, the muscles on either side being wasted ; the whole 
shoulder blades apparent like the wings of birds. If in these cases 
disorder of the bowels supervenes, they are in a hopeless state. But 
if a favorable change takes place, symiHoms the opposite of those fatal 
ones occur." 

During the Dark Ages Europe was essentially dominated by an 
unholy theology which required absolute submission and adherence to 
the teaching that plagues and epidemics were visitations of an angry 


God ; and tho tendency of this theology was to suppress a rational 
investigation of the causes of disease, such being lield to be a sort of 
sacrilege. As if indeed a just and merciful God would cruelly torture 
and destroy his own creations, which must appear to an omnipotent 
Creator (humanity must always have appeared to him thus) so pathet- 
ically helpless and innocuous ; as if reason and the ascertainment of 
knowledge Avere not states of the human mind as essentially God-given 
as any other, to be employed as conscientiously as any other; as if the 
use of tliese wholesome faculties were in any way incompatible with 
the possession and exercise of the deepest religious sense. Thus it 
was that many millions of lives were destroyed which might otherwise 
have been saved ; and, what will even much more appeal to the con- 
sideration of the humane, infinite w^retchedness and infinite pain could 
have been alleviated had it been possible to apply scientific measures 
to diseased conditions. 

However, let those who would consider this spirit of intolerance 
toward scientific research to have passed away, reflect upon the anti- 
vaccination movement which, in the most civilized communities, seeks 
to prevent the slight and harmless procedure, by means of which one 
of the most dreadful of scourges has been rendered practically obsolete. 
Moreover, the Health Boards of large cities have very great difficulty 
in enforcing the simplest sanitary regulations, not only among the poor 
and ignorant, but even among those who exhibit in most other matters 
the possession of elemental common sense. 

Then there are the pseudo-religionists of the present day, typified 
by the "Eddyots," who are causing much cruel suffering and many 
unnecessary deaths by their insistence upon the disregard of the 
simplest principles of sanitation ; some members of the community 
oftentimes becoming victims of the infection thus propagated. 

The candid student of history must admit that during the darkness 
of the Middle Ages in which Europe was enveloped, Mohammedanism 
exhibited a scientific enlightenment, the spirit of which is not excelled 
in modern civilization. There was among them a wonderful develop- 
ment in nearly all the arts and sciences ; and among the brightest 
jewels in this intellectual crown was Saracenic medicine. We may 
refer here only to Avicenna, the Arabian (1037),^ who, like the best 
•observers of antiquity, had definite ideas regarding tho infectivity of 
consumption ; he referred to " many diseases which are taken from 
man to man, like phthisis." 

' From the excellent book on " Consumption," by Dr. Hillier, to whom I am in- 
^1 debted for many of the data contained in this chapter. 


After the Renaissance, dissecUons were permitted and anatomy 
and pathology came to be more carefully studied throughout Europe, 
and in the middle of the sevenieenlh century tubercles or nodules were 
found in the lungs and first described. The connection between such 
tubcM'cles and jihtliisis was first demonstrated by Silenius, the Italian 
(d. 1G72). 

In the seventeenth century classic, "The Practice of Physic by 
Lazeriis Riverius/'' })ul)lishcd in London, the Ibllowing appears : 
" Moreover, there are external causes (of i)litliisis), as contagion, which 
is the chiefest ; for this disease is so infectious, that we may observe 
women to be infected by their husbands, and men by their wives, and 
all their children to die of the same; not only from the infection of 
their parents' seed, but from the company of him that was first affected. 
And this contagion is more easily communicated to them that are of 
kin, wherefore it is not safe for a brother or sister to enter into the 
chamber, for the miasmata, or vapors infective, which come from the 
lungs and infect the whole air of the chamber, and being drawn in by 
others (especially if they are in any way disposed to the same disease) 
beget the same disease in their lungs." 

Morton in 1689 taught that the tubercle was the pathological evi- 
dence of tlie disease in the lungs. And the idea of the infectivity of 
consumption was developed by the anatomists, especially the Italians 
Valsalvi and ^lorgagni. Under the influence of the latter, laws were 
made concerning the spread of phthisis which reflected the spirit and 
understanding of the Italian people of that time. In 1754, for instance, 
the sanitary magistrate of Florence asked for an expert opinion from 
the Florentine Medical College as to wliat articles would be most likely 
to be infected from the presence of a phthisical patient, and what means 
could be adopted to purify them. Antonio Cocchi therefore advised 
that phthisical patients who lived in large airy rooms exposed to the 
rising or midday sun, especially during the winter months, do not 
re(|uire more than that their rooms should be well cleaned and always 
purified by opening the windows as wide as possible. Rut phthisical 
patients were not in any case to be put in stuffy rooms with doors and 
windows shut, for still air increases the amount of putrefaction and 
makes it more dangerous to others. The sick should only spit into 
vessels of glass or dried })orcelain, which should be frequently and 
thoroughly cleansed. All the small rooms were to be thoroughly 
whitewashed, but in large rooms it was sufficient to whitewash up to 
a little above the lujight of a man. This advice, which reads almost 
like a circular of to-day on the subject, was the basis of an edict con- 
cerning tuberculosis, issued in 1857. 


The spread of the popular l)elief in the infectivity of phthisis may 
be inferred from a statement of Nocard that in 1750 the property of a 
^voman who had died of roiisuniplion, after having occupied the bed 
of another consumptive, was publicly and ollicially burned in the 
market place of Nancy. 

The present day tendency with regard to the separation of phthisical 
patients in hospitals had its forerunner in 17G0, wtien a hospital was 
erected in Olivuzza for the special accommodation of plithisical patients, 
who were moved there out of other hospitals in order that they might 
not spread the infection. The modern sanatorium is based upon 
much the same idea. 

In 1782 an edict was issued at Naples ordering the isolation of 
consumptives and the disinfection of their furniture, books, etc. Ex- 
cept for its historic atmosphere, this decree is in substance much like a 
circular issued by a modern health board. Thus: "The Deputies in 
this capital and the Governors or Locum Tenens in the Provinces 
should, immediately after the burial of a phthisical patient, be sure to 
have his rooms cleansed, the floors, wainscoting and ceiling renewed, 
the wooden doors and windows scrubbed and cleansed, and fresh 
l)lants introduced in order that the corrupt and infectious atmosphere 
may not be communicated to persons who live near; also that they 
should make use of any other precautions which physicians use in 
Hke cases." Again: "The GJovernors and Directors of the Hospital 
are ordered to keep apart the clothes, linen, etc., for the use of persons 
infected with this disease, that they shall be burnt, even in cases of 
cure, and that to provide ne^v clothes shall be the business of the ad- 
ministration in cases of poverty.'" 

The following penalties were imposed in this decree : 

" Those who oppose the officials making their inventories, isolating 
or removing the clothes to the crematorium, and the cleansing of tlie 
places where the patient died, sliall be sentenced to three years at the 
galleys or prison according to the condition of the person, and shall 
have three years imprisonment and three hundred ducats line.'' 
Pity these things cannot be done nowadays to a few Christian Scien- 
tists, Dowieites, and the like, without regard to personal conditions ! 
Again : "Regarding physicians who do not reveal the nature of the 
illness, they shall undergo a fine of three hundred ducats for the first 
offence, and for the second ten years' exile." Again: "Those who 
buy an infected robe shall have three years at the galleys, and those 
who sell three times the value of the robe sold, as a fine." "Those 
relations who refuse to send an infected person to a hospital, or remove 
such an one without the knowledge of the Officer of Health, shall have 


throe montlis' imi)risonnient if of low birth, or three hundred ducats 
if noble.'' 

In Sjiain and Portugal laws were also enacted providing- for the 
disinfection of the clothes, beds, etc., of consumptives after their 
deaths. For instance, in 1839 George Sand wrote, in a letter, of 
Chopin, with whom she was travelling, and who was already consump- 
tive, although ho did not die until some ten years after, thus : " Poor 
Chojiin. who liad had a cough since he loft Paris, became worse: we 
sent for a doctor — two doctors — three doctors — each more stupid than 
the other, who started to spread the news in the island that the sick 
man was consumptive in the last stage. As a result there was great 
alarm. Phthisis is rare in those climates, and is looked upon as con- 
tagious. We were regarded as plague-infestod ; and, furthermore, as 
heathens, as Ave did not go to the mass. The owner of the little 
house which we had rented turned us out brutally, and wished to 
bring an action against us to compel us to limewasli his house, which 
he said we had infected. The law of the island plucked us like chick- 
ens."' At Barcelona, as they w^ere leaving the inn, the landlord de- 
manded to be paid for the bed on which Chopin had slept, on the 
pretext that it was infected and that the police regulations recjuired 
that it should be burned. Fortunately, the science of to-day does not 
countenance such radical measures. 

In 1803 Chateaubriand wrote in Rome to a friend of the death of 
Madame de Beaumont : '• I am in a great ditiiculty : I had hoped to get 
2000 crowns for my carriages, but, by a law of the time of the Goths, 
l)hthisis is declared in Rome a contagious disease, and as Madame de 
Beaumont drove two or three times in my carriages nobody is willing 
to l)uy them." 

Concerning the history of the modern treatment of this disease, 
Latham instances the letter, in 1747, of "a Scotch physician," whose 
name is unknoAvn, in which he clearly asserts to his London colleagues, 
upon the incont(,'stable evidence of the results he had obtained, that 
hygiene and diet are the most important means of cure and that cli- 
mate and medicine are but nmre or less precious adjuvants. Never- 
theless, until fifty years ago both the public and most physicians 
regarded consumption as incurable. It was written in 1815: '-Even 
with the utmost powers of art, perhaps not more than one case in a 
hundred will be found curable." And in 1807 Ullesperger called at- 
tention to the fact tliat U|) to that time barely two hundred cases of 
cured, or what we slujuld now call arrested tuberculosis, were to be 
found in medical, as distinct from pathological, literature. A French 
writer, somewhat more hoiJeful, observed: "There are two kinds of 


consumption, — that of tlie ricli, which is soniotimes, and tliat of tlie 
poor, which is never, cured." The efforts of medical men liad been 
directed toward the comfort of tlie patients rather tlian the arrest of 
tlie disease. All cases, even those regarded as being in danger of 
contracting consumption, were wrapped up in heavy clothes, kept in 
a hot-house atmosphere and jealously guarded against exposure to the 
fresh air. We shall see by what means, and how triumiihantly the 
experience of the past is reversed in the present day. 

With regard to modern scientific researches : The physician Laen- 
nec, who himself died of consumption in 1826, was an exhaustive 
student of the disease ; he declared that phthisis followed upon the 
formation of tubercles in the lungs. Up to the time of Kieiike, in 1843, 
the views which were held concerning the infectious nature of tuber- 
culosis were not based upon direct experiment. He injected tubercu- 
lar matter into the jugular vein of a rabbit, and six months later found 
tuberculosis in its liver and lungs. And in 1865 Villemin also demon- 
strated that tuberculosis was a specific disease caused by a specific 
agent. By injecting tuberculous material from a phthisical patient 
beneath the skin behind the ears of a previously healthy rabbit, he ob- 
tained as a result the development of tuberculous nodes in this animal ; 
while, on the other hand, if he inoculated non-tuberculous material, 
no signs of tubercles were produced. 

But it was reserved for Robert Koch, of Berlin, in 1881, to discover 
the bacillus which he demonstrated to be beyond peradventure the 
specific cause of tuberculosis. 

Part II 


In 1882 Robert Koch announced to the world his discovery of 
the tubercle bacillus. His paper on " The Etiology of Tuberculosis" 
(jjrobably the most far-reaching in its importance to the welfare of 
the human race of any original communication), based on experi- 
mental research, at once threw a flood of light on the darkest page 
in the history of medicine, a light which revealed the microscopic 
fungus wliich is the direct cause of tuberculosis, gave a new impulse 
and opened a new horizon to medical thought. 



But, the great fundamentMil adviuice which signalizes the past decade is the lift- 
ing of lliis whole class of fateful genu diseases out of the region of the intangible 
and mysterious, and their establishment, on the basis of positive experimental re- 
search, in the domain of the comprehensible and definite. The things Avhich cause 
them are no longer for us mysterious emanations from the sick, or incorporate ex- 
pressions of malign forces against which conjurations or prayers could alone promise 
protection. But they are particulate beings, never self-engendered, never evolved 
in the body, always entering from without, — things which we can see and handle 
and kill. — Prudden. 

When, a few decades ago, the microscope was brought to a degree 
of development approximaling its present well-nigh perfect state, the 
study of an extraordinary phase of cosmic life became practicable. It 
was revealed that there are germs, or bacteria, or microbes, or micro- 
organisms, invisible by ordinary sight, without whose activity living 
would be altogether impossible ; and it was Louis Pasteur who first 
developed the knowledge of these things. Being in the earth, the 
air, the water, in our food and drink, the existence of most of these 
germs is altogether salutary. They thrive for the most part upon 
dead organic matter, upon material such as has at one time or another 
been a part of some living object. And it is their business to render 
possible the conversion of oxygen, hydrogen, carbon, nitrogen, and 
other elements necessary to animal existence into visible vegetation 
and other food products upon which animal life may subsist. Each 
germ acts as a minute chemical laboratory, absorbing the organic 
matter upon which it feeds, and resolving it into new compounds^ 
using a part of these for its own sustenance and reproduction, and 
giving off the rest into its environment. 

But among the many varieties of these germs there are some — 
comparatively a very few — which have proved inimical to animal 
health. And these have been studied with special care. There are 
three subdivisions of them, according to their appearance under tlie 
microscope : First, the bacilli (a rod) are rod-sliaped or perhaps slightly 
curved. (Fig. 9 B.) Such are responsible for tuberculosis, typhoid, 
cholera, and many other diseases, each causing its own particular dis- 
ease, and having distinctive features by which it is distinguished from 
other germs. Second, there are the cocci (a berry), which are berry- 




shaped, aiul which are of two sorts — the streptococci, which in multi- 
plying assume the chain formation, and the stajjliylococci, the groups 
of which a})i)ear like bundles of grapes. (Fig. 9 .1.) These cocci are 
generally afliliatcd with the bacillus of tuberculosis in the later stages of 

Fiii. s.— Germ multiiilication. 

Fig. 9.— Varieties of bacteria. 

the disease. Then there is a third form of 
bacteria, the spirillum, wliicli is responsible 
for certain fevers. With this, however, 
we have here nothing whatever to do. 

When a species of these bacteria gains 
lodgement in a vulnerable body, one suita- 
ble for its growth, the germ multiplies 
witli inconceivable rapidity. This is the 
reason why germ diseases are infectious or 
communicable. Every case arises from a 
preceding case. The infection originates 

in parasitic life, and is due to the propagation and dissemmation of 
these parasites, which take from the nitrogenous tissues of their 
"liosts'' material for their own nourishment and growtli. In turn 
tliey evolve and set free subtle poisons (toxins). It is these toxins 
which cause the temperature, the rapid pulse, the chills, and the other 
symptoms constituting the infective process. 

Let us emphasize here the vulnerability of the tissues. It is a 
matter of common observation that tliere are some who will contract 
an infection, while others living under the same conditions and cir- 
cumstances will escape. The fact is that there are two elements 
which are essential to the development of an infectious disease. In the 
first place there is the presence of the specific cause, and in the second 
place there is the condition of the bodj' — a tendency or a predisposi- 
tion — which renders it fruitful soil for the development of the germ. 

Tliis tendency or susceptibility to tuberculosis is a relative, not 
an absolute term, and there are a number of modifying considera- 
tions. For instance, it may be inherent in individuals ; or in races, 
as the negro. It may be natural, or acquired, or inherited. It 
is influenced by starvation, alcoholism, shock, sudden changes of 
temperature, fatigue, worry, or bad ventilation in dark rooms. Then, 
as regards the bacteria themselves, if their number is below a minimal 
amount, they are not effective ; if the dose of tlieni be maximal, 
one is the more easily affected. Then, again, the animal body has 


the power to produce C(Ttaiti substances, Avliich arc formed during 
exposure and which protect it against micro-organisms and their 
products or toxins and to neutralize these poisons. The nature 
of these substances is as yet vaguely known, but both the cells and 
, fluids in the body are concerned in their evolvement. There are 
I several theories upon w^hich explanations of this protective action on 
the part of the tissues and juices are based. That of Metchnikoff, 
though by no means conclusive, is very interesting. He declares that 
there is a property inherent in the leucocytes (the white cells in the 
blood and the wandering cells in the tissues — under certain circum- 
j stances the "pus cells"), and in certain other elements, by which the 
' invading organism is attacked and devoured. This is phagocytosis. 
A microscopic battle is assumed. The organism is safe if tlie phagocytes 
are able to devour the attacking germs. Disease results if the invad- 
ers are able to overcome the phagocytes. Of these contending forces, 
one is bound to succumb to the physiological demands of the other. 
The bacillus of Koch is a non-mobile organism. It cannot move by 
itself and must be carried around by other agencies. Thus can the 
leucocyte, by means of the amoeboid properties which it undoubtedly 
possesses, the more readily devour and destroy the germ. 

This theory of the physician-philosopher seems fanciful and has 
an eerie interest, because of the sentient properties implied in the 
leucocyte. It will seem less fanciful if tlu' behavior of the amoeba, a 
unicellular organism, be studied in relation to the processes by which 
it maintains its existence. 

I think this is a good place to get rid of the term contagion. This 
is applied vaguely to diseases contracted in indefinite ways, or by 
exhalations, etc. We speak, for instance, of diphtheria, measles, or 
scarlet fever, as contagious diseases. The practical point is this : One 
cannot be sure, after having been half an hour in the same room with 
a diphtheria patient, that he will not contract this disease. On the 
other hand the infection of tuberculosis is disseminated through the 
medium of air-borne droplets of sputum, or particles of bacillus-laden 
dust, and in bacillus-carrying food and drink. The mere breath of 
the sufferer does not convey the infection, the manner of which is 
thoroughly well understood. We shall find that one may live with a 
consumptive for months or years without jeopardizing his health, by 
observing certain definite and very simple directions whicli science has 
formulated. The term infection is all-comprehending. "It implies me- 
diate or intermediate, direct or hidirect contact, and it does not con- 
vey the vague and false sense of terror implied in the idea of a conta- 
gious disease. Let us drop the latter term. 



The kaloidoscopic ])h('n(Mii(Mia of this earth as we see them around us are the 
result of a continuous alternation of life and death. In this beautiful jjanorania 
death is as necessary as life. Something is always dying that something else may 
live. Inorganic matter continuously is bemg changed into organic matter and 
organic into inorganic. For changing organic matter into inorganic matter God 
has created the micro-organic world. 

A micro-organism which, perhaps, has slipped away from its natural place in 
organic nature, and in consequence has done much damage to man, is the tubercle 
bacillus. — Flick. 

I.\ 1881 Dr. Robert Koch, of Berlin, discovered the bacillus which 
is the specific cause of tuberculosis, and his investigations were con- 
ducted in conformity with the following rigid requirements, which he 
hhnself formulated : 

1. — The micro-organisms must be found invariably in a given 
disease and in no other, tlieir numbers and distribution conforming to 
the lesions of the disease. 

2. — The micro-organisms obtained from lesions of the disease nuist 
be capable of reproduction in pure cultures. 

3. — These cultivated germs must be capable of producing the 
disease if inoculated on a susceptible aniiual. 

4. — These artificial lesions contain the specific organisms. 

This bacillus is a fungus, of the class of vegetable micro-organisms, 
and is a slender, straight, or slightly curved rod-shaped body, in length 
about 1/10,000 of an inch. The biologist considers it to have become 
in the process of evolution an "obligate"' parasite, one of the class of 
germs which can subsist only upon the living animal liost. But it is 
probable that originally this bacillus was a "saprophyte." when dead 
organic matter was its natural hal)itat, and that, as Dr. Flick has ob- 
served, it has somehow slipped away from its })roi)er place in nature. 
This is a notable, though a very grewsome point, and one fit to be 
touched upon by Robert Louis Stevenson in one of his most uncanny 
moods, — that next to dead organic matter, the bacillus thrives best 
upon tissues which are made non-resistant hosts by reason of the de- 
moralizing effects of poverty, alcoholism, vicious heredity, and like 
factors. Even excessive cold will not kill it. It may live for many 
months — for years — in dark, foul, and dami) i)laces. Boiling, heat, 



and certain disinfectants destroy it. It seems, however, to have got so 
acclimated to its parasitic existence that it now rarely multiplies out- 
side the animal body except under laboratory conditions. At the 
bodily temperature it develops in such substances as glycerinated beef 
tea, — but slowly, recfuiring from two to three weeks for any consid- 
erable growth. It will not flourish in other temperatures than be- 
tween 90° to 100° F. Under favorable circumstances of multiplication 
a mass of these bacilli accumulates — a colony — which may be appre- 
ciated by the naked eye. 



There is every reason to believe that, though tubercle bacilli may live for cer- 
tain lengths of time outside of the animal body and may be cultivated on specially 
prepared media, they flourish only in the living body, and that if dissemination of 
the bacilli from diseased animals and human beings could be prevented the malady 
could be arrested. — ManjUotd Tnherculosis Commission. 

When the Koch bacillus becomes hiiplanted in any part of the 
body, it causes an inflanmiation with the result that there is a rapid 
multiplication of the tissue cells of that region. These abnormal ele- 
ments gradually increase in bulk until a tubercle is formed, a structure 

Fig. 10.— The lungs. (Courtesy of T. H. McAllister.) 

at first microscopic in size, becoming when visible of grayish or pearly 
appearance. These tubercles may exist in any part of the body, in 
the skin, the lymph glands, the liver, the spleen, the kidneys, and 
especially in children in the bones and joints, and the membranes 
covering the brain. It will suffice to describe those in the lungs, 
where they are most abundant ; here their appearance is typical. 

The healthy lungs are fairly well represented in Fig. 10. The 
trachea subdivides into the right and left bronchus, which ramify into 
their r(.'spective lungs. Tlie minute subdivisions of these bronchi are 
the bronchioles, the terminations of which are into air vesicles. 


Fig. 11. — A miliary tubercle X 300 and reduced. Involving two air-vesicles, of which the walls 
are infiltrated and tlie cavities filled with tubercle tissue. The blood-vessels of the air-vesicles are 
injected. (Delalield andPrudden.) 











Fig. 12.— Miliary tubercle in lung of child, showing the Bacillu.s tuberculosi.s— stained 
with fiichsin— in the contents of the air-vesicles and in tlieir thickened walls. (Delafield 
and Prudden.) 



Around llio latter arc capillary networks tlirouf^h which Uw venous 
blood is conveyed from the heart, to render up its carbonic acid and 
other waste substances into the air vesicles to be exhaled. On iiisjti- 
ration, the life-sustainin!,^ gas is taken into the air vesicles, from which 
it is absorbed by the blood containcMl in the capillaries which return 
to the heart, whence it is pumped through the arteries to the remotest 
tissues of the body. In Fig. 11 the spaces marked " N" are normal 
vesicles. But in two vesicles tubercles have formed, so that in these 
at least the normal function is destroyed. In Fig. 1 2, from a child's 
lung, we see the bacilli in the substance of the tubercles. In this product 
of disease there is no blood supply in the normal sense ; wherefore, 
and because of the irritation due to the presence of the bacillus and its 
toxins, one of several things results. Generally there is local death of 
tissue, resulting in ''cheesy" degeneration and liquefaction. Several 

Fig. l;! —Cavities in luns tissue, 

adjacent tubercles may break down together ; and then the purulent 
material, teeming with millions of bacilli, will be coughed up through 
a bronchus as the sputum of the consumptive. Thus does a cavity 
result. These are sometimes found upon autopsy to be so enormous 
that one is amazed how the patient could have lived at all with so 
much of the lung destroyed. Then an artery or a vein may be 
eroded during the tubercular process, so that hemorrhage from the 
lungs may occur. In such manner also may the products of tubercu- 
lar disintegration be carried by the lymph and blood channels to other 
parts ; and it is probable that in many cases the pulmonary type of 



tuberculosis is not a U^sion of the lutig tissue, but a jn'oduct transferred 
from a point of iiiiplantaliou elsewliere. 

If much broiven down tubercular material should gain access di- 
rectly to the circulation, the blood stream may carry the infection to 
many vital tissues, and '' miliary tuberculosis" will result ; this is a 
very dreadful form of the disease iu wliich there is rapid infection, 

Fig. 14.— An old miliary tubercle converted into fibrous tissue. ■ yu and reduced. 
(Delatield and Prudden. i 

with very pronounced and fatal symptoms. However, other and 
more favorable processes are likely. The connective tissue cells 
are often able to build a dense wall about the affected region, shutting 
it off from normal jiarts. Or a fibrosis results (Fig. 14) akin to the 
scar whicli follows a cut wound of the skin. This is a process of heai- 
hig which obtains when the patient gets well of his consumption. Or 
there is a deposition of innocuous lime salts, taking the place of tissue 
previously tubercular. 

Tiie advanced consumptive, in coughing, emits several billions of 
these bacilli in twenty-four hours. It would seem then that this germ 
is all-}jervasive. There have, indeed, been calculations made which 
would seem to substantiate this gloomy view, and which would war- 
rant the pessimist in tlie opinion that nobody can escape tuberculosis. 
However, this germ is in reality not ubitpiitous. Besides, outdoors, 
where there is fresh air aud sunlight and })ure water, the bacillus 


has little chance of life. It is only in lionses (enclosures of all 
sorts) that are dark and damp and ill-vciiiilated that tuberculous 
infection is to be feared. Besides, as we have seen, even though the 
bacilli enter the tissues of the healthy body, there are forces within 
tlie organism which are continually at work destroying these germs 
and nullifying their pernicious activity. 

Besides the means of protection stated there are the following : 
The nasal air passages are tortuous and lined with a moist mucous 
membrane, against which the inhaled air impinges. Thus are dust 
and many^ germs held fast, and perha})S expelled in blowing the nose. 
(Mouth-breathers do not enjoy this safeguard.) Many bacilli are 
liawked and S})at out. Then there are in the air passages, down to 
the bronchioles, delicate membranes made up of cells, the free borders 

■I :'■ ^-^ 

^ mHMmW' ^ =^^ 


Fig. 15. — Cells with cilia upon their free borders. 

of which have hairlike projections ; these '' cilia"' work continually 
with a forward motion, so as gradually to expel germs and other 
deleterious objects. 

Then certain juices of the body, and the lymph vessels and glands, 
are very important factors in the destruclion of the bacillus. The 
vessels drain the lymph from the affected areas ; and the glands ar- 
rest the invasion and act, in so far as they are able, as a barrier to the 
progress of the disease; their own structure, may be, being finally 
broken down and destroyed in the struggle. 

We find, then, that the bacillus of Koch is tlie specific cause of tul)er- 
culosis ; this disease does not exist in the absence of this germ. 
However, the entity tuberculosis is, as we shall see, the resultant of 
many factors ; and we will be cjuite accurate in saying that the tubercle 
bacillus is really an index of the complex of symptoms which we call 
tuberculosis. Tliere are indeed other germs which act in conjunction 
with the Koch bacillus, tlieir pernicious activity being generally subse- 


quenl, to its own, and these allied micro-organisms — the cocci — are 
ahvays present whenever the disease has assumed a serious aspect. 

Two or three terms may here be defined : 

I'lithisis means the same as consumi)tion, — a consuming or a wast- 
ing away. One term is Greek, the otlier from tlie Latin. 

There is a distinction between the terms " tuberculosis" and " con- 
sumption.*' As we have observed, very few^ of us die without some 
evidence of the activity of the tubercle bacillus ; however, in most of 
us tlie presence of tubercles is not evidenced ; but when the character- 
istic symptoms of the disease in the lungs are manifested, tlie term 
consumption is employed. However, I shall not in this book ad- 
here to this distinction. 



Every person is exposed to the danger of taking np the germs of tuberculosis 
into his own system, and many harbor them a long time without knowing it. 
Everv one must therefore be prepared for battle with this enemy. — Imperial Board 
of Health of Germany. 

The bacillus is generally found in the sputum of the consumptive ; 
the air which he exhales is not considered to contain it, and is there- 
fore not infectious. But the consumptive's sputum, when emitted, is 
taken up in the dust of the atmosphere ; or minute droplets of the 

Fig. 16. — Consumptive father witli infant as yet unaffected. 

Infected sputum may be conveyed by the wind. Then, if this dust or 
spray is breathed by susceptible people, they will be in danger of con- 
trading tuberculosis. It is such transfer of this parasitic organism, 
from one body to another, which makes consumption a communi- 
cable disease. 

And the sputum may be infectious in other sometimes very loath- 
some ways than by inhalation. Infants may become infected by 
picking up on the floor, while they are playing, objects upon which 
sputum may have been deposited, and, after the fashion of infants, 
they will put these objects into their mouths. The suckling may con- 



t the disease by contact from its consumptive mother. The hands 
/the consumptive, his Ups, his moustache, his beard, his napkin or 
andkerchief. may be bacilins-laden : and liis kisses may transmit the 

Besides being inlialrd. tlie bacillus may, not so frequently, be in- 
gested with the meat of tuberculous cattle, or the milk of tuberculous 
cows ; for other animals than the liuman species suffer also from 
tuberculosis. There has of late been some cjuestion of the likelihood 
of the transmission of bovine tuberculosis to man. Koch has denied 
this ; on the other hand very many careful scientific workers em- 
phasize the danger of such transmission. We will presently review 
briefly the situation, being content here to observe that if milk or 
other fluid is tainted, or if meat be diseased, nobody wants to eat 
or drink either of them, irrespective of any consideration that may 
be inferred ; nor should anybody want that his neighbor should 
have such things to eat and drink. 

A third and comparatively rare mode of infection is through 
wounds. Oftentimes there will be a tuberculous nodule at the seat 
of the injury. And in many cases the infection does not proceed 
beyond this nodule ; so that merely a local tuberculosis will result. 

All solutions of continuity of the skin and mucous membranes, 
either accidental or surgical, may facilitate the entrance of the bacillus, 
— as poisons of the skin and mucous membranes, bites, scratches, 
penetrative wounds at autopsies, such as physicians may inflict upon 
themselves, insect bites, tattoo marks, abrasions from pointed promi- 
nences of teeth or trom extractions of teeth, burns, wounds of the 
navel, sliglit injuries due to digging in tlie nose with the finger or 
puncturing the ears for rings, irritation from contact of different parts, 
injury of the eye. Blows may, moreover, act by contrecoup ; for 
instance, on a cheesy bronchial gland or on a tuberculous focus of the 
lung, so that an infection may be engendered, if the bacillus be thus 
made to enter the circulation. 

Bacilli have been found in the abdominal cavity and fa3ces of flies, 
which had sucked at the sputum cloths of consumptives. Thus these 
insects may be carriers of infection. Their activity, however, is 
limited to a few months in a year, and the amount of the dejecta in 
comparison to a single expectoration is minimal, and not important. 

Reinfection is always possilole. An implantation may have taken 
place at a time when the individual organism has been below par as 
the result of some predisposition. Perhaps the reinvigorated system! 
has destroyed this implantation. However, there may be recurring 
implantations with recurring infections. 



The chiof difference between them (the human and bovine bacilhis) is their 
virulence. The bovine tubercle bacillus lias a pathogenic power tremendously in 
excess of that shown by the human bacillus, and this holds true for all experi- 
mental animals which have been tried, with the exception, perhaps, of guinea- 
pigs and swine. These two animals are so susceptible to both types of the bacillus 
that it is hard to draw a distinction. The animals experimented on include horses, 
donkeys, sheep, goats, dogs, cats, rabbits, guinea-pigs and monkeys. There is 
absolutely no case in literature, so far as I am aware, in which one single animal 
has been found to be more susceptible to the human tubercle bacillus than to the 
bovine. This greater virulence of the bovine tubercle bacillus is shown by what- 
ever method of inoculation we use. — Ravenel. 

Before 1901 the medical i)ro{ession were in general accord finuch 
more so than on most subjects) concernmg the practical identity of 
human and bovine tuberculosis. In that year Koch stated, in an 
international congress in London, that according to his belief the 
human and bovine varieties were essentially different and not inter- 
communicable. This statement created no little surprise, in view of 
the large amount of scientific information that had been gathered up 
to that time, the gist of which was to demonstrate tuberculosis infec- 
tion by means of the meat and milk of tuberculous cattle. However, 
in the light of this opinion, by so great a man and so earnest a 
worker, it was very desirable that further investigations should be 
made. And since this memorable meeting much further work has 
been done upon this subject in America and in Europe, both privately 
and under official auspices. A royal commission was at once 
appointed in England. Its findings, but lately published, are quite 
averse to Koch's views. 

If equally competent workers get differing results from their tasks, 
it might be hard to say why one set of experiments failed and why 
another succeeded. However, negative testimony must always be 
less valuable than that which is positive. To discover experimentally 
if human tuberculosis is transmissible to cattle is easy, though unfor- 
tunate for the cattle ; this result has been obtained in so many in- 
stances that there is no room for doubt in the candid mind. As an 
odd instance of how such infection may come about hidirectly Dr. 
Darlington, the New York City Health Commissioner, states that in a 
hospital to which he was visiting physician, consumptives were allowed 



to play quoits in a pasture near tlic iiospital. At this time tliey did 
not use their spit-cups and spat upon the grass. Ten cows grazing in 
the same pasture were killed, and it was found that nine of them had 
general tuberculosis. On the other hand, deliberately to inoculate 
human beings for experimental purposes is not feasible, to say the 
least. However, it has been done, both by accident and intentionally. 
If disease has positively been transmitted by feeding or inoculation in 
only a limited number of cases, the fact certainly indicates an alarm- 
ing possibility. Part of Koch's error lay in that in his researches he 
looked in the wrong plare for effects. He fed tuberculous human 
sputum to undoubtedly healthy calves. And when he killed them a 
few months later he examined their intestinal canals. He could find 
no signs of disease there, and so inferred the animals had not been 
infected. Other observers repeated these same tests and did find 
results of infection by looking for them in other places besides 
the intestines. Dr. Sidney Martin, of the Commission, found such 
results ; as did also Ravenel, of Philadelphia, whose investigations are 
scientific and important in the last degree. Ravenel fed bacillus-laden 
butter to healthy animals, and having killed them shortly after their 
meal, found bacilli in the products of digestion in the thoracic duct, 
although the intestinal tract showed no evidence of tubercular infec- 
tion. Indeed, many experiments have shown that the tubercle bacillus 
may penetrate the healthy nmcous membrane and not leave any 
indication of its passage. It lias become established that the course 
of ingestive infection is oftentimes through the lacteals (the lymphatic 
vessels of the intestines), thence to the thoracic duct, and so to the 
great veins, to the right heart, and finally in the venous capillaries to 
the air vesicles. The commissioner found, moreover, that of twenty 
strains of human origin, seven gave rise at once in cattle to acute 
tuberculosis with widespread infection of lungs, spleen, liver, lym- 
phatic glands, etc. In some instances the disease was of remarkable 
severity. The other strains, with two exceptions, produced a more 
or less localized lymphatic infection, with almost a very small amounl 
of tubercle in the lungs and spleen. Tuberculous material, however, 
taken from the bovine animals thus affected, and introduced succes- 
sively into other bovine animals, or into guinea pigs, from wliici 
bovines were subsequently inoculated, has, in the case of five ol 
these strains, ultimately given rise to general tuberculosis of ai 
intense character. In the case of two strains the disease produced b] 
the inoculation was limited t,o the spot into which the material wa 
introduced. This occurred in two instances only at the very begin 
ning of tlie inquiry. The disease thus set up in the bovine animal b 


material of human origin was compared with that set up in the bovine 
animal by material of bovine origin ; and the one, both in the broad 
general features, and in its finer histological details, was identical with 
the other. The Commission failed to discover any character by which 
the one could be distinguished from the other, and states that its 
records contain accounts of the necropsies of bovine animals infected 
with tuberculous material of human origin which might be used as 
typical descriptions of ordinary bovine tuberculosis. 

Again, Koch assumed that bovine tuberculosis could not be trans- 
mitted because he found that there are among children an exceed- 
ingly small proportion of cases of intestinal tuberculosis. Besides the 
contradictory considerations here advanced, the possD^ility of latency 
in this disease is worthy of note. It is certain that milk may occasion 
tuberculosis among human consumers. The conclusions of the Com- 
mission and of many individual experts are here exceedingly impor- 
tant. The Commission found that from twenty-five to thirty per cent, 
of the milch cows in England were tuberculous. Even in private 
herds, under as perfect care as is possible, does this disease exist ; in 
one instance, one-half in a herd of sixteen, the lesions being evident 
in the slaughtered animals. 

The Lancet^ then, observes quite rightly that the conclusions of the 
Commission should prevent " the framing or modifying of legislative 
measures in accordance with the view that human and bovine tubercle 
bacilli are specifically different from each other, and a wholly different 
thing from the disease caused by the other." 

And we must conclude that the great German is mistaken in the 
position here indicated.^ 

^ The papers of Ravenel and Salmon are very informing upon this subject ; 
they give the names of more than fifty workers in the field of animal tuberculosis. 



There is always some levelling circumstance that puts down the overbearing, 
the strong, the rich, the fortunate, substantially on the same ground with all 
others. — Emerson. 

Therk is oftentimes a period of latency in tuberculosis. Exactly 
how this comes about is not well settled. There is the view that the 
bacilli, after having become located in a tissue, remain inert in the 
body for a time ; toxins may have been evolved, but not in sufficient 
amount to produce symptoms. This condition has been demon- 
strated in the febrine, a silk-worm disease. Here the pathogenic 
bacteria can actually be seen in tlie egg ; but they are quiescent 
during the germ stage, and do not develop until the growth of the 
caterpillar begins. 

Deaths from consumption are, with relation to other periods in 
life, infrequent before the fifteenth year, and the symptomiS of the 
disease, moreover, are manifested with comparative rarity before then. 
Pulmonary tuberculosis is rare before adolescence. But from the 
iiflcciith to the forty-fifth year every third or fourth adult dies of 
consumption, generally of the lungs. When we consider that infants 
and children are certahily as much, probably more, exposed than 
adults to tuberculous infection, we must infer that there has in many 
cases been a period of latency during which the infection has lain 
dormant tlirough the earlier years of life, until active infection has 
been induced by the advent of some acute exciting cause. 

The student has found such latency to be even more marked in 
other infectious diseases, such as syphilis, Avith which, for purposes of 
observation, tuberculosis may be compared. Of course, these are tw^o 
distinct morbid entities. Children, who have been impregnated with 
syphilis, may appear normal in infancy and childhood, and may not 
manifest this latent specific infection until the fifteentli or twentieth 
year. In the play, " (diosts," the symptomatology of cerebral syphilis 
in a young man, in whose previous life no manifestations of the dis- 
ease had ajjpeared, is set forth in a most grewsome manner. It may 
seem poor science to cite for an example a character portrayed by a 
dramatist for the stage. However, it is said that Ibsen got his basic 
facts from a physician profoundly learned in syphilology ; and no 


medical man will question the ghastly reality of the picture. Tuber- 
culosis differs essentially from sy|)hilis in that in the vast majority of 
cases it is not the disease itself hut a tendency to it whicli is trans- 
mitted by the parents. This vulnerability is exhibited in the scrofu- 
lous temperament with which such children are born. Upon such 
tissues the bacillus engrafts itself with peculiar ease in infancy and 
childhood. Even in children born healtliy, however, there is no 
difficulty about the reception of the Koch bacillus in the organism, 
and the analogy with syphilis seems from this point complete, — tliat 
the tubercle bacillus may remain inactive for years in some perhaps 
remote portion of the organism, such as a lymphatic gland, the bone- 
marrow, or a joint, until a blow, the shock of an operation, an aber- 
ration of adolescence, an acute fever, or some other exciting cause, 
may provoke it to pernicious activity. 

C II A 1' T E {{ \ 1 1 


When an organism, sulyecled to the action of some influence noxious to certain 
otiicr organisms, is found to be insusceptible to it, tliat organism is said to be 
iiinininc from that i)articul;ii' iioxa. — Barkeh. 

I HAVE stated that one may inherit a tendency to tuberculosis from 
one's parents. Nevertheless, it actually happens sometimes that one 
receives from his tuberculous ])arents an inmumity to tuberculosis. 
For inslance, a fatlier died at thirty-six of consumption, leaving six 
children, all of whom are now living, and the youngest of whom is 
even older than the father was at the time of his death. There has 
never been any manifestation of tuberculosis in any of these six chil- 
dren, except to a slight degree in the youngest. Of the four sisters, 
all of whom are excellent specimens of normal, vigorous womanhood, 
three have large families of very healthy children, — one, the wife of a 
Methodist clergyman, having the largest and an altogether stout 
offspring. Of the two strong Jjrothers, the elder, a man of forty- 
seven, has been under the imputation of using false teeth and of wear- 
ing a luxuriant coal-black wig from ^vhich gray hairs have been care- 
fully excluded, so serviceable and hardy do tliese members continue ; 
and their virility are an index of that of his frame generally. And 
this is the more remarkable since this elder brother is a poet and a 
Bohemian, wlio sedulously disobeys every hygienic canon that was 
ever invented with the unctuous abandon of a college freshman. 

Not a few cases akin to this, exemplifying the transmission of an 
innnunity, are to be found in medical literature. ' 

Witli regard to immunity, tuberculosis is akin to other infectious 
diseases, and the matter will be better understood by a considera- 
tion of the general subject. One is said to be immune when he is not 
susceptible to the action of bacteria and their toxins, such as affects his 
fellows. Inherited immunity has been found ex})erimentally in anthrax 
and tetanus; here the offspring enjoy a " nataral" innnunity handed 
down by either parent. This natural or innate imiiumity obtains 
in species and races, wilh wide differences, however. Mankind 
is susceptible to many infectious diseases, such as tyi)lioid fever, and, 
markedly, syphilis ; these, in the ordinary course of nature, never occur 

1 Flick, King. 


in other creatures. Different races of men vary much in their sus- 
ceptibilities. Tlie negro is very prone to leprosy and tuberculosis, but 
is iH-actically immune to malaria or yellow fever. Then tliere are many 
infectious diseases which yield inniumity by a single attack. Scarlet 
fever, measles, and typhoid are seldom contracted more than once. 
With age tlie frequency of infectious diseases diminishes. The reason 
for this probably is that the innnnnily of old age depends in great 
measure upon previous maladies and vaccinations. Indeed, it would 
seem that each infectious disease evolves its own antitoxin or antidote 
to its own poison, just as the antitoxin which protects against diph- 
theria is derived from the germs which cause that disease. How 
otherwise, indeed, would it be possible to recover from any infection 
that has once established itself when germs multiply so rapidly ? If 
tliis is the case, it is easy to understand how^ parents may in tliis 
manner protect their offspring. 

There are then several explanations possUjle of innnunity, both 
hereditary and postnatal. The germs do not proliferate in the body, 
because they do not find the conditions essential for their growth ; 
or tlie conditions may be favorable and yet substances may exist or 
be formed in cells and fluids of the body which destroy the germs ; 
or tlie tissues may become less vulnerable by adaptation to the 
baneful effects of the germs and their toxins. We shall amplify this 

1 Part VI., Chapter VIII. 

Part III 


In all tubercles two processes go on : the one — caseation — de- 
structive and dangerous ; and the other — sclerosis — conservative 
and heaUng. The ultimate result in a given case depends upon the 
capabilities of the body to restrict and limit the growth of the bacilli. 
There are tissue-soils in which the bacilli are, in all probability, 
killed at once, — the seed has fallen by the way-side. There are others 
in which a lodgement is gained and more or less damage done, l)ut 
finally the day is with the conservative, protecting forces, — the seed 
has fallen upon stony ground. There are tissue-soils in which the 
bacilli grow luxuriantly ; caseation and softening, not limitation 
and sclerosis, prevail, and the day is with the invaders, — the seed has 
fallen upon good ground. 




Death has iiol only particular stars in heaven, hut malevolent places on earth, 
which single out our intiruiilies. ami strike at our weaker jiarts. — Snt Tuomas 

Predispositions to tuberculosis may be either hereditary, or such 
as prove pernicious in the period between conception and birth ; or 
they may be postnatal. 

It is pertinent to the trend of this subject to repeat tlie mucli-quoted 
statement that life is the continuous adjustment of internal relations 
to external relations. This very inadequate definition nevertheless 
emphasizes the position in which tlie organism is placed with regard 
to its environment. And it is in this broad aspect that I am about to 
consider the effects of external phenomena upon the economy with 
reference to consumption. 

And I shall not be content to examine only into such predisposi- 
tions as may obtain in the time between birth and old age. I shall 
recognize the tremendous importance of prenatal influence. Indeed, 
the divisions of this subject which I have made are purely arbitrary ; 
for at conception, as we have seen, older cellular elements are but 
transmuted into a new cellular combination ; nor is birth more than 
another step in a series of life processes. 

It is not merely a fancy of the romancer, but a statement saturated 
with practical sense, that the past lies upon the present like a dead 
giant's body, so that it is as if a young giant were compelled to waste 
all his strength in carrying about the corpse of an old, an atavistic 
giant. We sleep in dead men's houses, bacillus-ridden as they are ; 
we are sick of dead men's diseases ; we live in dead men's lives ; in 
like manner as these sentiments are taken from a dead man's book.' 
And it is equally true that future generations must inevitably be 
affected by the disposition, physical or otherwise, of the lives of 
individuals in the present. 

^ The House of the Seven Gahles. 




The influences by which scrofula has become a permanent element in human 
sociely have probably affected several generations in succession. — Duckworth. 

With regard to heredity in general it would seem that one may 
assume almost any position and will be able to set forth many un- 
questionable facts in support of the stand he takes. In considering 
the heredity of tuberculosis we come upon a wide range of positions, 
from that of the transmission of the disease itself, to the fact that 
tuberculous parents actually confer upon their offspring an immunity 
to the disease. 

Since the demonstration of the Koch bacillus, and up to very re- 
cently, it has been generally agreed that only a tendency to the dis- 
ease, a vulnerability, and not the disease itself, a soil predisposing the 
organism to tuberculosis, may be transmitted. 

There are certain signs by which this hereditary tendency to tuber- 
culosis may be manifested. Chief among these is what I venture for 
the present to call the scrofulous temperament. The scrofulous child 
has a pallid skin and flabby flesh ; there is often chronic blepharitis ; 
phlyctenuloe are frecjuent ; the nose is large and broad and acne- 
studded ; there are nasopharyngeal adenoids and hypertrophied ton- 
sils, so that these children are mouth-breathers, starved for oxygen. 
There are tedious inflammations of the mucous membranes, — coryza, 
congested and unhealthy throats, and bronchitis exceedingly rebellious 
to treatment ; there are persistent adenitis and periadenitis, the lym- 
phatic glands becomhig enlarged and remaining so. There is a slug- 
gish, torpid metabolism. Altogether there is evidence of a radical 
nutritive disturbance. 

Besides struma, we find thoracic malformations, narrow chests, 
lacking also in depth, projecting shoulder-blades, and small respiratory 
muscles. There are emphysema and an evident capacity for breath- 
ing below the average. There is, again, defective development of the 
circulatory system, especially of the aorta ; there are congenital heart- 
lesions, and the lieart is small. There are anaemia and chlorosis. 
Among other manifestations are slow teething and deficient ossifi- 
cation ill cliildivii, infantilism, stunted growth, and defective genital 


It is evident that aiiion^'' these signs of hereditary transmission 
some are of an anatomical sort, while others are functional in charac- 
ter. This is an important distincfion from the view-point of practical 
therapeutics. For it is a well defined law of lieredity that funclional 
rather than anatomical modifications are transmitted: at any rate the 
latter are consequent upon the former, the development of any organ 
being regulated by exercise of that organ. 

Functional modifications may indeed be unaccompanied by ana- 
tomical stigmata ; the former may be exaggerated through successive 
generations without giving a hint of their existence, until the stimula- 
tion of some exciting cause, as a traumatism or an intoxication, may 
bring them to light. Thus it is that many having seemingly vigorous 
frames nevertheless succumb to the onset of the tubercle bacillus and 
its allied micro-organisms. 

This fact should appeal to those who would claim, from an absence 
of demonstrable anatomical lesions, that there is no sucli thing as he- 
reditary transmission. Tuberculous parents may not bequeath definite 
stigmata; nevertheless they often do impart a pernicious nutritive 
habit to their offspring. For instance, the latter may suffer because 
of insufficient respiratory activity. This w^ould certainly occasion 
deficient oxygenation, so that there would result a lessened vigor 
of cell-regeneration and of connective-tissue formation, an imperfect 
metabolism, and the like, — a condition of things pathological enough, 
yet in its incipiency at least non-inicrobic ; a condition non-infectious, 
but cordially inviting infection. 

Moreover, in examining these indications of a transmitted vulnera- 
bility to tuberculosis it is worthy of note that many of them are dis- 
tinctive also of other affections in which heredity plays a part, such as 
insanity, alcoholism and syphilis. Insanity and alcoholism, non-mi- 
crobic affections, are often correlated with tuberculosis ; and there are 
not a few analogous features between the latter and syphilis. The 
conclusion then would seem warranted that in all such affections, 
tuberculosis as well as the others, there is a like degenerated condition 
of the organs and tissues, which makes them fruitful soil for microbic 

Is tuberculosis a ''family" disease? In many instances it is so — 
so often that the fact is unquestionable. Generation after generation 
the disease manifests itself in given families, so that sometunes no 
member escapes. This, again, is not a transmission of the disease 
itself, but of vulnerable tissues. 


The gods always throw the dice impartially. — Sophocles. 

When ■^ve come to consider the period between conception and 
birth we find that specific congenital infection by the Koch bacillus 
undoubtedly exists. Tubercles containing the bacillus have repeatedly 
been found in the still-born. The bacillus has been found in the tissues 
concerned in reproduction in both sexes ; the bacillus and its toxins 
have been found in the semen of infected animals. And a conclusive 
analogy may be adduced from undoubted congenital infection in 
syphilis, smallpox, glanders, cholera, and pneumonia. 

Still, these infections are comparatively rare. What is probably 
much more frequent is a susceptD^ility to infection in the tissues of the 
embryo and f(ptus. Here the parental condition at the time of con- 
ception is an important consideration. Roger cites a case of parents, 
of unconnnon strength, who had three children. The first-born and 
the youngest were very well constituted and had inherited the strength 
of their parents ; the second, conceived at the time when his father 
was convalescent from pneumonia, was poorly developed, remained 
feeble, and at the age of twelve contracted tuberculosis, from which 
he died. Similar cases will occur to every practitioner. Bodily 
or psychic disorders in the parents, affecting either or both, must be 
considered. Such are : fatigue ; convalescence after a serious illness ; 
advanced age of the father at the time of conception ; unfavorable age 
for procreation, a parent being either too young or too old ; great dis- 
parity between the ages of the parents, more especially if the wife be 
older than the husband ; relative lack of vigor in the husband com- 
pared with that of the wife ; too rapid procreation — baneful both for 
parent and for offspring ; physiological poverty toward the end of 
sexual life ; concomitant diseases and conditions, such as the neuroses, 
syphilis, cancer, or privation ; exhaustion or depression aflfectmg the 
mother during pregnancy ; consanguinity — baneful both in itself and 
as increasing the potency of other factors ; causes accidental, or per- 
haps so slight as to escape notice, or which may be merely transitional 
in the parents. All such causes may induce a vicious nutrition, making 
the organism of the progeny receptive to infection, tubercular or 


During the embpyonic period tlie colls become differentiated and 
the organs of the body are formed ; during fetal life the organs thus 
formed increase in size and begin to take on tlieir several functions. 
Throughout both these periods, but especially the former, the organ- 
ism is most acutely sensitive to environmental impressions — to vari- 
ations in oxygen supply, warmth, the chemical constitution of the' 
maternal blood, uterine or placental diseases, and the like. When 
such influences are abnormal, it cannot be hoped that tlie tissues of 
the foetus will remain unaffected. 

We may note, then, in a review of antenatal conditions, that fresh 
parental blood, and all that it connotes, will surely beget healthy off- 
ii spring, having tissues resistant to pathogenic agencies. Impure blood, 
and its associations in the parents, will result in degenerated tissues in 
the offspring. This is as true for other diseases in which a vicious 
nutrition is transmitted — syphilis, alcoholism, epilepsy, asthma, insan- 
ity, and cancer — as for tuberculosis ; there is then no reason why 
the influence of heredity in the latter disease should be ignored. 



To wilful men 
The injuries that, they themselves procure 
Must he their schoolmaster. 


L\ coming to a consideration of postnatal predispositions, I revert 
to certain aspects of struma, the pronounced sluggish metabolism, 
and the tendency to inllammation of mucous meiubranes and of lymph 
glands, the respiratory membranes and the glands of the mesentery 
being marked sufferers.' 

Many observers tell us that tuberculosis is, to begin with, a purely 
local aifection. Generally it is quite impossible to discover the original 
point of invasion, or of implantation of the bacillus. Tissues which 
have had their circulation disturbed by traumatism, vasomotor, func- 
tional, and other disorders, become foci. The extension of Ihe process 
then depends largely upon the spread of the bacillus from these 
diseased foci by means of tlie lymphatics and tlie blood-vessels. 

The idea that pulmonary tuberculosis generally comes about in 
the first instance through the inhalation of the Koch bacillus into the 
air-vesicles is considered erroneous. It is held that tlie bacillus cannot 
be inhaled because the function of the respiratory tract anatomically 
and i)hysiologically is limited to the admission of gaseous substances 
only ; that air is changed in the alveoli, not by currents but by the 
subtler influence of the law of the diffusion of gases. The main 
routes by which the lung tissues are invaded are, then, two : by way 
of the bronchial glands to the thoracic duct, the right lymphatic duct, 
the riglit heart, and hnally the lung; and by way of the alimentary 
canal, the course being the stomach, intestines, lacteals. thoracic duct, 
the vena cava, the right heart, and the lung. 

The i)athologist has, in fact, found very little evidence of primary 
invasion by the Koch bacillus of tiie pulmonary parenchyma, the 
cellular elements upon which its functions depend. There is abundant 
evidence of primary tuberculosis in the bronchial glands : but these 
are not, strictly speaking, parts of the lung parenchyma. However, in 

' The layman had hest fortify himself for this chajjter hy reading the letter in 
Part VI., Chapter IV. 



almost every part of the body, differing in each iiuhvichuil according to 
his most vuhierable tissue, there is ])ossible a primary tuberculosis ; in 
the lymphatics, serous and nuicous membranes, skin, periosteum, in 
the intra-alKlominal, intracranial, and reproductive organs, in the nose, 
throat, ear, tonsils, mastoid, and the eye. The place of deposit is not 
necessarily the point of entry of the parasite. There may be tissues 
whicli for many years have latently harbored colonies of bacilli, with- 
out setthig up symptoms until the adv(Mit of some acute cause. 

But how explain, then, the frequency of pulmonary tuberculosis, 
particularly in the apices ? The first rib is frecfuently immovable, so that 
expansion is restricted. Schmorl has found a furrow running around 
the upper aspect of the apex, which he attributes to defective develop- 
ment of the first rib. He finds that the bronchial twigs which supply 
the neighboring parts of the lungs are crooked, narrowed, or otherwise 
deformed, so as to present a favorable situation for the persistence of 
catarrh in the mucous membrane. Then Esser points out that in 
children at least the inflamed bronchial glands often compress the 
bronchi and also the branches of the pulmonary artery, which supply 
the upper part of the lung. So that in the apical region there are 
lessened power of expansion, imperfect aeration, and insufficient 
blood-supply. The pathology of '^ taking cold" is suggestive here ; for 
tuberculosis frequently follows tliat condition. Cold will produce 
contraction of peripheral vessels, witli pulmonary ansemia, the blood 
being in most cases driven into the abdominal viscera. And anivmic 
tissues present diminished resistance to infection, particularly when 
the Koch bacillus is the agent. Again, the venous blood, bacillus- 
laden, from the thoracic duct, is first carried through the pulmonary 
circulation for oxidation before returning to the left heart. The lungs, 
therefore, bear the brunt of exposure to this infection, and act as a 
strainer to the general circulation. 

The alimentary tract is concerned in the spread of tuberculosis. 
It is to be emphasized here that in infants abdominal tuberculosis is 
more frequent than the pulmonary form ; it is striking also that gastro- 
intestinal diseases are very prevalent in infancy and childhood, and 
that there is at this time much imi)roper, or unsuitable, or artificial 
feeding. Here we must recall that the nmcous membranes of the 
infant and child are very delicate. The intestinal tract is particularly 
permeable ; here, moreover, there is a very rich supply of blood- 
vessels and lymphatics. 

The germ is often taken in with the food, or from bacillus-laden 
things such as infants are in the habit of putting into their mouths. 
Tuberculous excreta from the upper air-passages are swallowed. Iti 


the stomach the germicidal properties of the gastric juice are encoun- 
tered — an ineffectual safeguard, however. If digestion here is impaired 
or incomplete, the bacillus is passed intact into the intestines, Avhere 
unassimilated material, including the bacillus, must occasion intestinal 
hyperaemia. Under these conditions peristalsis mixes the undigested 
bacilli with the chyle. Then the lacteals and the lymphatics take them 
up and carry them into the mesenteric glands and the thoracic duct. 
Those which reach the mesenteric glands are likely to colonize and be 
carried iuto the thoracic duct, whence they will reach the pulmonary 
circulation by way of the vena cava. 

The tuberculosis of children is more common during the first 
year, when milk is the almost exclusive diet. The likeliliood is that 
milk often contains tubercle bacilli which may pass through the delicate 
and tender intestinal mucosa. Bone tuberculosis is frequent in chil- 
dren. The bone abscesses — white swellings of the fingers, the feet, 
the hips and other joints, the spine (Pott's disease) — are of this nature 
and they sometimes occasion deformities, such as hunchback, which 
persist throughout life. 

Von Behring is of the opinion that tlie principal danger of infec- 
tion lies in the greater relative susceptibility of the infant, especially 
on account of the vulnerability of the digestive mucous membrane at 
that age. He considers the chief soiu'ce of infection is to be sought 
in the food of infants, especially tlie milk which they consume — an 
extreme opinion, in conservative judgments. He believes that when 
an adult takes consumption there is simply a recrudescence of the 
tubercular process which originates in infancy. 

The young often have tuberculosis of the peritoneum, manifested 
by abdominal pain, swelling, and dropsy. Then there is the menin- 
geal form, in which the membranes covering the brain are involved — 
a truly dreadful condition. The tissues here attacked — bone, brain, 
lymph glands — are such as are in children undergoing physiological 
growth; and they are easily prone to "disease of an irritative, con- 
gestive, or inflammatory nature," such as tuberculosis. 

A faulty metabolism plays an enormous part in predisposing the 
tissues to tuberculosis. The presence in the body of nitrogenous 
matters in a decomposing or readily decomposable state affords an 
ideal pabulum for the nourishment and development of micro-organ- 
isms and their toxins; and such factors as unwholesome food, bad 
water, and foul air will further an excess of these effete matters in 
the tissues. Ordinarily such material is limited to the amount which 
is continually being excreted in the ordinary waste of the body ; and 
if the excretory organs all combine in normal action, this is drawn off 


from the blood-currents as fast as it is poured into them ; so that the 
stream is kept clean. But if such decomposing matter be introduced 
abnormally from without, as in habitual infractions of hygienic laws, 
such as many who contract tuberculosis are addicted to ; or if it be 
generated in abnormal quantities within the body ; or if the normal 
process of elimination be in any way obstructed — a rapid accumula- 
tion will take place, so that there will be provided a fruitful soil for 
the growth of the bacilli and their toxins ; more than this, ttiere result 
ideal conditions for the development of mixed infections, in which the 
cocci join the bacilli, so that a curable disease often becomes trans- 
formed into a fatal one. 

We have touched upon hereditary lesions of the heart and blood- 
vessels predisposing to tuberculosis. An impaired circulation means 
reduced oxidation, and consequently tissue starvation, particularly in 
the lungs ; for under these conditions the vast capillary system opposes 
the already weakened cardiac contractions ; and the pulmonary struct- 
ures will not receive even their share of the deficient blood-supply. 
In this connection Sajous holds that such symptoms as pallor, mus- 
cular weakness, a thin, compressible pulse, an undeveloped or slightly 
dilated heart, anaemia, anorexia, coldness of the extremities and ha- 
bitual hypothermia, point to adrenal insufficiency ; we may not agree 
with him as to the reason for these symptoms, but they do denote an 
ideal condition predisposing to infection. 

Chlorosis, or green sickness, an affection frequently related to tuber- 
culosis, is referred variously to lesions of the vascular system, to ado- 
lescent disturbances, and to digestive disturbances ; in each of these 
aspects is a relation logically established. 

Tuberculosis is prone to follow upon other diseases, such as bron- 
chitis, influenza, and neglected colds ; pleurisy is often a forerunner. 
Convalescents from the exanthemata, diphtheria, and typhoid, and 
the coexistence of such affections as syphilis, malaria, and diabetes, are 
powerful elements in the growth of tuberculosis. The Koch bacillus 
finds the sugar-containing tissues of the diabetic an unusually con- 
genial host. 

Other predisposing factors are overindulgences in eating and drink- 
ing ; sexual excesses ; exhausting labors, mental and physical ; the 
want of wholesome recreation, of heat, clothing, and shelter; per- 
nicious atmospheres ; poverty ; the effects of prolonged lactation in 
tired mothers and of too frequent pregnancies ; injuries; dangerous 
trades. These and many like factors will be considered in other 



Whatever amoinit of power an organism expends in any shape is the correlate 
and equivalent of a power that was taicen into it from without. — Herbert Spencer. 

It were impossible to set down even a mere enumeration of ex- 
trinsic predisposing factors. For we are told that living itself is but 
the body's response to environmental influences, eitlier physical or 
chenucal in character ; and such influences as these are about as 
numerous as are external phenomena. Personally, I would reserve 
the opinion that the whole of life is by no means comprehended in 
this statement. Still it is valid, as denoting the innumerable agencies 
which may make the organism receptive to infection, tubercular or 

Among these external causes we note, first, mechanical violence — 
various forms of direct injury resulting in contusions, wounds, and 
lacerations — which greatly favors the develoi)ment of tuberculosis. 
But this is not essential, for the bacillus may penetrate the unbroken 
skin and mucous membranes. It is very likely that these cases often 
result in tuberculosis by shock and other nervous reactions being ex- 
cited. Such " surgical tuberculosis" may appear in bones and joints, 
the tendons of muscles, and in various other tissues and organs. Poot 
wounds may result in infection of the lymph glands in the region 
about the hip. Then inhalations of insoluble, gritty particles induce 
in workmen a true tuberculosis. Continued pressure upon any part 
of tlie body may cause wasting or local death of tissue, making it re- 
ceptive to microbic invasion ; and this condition may lead to general 
toxic clianges which would facilitate the spread of tuberculosis in the 

Various states of the atmosphere — altitude, temperature, humidity, 
season — may be predisposing factors. Although consumption occurs 
in greater or less degree in all localities it is more prevalent in varia- 
ble climates and wliere there is much moisture. It seems to prevail 
inversely as the altitude progresses above sea-level. A rare atmos- 
phere strengthens pulmonary respiration by requiring greater effort in 
breathing. Long-continued heat predisposes by depressing the vital 

Other factors have to be considered as concomitant. The more 




isolated and loss densely populated a region the less there is likeli- 
hood of infection. Climates are modified, in general favorably, by 
trees, rocks, rivers, lakes, drainage, winds, rains, the proportion of 
sunshiny days, and the like. Vegetation has an important regulating 
effect, modifying the winds, equalizing the temperature and diminish- 
ing the dust. 

Animal life depends upon the free oxygen contained in the air. 
Pure air is essential to normal metabolism — the conversion of oxygen 
and the food-stuffs which are ingested into healthy tissues. An im- 
perfect supply of oxygen results in various degenerative changes in 
the tissues and increases susceptilDility to infection. 

Humidity in the atmosphere is related to animal perspiration. 
When the temperature is low the sweat usually evaporates as rapidly 
as it is excreted, so that it is "insensible perspiration." As the 
humidity increases, sweat may transpire, but its evaporation is pro- 

FiG. 17— Hester Street, New York City, 

gressively delayed, until, when the humidity reaches the saturation 
point the skin remains constantly wet. This reduction in evaporation 
diminishes the natural heat dissipation, so that with a high relative 
humidity, low or high degrees of temperature are poorly borne. 
Great humidity, by interfering with normal heat regulation of the 
body, may indirectly favor the taking of cold, and, by devitalizing the 
tissues, favor the development of infectious processes. Sickness is in 
general more prevalent in variable seasons. There is more illness in 
March, for instance, than in January, when the weather is more uni- 
form. Consumptives, by the way, do better in the winter months 
than in the summer. Marine climates, though ideally bacteria-free, 
are apt to increase coughs. 


A very dirty alinosphorc may l)o a |)redis})osing factor. Dr. 
Woodbury, tlu> New York City street-cleaning commissioner, has 
most strilciiigly demonstrated this by means of ])airs of plates which 
were exposed for an equal numbiu* of nniuites in various parts of that 
.city. Dr. James Ewiiig, of the Cornell Medical School, prepared some 
sixteen of these plates for him. Of two such plates one would repre- 
sent atmospheric conditions in densely crowded districts, the other in 
a very clean part of the town. One of these, for instance, which was 
exposed at the corner of Hester and Ridge Streets, at market time, is 
saturated with bacteria, moulds, fungi, etc.; its fellow, which was 
exposed for the same number of minutes at Madison Avenue and 
Sixty-sixth Street, is almost wholly free from impurity (Figs. 18, 19). 
The former is a very unclean district ; the latter is very salubrious.' 

A soil whicli is clayey, or moist, or marshy, or not well drained, is 
unwholesome. Healthful soils are sandy, loamy, or gravelly ; sucli 
are warm and dry and readily drain themselves, especially where there 
is a slope. 

' Mioruel gives the following table : 


Ill the sea, at 100 kilometres from the coast 0.6 

Altitude of 2000 metres 3. 

Summit of Pantheon 200. 

Observatory of Montsouris 480. 

Rivoli Street (in Paris) 3,480. 

New house 4,500. 

The air of sewers of Paris 6,000. 

Old house •. • • • 36,000. 

Hotel-Dieu (hospital) 40,000. 

Pitie Hospital 79,000. 

Fig. 18.— Hester Street, New York. 

Fig. 19.— Madison Avenue and Sixty sixth Street, New York. 



God lent his creatures light and air, 

And waters open to the skies ; 
Man locks him in a stifling lair, 
And wonders why his hrother dies. 

0. W. Holmes. 

The physician, whenever it can be done, sends the consumptive 
into the country, believing tliat in the enjoyment of the benignant 
sunshine and in the pure air, with rest, good food, and drink, he 
stands the best cliance of recovery. And he does stand the best 
chance under sucli conditions. But many nihabitaiits of rural dis- 
tricts, nevertheless, die of consumption. And we have to try and 
understand why such is the case. Sometimes it is the execrable diet, 
to which meats other than bacon are practically strangers — canned 
fruits and vegetables and condensed milk being largely consumed, the 
fresh food-stuffs, including eggs, being reserved to be sold in urban 
markets. I write from experience. When I was sixteen — it is longer 
ago than I like to remember — I taught school in a backwoods district 
for four months, and "boarded 'round." In all that time I did not 
taste meat other than bacon, I never ate an g^<^, and the only milk I 
drank was with my tea. 

Then there is oftentimes in the country a seemingly iiuiocuous 
imbibition of stomach bitters (which generally contain a very fair 
percentage of alcohol), of cider, and perha})S other insidious fluids 
(Appendix B). These conditions may seem more virtuous and more 
soothing to the conscience, but they are not in many cases essentially 
different from the inordinate alcoholism which lays the foundation of 
tuberculosis. Indeed, when cider becomes old and hard, there is 
nothing to be found in the city grogshops more "paralyzing." Then 
we must mention the effect of intermarriage through several genera- 
tions in families living within a few miles square, and of certain evils 
which have been reported by such accurate and responsible journals 
as the New York Evening Fast ^ to an extent really startling. Then we 
must refer, also, to a lack of regard to the bodily function which often 

1 November 8, 19U3. 



obtains in the Avintcr months throngh disinclination to venture to 
outhouses in the intense cold. Poole relates tlie following: 

The fiirin cure i)l;un and simple is not enough. A friend of mine sent one 
young Russian to a farm last March to be cured by Nature. The plague was only 
beginning. The time was right ; the place was wrong. At the end of the month 
a series of letters began, of which I quote bits that tell the whole story : " i am im- 
proving very nice — i aint coughing no more — i am getting fat — i sleep good and i 
have a good ajipetite to eat — i gained sixteen pounds — the country doctor here says 
the only thing i Need is plenty of exercise work all day plovnng and planting on the 
farm — so i do. Avhen i earn enough i will bring my wife and baby — it is a regular 
paradise — i will live here always — the faivere you have done to me will never be 
forgotten. ' ' Two months later : ' ' you write me not to work hard, you know as long 
as i am harnest up i must pull — my wife and baby are here and feel good — i will 
answer your questions — i cough again bad — appetite no good — sleep no good — 
sweat nights no- — fever yes." Ten days later : " i am coughing something terrible 
— werst i ever did." He died. 

Clement, a French rural physician, records that in the sparsely 
settled country district, which is the field of his labor, there is much 
tuberculosis. He believes cattle to be the main source of the disease 
in this region ; alive, through the milk and its products ; dead, through 
the insufhciently cooked meat. The latter comes from animals 
slaughtered clandestinely to avoid the loss sustained by taking 
them to the official shambles, where the government offers an insuffi- 
cient indeninity. 

Sucli considerations as these may explain how it is that many in 
the country do not get well of consumption, but, on the contrary, die 
of it. Years ago, when the erection of a sanatorium in a mountainous 
part of jN'ew York State was contemplated, an inhabitant of that 
region was surprised. '• Expect to cure consumption here ?"' said he. 
"Why, the people here don't die of anything else." Nevertheless, 
the sanatorium was built, and thousands of consumptives have got 
well while living in it. But they have been under the direction of 
wise physicians who have taught them wholesome living and the value 
of hygiene, and have secured for them good, substantial food and 
drink, in addition to the fresh air. the sunshine, and the pure water 
which Providence has vouchsafed so generouslv in this region. 


Part IV 


And is man any the less destroying himself for all this boasted 
brain of his ? Have you walked up and down upon the earth lately ? 
I have, and I have examined man's wonderful inventions. And I 
tell you that in the arts of life man invents nothing, but in the arts 
of death he outdoes nature herself, and produces by chemistry and 
machinery all the slaughter of plague, pestilence, and famine. The 
peasant I tempt to-day eats and drinks what was eaten and drunk 
by the jjeasants of ten thousand years ago, and the house he lives in 
has not altered as much in a thousand centuries as the fashion of a 
lady's bonnet in a score of weeks. But when he goes out to slay 
he carries a marvel of mechanism that lets loose at the touch of his 
finger all the hidden molecular energies, and leaves the javelin, the 
arrow, the blow-pipe of his fathers far behind. In the arts of peace 
man is a bungler. I have seen his cotton factories and the like, with 
machinery that a greedy dog could have invented if he wanted money 
instead of food. I know his clumsy typewriters and bungling loco- 
motives and tedious bicycles ; they are toys compared to the Maxim 
gun, the submarine torpedo-boat. There is nothing in man's indus- 
trial machinery but his greed and sloth ; his heart is in his weapons. 

Bernard Shaw 



Would you persuade? Speak of Interest, not of Reason. — Poor Richard. 

"Tuberculosis causes annually more than 150,000 deaths in the 
United States at the average age of thirty-five years. At this age the 
normal after-lifetime is about thirty-two years, so that the real loss of 
life covered, measured in time, is represented by 4,800,000 years per 
annum. If we assume that the net value of a year of human life 
after the age of thirty-five years is at least $50, the real loss to the 
nation resulting from the disease (a large proportion of which is 
known to be needless) maybe estimated at $240,000,000 per annum. 
These astounding and almost incomprehensible figures are far from 
being an exaggeration ; but let us assume that only one-half of this 
mortality is preventable, and we have a net possible saving to the 
nation of $120,000,000 per annum. This estimate does not take into 
account the social, moral, and sentimental value of at least 100,000 
lives, which, under different conditions, might reasonably hope to con- 
tinue for many years. The mortality from tuberculosis is, theretbre, a 
problem compared with which all other social problems of a medical 
character sink into insignificance, and it is safe to say that the possible 
prevention of a large portion of the mortality from this disease is 
justly deserving of the solicitude, the active personal interest, and 
liberal pecuniary support of all who have the real woKare of the 
people of this nation at heart." ^ 

Osier computes that there are at least a million and a ((iiarter 
cases of tuberculosis in the United States all the time, — certainly a very 
conservative figure. These are all more or less in the position of 
invalids, and all, if they hope to recover, should be able to maintain 
that role for at least a time. Assume that one-fourth of them caimot 
work; they must then be supported in some other way than by their 
own efforts, either by private or public help. In many cases they are 

^Statement by Frederick L. Hoffman, Esq., actuary of the Prudential Life / 
Insurance Company, of Newark, N. J., to whom, and to Miss Lillian Brandt, the ' 
statistician of the Charity Organization Society, New York City, I am indebted for ' 
many of the data in this part. 




heads of faiiiilics and liave wives and children dependent upon them, 
"^% who Ukewise must be cared for. The wages then of these one- 
fourth, or 312,500 men, at the rate of $1.50 a day, would amount to 
over one hundred and forty million dollars in a year. This represents 
P the sum lost annually hy llie nation because these men are unable to 
y work. If tliere were such a leak in our resources from any otlier 
cause wliich was preventable, there would be a continual agitation 
until it was remedied. The loss of $50,000,000 annually paid to 
foreign sliip-owners caused a ship subsidy bill to be considered, calling 
for an amiual expenditure of $9,000,000 ; yet here we have an annual 
loss of three times as much in money, and pain and suffering beyond 
description, but not one dollar is appropriated, and not one step taken 
to remedy it.' 

Seven thousand persons died of consumption in Illhiois in 1903, 
half of them between the ages of twenty and fifty years, while the 
estimated loss to that State alone, because of this disease, was $36,- 
000,000, and the medical authorities of that State have, as elsewliere, 
found that consumption is responsible for more deatlis than typhoid 
fever, scarlet fever, diphtheria, all forms of bronchitis, influenza, 
measles, and smallpox combined. 

Dr. H. W. Tliomas, of Chicago, computes that the loss of money 
in Illinois invested in the raising of cliildren who die of tuberculosis 
under the age of twenty is $1,187,800 ; the loss from inability to per- 
form labor on the part of tlie con- 
i^^i^BB^H^^^H^Mi Consumption gumpttve, $30,000,000 ? the loss 

of savings of those who die before 
the end of the producing age, 
$5,189,000 ; and the cost of the 
care of those sick and compara- 
tively helpless from consumption, 
$225,000. U])on this accounting, then, tuberculosis costs the State of 
Illinois, yearly, $36,551,000. 

The Oliio State Commission computed tliat in that State there are 
some 6,000 deaths annually. " If allowed to go on unheeded, fully 
400,000 of those now living in Ohio must die from this disease." 
The resulting economic loss is $7,000,000 a year ; tlie to this 
State from the withdrawal from work are over $8,000,000. Among 
orjihans in nine institutions nearly one - fourth lost their parents 
tlirouirh tliis disease. 

^^■■Tyi'hoiJ Fever 
■ WTiooping Cough 
I Measles 
Scarlet Fever 
■ Small Pox 

Fig. 20.— Deaths in Illinois, 1903. 




The Indiana State Board shows seven hundred and ninety (l''aths 
among mothers between eighteen and forty in one year, and four 
hundred and twenty-five fatliers between tlie same ages, leaving 2515 
orphans under twelve, and 1215 homes fatherless or motherless. 

The New Hampshire Commission, studying the deaths by decades 
of age from 1884 to 1901 inclusive found that the two decades which 
marked by far the greatest number of deaths are those between 
twenty and thirty, and from thirty to forty years, — periods when the 
individual is of most value to hiiiiself, to his family, and to the State. 

The Maryland Commission finds the following: 

'* The average individual loss entailed by the disease for each wage- 
earning male dying from tuberculosis in Maryland, is |741.G4. 

"The average potential loss to the connnunity entailed by the 
death of each wage-earning male, is $8,512.52. 

"The total potential loss to the State entailed by the deaths from 
tuberculosis each year cannot at the very lowest estimate be less than 
ten million dollars." 





Fig. 21.— Mortality from ten principal causes, white males and females. (Hoffman.) 

There are yearly more than 10,000 deaths from consumption in x\ew 
York City ; and at least thrice that number of sufferers. Biggs esti- 
mates the loss from tuberculosis to this community as follows : Dur- 
ing the last twenty years the reduction in the death-rate in this city 
from tubercular disease has been nearly forty per cent. " The total 
number of deaths in 1901 ascribed to this disease in New York City 
was 9412. For the Boroughs of Manhattan and the Bronx alone, 
concerning which we have more accurate data for a series of years, 
we find that during the past twenty years there has been an actual 


decrease in the total number of deaths, notwithstanding an increase 
of population; that is, in 1881 the deaths from the tuberculous dis- 
eases in the Horouglis of Manhattan and the Bronx numbered 6123; 
in 1901, twenty years later, they numbered 6051. During this time 
the population of these Boroughs had increased nearly 70 per cent., 
—viz., from a little over 1,200,000 to more than 2,100,000. Taking 
now the deaths for tlie whole of New York City, annually, at 10,000 
— as we may safely assume that several hundred deaths each year 
which should be ascribed to the tubercular diseases are ascribed to 
some other cause — we may estimate the economic loss to the munic- 
ipality. It may be conservatively estimated that each human life at 
the average age at which tlie tubercular deaths occur is worth to the 
municipality $1500. The cost of each life at this age is usually more 
than this. This gives a total value to the lives lost annually of 

" We may further assume that for an average period of at least nine 
months these persons are unable to work and must be cared for. The 
loss of their service during this period may be estimated at $1 a day, 
and the cost of food, nursing, medicines, attendance, etc., at $1.50 
more per day, making a further loss of $2.50 per day, for eacli person 
dying, for a period of 270 days. This gives us a further loss to the 
municipality of $8,000,000, making a total annual loss to the city 
from tubercular diseases of at least $23,000,000. It has been esti- 
mated that in the United States annually not less than 150,000 deaths 
are caused by the tubercular diseases, and estimating the value of 
these on the basis just given, we have an annual loss to the country 
of more than $330,000,000.'' 

Biggs estimates that tlie annual expenditure of a small part of this 
sum would result in a very rapid decrease in the prevalence of the 
tuberculous diseases in this country. And his opinion is weighty, for 
he has had an enormous experience in the sanitary supervision of 
infectious diseases in New York City covering many years. He lias had 
made a census of the cases actually under treatment in the hospitals in 
New York City annually fur a series of years, and the total number 
never much exceeded 1000, or less than four per cent, of the cases 
actually present in the city. The vast proportion oMhe remainder 
r are in tenement houses. 

" I have estimated that the total expenditure in the city of New 
York in its public institutions for the care and treatment of tubercu- 
lous patients is not over $500,000 a year, or not more than two per 
cent, of the actual loss to the city annually. If this annual expendi- 
ture were doubled or trebled it would mean a saving of several 


thousand lives annually, to say nothing of the enormous saving in 
suffering." ^ 

Conditions in the United States demonstrate that, the mortnlity 
from consumption is greater in cities tiian in rural districts.- How- 
ever, the fah in the death-rate during tlie ten years ending in 1900 
has been 24 per cent. ; and the ratio of decrease has been six for the 
cities, as against not quite live for the country. This ratio is surely 
due to the greater improvement in conditions of city life. 

The condition of things in cities generally may be inferred from 
that which obtains in New York. Here from the fifteenth to the i 
thirty-fifth year, one-third to one-half the entire mortality results from| 
tuberculosis. And these official figures do not begin to represent the 
limit. Thousands of cases are not reported to the authorities, for 
various reasons. 

For instance, up to very recent years, and to some extent even 
nowadays, mutual benefit societies have refused to pay claims when 
death was ascribed to consumption ; and such also has been, to a 
measurable degree at least, the practice of some life insurance com- 1 
panics, a large part of whose business is the writing of "industriar' 
policies. (It is not so nowadays among the important companies.) 
At any rate, it has been the well-nigh universal impression among the 
poor that claims would be refused under this circumstance. So that 
physicians have many a time been importuned by wretchedly poor 
people, who, fearing the loss of the few dollars so desperately needed, 
Avould ask that " pneumonia," or some other cause of death, be 
entered upon the death certificate. And who shall say how often the 
contest in the physician's mind between humane instincts, however 
mistaken, and strict honesty has resulted in the committing of a venial 
sin, — sufficiently often to suggest the inference that such deaths from 

' Handbook of the New York Charity Organization Society. 

^ Such data as are here set forth concerning the United States are for the most 
part based upon conditions in the "registration area." Populations of less than 
8000 are considered to be in rural districts. In the presentation of results in the 
Federal Census those States and cities whose registration records gave evidence of 
being the most nearly complete were classed together as the registration area. The 
total population of the registration area amounted to thirty-eight per cent, of the 
population of the United States. It comprised the States of Connecticut, Maine, 
Massachusetts, Michigan, New Hampshire, New Jersey, New York, Rhode Island, 
\ermont, and the District of Columbia, and included so many of the important 
cities throughout the country that it may be considered fairly typical. It is 
probable that the superior accuracy of the returns from this area makes them 
ordinarily more truly indicative of the country as a whole than are the defective 
returns given for the whole United States. 


consumption have been many more than have been set down in the 
statistics? No doubt many deaths recorded as h-oin other respiratory 
diseases have consumption at bottom. 

Again, ignorant an(t stub])()rn })eople have tried not to have cases 
reported as consumption, fearing registration anct the appHcation of 
such \vholesome and enliglilened administrative rules as are cal- 
culated to protect survivors in the conmnuiity — measures which 

really are not inconvenient. Even 
unci«i.rT.p ^ physicians have condoned such 

1 to 



concealment, on which account 
""»i5"" • many deaths from consumption 

> to 201 

40 to 60 
50 to CO 
60 to 70 

80 to 90 

Orer 90 

Not Stated 

20'o3o |i^— ■^■^ ^■^—i ^^^^^M are unrecorded. 

^"'^^"'^J^J^J^^"^ This diagram presents graphi- 

^"' cally the fact, so insistently dwelt 

oioi>okHH upon in this book — a very basal 

9of fact — that consumption claims its 

victims among those whose activi- 

FlG. 22.— Deaths from consumption in Illinois, 

1903, by ages. tics and whose lives are most 

needed by their families and their 
communities. And in the accompanying circles Miss Brandt has 
exhibited a like proportion. It is really pitiable to observe the num- 
ber of deaths in adult life from a preventable disease. There is, 
as we observe, between the years indicated a somewhat greater 
mortality among men than among women. This must be attributed 
mainly to the fact that men have more strenuous and dangerous 

Hoffman observes that while the mortality among males in cities 
has been twenty-one per ten thousand, as against sixteen for females 
— a difference in favor of females of five per ten thousand of popu- 
lation — in the country districts the death-rate has been tw^elve for 
males, as against fourteen for females, — a difference in favor of males 
of two per ten thousand population. The mortality of males in cities 
is higher than the corres[jonding mortality of males in rural districts ; 
also the mortality of females in cities is liigher than the corresponding 
mortality of females in rural districts. 

Still, conditions tending to tuberculosis have bettered in cities and 
the percentage of deaths from this disease has been less in proportion 
than in rural districts. However, not only the tuberculosis death-rate 
has to be considered, but also, and indeed much more, the condition 
of the living who suffer from it, and " the causal relation which this 
disease maintains towards many other social problems.'" 

Before the fifteenth year there are comparatively few deaths from 



tiil)('rcul()sis, altliou^'-li there has hecii in iuraiicy aiitl childlujod at. least /' 
as much danger of infection as during any otlier period of life. The / 
prohibition of child labor, which now generally obtains in this country, 
has here, no doubt, been effective. Young constitutions, which must 
formerly have been weakened to a degree of susceptibility to infection, 
now reach a measurably vigorous maturity. Many children have now 
no longer to endure the disease-engendering conditions of factory-life 
and indoor occupations. Children are now but little employed in 

20-29 years 

30-44 years 

20-29 years 

30-44 years 

Fig. 2o.— Proportion of mortality f-aused Ity cf)nsumption in New York City, 1901. (Hnindt.) 

pottery and glass work and like industries wliicli are ])articularly con-j 
ducive to tuberculosis and other respiratory diseases. 

Moreover, conditions in school-life have been very materially im- 
proved. Close, overheated schools have given place to large, airy, 
well ventilated and properly lighted structiu'es. However, conditions 
are as yet by no means ideal in schools. In attending a public-school 



60 ;t 




20 r. 



)io 40 








L— ^— ^ 

65 years and over, 












= married. 



Oi« 4C 

reception one will ()l)sorve how in sini;inii' llir expressions on the faces 
of many cliildren are strained, as if singing were an effort for them. 
These children have adenoids, hypertrophied tonsils, or otherwise un- 
healthy n})per air-passages. Sucli are mouth-breathers, starved for 
oxygen, — ideal conditions predisposing to tuberculosis. 

With regard to mortality from consumption among the single, the 
married, and the widowed. As a general pro})Osition it is lower for 

the married than for either tlif 
single or the widow^ed and lower 
for women than for men. Brandt 
fmds that the only time when the 
death-rate is higher for women 
than for men is among the mar-! 
ried between the ages of fifteen 
and forty-five years ; and here it' 
is also higher than for single 
women during the same ages. 
These data are in large part ex- 
ihf plained by the development of 
consumption as a sequel to ex- 

FiG. -24. -Mortality among single, marrierl, and / hanstiug and frcqueut prCgUail- 
widowed. (Brandt.) . i • i t i ii \ <• 

cies. liie liighest death-rate ot 
all is among the widowers under forty-four years. After the forty-fifth 
year the rates for both widowers and widows, while liigher than for 
the married, were lower than for the single. Hoffman observes that the 
death-rate among widowers is highest at the youngest ages, while lowest 
at the most advanced periods of life. The higher mortality of widow- 
ers at early ages is the result of disease transmission from wife to hus- 
/band. Conversely, there w-ould seem to be a lesser liability in the 
transmission of the disease from liusband to wife; possibly because 
the husband is away from home a large part of the time, wdiile the 
consumptive wife being so much more at home, infects tlie household 
the more. Widowers have a mucli higher mortality than widows at 
corresponding ages, — at ages up to forty-four years, sixty-seven against 
thirty-six ; from forty-five to sixty-four years, forty-nine against nine- 
teen : from sixty-five years on, thirty-one against twenty-one. 

The high death-rates among the single are largely due to occupa- 
tions ; to the fact that a far higher percentage of the shigle than the 
married live in cities, where the devastation is much greater than in 
the rural districts; and to habits of life detrimental to longevity, such 
as alcoholism, to which the single have more temptation than the mar- 
ried. This last factor may tend also to explain the greater mortality 


among the widowed than among the married. And the favorable 
mortality enjoyed by the married is certainly due in large measure to 
this institution being inherently a process of natural selection towards 
which only the fit tend, and also to the greater regularity and sober- 
ness of living essential to matrimony. Particularly is this so of con- 
sumption, a disease which thrives upon irregularities and exposures. 

The English National Association for the prevention of consump- 
tion finds upon investigation that one-eleventh of all the pauperism,., 
costing in England and Wales £10,500,000 a year, arises from con-l| 
sumption ; that one-quarter of all deaths during the wage-earning ago! 
(fifteen to fifty-five) are due to consumption, leaving many widows and 
children to receive aid from poor laws, friendly societies, and charity^ ,' 
organizations. The average age at death of sixty-two consumptives ' 
dying in Kendal was thirty-two, and of five hundred and seventy-four 
dying in Edinburgh was thirty-three. This is a loss of ten years of 
labor at an average wage power of £35 per year, a loss of £350 per life. 
In Brighton Workhouse, during three years, two hundred and eleven 
consumptives stay an average of forty-five weeks at seven shillings a 
week, costing £3300, — that is, £1100 a year for maintenance alone. 
The eight thousand consumptives in English workhouse infirmaries, 
when bearing their share of establishment and other expenses, cost 
£600,000 a year or £75 per head. If consumption were abolished the 
average duration of life of persons who reach the wage-earning age of 
fifteen would be increased by three and one-quarter years. 

Consumption is so costly to companies insuring against sickness i 
(consumption accounting for more than one-half of those incapacita-i 
ted at thirty years of age) that in Germany these companies find it 
pays to send nine thousand workingmen in a year to consumption 
sanatoria for an average of eleven weeks at a cost of a guinea and 
a half per head per week (a total of £153,000) in order to restore 
them to wage-earning power. 

The German Imperial Insurance Office reports that of every one 
thousand German workmen between the ages of 20 and 24 years who 
are rendered unfit for work, five hundred and forty-eight are so dis- 
abled because of tuberculosis, and of those between the ages of 25 I 
and 29 years, five hundred and twenty-one are rendered so because \ 
of this disease. When, then, the bread is taken from the mouths of I 
those dependent upon German workmen, in more than 50 per cent, of 
the cases it is throiigh tuberculosis. What is thus true of Germany 
would doubtless hold regarding other countries, were the necessary 
data at hand for comparison. Tables arranged under the supervision 
of this Office further show that in a total of 155,462 pensioners, of male 


Avorkers ('iiiploynl in iniiiiiig-, metallurgy, industry and building who 
become invalid np to the ago of 30, more than half suffer from consump- 
tion. The })roi)ortion of the female pensioners in the same avocations 
is just as unfavorable at the age of 20-24, while at the age of 25-29, 
ahiiost half of all invalid women of these avocations are consumptive. 
People engaged in forestry and agriculture do not so readily suffer ; 
yet among 1000 male pensioners thus employed tliere are more than 
350 of the age of 20-24. For the totality of the other professions, the 
proportion of invalid men of the age of 20-30 is such tliat out of 1000 
cases of invalidity, 450 are pulmonary consumptives, while about a 
fourth part of all invalid women of tlie same age and professions are 
like sutTerers. From those results, and also by the statistics of the 
Health Board for the year 1893, it is proved that of every 100 persons 
who died at the age of 15-60 in the German Empire, 33 have fallen 
victims to consul njjtion.^ 

Cornet computes that in 1894 there were in Germany 116,705 
deaths from diphtheria and croup, whooping-cough, scarlet fever, 
measles, and typhoid fever combined ; from tuberculosis there were 
123,904 deaths. These latter deaths were to an extent of more than 
seventy-five per cent, from bread-winners, whose ages ranged from 
fifteen to seventy years ; in this respect consumption differing cjuite 
radically from the other diseases mentioned. In Prussia, consumption 
produced one-third of the entire number of deaths. And Cornet 
reminds us that tuberculosis runs a number of years before it proves 
fatal ; but if we reckon the invalidism due to it to be only one year, 
and the average loss of wage (on unemployed labor) at a value of two 
marks per day, then the loss of earnings for each person per year, 
three hundred working days to the year, amounts to six hundred 
marks ; so for the total number of those who have died in the 
bread- winning period of life, 71,895 persons, the loss of earnings 
amounts to 43.137,000 marks annually. " If we add to this figure the 
money for doctors and medicine, for food and care (counting that the 
sick pay out 2.19 marks per day), f(3r burial, and furthermore, the ex- 
penditure for invalids not included among bread-winners, we may 
estimate at least twice as nmch as the previous figure, or 86,000,000 
marks as the yearly cost to the Prussian State. Consumption therefore 
demands an annual increase of the tax of 3.09 marks per capita, or of 
fifteen marks for each family of five in the Prussian State." 

These figures and the economic data here set forth are impressive 
enough; but upon reflection, how about their connotations? Such 

' BielefekU. 


deaths are among those in the prime of hfe, and between the ages when 
men and women are most valuable to tliemseh'es, to their families, and 
to the State. Let us dispel for a moment the sense of economic loss 
which these figures represent, and consider wliat they mean in distress 
and illness antecedent to death, in torture of heart and mind to the sur- 
vivors, and the inherent likelihood of infection and sickness for these 
latter. There is truly no other single factor, no other destructive 
agency — catastrophe, pestilence, blight, or warfare — which typifies to 
the extent that this disease does the pathos of existence and the cold 
indifference of Fate to human suffering. 



Effertz has bnen traveling urifre(}ueiiteil paths the world over for more than 
twenty-five years, and has been particularly interested in studying the comparative 
pathology of different generations and races. He has been much impressed with 
the variations in the frequency and virulence of infectious diseases. — Jaxus, 

The negro is exceedingly prone to consumption, which destroys 
every otlier adult among his people. It would seem, however, that 
tlie disease was unknown among the blacks in Africa until compara- 
tively recent generations, when the exploring whites decided to confer 

per 1110,000 


per 100,000 



700 1 
















f 200 









^ 1 

^' 1 

i 100 










i 1 


I IW l'J',1 n 630 'JL'S 373 170 309 ICO (») 250 123 55 53« 245 b'«i 220 138 72 5S2 271 140 7b 533 237 142 233 

Fig. 25.— Death-nitos from consumption, 1900. (Brandt.) 

upon them certain prearranged blessings of civilization. Their im- 
munity is ]jrobably due to the fact that barbarism does not suffer tlie 
; disadvantages of badly ventilated, badly drained houses, indoor and 
! factory life, and like conditions of civilization upon which tuberculosis 

/ Harris declares that before the Civil War tuberculosis was almost 

unknown among the slaves ; that it does not occur on the West Coast 

of Africa, except when it has been im[)orted by the white race and 

acquired by the negroes living in semi-civilized life. Millard states: 



"I have excellent authority for saying that the disease is rare among 
the negroes in Africa, and in the interior is almost never known." 
Flick considers that the negro race in Africa was free from consump- 
tion until it began to associate with other races. 

No doubt tuberculosis has taken the same course among the 
negroes as did measles among the Fijis. The latter was entirely un- 
known among these people until some whites who came there intro- 
duced it. On account of this the aboriginal inhabitants died off in 
enormous numbers of this disease, which is now comparatively innoc- 
uous among us, — 40,000 Fijis in a population of 150,000. This ex- 
emplifies the established fact that a light infection acquires an unusual 
malignancy when for the first time it invades a race previously im- 
mune. On the other hand an infection tends to lose its virulence in 
the course of centuries, as with the Jews, who are singularly less 
prone than other races to tuberculosis.^ 

Flick considers that the history of consumption in all new countries 
into which it has been introduced shows that it has had a rise, a 
climax, and a decline in prevalency, citing the experience in the islands 
of Madeira and Bermuda and the progress of the disease from east to 
west in the United States in illustration of his view. In New York 
City, from 1804 to 1820, the deaths from consumption were one in 
4.2; from 1820 to 1835, one in 5.4; from 1835 to 1850, one in 6.5, 
and from 1848 to 1859, one in 8.4. In Rhode Island the percentage 
of deaths from consumption was, in 1867, 20.74; in 1883, 15.03. 
The mortality statistics of the older States and cities show in the same 
way a progressive decrease ; those of the newer States and the Terri- 
tories show either a standstill or a decrease. " The avidity, however, 
with which the disease takes hold of new material illustrates its sub- 
jServience to the law of acchmatization better even than its history in 
different countries. It has decimated the natives of probably every 
island which has been colonized by England during the last few hun- 
dred years." The native-born African negroes have thus suffered ter- 
ribly from it. In Egypt the negroes and Abyssinians are decimated 
by it. In Gibraltar for twenty years the comparative deaths between 
whites and blacks have been per 1000: Whites, 6.1 ; blacks, 33.5. 
During the early American slave trade the proneness of the negro to 
consumption was noted by Rush and others. 

Certain habits of the negro are certainly predisposing. The fol- 
lowing observations are illustrative : I several years ago visited the 
island of New Providence, in the Bahamas, most of the inhabitants of 

^ Billings, Korosi, Fishberg, Hoffman, Brandt, Flick. 


which are negroes. There, as elsewhere, they are an extremely 
superstitious people, to wiiich hal)it of mind the conditions of nature 
in that region are certainly conducive. In the interior of this island 
1 found huts ensconced in luxuriant vegetation which sprang from 
ground made up of hard coral formation, — shrubs, weeds, vines, 
flowers, moss-covered magnolias, live oak " cottons," orange, pine- 
apple, mangrove, and gum trees making up a dense jungle, with here 
and there a solitary cocoanut tree looming up many feet, its leaves 
being turned all one way by fierce winds that blow unchanged during 
most of the year. There are sudden and most destructive hurricanes, 
and the thunder and lightning which accompany them are certainly 
awe-inspiring and must be very terrifying to the primitive mind. 
During such hurricanes many of these negroes perish while sponge- 
fishing despite the fact that they engage certain of their people to keep 
fires burning at home, over which they speak incantations calculated 
to protect against the elements while the sponges are being gathered. 

Hardly less weird than the fierce aspects of nature are those she 
assumes in her periods of quiescence. Many feet below the surface in 
the harbor of Nassau the water is of the hue of the emerald and of the 
translucency of the diamond. The variegated life in the coral beds is 
easily contemplated from a boat. Standing upon coral-reefed shores 
at midnight one sees the Saragossa sea-grass floating by continuously, 
glistening kaleidoscopic in the moonlight ; enormous yellow-backed 
turtles propelling themselves lazily ; flying-fish gleaming in long, 
rapid curves ; chambered nautili sailing by upon the lightest imagin- 
able zephyrs, ivory-colored, or pink, or diaphanous blue ; a solitary 
pelican, poised one moment high in the air and then swooping light- 
ning-like and disappearing into the water, to come up with a strug- 
gling victun in its beak. And all this in the midst of most eerie, 
wondrous stillness. Little wonder then that the negro in these parts 
peoples the earth, the air, and the water with beings inimical to soul 
and body. 

I have been told by our consul at Nassau, on this island, that 
it is a custom among the negroes in that region, no matter how hot 
the nights might be, to keep the doors and windows of their huts 
tightly closed, and to burn lamps or candles throughout the night to 
keep the evil spirits out and to scare them away. Such superstitions 
as these are common also, I believe, among negroes in our Southern 
States. The negro, moreover, eats much pork, and swine are among 
the tuberculous animals. To say the least, this is an unhygienic diet 
for hot regions. Tin; negro is said to be inordinately prone to alco- 
holism ; if so, this factor should predispose more than among the 


whites, for the same reason that obtains among the Indians, to whom 
I will presently refer. 

Coleman declares the negro to be nnusually ignorant of hygiene 
and averse to water; that his food is often insufficient and unwhole- 
some and unsuited to the climate in wliich he lives ; his clothing is 
unhealthful ; he is shiftless and hiiprovident. Syphilis and gonorrhea, 
by weakening the system, render many susceptible to tuberculosis. 
Many a negro now works indoors, and the houses in wliich he lives 
are overcrowded, — unfortunate conditions, since tlu; tendency of his 
race has been agricultural and toward outdoor life. 

Harris considers that the negro's small lung capacity, as compared 
with that of the white, and his deficient brain capacity render him 
less resistant to the disease wdien once acquired. Where the two 
races live together, three times as many negroes as whites die from 
tuberculosis. And Harris and Coleman both conclude that unless the 
hygienic and moral surroundings of the race are improved there is 
danger of its extinction. 

It seems that the Indian was free from tuberculosis before his 
contact with the whites, living as he did in the open air and without 
alcohol. The " fire-water" introduced by the white man (a most 
vicious, impure, cheap and harmful form of alcohol) has certainly 
been a large factor, all the more for the reason that the whites have, 
through many previous centuries, rendered themselves comparatively 
seasoned with regard to this stimulant, to which the Indian has not 
yet accustomed himself. 

Rush ^ stated more than a century ago that consumption was then 
unknown among the Indians of North America. Flick considers that 
prior to the advent of the white man — and especially the Englishman — 
consumption did not exist among the American Indians. Wherever 
England colonized the Indians took the disease, so that in the course 
of time it became even more prevalent among them than among the 
whites. The disease increased from east to west. John D. Hunter, 
who was for fifteen years a captive among the Indians, wrote in 
1822 : " I have known pulmonary consumption to occur among the 
Indians. It is rarely seen, however, except in those who are addicted 
to intemperance, and even in those cases it is by no means as common 
as among the whites. It is worthy of notice that their females are 
not as much subject to the disease as the males are." 

In 1854 George B. Buckley reported that Indians east of the 
Rockies suffered from inflammation of the eyes and consumption. In 

' Flick, "The Contagiousness of Phthisis." 



per 100,000 -j 
living I 

600 O 




Mothers born in 





"c .5 



5 cc 



1 = 1^^ 



1870 Dr. Thomas Williams wrote of the Dacotas, of Minnesota, that 
" of those over ton years who die of disease, I think one-half die of 
consuniplion."'' It has almost exterminated some American tribes. 

The dcath-rat(> from consmnplion among Chinese in this conntry 
is. I believe, very lii.uli indeed. As regards iNew York City, their dread- 

fnlly unhygienic living, their 
sleeping in bunks, in vitia- 
ted a t m o s p h e r e s, their 
overcrowding, their addic- 
tion to opium and other 
enervating vices, and like 
circumstances abundantly 
explain their high mor- 
tality from tuberculosis. 

Brandt, to whom I am 
indebted for the accom- 
panying diagram, considers 
that high mortality among 
the Irish people is no 
doubt due to tlie inordinate 
alcoholism w h i c h obtains 
among their poor, their 
careless, i m p r o v i d e n t 
nature, their iidieritance of poverty tlirough many generations, and 
the overcrowding among them in our tenements. 

The Bohemians come next, though a long way behind ; their liabit 
of congregating in cities, their unhealthful housing conditions, and 
their indoor occupations explain their mortality rate. 

The Scandinavians are reputed a healthy race, and so no doubt 
they are at home. However, the effect of ne\v climatic conditions 
upon them and the fVirmation of a radically different physical type in 
the second generation may account for their comparatively higii mor- 
tality in this country. Urdil we reach the Italians the conditions are 
such as prevail in civilization generally, and no observations are strictly 

We would expect a higher mortality among the Italians, for their 
indoor life in New York City is very unhealthful ; they are exceedingly 
dirty, and they are said to be much underfed. Moreover, being an ig- 
norant and superstitious people, and no doubt fearing often the imagin- 
ary terrors connoted by registration, they are given to concealing their 
cases, so that by no means all are reported. This observation proba- 
bly applies to many of the fifty odd tongues represented in New York 

Fig. 2fi.— Mortality by races. (Brandt). 


City. Many Italians want to die in llieir fatherland; so that nunici- 
ous cases no donbt leave lor home before they become very bad. 
Many i)oor Italians work in tiiis conntry dnring the snmnier months 
and return to Italy in the fall. Besides, the Italian's natni-e is sunny, 
not given to worry, and lliese people are largely engaged in outdoor 
work ui)on public roads, i)eddling, etc. 

Stone and Wilson, in giving the tuberculosis death-rate in Boston, 
state the percentage of parents' birthplace to be : 

Ireland 10.20 

Sweden 13.70 

British America 13.30 ^ 

Scotland 11.73 

England 10.85 

Germany 10.73 

United States (ineludinff colored) 6.87 

Italy 5.81 

Russia . 5.35 

This table accords fairly well with that of New York and with similar 
statistics from other cities. 

The R.ussians and the Poles in New York and elsewhere in the 
United States are, I think, mostly Jews. We observe that in Miss 
Brandt's diagram (Fig. 26) these people have the lowest death-rate. 
It appears, indeed, that the Jewish race in general suffers less from 
consumption than any other people, except perhaps the Quakers. And 
here I would ask the reader to turn to two maps made by Miss Brandt 
of lower Manhattan Island, which appear in the next chapter. I have 
exhiliited these maps before scientific bodies, together with my opinions 
concerning them : and have been the recipient of a very choice collec- 
tion of objurgatory brickbats during tlie discussions which have fol- 
lowed. I keep addhig to my collection with unabated enthusiasm. 
These maps, as Carlyle might have put it, are indicative of nuich. 
The first shows various districts in which the density of the respective 
populations is represented. The darkest shading of all is put over the 
region of the lower East Side through w'hich Grand Street runs. The 
region is occupied by the Jews, to tlie practical exclusion of all other 
races. In New York there are upwards of 750,000 Jews, — from one- 
fifteenth to one-twelfth of all the Jews in the world ; and the vast 
preponderance of those in New York is to be found in the region just 
noted, the most densely populated, I believe, in the whole world, 
certainly in either Europe or America. 

Now, with regard to the second map. Here the districts are out- 
lined exactly as before. But the one among all of them which has no 


shading at all is lliis same Jewish quarter, — that is to say : the Jews 
are more closely crowded than any other community ; yet tubercu- 
losis is least rife among them. What does this overcrowding among 
the Jews connote ? Practically every factor which is causative save 
three, which I shall presently set forth. 

The very ])oor Jews are not cleanly in their personal habits, at least 
according as I have had occasion in my own dispensary experience to 
note. The proper disposition of sputum, such as present-day prophy- 
laxis re(|uires, is not practised by them. The air in the crowded 
tenements in which they live is in the last degree vitiated and un- 
wholesome ; it is saturated not only with himian exhalations, but also 
with smells emanating from ill-kept back-yard closets. Such air 
should surely be conducive to tuberculous infection. Out in the 
streets the air is also much vitiated, as witness Dr. Woodbury's ex- 
periment (page 84). 

They work very hard indeed, do these poor Jews, most of them in 
sweat-shops. In violation of the law, children, as soon as they are 
old enough to thread a needle, are set to work. From early morning 
to ver}^ late at night, in their wretchedly ventilated rooms, do they 
bend over their machines. Their lungs expand but poorly ; " they 
have no chests." 

The first exception among etiological factors, to which I have re- 
ferred, is the character of the food consumed by the Jews. While 
other peoples have comparatively little regard to what they eat and 
drink, I am positively assured that, with rare exceptions, the orthodox 
Jews, no matter how poor they may be, obey with strictness 
the Mosiac laws concerning food and drink. Oftentimes the meat 
which their religious officials reject as unsuitable for Jews to eat, 
is sold to Christians and eaten by the latter without thought of its pos- 
sible impurity or of its effects upon metabolism. The Reverend 
Madison C. Peters, in his book, " Justice to the Jew," states that nearly 
half the meat is thus rejected and thus sold in Christian markets. 

Here appears to me to be evidence corroborative of the present- 
day scientific opinion that the alimentary canal is concerned in the 
spread of tuberculosis within the organism ; that even pulmonary tuber- 
culosis results often from infection by means of bacillus-containing 
food-stulfs. We may, in comparing the enormous tuberculosis mor- 
tality among the negroes and the comparative immunity among the 
Jews, note that the meat of the former is almost exclusively pork, while 
the orthodox Jew will not eat this meat, which is likely to be tuberculous, 
much of the food of swine being the swill from cattle and the decayed 
products of dairies. 


The second exception is I hat the Jewish race, during the forty- 
centuries of its existence, must have achieved for itself a comparative 
immunity to consumption. Tliis is in conformity witli tlie principle; 
we have just set forth, and which applies conversely to the negro. I 

Third, the Jewish people have no drink problem. They are saidi 
to be a temperate people with regard to alcohol, which they take, but) 
in moderation. This factor is an important one, as we shall see. / 



Mr. Lawrence Veiller, in descril)ing tlie iiiiseral)le surroundings of the poor 
in a city tlie size of New York, said that these evils were of man and not of God ; 
that they were no part of nature or of nature's laws. He asked if it was neces- 
sary that in this modern city of New York 9,000 human lives be sacrificed each 
year to " the white plague," when all that was needed for its cure were fresh 
air and sunlight and wholesome food. Was it necessary, he asked, that from 
75,000 to 100,000 members of the Jewish community be unable to supply them- 
selves with the immediate necessaries of life without the aid of charity, or that 34,000 
children be deprived of the care and solicitude and devotion of a parent's love, and 
be brought up in institutions as wards of the State? Was it a sign of a healthy 
or a diseased civilization that the State pays annually $25,000,000 for charitable 
purposes ? 

"To say that the lower East Side of New York is the most densely populated 
spot on the habitable globe gives no adequate idea of tlie real conditions. To say 
that in one section of the city the density of population is 1,000 to the acre, and 
that the greatest density of population in the most densely populated part of Bom- 
bay is but 759 to the acre, in Prague, 485 to the acre ; in Paris, 434 ; in London, 
365 ; in Glasgow, 350 ; in Calcutta, 204, gives one no adequate realization of the 
state of affairs. No more does it to say that in many city blocks on the East Side 
there is often a population of from 2000 to 3000 persons — a population equal to 
that of a good-sized village — and that in many such blocks the density is over 
1,000 to the acre." — N. Y. Evening Post. 

Consumption lias been found to exist predominantly in congested 

With regard to New York City this map, made by Miss Brandt, 
presents "a seemingly anomalous situation.'" Below Fortieth Street, 
taking ward by ward, " the alternatives present themselves of denying 
to density any influence whatever, or of concluding that it is a 
powerful advantage." However, in explanation, certain things are to 
be considered, hi many of the downtown wards, where the tene- 
ments are being displaced by business houses, the actual density of 
the part of the ward that is used for residence purposes is far greater 
than is indicated by the average number of persons per acre. Again, 
cerlain radical factors overshadow the influence of density. The 
Hebrew element to which we have referred gives the notoriously 
congested Tentli Ward a comparatively low rate of tuberculosis. For 
the same reason the Seventh, Eleventh and Thirteenth, which rank 
next the Tenth in density, have the very least consumption. In the 



First Ward, wliere the average density ])er acre is low, tlie density 
per room is witliout doubt very higli, since much of its area is 
occupied by warehouses and other buildings devoted to business 
purposes. The houses here occupied as dwellings are old and un- 
improved. This is the site of the Syrian colony, otlier inhabitants 
than these being chieflv Irish. 

1 I 10(1-1 99 

Ka%j 2U(l-299 
^^ 300-399 

■■■ 5i^i) aiid c 

I I LeBa than 20 per 10,000 living 

t'\-'-,v-M 20-29 

m^m 30-39 

^^ 40-49 

■■ 50-59 

f'iG. 27.— Borough of Manhattan by wards. (Brandt.) 

The Sixth Ward contains Chinatown, and the rest of the ward is 
made up mostly of solid tenement blocks of the same dreadful type 
as the two that were razed some years ago in Mulberry Bend; hence 
the high death-rate from consumption. 

The Fourth Ward is one of the oldest and most unsanitary districts 
in the city ; the main element in its population is tlie lowest type of 
Irish-Americans, whose physical constitutions are w^eakened by ex- 
cesses of all sorts on their own part and that of their parents. These 



conditions prevail generally in the Ninth and Twenty-first Wards. 
In the Sixteenth and Twentieth there are large negro colonies. 

The New York City Health Department instituted a system of vol- 
untary notification of living cases of tuberculosis in 1894. From this 
registration of living cases, and from the records of deaths, we find 
tliat not only is consumption more prevalent in certain parts of the 
city than in others, but that in any given district it is concentrated in 
certain si reels, blocks and houses. There are houses in which cases 
have occurred yearly for nine years past, as in the case of the " Lung 
Block," which I shall i)resent.' 






III II II 3C01-3500 


llpoi S^^, 

Fig. 28. — Mortality from tuberculosis of the lungs in Euroijean states per million living. 


William Penn, lofty and generous spirit that he was, originally 
mapped out the " squares" of Philadelphia upon ample lines. The 
end he had in view was that the citizen should have not only a street 
in front of his house, but plenty of ground in its rear, upon whicli he 
and his might breathe fresh air, get a glimpse of the sky, and enjoy 
the sunshine. But modern ingenuity has nullified all that. The 
original street boundaries remain, but the space to the rear of the 
houses of many squares is choked up with structures designed for 
habitation, which are reached by means of blind alleys and like con- 

* Stone and Wilson present valuable data akin to these concerning the city of 



trivancos. The resulting coiidilions are in the last degree unsanitary 
and subversive of human civilization. 

In many parts of Washington the same state of things obtains. 
There is in this city, the magnificent capital of our country, a very high 
consumption death-rate, due to a large colored population, and to the 
unsanitary condition in which many of these people live. For years 
physicians have been trying without avail to get Congress to pass a 
law providing for the condemnation of unsanitary houses.^ There are 
large numbers of frame shacks down on the ground, without any ven- 
tilation under the floors, without water in the houses, and without 
sewer connections. These buildings are hidden away in the centres 
of the squares, and people living on the main streets are often uncon- 
scious of the fact tliat there is such a population on these interior 
alleys. That is where the " lung blocks" are. During the winter of 
1904-05 the physicians of Washington had a very satisfactory bill 
passed through the House, which, on going to the Senate, was referred 
to a committee the chairman of which 
was, unfortunately, "down on the 
health officer." The result was that 
practically nothing was accomplished. 

As regards other countries than 
our own, Hillier presents this map 
(Fig. 28), which demonstrates that in 
Europe, Great Britain, Norway, and 
Belgium have the lowest phthisis 
mortality ; then follow Italy, the 
Netherlands, Denmark, Ireland, 
Switzerland, Germany, Sweden, 
France, and lastly, Hungary, Austria, 
and Russia. Concerning Germany, 
however, we must observe that al- 
though the tuberculosis death-rate is, 
as a whole, still somewhat high, it 
has been steadily declining in Prussia since 1886, and is now about 
the same as in Great Britain. 

In Fig. 29, moreover, will be seen the mortality in fourteen large 
towns of over half a million inhabitants. Evidently the phthisis mor- 
tality is highest in Moscow, St. Petersburg, and Vienna, and lowest in 
Amsterdam, London, Naples, and Buenos Ayres. 

















_ 2000 











o . .2 s s .^ i ^ J 03 H o a 5 
^ aa > (S(i,Bi!z;Pma-«;i-l^;M 

Fig. 29. — Mortality from tuberculosis of 
the lungs in cities of the world with more 
than 500,000 inliabitants per million living. 
(Koehler-Hillicr. ) 

^ Sternberg. 



The consumptive is far more a source of danger to his fellow-workingmen 
than to his family, especially if liis calling he within doors. — Cornet. 

Some preliminary observations are essential before considering 
occupations in detail. Of first importance, of course, are physical 
conditions, — the physique of the workingman. Then there are the 
low wages in some callings, because of which physical needs — food, 
fresh air, and the like — cannot be adequately satisfied. Next come 
family tendencies concerning occupations. This obtains in other coun- 
tries more than our own. In England, a bricklayer, for instance, 
has been for generations of a bricklaying family, with no aspirations 
for anything else than to lay bricks. Among us the son of a brick- 
layer may not be content until he has become a politician, a poet, a 
philanthropist, or a physician — poor fellow ! 

Then there is a process of natural selection with regard to occupa- 
tion, some men by nature and physical endowments tending to farm- 
ing ; others of sedentary habits to book-keeping ; others by reason of 
mental and moral tendencies, allied with enervated physique, to bar- 1 
tendhig, or hotel service. Then there are in individual cases long 
periods of decline in strength of body and mind when a man success- 
ively drops from a good job to one not quite so good; so that from 
grade to grade he finally reaches the ranks of the unemployed. There 
is no little pathos in the popular impression that after forty a laborer 
is •' a dead one." Then some men are steady workers ; others are 
intermittently employed. 

Among the pregnant observations of Mr. Easton, whose work is 
noted in the next chapter, are the following : Many workingmen take 
up a poorer grade of work on becoming ill, — a commercial traveller 
may take to peddling cheap pictures in his old age ; a compositor has 
become a lamplighter ; a gardener has taken to making beds ; a 
skilled mechanic to loading trucks. And a pathetic feature of such 
cases is that oftentimes such an unfortunate man will be cut by his 
former associates on account of his industrial decline, — like healthy 
animals who push aside and appropriate the food for which their 
sickly fellows have not the strengtli to light. 



Very important is it to consider the conditions of life outside the 
working hours ; here the workingman's social stratum is important. 
For instance, the very poor man goes in the evening to a sf[ualid 
home and eats food cooked outrageously in a frying-pan. It has been 
said (I make no doubt of it) that many a poor man is driven to drink 
by the dreadful things which his wife has prepared for him to eat. 
An experienced nurse ^ reports as follows: "What is the particular 
factor in the home life which predisposes more than any other to this 
disease ? The nurses almost invariably answer, ' Poor food, poor in i 
quality, in quantity, and, worse still, the way in which it is cooked.'" 

Cornet notes from the records of a numl)er of Berlin iimtual aid 
associations that there is among engravers a mortality from tuberculosis 
of 40 per cent., among Avaiters 45 per cent., painters 47 per cent., 
polishers 54 per cent., bookbinders 63 per cent., cabinet and piano- 
makers 55 per cent., upholsterers 61.5 per cent. It is quite certain 
that in factories where there are no cuspidors, and where careless and 
uncleanly consumptive workingmen spit on the floor, so that the 
sputum is swept up in tlie dust, the danger of infection is greater. 
And the dissemination of sputum may occur in other ways, as by 
emptying cases of mull or in beating carpets and cloths. In many 
cases it is difficult to determine the sources of infection. 

The City of Munich presented at the Dresden Exposition of 1903 
an analysis of its cases of tuberculosis on the basis of occupation. 
The greatest number of cases came from the classes described as 
workers in dust, and of these, especially those in metal dust. Next 
came the workers of wood, such as carpenters ; then the manufacturers 
of clothing ; while the fislierfolk and farmers are a]iparently hardly 
represented. We shall sec that these data corresfidiid fairly well 
with others. 

In Fig. 30, for which I am indebted to Miss Brandt, fifty-three 
occupations are specifically considered. The consumptive death- 
rate of marble and stone-cutters is shown to be six times that of 
bankers, brokers, and officials of companies, — an excellent reason, 
among others, why one should cast his lot among the latter fraternity, 
if possDDle. The high mortality among marble and stone-cutters is 
undoubtedly due to irritation of the respiratory tract by remote inhaled 
' particles of stone. The high mortality among cigarmakers is due largely 
to the irritating effects of tobacco upon mucous membranes ; but the bad 
, air and the wretchedly unsanitary condition under which these i)eople 
I work, both in factories and in tlieir homes, are essential factors. Cabi- 

^New York Medical News, Oct. 24, 1903. 



neliiiakers and ii[)ho]sterers breathe in dirt, while plasterers, white- 
washers, and llie hke inhale in addition cement and other injurious 

* 47C.9 
349. S 

E ll.arble and stone cutters (IV) 


I^H CiiJror makers and tobaceo workers (IV) 
I Plasterers and white washers (IV) 


311. ip 

305.5 ■ 








25 •= 


26 ;i 251.1 pi 

27 S 250.9 ■■ 

28 § 25U.1B 

29 ~ 236.2 Ib 
229.7 B 

227.3 taBB 

212.9 LbB 
210.3 L^H 

207.6 pn 




B Compositors, printers and pressmen (IV) 

an Hat and caij makers (IV) ! 
I I 

I, Bookkeepers, clerks, and copyists (II) 

[Laborers (not agi-icultural) (I) 
^B Tinners and tinware makei-s (IV) 
(H*^abinet makers and iiphoLstei-ei-s (IV) 

IGlass blowei"s and class workers (IV) 

BH Sailors, pilots, fishermen, and oystenuen, (VIII) 
B Painters, glaziers, and varnishers (IV) 
I Leather makers (IV) 

I Apothecaries, 

H; Coopers ( IV ) 
IBR Plumbei-s, gas 

pharmacists, etc. (VII) 

nd steamfittei's (IV) 

I 3Iasous (brick and stone) (IV) 

I Butchers (IV) 
I S;iIoon keepers, liquor dealers, 
ivery stable keepers and hostler;^ 
|I>-aymen, hackmen,! teamsters, etc, 
I Boatmen and canalnien CVIII) 
iJanitors and sextons (V) 
iHticksters and peddlers (VII) 
I Bakers and confectioners (IV) 

I Iron and steel workei-s (IV) 

B Carpenters and joinei*s (IV) 

^B^H Engineers aud firemen (not locomotive) 

■IBB Leather Joikers (IV) 

BBB Tailors (ivl) 

■BDlacksmiths UrV) 

■B Hotel and boarding-house keepers (III) 

■8 Mill and factory operatives (te.\tiles) (IV) 

B, Machinists (IV) 

I Architects, ai-tists, teachers of art (VI ) 

I Gardeners, florists, nurserymen and vinegrow 

bartenders, restaurant keepers (III) 




I Physicians and surgeons (VI) 


iKngineers and surveyors (VI) 
I Teachers in schools (VI) 

Lawyers (VI ) 
iPolicemen, watchmen, and detectives (VJ 
I Boot and shoe makers, (V ) | 

Soldiers, sailors, and marines (U.S.) (Vi) 
Collector^, auctioneers, and agents (II) 
Steam railroad employees (VIII) 
Clergymeil (VI) | 

Miners andj quarrymen (Villi) 
Farmers, planters, farm laborers (VIII) 
Cankers, brokers, officials of companies (II) 

Fig. 30.— Death-rate from consumption, of men iu fifty-three occupations, iu the registration States 
of the United States— 1900. (Brandt.) 

As regards musicians, all of the artist callings are in Miss Brandt's 
classification included in tliis occupation, — the orchestra conductor, as 
well as those who play in theatres, dance lialls, restaurants, upon the 



streets, and the like. Many of ttiese most lovable people lead irregu- 
lar Bohemian lives, having no thought for the morrow. During periods 
of poverty they become enervated from exposure and lack of food. 

Draymen and teamsters work in the open air ; so it would seem 
they should not be very tuberculous. But they lift tremendous loads. 
They carry cases on their backs, sucli as ordinary men are Ijarely 
able to turn on end. They drink heavily, moreover, as is also the 
case with hackmen, hucksters and peddlers. In all these occupations 
the hours are long and irregular, and there is much exposure. Janitors 
live mostly in unsanitary basements. 

Saloon-keepers, hotel servants and ])artenders show a heavy mor- 
tality. They are, by tlieir physical and moral make-up, unfitted for 
any other occupation. Besides, saloons are dark, dank, tlirty and 
l)acillus-laden. In this table they are classed with restaurant-keepers, 
otherwise their mortality surely would be much higher. 

Hat and cap-makers work in overcrowded, ill-ventilated apart- 
ments. Their hours are long, and their wages are said to be very 
low; besides, injurious dust and dyes are used in these trades. The 
iailors and tlie garmentmakers, however, have a death-rate which 
would be surprisingly low were it not for the fact that Jews, who, 
as a race, certainly enjoy a comparative hnmunity to tuberculosis, 
monopolize these trades. 

Glass-blowers show the influence of exposure to extreme heat ; 
they are apt also to sit for many hours in constrained positions. 

The laboring class (the non-agricultural) is very large, and is made 
up of many elements. Its members work irregularly at tremendously 
exhausting labor. There is among them much intemperance. Tlieir 
food is badly cooked at home, and many of them bring from Europe 
constitutions weakened by a struggle with hard times there ; and they 
live in the cheapest of lodging-houses or the worst of tenements. 

It will be noted that occupations with a high mortality are con- 
diicled generally in cities and large manufacturing towns, while those 
having a low tuberculosis death-rate are almost all carried on in small 
towns or in rural districts. 

It seems odd that miners and ciuarrymen should occupy aposilion 
so low in the list ; for their work is exhausting. It would be pre- 
sumed that they inhale much coal and other dust. Various explana- 
tions are given for this. Brandt observes that there is a very high 
death-rate among cjuarries in England, and that among miners the 
rates vary enormously, with the kind of material mined and with 
the locality. The statistics show very high rates for tin, copper, and 
lead-miners, while coal-miners show varving rates in diiferent coal 



fields, but all low. The slij^lit sus('e})til)ility of coal-miners is attribu- 
table in a measure to their being a picked class of men, the work 
precluding the entrance of any one not of a physique above the 

Cornet attributes this comparative infreciuency of pulmonary tuber- 
culosis among coal-miners to the fact tliat the amount of moisture in 
the subterranean atmosphere of the mines approaches the saturation 
\ point and renders tlie desiccation and dissemination of sputum im- 
I possible. No doubt this lias much to do with the matter. Possibly 
\also the coal-dust possesses a slight disinfecting power. 

Dr. Oliver, of Newcastle-on-Tyne, England, has produced an excel- 
lent paper on the gold-mines of Soutli Africa, in which lie reports a 
very higli death-rate of 70 per 1000 among white rock-drill miners 
of the average age of thirty-five, as against the mortality among 
Englisli miners in coal of 6.3 per 1000; in ironstone of 6 per 1000; 
in tin of 8.1 per 1,000. He considered that this very great difference 
in the mortality rates was probably due to the insutficient precautions 
taken in the Transvaal mines to prevent the scattering of dust, and 
therefore recommended that dry mining should be converted into wet 
mining by means of jets and sprays. Here Oliver coincides with 

It is interesting in this connection to note an editorial in the Iron 
Aye upon the Water Drill as a Preventive of Miners' Phthisis. It is 
here again recognized that one important cause of the great prevalence 
of this disease ui the South African mines is the presence in them of 
large quantities of dust, and that the remedy is to remove this dust as 
far as may be. The Transvaal Chamber of Mines in October, 1903, 
invited a submission of methods to lessen this evil. Among many 
suggestions two- were valuable, — one a water drill, the other an atom- 
izer. The Leyner drill seems the best means of laying tlie dust, 
doing so at the very point Avhere the dust is generated. One atomizer 
submitted by T. J. Britten was found to lay 75 per cent, of the dust 
in the level wdiere it was tested, and possessed the additional advan- 
tage of laying the nitrous fumes generated in the blasting. This process, 
however, involves the use of a separate machine, whereas the water 
drill is a part of a regular mining instrument. On this account the 
latter is likely to be preferred in practical mining. 

W. 0. Eastwood, Esq., of Whitby, Ontario, comments upon a 
form of tuberculosis popularly known as '• knife-grinder's rot," which 
prevailed some time ago to a much greater extent than it does nowa- 
days. It affected chiefly those engaged in grinding on the dry stone. 
It was recognized as the wellnifdi unavoidable fate of those who were 


tempted by the hij,^h wages to uinlertake this work. Latterly, how- 
ever, some kind of an exhaust or blower w^as devised that carried or 
drove the grit and small particles of steel in such a direction that the 
workmen no longer inhaled them ; and, thereafter, a deadly tendency 
became practically eliminated from this occupation. From a medical 
work published fifty years ago, Mr. Eastwood quotes : •' The fork- 
grinders of Sheffield, who grind dry, died from twenty-eight to thirl y- 
two years of age; razor-grinders, who grind both Avet and dry, died 
from forty to forty-fivo years of age, while lable-knife grinders, who 
work on w^et stones, lived to between forty anil fifty years." 

Street-sweepers do not seem to be ])articularly prone to tuber- 
culosis. Flick and others declare such to be the case. It seemed at 
one time that many among the New* York City street-sweepers Avere 
tuberculous, all the more because the streets of this city are not 
sprinkled nearly as much as upon general principles they should be — 
not nearly as much as continental cities. New York is an extremely 
dusty city, and Street-Cleaning Commissioner Woodbury, assisted by 
the health department, instituted an investigation. Out of a total of 
1872 men, 283 Avere found to have pulmonary affections. Of this 
number, 60 Avere tuberculous — rather a small proportion among nearly 
2000 men. And this proportion is measurably accounted for by the 
fact that the sunshine and pure air, rain and other AA^ater out of doors, 
kill the micro-organisms. 

In the excellent book entitled •• Dangerous Trades," the following , 
occupations are enumerated as being more than others conducive to 
tuberculosis : 

Potters, Printers, 

Dusty occupations, Hatters, 

EarthAvare-makers, Tailors, 

Cotton operatives. Drapers, 

Locksmiths, Shoemakers. 

Bakers, Miners, 

Blacksmiths, Soldiers, 

Coopers, Sailors, 

Woodturners, Gardeners, 

Kope-makers, Porcelain- and cenient-niakers, 

Bricklayers, Masons, 

Carpet manufacturers, Typographers, 

Tin-workers, Mother-of-pearl grinders. 

Cutlers, Lead-miners, 

File-cutters, India-rubber makers, 

Glass-makers, Millers, 

Copper-workers, Brewers, 

Gunsmiths, Carpenters, 



Zinc-, iron-, and st 


Chemical- and ilax-workers 














Coal heavers an<l trimmers 

In practical confirmation of much that we have noted concerning 
occupations is the plate of Mr. Hoffman, from which it appears that 
consumption causes the highest death-rate among stone-workers, 
printfTs. glass-workers, hrass-workers, book-keepers, plumbers, sales- 

FiG. 31. — Consumption death-rate among workmen. (Holl'man.) 

men, hatters, silk-workers, and cigar-makers. In all of these occu- 
pations over 33 per cent, of all deaths were due to consumption. 
Between the ages of twenty-five and thirty-five the proportion was 
over one-half among stone-workers (64 per cent.), glass-workers 
(58.7), batters, book-keepers, and printers. 

With regard io the occupation of the soldier. Cornet quotes 
SchmidI : "The civil jjopiilation was (^'erywhere better off than the 
army with respect to mortaHty from tuberculosis," so that it would 


not seem that this disease was generally hitroduced among the military 
]iy the civilian recruits. Tlie greater frequency of tuberculosis among 
the soldier class was ascribed to the excessive exertions and hard- 
ships of the service, to carrying knapsacks, to insufficient nourish- 
ment, to a completely altered mode of living, and to homesickness. 
Cornet, however, from a consideration of conditions in the Prussian, 
Bavarian, Austro-Hungarian, and Belgian armies, reached other con- 
clusions, — that a number of tuberculous individuals enter the army, 
and that the military service, as such, in spite of the greatly increased 
demands on the physique, cannot be held primarily responsible for 
its occurrence. In fact, the decrease in the nimiber of those taken 
sick during the second year of service, which becomes still more 
marked in the third year, almost seems to indicate that the same age 
and class in the army enjoys a greater immunity from infection than 
the corresponding class of civilians. This protection is not absolute, 
for cases of infection undoubtedly occur in the army, especially when 
the hygiene of the barracks is faulty. Formerly, when barracks life 
w^as equivalent to crowded living and uncleanliness, infection probably 
occurred very often, and it may still do so in some armies. It is 
possible also that the quartering of soldiers on citizens during ma- 
noeuvres furnishes much chance of infection. But there is a compen- 
sating factor in the extended stay of the soldiers in the open air which 
does not obtain among civilians of the same age. A causal relation- 
ship between tuberculosis in the armies and the so-called ill effects 
of military service, over-exertion, etc., cannot be supported. 

For much the same reasons, therefore. Cornet considers that con- 
sumption does not become more prevalent daring wars, in si)ite of 
the fact that soldiers are exposed to great bodily hardships, to cold 
and wet bivouacs, to insufficient nourishment, and to sudden climatic 



The consumptive himself is ahnost harmless, and only hecomes harmful 
through bad habits. — Cornet. 

The establishment of the Tuberculosis Infirmary on Blackweirs 
Island is described in an interesting paper by Homer Folks, Esq., 
Commissioner of Charities for New York City in 1902. Mr. Folks 
found himself " in some uncertainty as to the value of the institution.'" 
Many patients were discharged otherwise than as improved, and the 
nurses and physicians seemed to have no clear idea why the roll of 
inmates changed so rapidly. In order to get some knowledge as to just 
how much was being accomplished for the patients while in the In- 
firmary, and for a better insight into the actual workings of the in- 
stitution from the patient's point of view, Mr. Christopher Easton was 
appointed Deputy Superintendent with instructions to give special 
attention to personal acquaintance with the patients, to the social life 
of the institution, and to its economic and social features. This gentle- 
man, a Princeton graduate, had no previous experience in institutional 
or hospital work. He was instructed to become personally acquainted 
with each patient immediately upon admission, and to secure from 
him such information as might, when added to hundreds of similar 
histories, throw light on the general question of the treatment of the 
tuberculosis problem by municipal and private means. He was to 
explain to each patient the objects of the institution, how to adjust 
himself to the life within it, how to get the most benefit from it, 
and how to exercise the greatest precautions in his own behalf and 
in behalf of the other patients. He was to explain the printed rules 
and to encourage reports to him any matter about which there 
seemed to be reasonable cause for complaint. He was to investigate 
carefully each such complaint, and to see that substantial justice was 
secured. He was to interview every patient discharged, either at his 
own request or because of insubordination or misconduct, or as ap- 
parently cured, and was to keep full records showing why he left the 
institution, and his condition on leaving as compared with that on 
admission. He was also to keep in touch as well as he could, by 
correspondence, with patients discharged as improved and apparently 
cured. He was given direct and special oversight of the sanitary 
discipline of the institution, the daily life of the patients, their recrea- 



tion, games, exercises (under the direction of the physicians), reading, 
and entertainments. An elaborate schedule of questions concerning 
personal liistory, family relations, history of disease, etc., was fol- 
lowed ; ^ and the patients seemed, as a rule, willing and glad to give 
the desired information. 

It seemed to Mr. Easton that hopefulness and good cheer are the 
general tone of this institution, which one might expect to be the least 
cheerful in the Charities Department. His statistics cover only one 
hundred cases, too small a number to have any considerable value. 
However, taken in connection with similar statistics in other institu- 
tions, or Avith the larger number accruing from a continuance of his 
labors, they should be invaluable in indicating the social conditions 
and factors which are prominent causes of tuberculosis. 

It was found that the average duration of the disease before the 
patient's admission was seven months and twenty-one days ; the 
average period of unsteady employment three and one-third years. 
The latter figure is much larger than it would otherwise be by reason 
of the large number who had been unsteady workers, owing to dis- 
sipation or some other cause than consum})tion. The duration of the 
disease above given prior to admission is, on the other hand, probably 
too short. Many patients have not realized their condition in the 
early stages of the disease. The corresponding period of the i)atients 
admitted to the State Sanatorium, Rutland, Mass., is stated as twelve 
and one-quarter months, although they receive a more incipient class 
of patients than the Blackwell's Island Infirmary. 

Almost exactly one-half of the patients were between the ages of 
thirty and forty-five ; forty-one per cent, were native born, and fifty- 
nine per cent, foreign born. The birth-place of the mothers showed 
only twelve per cent, native born, and eighty-eight per cent, foreign 
born ; among the latter, exactly half (forty-four) were from Ireland. 

The following data indicate a very wide range of conditions : 

Professional, 2 per cent.; commercial, 9 per cent.; mechanics, 21 i)er cent.; 
trades, 22 per cent.; unskilled, 46 per cent. 

Average length of time which patient has not worked at all hefore coming to 
this hospital, 2 months, 14 days. 

Average period of unsteady employment before stopping work entirely, 3 years, 
4 months. 
Number of patients in the condition of whose employment nothing unheallhful 

was revealed . . 22 

Number who have taken up a poorer grade of work than their main occupation 

at time consumption appeared or after becoming ill with consumption . . 27 

' Appendix G. 



Nuinbor who have maintained the same grade of work after becoming ill with 

consumption, l)ut followed it unsteadily 12 

Number who were doing nothing at time consumption appeared 3 

Number who did not work after becoming ill with consumption 26 

AVitli reii-anl to recreations of the patients, where they spent their 
evenin^rs and their Sundays, tliis ta]3ulation was arranged. 

Recreation. Evenings. Sunday. 

Home — 45 4J 

Reading home 18 13 11 

Reading-rooms 14 6 2 

Baseball 2 — 1 

Theatre 23 7 2 

Walking 20 16 ,17 

Club-room 7 3 3 

Visiting 7 5 7 

Saloon 41 41 19 

Excursions 12 1 9 

(Four of them to Coney Island.) 

Church 5 1 5 

Smoking 3 2 2 

Park 2 1 2 

Mission 2 1 2 

Fishing 1 — 1 

Music 1 1 1 

On docks 1 1 1 

Cards 3 1 — 

On streets 7 7 2 

Pool-room 5 2 5 

Billiards 1 1 — 

Y. M. C. A 1 1 — 

Lectures 1 — — 

Disorderly houses 1 1 — 

Dancing 2 2 ^15 

No time 6 8 24 

Mr. Easton's comments on this table are : 

" The information as to recreation, or lack of recreation, was taken verbatim from the patients. For example, undoubtedly more 
than forty-five spent their evenings home, but only forty-five gave 
home ill answer to the ciuestion where they spent their evenings. 
Home, of course, means where they slept. It might mean a kitchen, 
or a forecastle, or a stable, or a lodging-house. It will be noticed that 
the nine chief forms of recreation, arranged in order of their iK:)i)ularity, 
begin with the saloon and end with the church. The small number 

* Working. " Sleeping. 


giving theatre in tlie evening, although it is third in popularity, is ex- 
plained by the fact that most of them give it under tln^ (piestion on 
amusement. Walking, reading, and visiting are relatively more popu- 
lar in the evening and on Sunday than in general. This is explained 
by the foct that they are usually given more than once ])y the same 
person, while rank in popularity de])ends on the lumilx^r of different 
persons giving a certain amusement. The saloon is the most popular, 
both to persons patronizing it, and as a way of spending the evening 
and Sunday. With regard to drink, of these one hundred patients 
two said they were total abstainers, eleven that tliey were occasional 
drinkers, forty-three that they were moderate, and forty-four that 
they were hard drinkers." Among interesting personal items are tlie 
following : 

A man liad been a cloak-designer in Germany. Of two and one- 
half years in the United States, he had been ill two years. He found 
methods of trade different here, and had to take anything he couht 
get. He was first waiter in a good place, and then extra waiter. 
Finally, his voice got so weak he couldn't even get an extra waiter's 
job. A well-educated man. 

A man did restaurant work in a dam}), dirty basement in Bleecker 
Street. There were thirty in the room where he slept, two of them 
i'onsnmptives. The cots were in two tiers. The food — weak soup 
and bread — "had no nourishment." The floor was not scrubbed 
during, the four months he was there. The place was run by a re- 
ligious charitable association : '• they had men working in a filthy, 
damp subcellar." 

x\ patient who had alternated iceman and kitchenman for several 
years, the former involving getting overclothes wet, the latter all kinds 
of bad conditions. 

A patient who had worked in bakeries two and one-half years after 
becoming consumptive. He worked with a careless consumptive in 
one bakery for three years. 

A patient who stated that three girls went out with c()nsum[)tion 
from the laundry where he worked. One man told liim that seven 
men with consumption had left the machine-shop where he worked 
the year before becoming ill. 

A railway porter who became infected from consumpUve travellers 
in sleeping-cars, on their way to health resorts. 

A patient liad been covering furniture from liouse to house for 
seven months. He had felt very weak and would do a cjuarter of a 
day's work and then rest for the remainder of the day. He had had 
no treatment. 



It is madness to come to California in search of hcaUli without ample means 
to supply all the comforts and luxuries. — Edwards. 

Dr. Earl S. Bullock, formerly of New York, now of Silver City, 
New Mexico, having become consumptive, was sent AVest by his 
physician. He recently revisited for a brief season his old home 
when his confreres heard from him a very illuminating paper on Six 
Years' Experience with Tuberculosis in the West, from which the fol- 
lowing paragraphs are taken. The reader will appreciate my quota- 
tion marks : for Dr. Bullock has literary vision ; and he can create 
atmosphere ; and he has temperament, as I realized in meeting him 
and grasping his genial hand : 

" I liave had personal experience in all the following health resorts, 
a good deal in some and little in others : Denver, Colorado Springs, 
Fort Collins, and Pueblo, in Colorado ; Raton, Las Vegas, Santa Fe, 
Albuquerque, Deming, Fort Bayard, Las Cruces, and Silver City, in 
New Mexico ; Phoenix and Tucson, in Arizona, and El Paso, in Texas. 

" Resorts for consumptives all have much in common, though they 
may differ widely in details. Some, though few% are well-built towns 
and cities, though most, from an Eastern point of view, are miserable 
places of habitation. Everywhere is the ubiquitous consumptive spit- 
ting [tromiscuously, and the fact that there are so few cases of local 
infection speaks most forcibly for the truly wonderful healthfulness of 
tlie arid region. In few places is the consumptive really wanted. The 
doctors may desire his presence, but, as a rule, the people do not. It 
is a fact though, that money is potent with the health-seeker as with 
others, and when well supplied with it the invalid gets pretty much 
what he wishes. There are, of course, a lunuber of excellent places 
open to invalids, but most of them are very expensive or receive 
patients so far advanced as to make them objectionable to the average 
health-seeker. What I particularly mean to imply is, that the invalid 
finds great difficulty in placing himself under anything like as good 
conditions as he would enjoy at home for an equal expense. As a 
rule, there seems to be but one compensation in having a consumptive 
about, and that is to get all possible out of him. It has often seemed 
to me that the consumptive is managed for the benefit. of tlie people 
where he goes rather tiian in his own interest, though in justice I must 


say that thoro is hardly a coiuity hospital in the West that does not 
have its quota of Eastern invalids, and I have never heard any objec- 
tion, every one seeming to accept the l)urden of supporting the citizens 
of other States as a matter of course. A great many poor people go 
West for health's sake, and many of them become actual burdens lo 
the communities to which they go. So, to take every possible ndvaii- 
tage of the moneyed invalid may work out fairly in the long run, 
though it seems rather a hard practice to be gracefully accepted by the 

" Everywhere one is impressed by the fact that the invalids are 
usually doing what they ought not to do. They are essentially idle 
folk and prone to follow the ways of the idle. They always find the 
centre of population, and, gathering together, support tlie adage that 
'like seeks like.' Nothing can be more pathetic than to see the poor 
creatures sitting about the plazas, spitting and talking. To an observer 
picking his way carefully between expectorations, sometimes a difficult 
thing to do, and making the circuit of the square, the occupants of the 
crowded benclies seldom or never show among them a happy, con- 
tended face. Standing about the hotels, watching the trains or the 
roulette wheel in the corner saloon, sometimes risking a liltle money 
themselves, they are always the same pathetic victims of the scourge 
of civilized States. Hunting, riding horseback, or taking tiresome 
walks, they are seemingly constantly violating every principle laid 
down by the immortal Brehmer. One exclaims : Poor old climate, 
what a lot you are expected to do ! Now and then, fortunately, may 
be seen a porch or tent fitted up for out-door life. Everything is 
comfortably and tastefully arranged. The invalid, occupying his cot 
or chair, is reading, maybe, and it is recognized at once that here is a 
properly managed case, and inquiry will elicit the fact that a careful 
physician in the East has sent the patient to some careful physician in 
the West. Such a patient is a very great contrast to those previously 
described. The daily life is purposeful and filled with little duties, 
from egg-nog to massage, all tending to make a useful citizen again. 
The patient may lie on his cot nearly all day, yet he is not idle. On 
the contrary, he is very busy getting well. A wistful, homesick, dis- 
contented expression will be absent in such a case. The fact remains 
that most people are sent West in an utterly irresponsible way and, 
if they come under medical care at all, it is usually delayed until every 
chance of recovery is past. It seems so simple to send patients to 
some one w^io is known to be capable of managing them properly, 
that it is difficult or impossible to condone this careless way of ship- 
ping people to a strange land to shift for themselves under new condi- 


tions and surroundinfrs. As in nearly every case a doctor has sug- 
gested the advisability of jioing West, tlie responsibility for this state 
of affairs rests S([uarely npon tlie slionlders of our profession. 

" One of the first lessons I drew from my experience was that most 
people who go West for their health are disappointed in the result, 
partly for reasons which I have endeavored to make clear, and partly 
because more is expected of the climate tlian it can possibly perform 
under any conditions. The majority of the tuberculous invalids that 
are observed have long since passed the point at which they would be 
favorable cases for admission to the large institutions in the East, and 
it does seem absurd that cases deemed hopeless at home should at 
once be regarded as hopeful because they have been sent West. I 
am, moreover, convinced that during recent years we have overesti- 
mated the curability of tuberculosis, even under the most favorable 
conditions in a favorable climate, and, furthermore, that there is a 
great tendency to underestimate the length of time required to effect 
a cure. During the first eiglit months of my own invalidism I was a 
model patient, and laid the foundation for a subsec{uent recovery, 
which, however, was not achieved until four years had passed, 
although mine was an incipient case of the best or afebrile type. I 
was thus impressed with the fact that to get well at all is a large con- 
tract to fill, and requires a much greater expenditure of time than is 
ordinarily allotted to it. Cases are so variable and the constitutional- 
equation upon which so much depends is so little known that it is 
never more than guessing to put a time limit upon tuberculosis. I 
have several instances in mind in which patients were sent West five 
or ten years ago to get well in six months and they are still coughing. 
The Lord only knows how many are dead who were assured of an 
early and brilliant recovery ! 

"An interesting class of jnitients observed is exemplified by the 
person with anqjle means and the invalid liabit. Though recovery 
lias occuiTed, possibly years before, a certain delicacy of constitution 
and long-established custom have impelled a conviction that idleness 
is the only business compatible with living. With some this becomes 
a fixed idea which drives them South for the winter and North for the 
summer, ad infnifuin. For my part, I cannot understand what good 
it does to get well when it requires the energies of a lifetime to keep 
well. Then there is the invalid witli the climate habit. He is always 
interested in the place in which he does not happen to be. I knew 
one poor chap, visiting thirty-seven towns in two years, who followed 
that i(/)ils fafniis^ the proper climate for liis casi-. When failure is 
progressive? and the end is near, it is indeed sad to see such as he race 


from town to town, eacii juurnry bringing liiin a little nearer the final 
stopping'-place. This, too, is often the fault of a doctor who lacks the 
<'ourage frankly to advise a return home, and yet will liold out a false 
hope in order to rid himself of a dying patient. 

"During even a few years' experience one comes in touch with a 
number of old chronic cases in which liope of recovery has long since 
hoen abandoned. Yet many of the people tlms doomed lead very 
iisefid hves, and unquestionably live longer in our beautiful climate 
under the more natural conditions thus possible than they would had 
they remained East. Once in a while a man will be observed who 
lias recovered while roughing it. But where one gets w^ell in this way 
many discover that it will not do, though often the knowledge costs 
more than can be ])aid. Fewer people than formerly have the idea 
that large quantities of whiskey must be consumed in order to make 
a recovery. There are still enough, however, to demonstrate the n.'al 
character of this rather agreeable method of committing suicide.'' 

Frank D. Witherbee, Esq., describes the great migration of tuber- 
culosis patients to the Salt River Valley of Arizona, and of the life 
they lead in tents and shacks in and about Pha^nix. Out of a winter 
population of some fifteen thousand, fully one-third are health-seekers, 
drawn to Arizona by tlie dry climate and constant succ(^ssion of sunny 
days which are essential for their relief and cure. Fully 90 ])er cent, 
of the days in Phoenix are clear and bright, and the relative humidity 
of the atmosphere is far below^ that of the average. '-On the one 
hand these conditions lead to a remarkable^ ])erceiitage of recoveries; 
but on the other there is an amount of social and spiritual sulfering 
which is not generally understood. As a matter of fact, a great 
majority of people go too late to be helped by any power on earth. 
A Phoenix physician has said that fully four-fitllis of the visitors are 
incurable. The streets are fdled with them, — thin and wretched, 
homesick and suffering. Heedless physicians and relatives send 
patients to Phoenix alone and with scant means of support. The 
blundering argument is made that all the sick one needs is to get to 
that country and his condition will permit of his doing light work 
which he can easily find. But the facts are that tliis incapacitated one 
is going to a country swarming with people looking for like chances ; 
that it is essentially a ranching community, where the bulk of the 
workers to be of any service must be able to plow and sow and reap 
and herd cattle, often standing in water all night long to irrigate. 
What few chances there are for light work ought not to be accepted 
because they are too confining. Here, as wherever consunq)tives have 
taken up work in desirable climates, they have by their underbidding 


and their iiiiiiibcrs steadily t'oncnl wai;'cs d()\vii to a point where they 
can sc'arc(>ly earn onongh to live. Many of the necessities of life, by 
reason of lii^li freight rates, are much more costly than in other com- 
munities. Out on the desert, at the outskirts of the irrigated parts 
of tlie valley, and extending to the foothills, there are tents of all sizes 
and descrijilion. Some are in groups and others stand alone; some 
are roomy and attractive, others are cramped and desolate-looking. 
Some of the ranchers near Ph(jenix have made a specialty of provid- 
ing acconmiodations for health-seekers, and offer furnished tents or 
rooms in specially constructed houses with board at the ranch house. 
Ttie local fraternal lodges, the churches, the county almshouse, and 
the one free sanatorium are crowded to their utmost capacity year 
in and year out. Many a patient reaches Phoenix with his small 
capital exhausted by traveling expenses, and finds himself dependent 
ui)on the resources of a community which has no interest in him and 
where lie finds on many sides an almost hardened indifference to his 
})itiable need. This is not because residents of Phoenix are lacking 
in the finer feelings which prompt to charitable service, but because 
the people of the East and Middle West are, by their lack of fore- 
thought, putting upon them a burden which in no sense belongs to 
tliem. The supervisors say that the poor in the almshouse cost the 
county »^20,000 a year, and three-quarters of tliis is spent in the care 
of ailing consumptives." 

All these dreadful conditions will in the course of time be miti- 
gated when it becomes understood that the climate of the West is not 
essential to recovery from consumption, and that sufferers are quite 
as likely to get well near their own homes in the East. 

Part V 


What an amount of pain and distress, of social misery, is due 
to the fact that families, having lost their support, sink into pauper- 
ism, and eventually fall back upon the charity of the community ! 
And aside from the monetary question, what an amount of moral 
undomg and wrong is visited upon society through the fact that chil- 
dren have been robbed of their mother and of the educative influ- 
ence of home. Look at the orphan asylums, — how many of their 
inmates have lost their parents through tuberculosis ! 





A grave danger to adults and cliildreii, mainly the latter, are our bed-rooms. 
Indeed, my friend Biermer, late professor in Zurich and Breslau, called tut)ercn- 
losis a bed-room disease. With what right? A baby is at least si.xteen hours a 
day in that narrow, confined, airless, windowless bed-room ; a child at least ten or 
fourteen hours, the greater part of its young life. The air is the reverse of what 
it should be to protect blood formation, circulation, and digestion. What can be 
done to improve it to a certain extent? Some window should be open all night 
and day. If there be none in the bed-room there is one in the adjoining front 
room, or the kitchen at the rear. Unfortunately not always, for we are still in an 
era of the selfish refusal on the part of man to be held responsible for the evils and 
ills of his neighbors. We are hardly entitled to call ourselves a civilized com- 
munity when fifty thousand families at least, with three to six children each, live 
each in one light room and one or two small dark holes. In these holes they 
breed tuberculosis. But it is no consolation to you that they die of it. Before 
they die they infect their neighbors : and their neighbors, in the capacities of seam- 
stresses, servant girls, laundresses, cooks, and teachers, infect you and your chil-l 
dren and vour friend's children. — Jacobi. 


Dr. Flick emphasizes the importance of the house in the develop- 
ment of tuberculosis. An enclosure of some kind — a hut, a tenement, 
a factory, or a vehicle — " is the granary of the tubercle bacillus outside 
of its host." Here the soil 
is prepared, the seed is gar- 
nered and implanted, the 
tender shoot reared, the 
full-grown plant nurtured, 
matured, and harvested. 
Obversely to normal, natural 
growth, this seed thrives in 
dampness and darkness. In 
the house tuberculous matter 
may remain vital for month? 
or years. 

Up to witliin recent 
limes the consunii)tivc, 
being aftlicted with chilliness 
and a general sense of dis- 
tress and illness, has sought shelter in some enclosure, being deluded 
with the idea that the further he could get away from sunshine and 
pure air, from draughts and the cold, the better were liis chances of 


Fig. o-'.— An 

sluU't VI iiiflu's wide and si.\ tloors deep. 

132 coxsiMrrioN 

rt>covery. For iiistanci', Michael IVters wrote: '■ I know nothing 
more liidcoiisly Mid tlian (lie bed-chamber of a ricli consumptive. 
It is a spot carerully elos(Hl, wliere both air and liope are alike for- 
bidden to enter. There are sand-bags to doors, sand-liags to windows, 
thick curtains envelop the bed, where the unforlunate eousumptive 
swelters in pei'spiralion and an atmosphere tweidy times respired, 
twenty times already contaniinaled by contact with his own diseased 

The recluse and the home-body, under such circumstances as 
these, easily become a })rey. And domestic animals are very prone 
to tuberculosis. Occasional contact is not dangerous, but intimate, 
repeated, and much prolonged contact with a person, place, or thing 
that has been permeated witli tubercular matter, is likely to end in 

Fig. S,',. TUltl' are :-;61,0(M) sucli 'daik n.mas" in New "^'Drk City. 

tuberculosis. The mere presence of a few Ijacilli will not occasion 
this disease. Besides, their virulence differs in intensity. Every one 
has some resisting power. With every one there is a minimum dose 
of l)acilli, varying according to the individual constitution whicli will 
give an implantation. This is facilitated when the organism is sub- 
jected to hni)ure air and poor food in dark unventilated rooms. An 
enclosure is the one place in which contamination can become sufti- 
ciently intense to create an environment capable of overcoming the 
resisting i)Ower. Tubercular matter ejected in a house, unless 
innnediately devitalized, dries artiticially, and is distributed about in 
particles, varying in sizt; from weighable tjuantities to impalpable dust. 
In these particles the bacillus is cached and preserved. Thus hi the 
course of time (juite a great deal of vital tubercular matter accumulates. 

'riiK iiorsi; 133 

The occupancy of such a room means constant inlialiilioti and 
frequent, swallowing- of tin; infeciixe material. 

The lionie and the workshop are tlie two kinds of enclosing which 
offer the best environment for implantation. Tuberculosis is a family 
disease in the main, because it can so easily be implanted around 
tlie hearthstone. When once it gets into a family, it follows that 
family in all directions niilil 11 either has exterminated the latter or 
has exhausted the soil, and made the remaining members immune. 
The bed-room, and next to the bed-room the dining-room, are the 
l)arts of the home most dangerous in this respect. In the bed-room 
the consumptive spends his last weeks or months, — a period during 
which tlie disease is most intensely infectious. Often among the very 
[>oor the dining-room is used as tlie only living place for tlie sick one 
until shortly before his deatli, 

Tlu3_\\ork-_s]iop is a very c^mnioii ineaiis of spreading tuberculosis. 
Cornet considers it the inost_cpmmon of all. These buildings are 
often crowded. There is likely to be air-space inade(juate for the 
number of employees. In some trades the air may become cliarged 
w itli irritatating A^apors or particles. Noxious dirt may be introduced 
u|)on the shoes of employees. Sometimes workmen are suffering from 
L^erm diseases which do not incapacitate them, but which knver their 
\ itality and invite tuberculosis. Usually the workman " lives in a house 
wiiich has been built for money-making, about the sanitary condition 
of which he has practically nothing to say. He cannot select his place 
of abode, because it is necessary for him to be near his work. Me has 
no voice in tlie sanitary construction or management of his worksho}). 
It is true he can work there or not as he pleases, but if he wants to 
earn bread for himself and for his family he must work there or in a 
place like it." 

Tuberculosis is an extremely chronic disease, and usually runs a 
long course even in its infectious stage before its victim is incapaci- 
tated. Some consumptives work thus for the greater part of a working 
lifetime, occasionally having to stop for a few^ weeks or months for 
rest and treatment, and again returning to work as soon as they are 
able. Unfortunately, uncleanly consumptives very easily contaminatel 
the shops in which they work by promiscuous spitting. One con-l 
suinptive can produce an environment around his own stand capable 
of implanting the disease in those who are next to him, and betbre 
long these are associated with him in the task of polluting the shop. 
Deaths will occur from such a shop at regular intervals for an indeliiiite 
period so long as it is permitted to remain contaminated. 

Hotels, churches, public halls, and places of public convenience, 


in which people stop for a short time only, are not so dangerous, be- 
cause a consumptive rarely remains in them long enough to produce 
an infectious environment ; and again, because healthy people seldom 
remain in them long enough to get an implantation. Cleaners and 
caretakers of such places are in some danger, but for the casual visi- 
tor there is practically none. The house nurtures the tubercular 
growth when an implantation has taken place. The disease always 
begins in a very small way. The first crop develops and runs through 
its course, and the second follows, perhaps a little larger than the 
first. Then a third and a fourth follow, each a little larger than the 
preceding one, until finally so much tissue has been invaded and de- 
stroyed as to make death inevitable. Things which have been in- 
tensely contaminated by having been used for a long time by a 
consumptive may give the disease to others when kept or used in- 
doors. Dust in the neighborhood of a bed in which a consumptive 
had died was found six years after the death to contain virulent tuber- 
cular bacilli (Cornet). 

House-life undoubtedly plays an important role tliroughout the 
entire course of tuberculosis to its culmination in consumption and 
death. With every recurrent crop of tubercle bacilli the organs of 
the body become more embarrassed and the economy is less apt to 
carry on the warfare against the disease. In the lungs the air supply 
grows less with each destruction of lung tissue. Tuberculosis makes 
its progress generally because its victim is shut up in a house where 
he cannot get fresh air. In the houses of the poor an ample supply of 
fresh air is impossiljle. 

Osier has had his outpatients in Baltimore visited in their homes 
by intelligent women with a view to noting the conditions in which 
they live. These visitors reported bad sanitary location in 62 per 
cent, among Russian Jews, 53 per cent, among negroes, and 16 per 
cent, among whites. There was overcrowding in 61, 41, and 32 per 
cent, respectively ; personal and household uncleanliness in 70, 56, 
and 30 per cent, respectively. 

European observers conclude that the large mortality from tubercu- 
culosis, especially among the poor, is to be attributed largely to the 
crowding of tuberculous cases in certain houses. Therefore, they 
consider quite rigidly the fight against tuberculosis is especially to be 
carried on in the dwellings of the very poor. 



It is hard for men to make headway when their virtues and energies are i 
cramped by poverty. — Juvenal. 

The poverty of Lazarus makes itself felt in the house of Dives. — S. Solis Cohen. 

Poverty, with all that the word implies — underfeeding, deficiency 
of sunlight, defective ventilation, overcrowding, uncleanliness, and bad 
drainage (which induces damp walls in houses) — stands enormously in 
a causative relation to tuberculosis. Biggs' has graphically demon- 
strated this by means of maps of various sections of New York City. 
Bulstrode submits the death-rate from pulmonary tuberculosis in 
Hamburg among the several income tax classes (inclusive of the 
dependents of taxpayers). For incomes from nine to twelve hundred 
marks the death-rate is 55.4 ; for incomes of from twenty-five to i 
fifty thousand marks the death-rate is 7.5; a proportion against the 
poorer classes of nearly eight to one. | 

Korosi, of Budapest, found that consumption caused over 22 per 
cent, of all deaths among the poor, but only 16 per cent, among the 
well-to-do. London statistics show that the consumption death-rate 
varies according to the number of persons to a room. In Dundee it 
has been found that it varies inversely as the number of rooms in an 
apartment. In France, states Lagneau, the consumption mortality 
varies du'ectly according to the size of the city from 490 deaths per 
100,000, living in Paris, to 181 in the ninety-five cities of less than 
5,000 inhabitants. 

In American cities of 8,000 and over in the registration area, the ; 
mortality from consumption was 53 per cent, higher than in the rural 
districts. The towns of 25,000 inhabitants or more in New York 1 
State have a death-rate from this disease not far from twice as great 
as the rest of the State. 

In Miss Brandt's table it is shown that cities with a population of 
over half a million have the highest mortality, both from all causes 
and from consumption. This is explained on the basis that in these 
cities " slum " conditions, such as are ideal for the propagation of 
consumption, exist at their worst. The striking thing here is that 
the thirty-seven cities between 50,000 and 100,000 inhabitants, though 

' See Page 147. 




coming fourth on the list, rank second as regards consumption mor- 
tality., having both a general death-rate and a consumption death-rate 
close to those of the six great cities. Possibly these figures mean that 
in the United States cities are generally allowed to attain a consider- 
able size before the public realizes the housing, the drainage, the water 
and milk supply, the street cleaning and other problems that have 





Popuhition of the 

Number of 


Per 10,000 


= 2c 


a 01 o 



60 J-, 
.5 O . 










500,000 inhabitant.? and over. 
200,000-.500,000 inhabitants. . . 


2.5,000- .50,000 









Total registration area 







been growing up, and sees its responsibility for them. The prevalence 
of the l)ad conditions in the six largest cities would explain their rank, 
without discrediting the efforts of the municipal government. Per- 
haps, moreover, the small city between 50,000 and 100,000 is large 
enough to have its serious sanitary problems, and has not yet realized 
their gravity. 

The various large cities in the United States vary also considerably 
in their consumption mortality. Between the highest and lowest 
death-rate in twelve cities there is a difference of almost 150 per cent. 
To reach a lucid conclusion here we would have to investigate care- 
fully the climatic and sanitary conditions of each city, the composition 
of its population as to race, sex and age, the industrial situation, and 
/the method, of reporting deaths. New Orleans has the highest death- 
/ rate, probably because of its large negro element. Next comes San 
/ Francisco, probably because of its Chinese population. (Brandt.) 

Two practical observations are pertinent. The poor move fre- 
quently several times a year. They become discontented, or ill. or 
they are too poor to pay the rent. If any member of the moving 
family be consumiitive, that apartment and the next, and the 
J others to wliicli they go, will become infected. So that it has been 
I counselled tliat not only consumptives but also apartments in which 



they have lived should be registered, aiul that the law shuidd require 
the owners of buildings to make such notifications. Then the poor 
servants of the well-to-do, if there be consumption in their own homes, 
are likely to bring the infection into the families of their masters : as 
are also poor consumptive workmen who are employed upon repairs 
in the houses of the rich. There is, in fact, no limit to the extent to 
which the disease may bo disseminated from its primal base — the 
homes of the poor sufferers. For instance, tailoring establishments 
often put out their work to be done in sweat-shops or in tenements 

Fig. ol— Basement of tenement-house in block known as " Lung Block," because of prevalence 
of tuberculosis. No day-ligiit — a;as burning at mid-day. A woman in the last stages of twbtrcnlnsis 
working on fancy collars. [Ulustrating Dr. Annie S. Daniel's article on "The Wreck ni tin- Honu ," 
Charitira, April 1, 1903.] 

of a most unclean and germ-ridden sort. In such manner does 
danger lurk for the whole community. Poole ^ states that in a row 
'tf fifteen old houses on Cherry Street, in New Yofk, he found thirty- 
one little children and eighty-seven women sewing on garments. 
These garments — the kind for sale in clothing stores — were almost 
all to be worn by young children. 

Again : " A man was dying down in the Ghetto. His cough 
kept on day and night. It was January. Coal was high. The room 
at night grew freezing cold. The Plague grew worse. He worked 

^No one should fail to read Mr. Poole's paper in the Handbook of the New 
York Charity Organization Society. And in that volume also, as in the collection 
of the Hebrew Aid Society, the Children's ilid Society, and other associations, are 
many pitiful stories illustrating the dreadful tenement conditions in New York 
City, particularly as illustrating the infectious nature of consumption. 



on in bed. He had l)ut one blanket. lie used the coats and trousers 
to cover him. Now coiisi(h^r our tense, rushing, strained city life ; 
remember the scores of your own friends whose vitality is now at 
tlie lowest ebb ; and then think of the constant danger to them from 
a plague whose victims keep on working ; who are constantly in the 
streets, the cars, and all public places. We all use the products of 
their work. Only be human and think of these hundreds of thou- 
sands, rich and poor alike, in constant danger. Thousands of these 
will inevitably be taken with the plague this year, as thousands were 
taken last vear and before."' 

Fig. 35. — A where the occupants work on women's wear. 

^Vykoff has powerfully characterized these sweat-shop conditions: 

" While the Unionist was talking to the Sweater, I walked between 

I the close lines of machines over a floor covered deep with accumula- 

\ tions of dirt and shreds of cloth and broken threads to where in a 

I corner a group of girls were sewing. The oldest among them may 

1 have been twelve, and the youngest could have been a little over 

j eight, and their wages averaged about seventy-five cents a week for 

hours tliat varied widely according to the stress of work. 

" Near the corner was a passage, and through it I could see into a 
small room which had no windows nor any opening but the door; 


there, in perpetual clarlviiess, lit up by one oil lamp, was a man who, 
for twelve (and sometimes fifteen) hours a day, pressed the new-made 
clothing for a living. 

" It was ladies' cloaks that the sewers were making ; of course, tliey 
worked by the piece, and the best among them could earn a dollar in 
the day, and sonictimcs more by working overtime. They were very 
smart-looking garnuMits, and their air of jaiudy stylishness was a most 
incongruous hitrusion upon their surroundings. When I asked the 
Unionist for whose trade they were being made, he seemed lo lliiuk 
uothing of the fact that he mentioned in answer one of the foremost 
merchent-citizens of the town. 

"We were on the point of leaving when a lieavy footfall sounded 
on the wooden steps and the door opened to the touch of an inspecting 
officer, whose glowing liealth and neat, woven uniform were as tliougli 
a prosperous breeze was sweeping the stagnant room. The work, 
however, was as unaffected by his coming as it liad been by ours. 
Not a sewer noticed him, and tlie stitcliing of machines went racing 
on with unabated swiftness. Only ' the old man' watched nervously 
the movements of the officer as he walked about the shop, making 
note of the bad air, and the filth upon the floors, and the group of 
little girls, and the dark, unventilated chamber beyond. 

"The Unionist had caught me by the arm. ' We'll wait,' he said ; 
and we stood together in the shadow of the open door. 

" Returning finally to the side of the old Sweater, the officer 
handed him a printed form. 

" 'You must make out this blank,' he said, 'and have it ready for 
me when I call again.' And without another word he started for 
the stairs. But on the way some evidence of unsanitary conditions 
more shocking than any met with yet — a heap of offal on the floor or 
a fouler gust of poisoned air — checked him, and he turned indig- 
nantly to the nearest worker. 

" ' Look here,' I could hear liiin say, ' you've got to clean up here, 
and right away. The first thing you know you'll start a fever tliat 
will sweep the city before we can stop it.' 

" The young Hebrew had stopped his work and turned half round 
in his chair until he faced the officer. There were deep lines in his 
liaggard, beardless face, and his wolfish eyes were ablaze with the 
sense of sharp injustice. 

•• ' You tell us we've got to keep clean,' he answered, in broken 
English, lifting his voice to a shout above the clatter of machines. 
' What time have we to keep clean when it's all we can do to get 
bread y Don't talk to us about disease ; it's bread we're alter, bread !' 



And ihoro sounded in the voice of tiie boy the cry of the hungry for 
food, which no man who hears can ever forget. 

"■ Tlie officer passed, speechless, up the steps, and we followed 
into the clean, pure air, under the boundless blue of smiling skies." 

This rather attractive picture (Fig. 36) is of a room in Philadel- 
phia occupied by a family that had a suggestive history. A daughter 
contracted consumption. In the place where she was employed at 
sewing a consumptive girl had sat day by day next lier. Soon the 
mother contracted the disease. The fattier, a reformed drunkard, 
came down with it. Then anotlier daughter came to suffer. Then 
a son, a cooper by trade — a strong man, "able to liil a hogshead" — 
began to think that consumption must be an infectious disease. And 
then he came to be fearful for himself. His wages were eighteen dol- 
lars a week, — enough to support the family if he remained home, but 

Fig. 36.— Six deaths from consumption in this room. 

not enough for both liim and the family if he should go away. Having 
thoroughly considered the matter he made up his mind. He stayed 
witli the rest, supported them, became consumptive, and died. The 
seventh of the family, a child, did not contract pulmonary consump- 
tion, but developed instead tuberculous spine. Here the disease 
claimed six deaths. 

Dr. Milliken, of Silver City, New Mexico, narrates that in 1890 a 
farmer, of good family history as regards his physique, took the Grippe ; 
and, owing to a relapse, was very slow in making a recovery. He 
spent mucli of his time during convalescence witli a friend wlio was 
ill with tuberculosis. He himself contracted consumption, of which 
he died. His son, a strong, hearty fellow, who nursed hhn when he 
became too weak to take care of himself, became consumptive and 


^ died four years later. A second son [ml into his own room the carpet 
that had heen in his fatlier's room. In about one year he began to 
decline. His iUness was also shown to be tubercular, with which he 
struggled (or seven years, finally achieving a return to good health. 
Another son bought the couch upon which his father had slept, and 
used it to sleep upon himself. He soon evidenced tuberculosis, which 
disease he succeeded in arresting after a five years' struggle. A fourth 
son and three daughters, who were away from home, at college;, 

) remained well. 

A young farmer rented the place and moved into the house. 
Within two years liis wife died of consumption, and two children of 
marasmus, — probably intestinal tuberculosis. 

Anotlier young man, with a healthy family, moved into the house, 
and lost three children within eighteen months of an obscure bowel 
trouble (probably tubercular) ; and the father died a few years 
later of "bronchitis," which was most likely tuberculosis. It was now 
suspected that the house might have something to do with it. So a 
thorough cleaning was ordered. The paper was torn from the walls, 
which, with the woodwork, floors and ceilings, w^ere washed down 
antiseptically ; there was thorough disinfection, since which time not 
one case of tuberculosis has developed in it. 

To conclude this narration of cases : About a year ago the Duchess 
and her mother called upon me. I had been her doctor from child- 
hood. She was then a salesgirl, quite poor, fourteen years old, and 
i hence not yet quite old enough to be a " saleslady." She belonged 
at that time to a dramatic society of young church peopl(\ A Cek- 
bruied Case was to be presented on an evening a couple of months later, 
and she was to be the Duchess in the play. That is why 1 thereafter 
addressed her by this title. She never, however, took part in the 
performance ; which was a great pity, for she was of a Avinsome and 
sunny nature and would certainly have played the character agreeably. 
And the reason of it was that she came to me because her knee was 
swollen and gave her great pain ; and she wanted this cured before 
the night of the performance. It was pathetic the way she looked 
when I counselled that instead she must go at once to a hospital, where 
I feared she would have to stay for some time. To the hospital, then, 
she was taken at once by her mother : and for some time she was be- 
yond my observation in the hands of its excellent surgical staff. 

One night some time afterwards I was sent for by her mother to 
attend the Duchess at her home in a crowded tenement. 

"How are you. Duchess? 1 am very glad to see you," said I, 
taking her liand. 


She greeted me cheerily, but with a most melancholy cheerfulness. 
For her face was white and very thin, with a clauuiiy sweat upon her 
cheeks; and her eyes were luminous, almost phosphorescent. Her 
breathing was labored and hurried — sixty times in a minute : and her 
heart l^eat tunuiltuously with the fever that was in her. 1 tried to 
examine her chest ; but she sank back most painfully in a paroxysm 
of coughing. 

Then 1 went away and tele})honed to the hospital to learn what 
had been done. Her tubercular knee had been resected. Then 
gangrene had set in ; and so the leg had to be amputated at a second 
operation. But the infection had become disseminated and so, after 
the lapse of a few months, had remanifested itself in the thorax. 
And then I came back and told her mother how soon I thought 
it would be when the Duchess would cease radiating a benignant 
effulgence about her, except in the memories of those, including my- 
self, who loved her. Her mother also became consumptive. 


L'alcoolisme fait le lit de la tuberculose. — Laxdouzy. 

Alcohol certainly stands in a causative relation to tuberculosis. 
Pulmonary tuberculosis is almost invariably found in persons dying in 
the course of chronic alcoholism : tubercle of tlie peritoneum or 
pleura frequently accompanies hobnail liver; acute miliary tubercu- 
losis finds alcoholics an easy prey. Kellynack finds 80 per cent, of 
pulmonary tuberculosis in patients dying of alcoholic neurifis ; Osier 
finds a proportion of eight in eleven under the same circumstances. 
It is declared that pulmonary tuberculosis is more frequent in heavy 
drinkers than in people of moderate habits in the proportion of three 
to one. Lancereaux computes that more than one-half tlie cases of j 
tuberculosis are due to alcoholism ; and this, I believe, has been about 
the ratio in the medical wards of the City Hospital on Blackwell's 

It is difficult to explain the effects of alcohol. Like most of the 
simplest things in life, no definite agreement lias ever been reached 
concerning its mode of working. Some fiippantly consider that it is a 
preservative for living tissues in the same manner as for anatomical 
specimens. Prof. Atwater, among otliers, has demonstrated to the 
satisfaction of the unbiased mind that alcohol in moderation is a food, 
and is beneficial and not injurious to the system. Certain it Is that 
there is no hardier stock than in wine-drinking countries. Others 
hold that chronic alcoholics are more liable to tuberculosis because of 
the resulting tissue impoverishment. 

The bad effects attributed to alcohol lie largely in the state of 
affairs which it connotes, — unsanitary habits, poverty, lack of nutrition, 
bad food, ill-ventilated living-rooms, and most of all a condition of 
the organism exhausted by overwork, in which the reserve force is all 
that is letl to carry on the struggle for existence. Oftentimes alcohol 
is taken first with a view to keeping a defective econoniy up to the 
working-point, perhaps in a tuberculosis subject, or in one in whom 
all the conditions are receptive to tuberculosis : alcohol is then taken 
in increasing amounts with the pathetic aim to stimulate the fiagging 
energies, thus making a bad matter worse. Some who contract 
tuberculosis have occupations conducive to alcoholism, such as 



\v(irkci-s ill \\\v li(|iioi' Inidc. barmen, waiters and liotel-scn'vants, people 
who are thus employed Ix-cause they are I'rom tlieir physical and 
moral make-nj) unsuited for another sort of work. 

Then again, people who depend upon stimulants take insufficient 
food. This is the baneful property of stimulants, especially when 
taken upon empty stomachs. They give a transient sense of suf- 
ficiency, and destroy the appetite for food, particularly when, as is so 
often the case in the homes of the poor, the latter is badly prepared. 
This is so, not only with alcohol, but with other stimulants as well. 
Tea is the housewife's dissipation. There are among women many 
who will tell you that in this drink they find almost their only nour- 

There is one point about these stimulants which I consider essen- 
tial to emjihasize. Most of them are, as a rule, distasteful in the 
beginning. I think they are generally taken not because they satisfy a 
vicious and depraved appetite, but because tliey satisfy, for the time 
being at least, a need of the system. Stiiuulants (wine, tea, coffee, 
tobacco, and the like) are " paratriptics."' They are the savings- 
banks of the tissues. They tide the needy system over a critical 
period. They are not always used with vicious intent. 

In by-ways one comes upon suggestive experiences. I once w-as 
called about dawn of a cold winter morning to see a man in a saloon, 
who had been taken very sick and was likely to die. There were here 
in this saloon at this hour a number of men, too numerous to be 
waited on in the usual way. They did not crowd up to the bar, but 
formed an orderly line, each man taking his early morning dram as it 
was served to hini.^ These were men al)out to go to work, — good, 
industrious, well-meaning fellow's, to alt appearances. They were not 
drinking to satisfy a vicious i)ropensity; they were drinking to prepare 
\ tlKMTiselves as best they could for tiieir day's work. For them alcohol 
\ was a food and a necessity, their systems being in the condition to 
require it. 

Deferring for the present further consideration of this phase of the 
tuberculosis problem, I note in an editorial on Public Houses and 
the Spread of Tuberculosis that the Loyidon Lancet considers there is 
here a fruitful source of infection. It seems that public-house servants 
are especially prone to consumption. The floors of the poorer 

^ A folleague relates lliat on Avenue A, in New York City, there is a tii)ple 
niucli in vogue called Seeleifa Best. A patient stated as a matter of course that 
he was accustomed to take before breakfast a couple of drinks of this whiskey. 
The drinks cost ten cents each, and each drink was one pint — a quart before 


resorts are covered with sawdust, which bocunics much impregnated 
with sputum. This dust is being constantly stirred up by the feet of 
drinkers. Not only are the servants and the customers thus exposed 
to infection, but the unfortunate children who are brought by their 
mothers are likewise in danger. The public house is the poor 
woman's club, where she can discuss with her neighbors social and 
domestic incidents. The children cannot be left at home, and so 
they sit on tlie public-house floor during their motliers' gossij) time. 
For an instance, several slatternly women were drinking at the 
counter, while crawling on the floor of the bar and rubbing their 
hands in the sawdust were two babies from eighteen to twenty-four 
months old. This is not an uncommon occurrence. No wonder 
" the race is degenerating or that medical science should have such a 
liard up-hill fight against disease. Granting that these children, prob- 
ably the offspring of degenerate beings, become infected with the 
bacillus. The environment in which they live will necessarily be a 
potent factor in the development of consumption, and not only will 
they themselves suffer, but they will also involve the public in great 
expense for their subsequent treatment and keep." 

Walter C. Hamm, Esq., our consul at Hull, England, has presented 
a most pertinent report upon physical deterioration in that country 
which " is now making a vigorous effort to remedy the physical 
deterioration of her working population which has followed from past 
mistakes. She will succeed, although it will require a generation or 
two to restore the lost physical stamina. America could also recover 
from a similar condition, but it will be better if she is warned by the 
experience of others and avoids the mistakes entirely." It was pointed 
out during the Boer war that sixty per cent, of the population from 
which the fighting men of England were drawn lacked the physique to 
endure the hardships of active military service in the field. A Par- 
liamentary committee of investigation reported that among these 
causes of deterioration were " overcrowding, pollution of the atmos- 
phere, unhealthful conditions of employment, alcoholism, depletion of 
rural districts by the exodus of the best types, alleged diminished rate 
of reproduction among the better classes, bad and insufficient food, 
and bad conditions attending the life of children." That a very large 
percentage of the children of the poor in the English cities were under- 
fed was amply demonstrated; in London, for instance, 122,000, or 
sixteen per cent. ; in Manchester, fifteen per cent.' Most of these 
conditions, as regards our own community, have been referred to. 

'Like statements are made concerning children in American cities. 



The Parliamentary commission was obliged to give much of its 
attention to drink as a cause of degeneration. The evil appeared to 
be growing among the women of tlie poorer classes. The children of 
these women were sometimes born permanently disabled, and after 
birtli were often neglected. There was evidence of a close connection 
between the craving for drink and bad housing and long hours of work 
in overlieated and ill-ventilated rooms. Tlie desire for a stimulant 
could not be resisted. Juvenile smoking was found to be another 
cause of pliysical debility ; it was considered that scarcely two per 
cent, of stunted men had not been heavy smokers from boyhood. In 
answer to the cjuestion, " What are the chances of a child brought up 
for the first seven years of its life in a central part of London growing up 
I strong and healthy, enjoying the buoyancy of childhood, and possessing 
I eventually a sound, vigorous constitution ?" it was replied, " Very small 
I indeed, except the parents are of exceptionally strong constitution and 
intelligence.'' In Finbury, a congested London borough, the death- 
rate per thousand in one-roorn tenements was 38.9, in two-room 22.6, 
in three-room 11.7, and in four-room tenements 5.6. 



Luft — Luft — £?iel)t iiiir Luft. — The Pnti/rr of the Tenement. 

" In a rear tenement a young- Roumanian Jew lay dying of con- 
sumption. I had come in with a Jewish doctor. With every breath 
I felt the heavy, foul odor from poverty, ignorance, filth, disease. In 
this room, ten feet square, six people lay on the floor packed close, 
rubbing the heavy sleep from tired eyes, and staring at us dumbly. 
Two small windows gave them air from a noisome court — a pit twenty 
feet across and five floors deep. The other room was only a closet 
six feet by seven, with a grated window high up opening on an air- 
shaft eighteen inches wide. And in that closet four more were sleep- 
ing, three on a bed, one in a cradle. 

116 IIB 120 128 124 126 123 130 132 134 136 1381381^140 142 144 146 148 150 162 154 166 168 163!^ 162 164 


Fig. 37.— Ground-plan of the " Lung Block." The shaded sections are courts and air-shafts. 
Each letter represents one case of consumption reported to the Health Department since J894. 
a = one case in 1S94. b = one case in 1895. c = one case in 1896, and so on to k ^ one case in 1903. 
(As it is not possible from the records to tell whether a given case occurred in the front or rear 
tenement, all have been assembled in the front building, except in 144 Cherry Street, where there 
was not room.) In the plans of the Health Department (Part XII, Chapter II) dots (.) take the 
place of letters. 

" ' Breath — breath — give me breath.' The man's disease was in- 
fectious ; and yet for two long weeks he had lain liere dying. From 
,liis soiled bed he could touch the one table, where the two families 
ate ; the cooking stove was but six feet from him ; the cupboard, over 
liis pillow ; he could even reach one of the cradles, where his baby 
^iri lay staring, frightened at his strange position. For his wasted 
body was too feeble to rise ; too choked, too tortured, to lie down. 
His young wife held him up while the sleepers stared silently on, and 
hat Yiddisli whisper came over and over again, but now with a new 



and more fearful inoaninpr: ' Broath — ]n*oafli — breath. Or kill me; 
0. kill me.'" 

'Hiis man. states I'oole. was one of nearly half a million immigrants 
who lunl come in a single year into our land of the free, and had found 
that here not even air was free. He had come two years before, 
young and healthy, wilh a wife and an infant son. There were now 
three children in his family. He liad from six in the morning until 
ten or eleven at night oidy the sweat-shop air to breathe. There are 
now over fifty thousand in that city alone working as he did. And 
after sweat-shop work lie had gone to sleep in a dark closet six feet 
by seven. (There are 361,000 such closets in New York City.) In 
the sweat-shop he worked, infecting the garments he had been sewdng 
and contaminating his fellow-workmen, so that they in their turn 
suffered and spread the infection. 

The lung block, being near the East River, should be wholesome. 
It will serve as an example. It is in the Seventh Ward, the most con- 
gested in the most crowded city of the world. This ward averages I 
four hundred and seventy-eight human beings to an acre. The lung '; 
block alone holds nearly four thousand, of whom some four hundred \ 
are babies. There are also plenty of animals. — dogs, cats, parrots, and 
one weazened old monkey. The block is closely packed with huge 
grimy tenements, which are honeycombed with rooms. Light and 
air have been slowly shut out to make more rooms. Halls, courts, 
air-shafts are cramped and deep and sunless. 

In observing the map of this block let us note the Market Street 
end, which is inhabited mostly by Jews, upon whose comparative i 
immunity to tuberculosis I have dwelt. Mr. Poole found among these 
Jews of the Market Street side hardly a case of consumption. The 
body of the block is packed with Irish and Italians and a sprinkling 
of twelve other peoples. Of two hundred and sixty-five cases re- 
ported on the block, one hundred and four cases came from six old i 
tenements alone. At No. 144 Cherry Street, we observe, there w^ere J 
eleven cases of consumj)tion in one year. 

One house, called the '• Ink Pot,"" has front and rear tenements, 
five floors high, with a foul narrow court between. Here live oim 
hundred and forty people, of whom twenty-three are babies, and 
here the plague thrives in darkness and filth, — filth in halls, over Avails 
and floors, in sinks and closets. 

'• Rooms here held death ready and waiting for years. Up on tin 
third floor, looking down into the court, is a room with two little closet.- 
beliind it. In one of these a blind Scotchman slept and took the plagut 
in 1894. His wife and his fifteen-year-old son both drank, and the 


lioMie greAV squalid as llic tenement itself. He died in the lios|jital. 
( >nly a few months later the plague fastened again. Slowly his little 
(hmghter grew used to the fever, the coughing, the long, sleepless 
MiLihts. The foul court was her only outlook. At last she, too, died. 
The mother and son then moved away. But in this room the germs 
lived on. They might all have been killed in a (l;iy by smdight; they 
(an live two years in darkness. Here in darkness they lived, on grimy 
walls, in dusty nooks, on dirty floors. Then one year later, in October, 
a .lew rented this same room. He was taken, and died in the summer. 
The room was rented again in the autunui by a German and his wife. 
She had the plague already, and died. Then an Irish family came in. 
The father was a hard, steady worker, and loved his children. The 
home this time was winning the fight. But six months later he took 
the plague. He died in 1901. This is only the record of one room 
in seven years. In the rear house is another plague room — on the 
ground floor, to the right of the low, narrow entrance. Here, in 1896, 
lived an old Irish hatmaker, with his wife, his small daughter, his two 
sons. He was housekeeper. He took the plague, worked a year or 
,more there on his hats, then died. The cough came on his wife soon 
after. She suffered long, weary months, only to see at tlie end her 
young daughter begin the same suffering. The mother died. The 
home was shattered. The girl was taken away by her aunt, and soon 
followed her mother. The two sons died of the same disease, s])read- 
ing it out into other tenements. So by this room one whole family 
jwas blotted out. Tliis is not all. When the next housekeeper came 
to this same room with his wife both were strong and well. The man 
took the plague in 1899. He still fought for life when all knew he 
Iwas hopeless; he still lived when he could not rise, could barely 
speak, but only lie alone in one of these closet bed-rooms. There are 
no fewer than twenty such rooms in this rear house — windowless, six 
feet by eight. That winter of 1900 brought the memorable blizzard. 
iVVhile it was raging, a settlement visitor came to this room and found 
Ihe water-pipe burst, the room flooded. The plucky little wife had 
'"arried her husband upstairs on her back. A few days later his 
struggle was ended. The wife is si ill here. 

"Infection comes not only from the room, but as well from halls 
tnd stairways. An old Italian, a hoi)eless victim, sits out on the steps 
n front all day long in the sun, while the children play around him, 
ind all through the evening, with men and women beside him. His 
ough never stops. The halls behind and above are grimy, offensive, 
iimg heavy with cobwebs, and these cobwebs are always black. The 
stairways in the rear house are low and narrow, uneven, and thick 



Avitli (lust pilod nji in evory nook and corner. This dust is virulent 
Avitli disease. Tlirougli tlie years a score of consumptives have lived 
liere, groping their way each night up th(^ stairways, stopping on the 
landings to catch their breath and cough, and so s|)read the infection. 
But for light trickhng through grimy panc^ls in doors, these halls are 
fonner dark. It is in halls like these that the germs can live two 
years or longer. It is with halls like those outside that one clean 
room cannot bring safety." 

Thus does Mr. Poole narrate the history of one tenement ; nor 
have I given all his narrative of this one house. In every crowded 
cjuarter there are stories to the same effect and of like import. 

One '' servant of the slayer" is the air-shaft ; there are thousands 
of tenements with air-shafts five by five. Rooms opening on these are 
technically dark. Such a shaft is two feet wide by fifty feet deep. It 
is foul with garbage, decayed refuse, old clothes and filth. Many of 
these tenements, moreover, have no skylights. All the hot, fetid air 
from below rises up, and having no vent above, settles in the halls and 
rooms throughout the house. 

But we may not linger further over Mr. Poole's fascinating but sad 
and grewsome story. The reader must not fail to get the whole 
account of the tenement called " The Bucket" ; of another called 
"The Morgue", because of the many lives which the plague has taken 
in it ; of rooms pathetically called " best rooms" ; of unspeakably filthy 
school-yard sinks, between wdiich weazened little children play hide- 
and-seek ; of pork-shops, where huge cauldrons boil day and niglit, 
while near by runs a huge sewer-main, its odor, from " three ga})- 
the size of your fist" and two long rents, mingling with that of tiie 
boiling fat ; of little children who play in hallways, dark and filthy, 
with grimy streaks on walls and ceilings, because the good mother 
would not have them on the street, where drunken men and women 
are to be seen at any hour ; of there being eight saloons on one side 
of the street alone and several houses of ill-fame ; of gentle Rosalie, a 
''little mother" of seven years, wdio took care of three still younger 
tlian she while her mother was out scrubbing, and wdio became a 
pitiful sight, "only skin over bone," until death' benignantly came to 
her ; of the Danish wife who saved her husband, despite the doctor's 
prognosis, by her iron-strong mind and soul, declaring that " all 
doctors were fools," that he was "a coward," and that "lie musi 
get well." 

Mr. Poole has found that many consumptives wait until tliey an 
no longer able to work ; then tliey see a doctor, and at last are re- 
ported hopeless. "The hopeless report; the hopeful don't. Why' 


Jiccauso places of euro have up to lately not inspired hope and trust. 
Because the city's accouiuiodalion has been hopelessly inadequate. 
Because the disease has heretofore been supposed to be fatal. Because 
the poor fear to lose tlieir insurance. Because they want to live to- 
day, not after six months of tedious, doubtful recovery. Because many 
avc uuwiiliug to leave home, and to sunder its ties. " Because they 
won't give up." The right tiuie, the right place, the right way are all 
demanded. The sick will never report at the right time until they 
believe they can be healed ; until they know we have the right ways 
and the right places to cure them. These right places must now be 
made. They are being made, and many of the defects have been 
and are being remedied, thanks to such earnest agitation as is pro- 
mulgated by Mr. Poole. 



If provpntnhlp. why not prevenfedV — Withered. 


During several summers past I have been inspecting the weekly 
parties which a New York charitable society has been sending to the 
seashore. The main object of these inspections Avas the exclusion of 
cases of infectious disease. But besides this there w^as to me much 
else of professional interest, and which was germane to our subject. 

Women and children made up the parties, and many of them, 
especially the infants, needed greatly the change from the air of the 
tenements to that of the sea. The eyes of these latter were sunken, 
their colorless faces had a clammy sweat upon them, their limbs hung 
flaccid, and they were listless and quite without the restlessness 
characteristic of healthy early childhood. Their appearance con- 
noted the vitiated air, the poverty of sunshine, the pathogenic lack of 
cleanliness, and the dreadful summer heat in the crowded tenements 
of this city. To comprehend well the condition of these people one 
should examine some of the thousand odd photographs taken by the 
Tenement House Department of New York City, some of which are 
here shown. ^ 

Many infants and children evidenced irregularity in feeding and 
overfeeding. The conditions which thus obtain will probably never 
be entirely corrected, — crying and peevish infants, and solicitous 
mothers who know of no better way of pacification than the giving 
of the breast. Medical men have done much in the way of education 
here, but maternal instincts have not thus been entirely overcome. 

Many infants were very much overclothed, — eight garments upon 
one infant ; seven upon another of three months, " so as not to make 
a bundle.*' A weak infant of two months, whom the mother felt was 
gradually getting worse, was enveloped in nine liot, moist garments. 
One mother had four children die of "bronchitis.''* Therefore she 
covered her baby's tliorax heavily with woollen garments ; so that 
it has no doubt since gone the way of the rest. Another had a 
reddened face and it puffed laboriously. The mother wanted to know 
why it had prickly heat. Its clothing was removed. There was a 
flannel binder, then two woollen garments, next a cotton sliirt, and 
lastly a heavy woollen cloak. And so on. 

Part XII, Cliapter III. 


Cases of ncgloctod middle-ear disease were often iiiaiiifcsled ; as 
were also enlarged tonsils, adenoids, retracted ahe, contracted chests 
with resulting oxygen starvation. These conditions, with swallowed 
excreta (often bacillus-laden) from the upper air-passages, mingled 
with unwholesome food and fluid, furnished ideal predispositions to 

It was a pleasure to anticipate the beiietit these poverty-stricken 
women must have received from their outings, which lasted from one 
to two weeks, — women who have borne many children, who had 
chronic affections of various organs; old women going for convales- 
cence after treatment or operation in hospital, or who were going to 
recuperate in order to undergo operation on their rduni. Many 
women regained thus the tidal strength of body which they had lost 
in the stress of the winter months, having been comi)elled to draw 
constantly upon the reserve force which should normally remain 
latent for emergency or unusual ordeals. Many seemed indeed to be 
in a condition when the proverbial last straw would be fatal. 

Among these women one much emaciated was married at sixteen, 
and her first child was born at seventeen ; another was married at 
fourteen and had a child before her sixteenth year ; another of twenty- 
six years had a child of twelve ; one thirty-seven years old had had 
nine children ; another of the same age had had eleven, of whom eight 
had died; another, aged thirty-one, had had ten children; another at 
thirty-six, having nine children, had just come from giving birth to a 
tenth in a maternity hospital. Another had had eiglit children, but 
two of whom were living. She wept over "a beautiful baby, with 
lovely gold hair," tiiat had died a few days after its birth. The other 
five had died at almost the same time of '' diphtheria and scarlet fever, 
that had been brought into the house." This woman's dissalisfaction 
with the part allotted to her in the universal scheme was not because 
of the number of children which she had borne, but because they had 
been taken from her care. 

One mother of seven children had to go out to work during the 
clay — and showed it; there were tea-drinking mothers with weak 
spells, so that they felt " faint-like" ; a mother who gave her baby the 
breast at night, but had to go out to do washing during the day ; sev- 
eral manifested tuberculosis. One woman had made a splendid fight. 
She had been playing the game of life with an optimism most pleasing 
to contemplate. At thirty-six she was the mother of nine children. 
''Are you well?" I had asked. '^Snre." was her answer, with a grin 
and a wink, '' only for that I couldn't stand the racket." Shice then 
this heroine has died of consumption. 


Awliile iv^i) we wciv vouclisafed sonic stiviiuous expressions — as 
unquestionalile as they were plaliliidinoiis — upon the subject of race 
suicide. Wlien we consider tlie life-stratum here sketched we must 
conclude tliat the matter is not so readily adjustable as might appear 
to the superficial observer. Would that the means for nurturing 
their families were connnensurafc with tlie alfection these mothers 
bear tlieir offspring. 

As I look back u[)on these inspections I seem to have been con- 
templatiiiL^- a truly liogarthean panorama. Old women, mothers and 
children passed by me successively, — old women who could but 
guess how old they were, and who were sulli3ring from rlieumatism, 
asthma, heart disease, and the like ; a lame woman over seventy, 
whose leg had been broken in childhood ; a child with tuberculosis 
of the hip, that had two abscesses draining away its strength ; a child 
who was a cretin ; another wdtli scoliosis ; an infant, thin, weazened, 
marasmic, that had the bottle given it " whenever it cried " ; a child 
with " stomach trouble" tliat gripped a huge cracker and had its 
mouth tilled to overflowing with half-masticated food, which was sup- 
plied it whenever it wanted something to eat ; a child having its face 
j disfigured with impetigo ; a large family coming by themselves, tlieir 
^ mother being sick hi hospital ; several members of a family all obvi- 
ij ously hysterics ; children aged two years still suckling, their mothers 

C hoping thus to avoid pregnancy ; a young woman with hysterical 
r' paralysis, wdiich came on shortly after her marriage — w-ith a China- 

-^ man ; a woman who could not remember if she had three or four 
<> cliildren, and had to ask her mother to tell her ; a w^oman who, to 

" her great sorrow, had lost one among eleven children; an idiotic child 

who had become so after an attack of cerebrospinal meningitis ; a 
^ child with facial ])aralysis, which came on as the result of a button 

^ having remained for months unsuspected in her nostril ; a woman 

5^ witli exophthalmos, fast-beating heart, and an immense goitre ; a 
[^ woman who alone supported her family, her husband having an 

^~ aneurysm, wdiich must inevitably prove fatal ; a mother with paralysis, 
consecpient upon the birth other child; a girl of twenty, nearly blind 
from measles, which she had contracted in childhood ; an infant with 
-; an enormous hydrocephalus, certainly larger than a man's head; a 

'^ boy paralyzed and imbecile since birth ; a woman witli liysterical 

^ deafness, wliich came upon her in an instant, and wliicli is likely to 

leave lier as suddenly ; a woman whose whole left side had been 
burned, the cicatricial tissue Jjeing so tense that she could not bend 
■<, forward; children choreic ; with tuberculous vertebnie ; two syphilitic 
O infants whose father had had ••blood-poisoning.'" A girl in her teens 


was hopelessly blind, and liad Ix-eii so siii('(> throe days aflrr ])irUi ; 
she had contracted an oplilliahnia noonatornm from her uncleanly 
mother. An mfant a lew months old had a specific erui)lion dis- 
tributed over its body. The father had t)("eu ''burned, and the blood 
turned uito blood-poisoning,'' so the niotlicr assured me. Perhaps 
she believed tins herself; perhaps she was trying hard to make her- 
self believe it. Here was a feminine subth^ty for a De Balzac to dilate 

I sketch thus but one among many phases of life such as fall within 
the experience of all physicians. Evidently lack of foresight and of 
education and unhygienic living were responsible for most of the con- 
ditions here touched upon, — preventable conditions. And this may 
in general terms be said of the factors which go to make up the patho- 
logical entity which we term tuberculosis. 

Part VI 


The object of preventive medicine is to curtail and, if possible, 
to prevent disease, to prolong existence, and to render life happier 
i)y means of improved physical conditions. 




While we must recognize the hrand which is put upon us at hirfli hy heredity, 
nevertheless most of the ills of life are due to environment. The conditions iinder 
which we live are responsible for them. This environment is changeable. Herein 
lies our hope, and to this end must we direct our prophylaxis. — PoTTENf;EH. 

The development of tuberculosis, as we have seen, depends upon 
two main considerations : First, the presence of the Koch bacillus 
and of its allied micro-organisms; and, second, the condition of the 
body by Avhich it becomes predisposed to infection. Logically, then, 
to prevent consumption the bacteria must be destroyed, and the body 
must be fortified so that it will be made resistant to invasion. 

As regards the first of these two propositions — the destruction of 
the germs — the procedure is, theoretically at least, an extraordinarily 
simple one. It enters the organism by means of inhalation, or by in- 
gestion, or by absorption through wounds or abrasions in the skin 
and mucous membranes. To the disposition of infective material in 
each of these phases we devote a chapter. The latter of these proj^o- 
sitions — the fortifying of the body — is of at least e({ual imi)ortance. 
For, as we have seen, practically no one ever escapes contact with 
the germ ; and those of us who are not tuberculous are so because 
our systems are strong enough to fight it and to resist triumphantly 
the invasion. To this part of the subject, then, we devote the re- 
mainder of the chapters on prevention. 




Prevention is better than cure — and miicli cheaper. — John Locke. 

The mere breath of the consumptive is not infectious. But hquid 
particles may be ejected during coughing, sneezing, or speaking. It 
has been demonstrated that such particles may remain suspended in 
the air for a distance of some twenty feet and will then subside by 
gravitation. Infection may thus be conveyed, the sputum which is 
emitted, if it be not disposed of properly, being deposited at home 
upon floors, carpets, walls, napkins and dishes ; or abroad, in public 
buildings, i)ublic vehicles, and the like. And this sputum dries and is 
taken up in the air or dust which other })eople breathe. Sunshine, 
fresh air, and pure water destroy the bacillus. Nevertheless, these 
agents do not always destroy it, because the broken-down tissue con- 
tained in the sputum, or the sputum itself, or the dust with which it 
becomes incorporated, makes a cache or envelope for the bacillus, 
which may give it some protection. So that, except in gutters, there 
should be no spitting in public thoroughfares. Flies may thus carry 
about infection ; and shoes and trailing skirts may take it into homes. 

The consumptive should invariably, while indoors, have some 
cloth or tissue paper before his face during coughing or sneezing. 
Many bacilli will be revealed in such cloths upon microscopic examina- 
tion. And he should spit into a receptacle made expressly for the 
purpose. If this be a cup, it should be made of card-board ; or of 
metal, glass or porcelain. The latter should be partly (not completely) 
filled with water, or a watery solution of a disinfectant. The sputum 
must not be left to dry in the vessel. The card-board receptacle should 
be burned every day. The cup, if of durable stuff, should be emptied 
into the closet at least twice a day, and carefully washed with boiling 
water. Consumptives who are too weak to use a cup should use 
moist cloths. They must be taught not to let their sputum soil their 
hands, face or clothing. In this event there should be frequent ablu- 
tions ; and soiled clothing should be washed at once with soap and 
hot water. They should brush their teeth constantly ; and should 
rinse and clean out their moutlis especially after ealing. 

Male patients had best be clean-sliaven ; if they will not, their 
beards and moustaclies shonld be abbreviated as much as may be, 



and kept as cleanly as possible. Tli(;re should be frequeid, al least 
weekly, shampooings. 

All spitting should in general terms b(^ frowned upon, it is an 
uncleanly and often an unnecessary habit. Tlie sputum of early and 
obscure tuberculosis may be infectious. Tlie germs, not only of this 
disease, but also of others — pneumonia, diphtheria, influenza and ihe 
like — may thus be distributed. Besides, universal observance of a 
rule prohibiting this practice would deprive it of its sting for the sensi- 
tive consumptive. (Cornet.) 


5pits on the 


GYOffOe/1 OF SUPX:.mNT£rt0Ufi 

Fig. :W.— From the circular of the Illinois State Board of Health. (By courtesy of Dr. J. A. Egan.) 

Whenever the patient leaves his home, ell her temporarily or for 
the day's work, paper napkins or old clotlis or card-board pockets 
should receive his sputum. This is in the highest degree essential as 
regards the workshop. Advanced consumptives who work near their 
fellows, such as tailors, might use the Fraenkel respirator, a metal 
mouthpiece provided with a shield of cambric or gauze, which may 



be frequently changed, and wliich effectually prevents the dissemina- 
tion of tlie cougii spray. However, to wear a mask thus is imprac- 
ticable, and a great liardship, and it is comparatively unnecessary. 
Cornet ti nds (hat the dissemination of bacilli by coughing is insig- 
nificant ill comparison with the number liberated by the drying of 

The cloths and paper thus used should be put into paraffin paper 
or ordinary paper bags to be burned on returning liome. Handker- 
chiefs should not be used for sputum. But if they are, should be boiled 
half an hour separately before being put in the general wash. 

The elegant consumptive may have a metal receptacle (orna- 
mented in any Avay she may fancy) which, in obedience to the natural 
wish not to draw attention to her illness, she can carry concealed in 
her handkerchief. Manufacturing houses make all sorts of receptacles. 
There are card-board affairs costing the fraction of a cent. Neverthe- 
less, there are many (perhaps most) consumptives who cannot afford 
even this. But tissue paper in plenty can easily be had, which can 
be cut up into convenient sizes. And any corner grocer will gladly 
(such is the subconscious Christianity which I find to be prevalent 
among the poor) furnish without price all the paper bags that are 
needed. So that the poor patient may put a bunch of papers in his 
pocket with one paper bag. And as he has occasion to use each 
paper he puts it into his bag and burns the whole on his return home. 
Or lie may use a waterproof receptacle, as a tobacco-pouch, which 
should be cleansed and boiled frequently. For those too weak to sit 
up a small card-board cup, with a handle, should be used. 

Spittoons of all sorts are made. Those which lie upon the floor 
should be covered when not used, and should be partly (not entirely) 
filled with water. There are spittoons made upon stands breast-high. 
There is one in which the receptacle for sputum is hidden, and may 
be pulled out for use like a drawer and then pushed back out of sight. 
Above this device is a flower pot ; and the pious fraud is practised of 
having the visitor think it is only a flower-pot and nothing else. Such 
a spittoon, being on a stand, with heavy metallic base, children play- 
ing on the floor or domestic animals are not in danger of infection. 
Or wall cuspidors may be utilized. These have the advantage thai 
they cannot be tipped over ; vessels such as these should be supplied 
generously in factories and workshops. They are made to be covered 
when not used, so that insects cannot get at them. 

For use on sanatorium grounds and at health resorts, Knopf ha:- 
devised an excellent contrivance — a self-cleansing spittoon, supportec 
by heavy tubing and made of copper coated with pure tin on tlu 


1 G;>, 

inside. To the upper edge is screwed a perforated lead pipe \\ iiidi 
supplies the water for constant flushing. The heavy tubing is to be 
connected with the sewer, and the lead pipe is to be attached to 
the street hydrant.' 

The possibility of contaiiiinalion by kissing must be considered. 
It were a pity, indeed, to interlcre with emotional spontaneity and 
the comfort resulting from interchange of affections, imder the unfortu- 
nate circumstances we are considering. And one osculation isn't going 
to produce consumption any more than one swallow will make a sum- 
mer. However, in general terms, consumptives should kiss as little 
as may be; and should not, in any event, kiss others, especially 
children, upon the mouth. 

The consumptive should sleep alone; in his own bed, and, if he 
can, in his own room. His clothing, bedding, and I lie like, should 
be boiled at least half an hour before being added to the general 
iwash. His liandkerchiefs should be soaked in antiseptic solutions, 
and then boiled separately ; if antiseptics are not handy, boiling will 
do. Let him use old cloths. The dishes, etc., from which he eats 
should be kept apart, if possible ; perhaps they can be had shaped 
or colored differently from those of the rest of the family. In any 
event they should be thoroughly cleansed by themselves in boiling 

The bedridden patient, especially during the last few weeks of his 
life, will be quite unable to prevent the spread of infection. It is essen- 
tial, in such cases, constantly to clean everything that may become 
soiled ; and to keep a pail containing a disinfectant at hand for that 
purpose. Into this pail clothing, blankets, slieets, towels, etc., used 
about the patient, sliould be dropped immediately after use and before 
being removed from the room. 

Every room, especially every bedroom, should be tiiorouglily veii- 
lilated. Air that is constantly rebreatlied soon becomes poisonous. 
Cold air, by the way, is not necessarily pure, simply because it is cold ; 
t needs changing just as warm air does.^ 

To have rooms constantly supplied with fresh air there should be 

'As I proceed with this subject of the consuiiii)tive's sputum, I inar it l)ecomes 
nore and more disagreeable to the lay reader. However, there is no help for it. 
used, in attempts at mitigation, to speak in my work of expectorations. But I 
lined that President Roosevelt, in the cosmic lunge of his activities, had taken 
ins important subject under consideration, and had issued a State paper from the 
rVhite House to the effect that the correct term is " spit." So "spit " it is ; and 
aust continue to be. 
I * For Disinfection, see Appendix A. 


an arraiiiioiiiciit by which aii' from out oC dooi's is supplied all the 
time. A euiTeut tVoiii room to room will not suffice; the air must 
oriiiinah* from out of doors. It were best to liave tlie foul air exits at 
the floor level, so that theiieneral drifl of Ihe air would be downwards 
and not U[)\vards into the nostrils. Tlie room need not be cold, — a 
fire on a cold day is essential to health ; but a room can be ventilated 
and warmed at the same time. Stoves are generally supplied with 
vessels containing water, Avhich is supposed to absorb deleterious 
gases. I do not think this plau effective ; but among the very poor 
stoves are nowadays almost the only means of lieating. Stoves are 
in a measure pernicious. They are ravenous of oxygen, and they 
emit poisonous gases, sucli as result from imperfect combustion. 

An open grate or a register may cause a sufficient current. We 
may raise the lower sash of one window several inches — never less j 
than an inch — and lower the upper part of a window adjacent. There 
should be such a current in the slee})ing-room all night long, and there 
will never be a night so cold that this should not be done. Or we 
could raise the lower sash six inches and fit a board beneatli it, so 
that air will pass between the sashes. Dust-excluding nets and like 
contrivances are made cheajjly to fit into these spaces. Of course, 
drauglits are to be avoided by the sleeper. This can be done by 
means of screens or blankets liung up. Tliere will be no draught 
when the air comes from one side only. The ordinary indoor tem- 
perature should be between 60° and 70°, never more than the 
latter; during the night it should be mucli lower. These observations 
are of general scope. The consumptive l)atient, as we shall see, 
sleeps (well covered) with wide-open windows, no matter liow cold 
the night. The house should, as nuich as possible, be permeated 
with dry air and sunliglit, which kill the tubercle bacillus. 

The liouse is the place where infection is most developed; and b\ 
a house is meant any enclosure whicli may, by reason of negligence 
uncleanly liabits, or indolence, become dark, dirty, damp, and ill ven- 
tilated. Under this category, then, are to be considered private dwell- 
ings, but also many other structures. — in fact, any enclosure in whicl 
people may congregate. Among these certainly the most important i 
the factory or the workshop. Here, as in all places where many corm 
I together, there should be spittoons in abundance ; and tliere shoul* 
I be plenty of air-space between the workingmen. F^actory condition? 
though now much improved, are still generally very unsanitary; an 
it is here that the ( onsumplive workman should make the proper dis 
position of liis sputum an obligation as serious as any in life. Fc 
the matter coughed up, if distributed hi the oppressive atmospher 


which prevails in many workshops, becomes exceedingly infectious. 
Saloons come next in order of inCectivity. Many poor fellows ulio 
are' consumptive frequent them, and the atmosphere in Ihem is 
generally sog-gy and unhygienic in the last degree. The strictures laid 
upon factories and other places should in even greater measure he laid 
upon them. 

Family hotels, boarding- and lodging-houses come next. They 
should have periodical renovation, at least weekly. Hotels for tran- 
sient guests should have rooms occupied by consumptives thoroughly 
disinfected. This is now systematically done in many hotels. The 
danger here is not so great as in rooms i)ermanently occupied. For 
tuberculosis is relatively not to b(^ feared from occasional contact. 

Of course, good results from scientific cleaidiuess (disinfection, 
etc.) cannot be assured if tlie grounds in which the house is situatcMJ 
are not also attended to. Scrupulous cleanliness sliould be enforced 
within and without the house, wherever it may be. All decaying 
animal and vegetable matter and every kind and source of filth in and 
about the house should be removed and disinfectants should be freely 
used. Surface drains and gutters, areas, out-houses, closets, shelters 
for domestic animals, fowls, etc., should be constantly attended to. 
Basements and cellars must be kept dry and well aired. Here 
unslaked lime should be used freely. 

In general terms, the paraphernalia incident to certain occupations 
should receive attention ; glasses and dishes should be washed 
thoroughly in saloons, restaurants, (piick-lunch counters, at soda-water 
fountains, and ice-cream "parlors.'' There is an ingenious "public 
cup*' made — practically a miniature fountain through wliich the water 
spouts up — and to which one stoops and drinks without having his 
lips touch the vessel. In laundries, cook-shops, fish-markets, and 
like establishments, there should be scrupulous cleanliness. 

In jKiblic conveyances, especially during " rush hours" in Jjig cities, 
when the elevated- and street-cars are indescribably crowded, when 
men have to hang desperately upon back platforms in order to get 
the ride they have paid for, tliere is danger of tuberculosis infec- 
tion. A consumptive passenger may, in coughing, impregnate the 
already much vitiated atmosphere of the car; or minute droplets of 
his sputum may be deposited upon the clothing of his fellows. We 
may here include the ferryboat, where the "spitting hog" does his 
proudest, and the waiting-rooms in the railroad stations. The dust- 
inviting upholstery in railway sleeping-cars is still more a menace, for 
passengers remain in them longer. It is now an excellent feature of 
some roads that they provide special cars for consumptives. 


The problem of the subway air in Now York City lias become a 
subject of discussion. It was all begun when a lady fainted in a sub- 
way-car. Of course this incident is inconclusive ; for ladies have been 
known to faint under most salubrious conditions. It was found by 
Professor Chandler that the subway air contained i)ractically as much 
oxygen as tiie air above in the open ; it could, therefore, hardly be an 
unduly vitiated atmosphere. However, tlie following aspects of the 
tuberculosis situation are here peculiar : sunshine, which destroys the 
bacillus, does not enter; spittoons should be provided at the stations, 
and those who si)it anywhere else than in them should be sternly dealt 
with, much more so than on the open thoroughfare ; the spaces 
between the tracks should be asphalted, so that they may be easily 
cleansed, instead of as now, when the road-bed is made up of broken 
stones ; and workmen in the tunnel with predisposition to consump- 
tion should certainly be induced to seek other employment. 

It is unquestionably very important — considering the tender tissues 
of children — that school-rooms should be very light and well venti- 
lated ; and that they should be cleaned often and disinfected regularly. 
This is now, I believe, well done in New York City schools. Stores 
and offices where business is done should receive like treatment. 

Court-rooms, in my haply limited experience, are abominably 
ventilated. In taking the oath, the Bible should not be kissed, at least 
not the cover. It is difficult to perceive how any predisposition what- 
ever can escape development in the tissue-destroying psychology which 
is generally pervasive of those temples, where J(^s and Lex so inces- 
santly and so inconclusively play hide-and-seek with one another. 

Public halls and meeting-houses are infrecjuently used, and for 
but brief periods ; so that tuberculosis infection is comparatively not 
so much to be feared in them. Nevertheless they should be subjected 
to the general principles of hygiene. 

Churches are, for the same reason, not so dangerous for infection. 
And cleanliness, which accompanies the religious sense, obtains 
generally in them. Still, the following circular issued by the Bishop 
of Fano. quoted by Knopf, is n y>/-oy>o.s' .• 

"(1) hi t'VPiy cliuich, the floor must l)e reiJ^ularly cleaned witli sawdust 
saturated with a strong suhhmate solution. This thorough cleaning should take 
place particularly after holidays when great masses of people have visited the 

"(2) Every week ail ordinary chairs and confessional chairs must be thor- 
oughly cleaned with moist rags. 

" (3) The grate of the confessional chairs must he washed every week with lye 
and then polished." 


Crosses, statues, and like symbols, which are kissed b} Uil' devo- 
tional, should be reverently cleansed from time to time. The likeli- 
hood of tuberculosis infection during the communion service is so 
remote that I do not consider the use of individual communion cups 
essential. There is here a fitness in considering religious emotions ; 
man shall not live by prophylaxis alone. 

The danger of infe(;tion in the public thoroughfares is not great. 
In the open air there is comparatively least danger, for the bacilli are 
generally destroyed by sunshine and fresh air and water. Still, the 
possibility is not to be ignored. The streets should be thoroughly 
cleansed, if only on general principles. Besides, many infections 
other than tuberculosis may be contracted upon or from unclean 
streets. And it is unquestionably important that the dust should be 
laid by frequent sprinkling and watering. Dust containing germs may 
be brought into clean houses upon boots or clothing which has been 
trailing upon the streets. And by dusting and cleansing these gar- 
ments within doors sources of infection are no doubt oil en set free. 
Moreover, gentlewomen tell me that when they take the air they have 
to watch and pick their way lest their skirts become soiled. This 
consideration will surely appeal where others would not receive at- 

The arrest of spitters is no easy matter. The New York Health 
Department has proceeded vigorously, and accounts of arrest and 
consequent discomfiture of many spitters has surely produced a 
wholesome effect upon others. The gutters are for this purpose. 
In street- cars the citizen might proceed by looking along the 
streets as the car goes by until he sees a policeman, whom he should 
then liail and require to arrest the spitter. It will lie essential for 
the citizen to go along as witness and complainant against the i)ns- 
oner. Under all the circumstances this course will require much 
self-sacrifice and public spirit. I understand that policemen are now 
detailed at allotted stations upon the elevated roads. It is certain 
that in these matters of public decorum w^e are quite too complacent. 
In this land of the free and the unlicensed we endure much that 
would not for a moment be tolerated in "effete" European com- 



For that which befalleth sons of men befalleth beasts ; even one thing befalleth 
them : As the one dielh so dieth the other ; yea, they have all one breath, so that 
a man liatli no pre-eminence above a beast. — Ecclesiastes. 

The extent to which ingestion infection occurs is as yet an un- 
settled medical problem. That it does frecjuently occur is unques- 
tionable. That the settlement of this question is of great importance 
is manifest. However, from a broad human view-point — not alone 
that of the medical man — it is axiomatic that only fresh, clean food 
and drink should be consumed. Uncontaininated meat, milk, butter, 
vegetables, fruits, and pure water are essential ; Ave need no scientific 
argument to this end.^ 

Practically, the thorough cooking of meats is a sufficient precau- 
tion. In case of the slightest doubt the viscera of animals — the liver, 
kidneys, etc. — should not be eaten. In them tuberculous processes 
thrive to a much greater extent than in the musculature. 

The question of fruits, fish, and other eatal)les, as also merchan- 
dise vended on push-carts, is a very important one. Much of this 
material which is displayed for sale on open-air stalls and carts pro- 
vides a convenient receptacle for dirt and gathers many varieties of 
micro-organisms, some of which are distinctly prejudicial to the public 
health. Among these the tubercle bacillus from infected dust and 
spray spread by coughing has redundantly been demonstrated. We 
may note that — 

The consumptive should not cough lying on his back, and should 
not swallow his sputum nor excreta from the upper air-passages ; he 
may thus contract intestinal tuberculosis. 

The bacilli have been found in the abdomen and excreta of files ; 
there is. therefore, some danger from this source. 

]\Iany infants contract the disease through taking into their mouths 
infected objects while playing on the fioor. 

Himiaii excreta containing the bacilli are in general effectively dis- 
posed of; tliere is practically no danger from them. 

Nothing short of lynching should serve for cigar-makers who seal 
their cigar-wrappers by means of their spittle, and for bakers who 
paste labels upon loaves by the same method. 

' Part XIV, Chapters IV and V. 

C 11 APT Ell IV 


If one takes a larger view, and grasps the root of the evil, the rare and occa- 
sional modes of infection may he disregarded. — Cornet. 

This mode of infection is comparatively rare. It is incnrred ^'•en- 
erally tlirougli open wounds, especially of tlie tliorax. Surgeons, stu- 
dents in the dissecting-room, and butchers are especially liable. We 
should recall that the bacillus may even traverse the unbroken skin 
and mucous membrane. 

Those who clean glass or painted metal should be careful, espe- 
cially if they have open sores or abrasions on their liands. Servants 
who clean spittoons should certainly wear rubber gloves while doing 
so. If infection is feared, cleansing and surgical antiseptics should be 
employed in dressing or bandaging the wound. 

By way of resume^ then, concerning the disposition of infective 
material we observe that, especially with regard to inhalation infec- 
tion, it is essential to have a sense of proportion, to consider the de- 
gree in which infection is likely to be incurred. We should api)ly the 
underlying principles here set forth to the varying circumstani-es in 
a given case. We should appreciate that in darkness, damp, dirt, un- / 
cleanliness and vitiated air the tubercle bacillus thrives, and that sun- ) 
shine, fresh air, and pure, clean water kill the germ. We rightly I 
emphasize the danger from the indoor inhalation of the bacillus, but not 
so much do we emphasize the possibility of infection on open thorough- 
fares. It is essential to have this sense of proportion, because our 
lives and those of our lay fellows would Ix' unlivable if we were to be 
constantly fearful of infective processes. To live thus would be an 
effective way of inviting infection. 

The Maryland Tuberculosis Commission makes thes(^ succinct 
statements : 

"Measures of general puhlic protection, such as the control of jnomiscuons 
spitting in street-cars and puhlic places, while of course of great valiu'. do iml ivaili 
the largest sources of dissemination of the disease. It cannot he claimed hy any 
student of tuherculous infection that three per cent, of tuherculous persons have 
received their infections in street-cars or puhlic huildings. 

"While some conservatism must he maintained against tlie more extreme 
views, there seems good reason for according with the belief held by many of the 
I most careful investigators that tuberculosis is essentially a house disease. 
I 169 


"The it'in'iited exiiosuics ;ijti);in'iitly iicci^ssary to (Migraft a tuberculous infec- 
tion would ])rol)ably cause liability of public infection to take a secondary import- 
ance. Of the infections of reasonably deiinite origin probably from ninety-five per 
cent, to ninety-eight per cent, take place in the living-rooms of those affected, while 
a furilier considerable percentage takes place in the work-rooms." 

If we do not maintain and teach this sense of proportion, if we do 
not constantly bear in mind the scientific principles upon which the 
warfare against tuberculosis is based, the work will certainly not bear 
a righteous measure of fruition. In this country, at least, no measures 
will liave success or compliance which are not generally understood 
to be rational and feasible, and which have not the sanction of public 

It is quite appropriate here, I think, to set forth a letter by a 
genial clergyman wliom I have the honor and the good fortune to 
knoW' . It was occasioned by my having sent him a reprint of a med- 
ical article I had written : 

De.\r Dr. Huber : 

I thank you very much for your pamphlet on . I cannot say that it is 

easy reading. The words of Itrobdignaggian majesty and geological construction 
made getting along like riding on a log road. It is fortunate that one is not con- 
fined to such words in making love or even in preaching. Theology has much to 
answer for, but for outrageous nomenclature science beats her ten to one. There 
is hardly what I should call a smooth and gentlemanly spoken line in the book. 
It reads as I should suppose a human mastodon would talk. Even the names of 
your authorities sound as if you had picked them up in the Indian Territory or 
Southern Russia, or even Independent Tartary, — Kelynack, Biggs, Bullstrode, 
Sclimorl, Sajous, Metchnikoff. Still, the book is fine. I feel braced up by it, just 
as I do when I have been chopping trees in an Adirondack camp in winter. And 
yet I laid the book down with a certain fatalistic fear. If all those things are after 
a man, of what use to struggle at all? Better die at once. What can a fellow do, 
for example, when tuberculosis excreta from the mesenteric glands gets into him, 
or when he beholds upon his tongue undigested bacilli with intestinal hyperaemia 
and chyle? Better make your will at once, and leave your money to the publication 
of a new dictionary. 

Yours thankfully and sadly, 



Many a young iiiiiii has sacriticod liis chances of recovery on the altar of 
Hymen. — Fuck. 

We here consider such predispositions us uiay ()i)tairi up to tlie 
period which terminates infancy. 

To do tliis conipreliensively would seem to require the expression 
of a Hiloernicism, — that to fortify the organism with a view to <'nat)ling 
it to withstand infection we must begin long before the birlli of the 
child ; or, as Oliver Wendell Holmes whimsically expressed it, '• a man 
should be careful in the selection of his ancestors." Yet if we 
consider the matter deeply, we will be proceeding quite logically. For 
birth is but an incident in a succession of biological processes ; nor is 
conception indeed anything else than a transmutation of older cellular 
elements, such as are contained in the ovum and the sperm, into a 
new cellular compound. And it is after all with tlie quality and 
virility of cells that we have primarily to do. 

The practical deduction here is that those who contemplate mar- 
riage should proceed with caution, if they are conscious of any 
abnormal stigma, any suggestion of degeneracy in tliemselves. Un- 
doubtedly the possibility of parentage on the part of men and women 
who are unfit, — the nearly related, couples whose ages vary widely, 
the neurotic, or pervert, or insane, the drug-habitues, those who have 
hereditary taint of alcoholism, the syphilitic, the consumptive, — the 
possibility of parentage among such as these should be precluded as 
far as possible. Generally speaking, all such are likely to transmit to 
their ofTspring vitiated tissues, upon w^hich with unusual ease the 
Koch bacillus and its allied cocci may implant themselves and multi- 
ply. The principle of " natural selection" will act to prev(Mit many 
such marriages. However, when they are contemplated, and the 
physician's advice is asked, he should permit no marriage where 
tuberculosis is active in either man or woman. Especially with 
regard to the latter is to be emphasized the possibility of death in 
childbirth, or perhaps even graver likelihood of physical wreck and 
death by lingering stages subsequent to delivery. The physician 
should certainly not approve — for her own sake — the marriage of a 
tuberculous woman. " Pregnancy is found to complicate, to precipi- 



tate, or to develop plithisis reinarkal)ly.*' (Osier.) Another author 
states too truly : " When consuinptiou is hangmg about a girl, the 
distance between the marriage-bed and the grave is usually short with 
her. The husband, if he do not become a widower soon after the 
birth of the first child, may count upon a perpetually ailing wife." 

A consumptive should not marry a person in health, especially if 
the disease has existed a long time and is })rogressive : moreover, a 
latent tuberculosis may thus be transformed into an active and acute 

On the other hand, a patient who has had no physical signs or 
other discoverable symptoms for two years, and whose metabolism 
appears to be normal, should be allowed to marry. Cornet considers 
there should be no marriage so long as the disease progresses. How- 
ever, alter there has been a relative recovery, when the symptoms 
have been in abeyance for tw'o or three years and a satisfactory 
general condition has been maintained, marriage need not be objected 
to. If a man be sufficiently well-to-do, and if his wife makes no 
great demands upon him. he is better off married than a bachelor, 
witli all the unhappiness and discomfiture the latter implies. On the 
other hand a woman may be seriously harmed by marriage, with all 
its consequences. She should be strong and toned up beforehand, 
not only for her own sake but for that of her offspring also. Con- 
ception must be advised against in consumptive women ; they stand 
the puerperium badly. The disease often assumes its most acute form 
after childbirth and then proves rapidly fatal. To save the mother s 
life interference may have to be counselled. Multiple births should 
certainly be discouraged. 

After the melancholy features have been fully dwelt upon, the 
bright side of the matter is entitled to consideration. Although 
the observation first set forth concerning the transmission of a vulner- 
able organism by tuberculous parents generally holds good, many 
instances are scientifically recorded ^ in wliich the offspring of con- 
sumptive parents have been found to be singularly immune to that 
disease. Cornet has '' seen a number of such marriages give origin 
to many children who are perfectly strong and well developed." 

Besides, there are many (blessed and glorious fools) who will 
marry without regard to the opinions of physicians. I once met a 
fine old man in wliose marriage the element of spontaneous and 
uncalculating love happened to have a place. His mother had 
counselled him not to marry his beloved, who was consumptive. 

M'li.-k. Kill-. 


Nevertheless, tliey did iiiarry and iiiiiiicdiatcly idler went iid(» the 
country. This was many years ago when Ihe ijrofession were not 
laudmg sinishme, fresh ah-, and good food in the treatincnl of this 
disease. lie went at once to the butcher and made arraiiyumenls for 
liie best meats to be sent to his house. Then he went to a neiglibor 
who liad a large vegetable garden and asked him to name liis price 
(that was no object; no matter what it was it would be paid) for the 
privilege lie desired of going into this garden as often as he liked and 
taking away as many vegetables as he should please to. And then to 
others who liad good nutriment to sell. And so tliis couple lived 
together; and the wife did not die of consumption, but achieved good 
health and lived to bless him through many years. Was ever man 
more deserving of happiness? 

When a consumptive has married the pair should be counselled 
that intercourse should not occur in times of bodily or psychic fatigue, 
or during such ill health as complicates the original affection. 

When conception has occurred the physician will recall that 
during embryonic life the cells of the body become differentiated, 
and the organs are formed, increase in size, and begin to take on their 
several functions ; that during this period the organisiu of the coming 
infant is most acutely sensitive to environmental impressions, — such 
as variations in oxygen supply, warmth, the constitution of the 
maternal blood. Before the birth, then, the mother should be safe- 
guarded to the fullest possible extent, for the good of her of!si)ring. 
She should have wholesome diet, sensible and hygienic clothing, 
should rest well at night and for an hour after lunch, and have fre- 
quent baths in tepid water, and the like. Especially should she be 
subjected to no uijdue mental strain or excitement. 

If, unfortunately, the child at birth exhibits stigmata, either func- 
tional or anatomical, the physician should act without delay. He may 
have to deal with manifestations of the scrofulous temperament. — the 
pallid skin and flabby flesh, tedious and subacute inflanunations of 
the mucous membranes, enlargements of the lymph glands, unhealthy 
throats, bronchitis, disorders of the gastro-intestinal tract, sluggish 
metabolism. There may be strumous malformations of the chest, 
deficient ossification, stunted and weazened growth, a capacity for 
breathing obviously below the average, a defective develoi)meiit of 
the circulatory system, and impoverished blood. Rectification to the 
normal point may be impossible. Nevertheless, everything should be 
done to mitigate abnormal conditions as much as may be, not only 
for the sake of the child itself, but for the avoidance of baneful effects 
upon future generations. Functional modifications are more important 


than anatomical ones. They are more likely to be transmitted. And 
olniously they are more amenable to treatment. Although there 
may be no defunte anatomical stiLiiiiala, a ix'rnicious nutritive habit 
is often transmitted, with which the ])liysician may have to deal. 
Such ]tatienls will have to be kept under observation, not for weeks 
or months, bul for years. 

A weak and consumptive mother should not nurse her infant. 
Although there is little likelihood of her milk itself being infected, it 
is generally not sufficiently nutritions. Lactation is a great drain upon 
the mother's strength and may precipitate a fatal t(»rmination to her 
disease. Besides, the infant may contract inhalation tuberculosis 
while taking the breast. Either a wet-nurse should be found or the 
infant should be bottle-fed. The latter is tlie better way, in view of 
tlie well-nigh perfect system of infant feeding which physicians have 
now evolved. In large cities, both public and private charities have 
become so active in tliis regard that the poorest people may have 
excellent nnik, projjcrly modified, at little cost, or no cost at all, if 
need be. 

The separation of an infant from tlie tuberculous mother is a 
matter not easy of adjustment or decision. Certainly there is little 
occasion if the mother be properly instructed and conscientious, and 
if the infant be bottle-fed. The maternal impulses should receive 
much consideration. Such separation is often im})racticable among 
the poor. In many casfes it were well if the mother would have her 
child taken care of for part of the day in a general nursery, such as 
the charitable provide in cities. Many poor people cannot be with- 
out their children ; many are not willing to be : separation should not 
be — nor can it be — compelled. In any event the infant's home should 
be made free of infection by disinfection and thorough purification. 
Tlie floors should be particularly clean, and carpetless, if possible. 
The infant should be pro])erly cloLlied and vrell bathed. 

Adenoids and enlarged tonsils should be removed. The child 
must not be starved for oxygen. Sleeping children shouki have 
plenty of air. Their uncovering themselves in cool air need not be 
feared. Sleeping garments of the grain-bag variety may be provided 
them. All respiratory and circulatory affections — sore throat, bron- 
chitis, aiitemia and the like — should be efliciently treated. Convales- 
cents after weakening diseases — diphtheria, pertussis, measles, scarlet 
fever — should be carefully nurtured, and, if possible, sent into the 
country. Pains in the head, " running ears," and abdominal symptoms 
should be promptly considered, as also accidents or injuries involv- 
ing bones or joints. The latter often engender tuberculous •'while- 


swollin^^s."' All young structures urc less liruj, less orgauizud, and less 
vulnerable than tliose of the adult. 

As soon as may be the child should be taught not to swallow its 
sputum or excreta from the u[)per air-i)assages ; these may be bacillus- 
laden and may cause intestinal tuberculosis.' 

^Concerniii!; Un- " lianliMiint,'" of the child aftor tho periofl of woaning', see 
Appendix C. 



That man, I think, has a lihcial cducaUon whose l)o<ly has been so trained in 
yonfli that it is the ready servant of iiis will, and does with ease and pleasure all 
that as a mechanism it is capable of ; whose intellect is a clear, cold, logic engine 
with all its parts of equal strength and in smooth running order, ready, like a 
steam engine, to l)e turned io any kind of work and to s])in the gossamers as well 
as to forge the anchors (jf the mind ; whose mind is stored with the knowledge of 
the great fundamental truths of nature and the laws of her operations ; one who, 
no stunted ascetic, is full of life and fire, but whose passions have been trained to 
come to heel by a vigorous will, the servant of a tender conscience ; one who has 
learned to love all beauty, whether of nature or of art, to hate all vileness, and to 
esteem others as himself. — Huxley. 

It is evident from a consideration of all that has thus far been set 
forth that the tender years between early childhood and adolescence 
nn]st be safeguarded, as far as may be, against both tubercular in- 
fection and predisposition to it. As regards the time si)ent in school, 
there are many data to be considered. 

The school must cultivate, first, health, strength, and energy. 
After these should come honesty, courage, and patriotism, and then 
the ability to speak, read and write one's own language, together with 
a knowledge of arithmetic' 

Upon tliis foundation all else may be built. The most important 
part of any school — public, or private, or boarding — is the school- 
room. It should be well lighted, and the desks should be so arranged 
that the ligiit comes preferably from the left side and the rear. This 
will jjrevent shadows falling upon the writing. A north light is pref- 
erable, if possible to be had, being more uniform. The number of 
feet of transparent glass should be from one-quarter to one-sixth the 
floor space of the room. 

No school-room should have nH)re than fifty desks ; a single 
teacher cannot well manage more than fifty pupils. Each pupil 
should have at least fifteen square feet of floor space and two hun- 
dred cubic feet of air space. For forty-eight pupils this would mean 
a room of 30 x 25 x lo feet. 

1'he ventilation of each room should be ample, not only througli 
tlie windows, but by means of inlets high up on one of the walls, 
and bv outlets low down on the same wall. 

^ La Fetra. 


A good gyinnasium, or aL least a largo playground, is essential. 
There should be shower-baths, and if possible a swimming-tank. 
The temperature of the school-room is at the Rugby schools from 50° 
to 60° F. It were well to have a temperature of G2°-64° for larger, 
and from 66°-G8° for smaller children. The best method of heating 
is probably that by indirect radiation. There should be fire-escapes 
and fire-drills. In boarding-schools the sleeping -rooms, whether 
dormitories or single, should have the sunlight all day, for its germi- 
cidal effect. 

An ideal location for such a school-building would bo " on some 
commanding knoll, with a grove at one side, and sufficient grounds 
around for games and athletics." Thus would the {^esthetic instincts 
and the love of the beautiful in nature be fostered. In cities the 
school should, if possible, face a park or a small plot of ground. The 
roofs of city schools should be used as playgrounds. There should 
be cloak-rooms and individual lockers, so that parasitic diseases may 
not be communicated by the clothing. 

During childhood and youth everything possDjlo must be done in 
the school to favor the development of a sound physique. There 
should be games, athletic sports, gymnastics and manual training. 
" Many of the problems hi moral and intellectual training must be re- 
ferred to the playground for their solution." For any special weak- 
ness the gymnasium affords the means of correction. Bathing does 
more than simply improve the appearance, cleanse the pores, and 
promote elimination. Cold-baths or shower-baths are an excellent 
stimulant to the nervous system and give tone and vigor to the 
muscles. In some German cities the shower-bath is a compulsory 
part of the school curriculum, — the children going to the baths in 
relays during scliool hours. 

The amount of study or muscular exercise whicli produces normal 
fatigue in a healthy child may produce abnormal exhaustion in a child 
who is physically below par, The offspring of alcoholic or neurotic 
parents, the anaemic children, the mouth -breathers and those who 
have defects of sight or hearing, or which grow rapidly, and especially 
young girls entering the period of adolescence, are very susceptible 
to cohapse from overwork. These abnormal strains are most apt 
to show themselves in spring after the indoor life of the winter. 
Awakening unrefreshed in the morning is one of the early signs of 
abnormal fatigue. Inability to concentrate the attention, loss of memory, 
irritability, morbid introspection, and worry, are other signs. St. 
Vitus's dance indicates a very advanced stage of overfatigue. The 



observation of Caille is apt : " The days of brutally whipping chil- 
dren are gone. We are now refined and whip their brains to death." 

The arrangement of studios should be such that those requiring 
more mental power, such as mathematics and grannnar, should be 
taken up in the morning when the mhid is the fresher. Children who 
are physically w^eak are often brighter mentally and more studious in 
their habits than strong and healthy children. They do not engage in 
athletic sports or exercises of any kind. Unless their studies are 
directed and restrained within reasonable bounds, they are likely to 
sacrifice health and perhaps life itself in the rivalry of school studies. 
Many a consumptive lias been developed in this way. Such children 
should be compelled to be outdoors a goodly part of the time ; and 
very great care should be exercised with regard to their food and 
their digestive functions. 

In many schools, especially in public schools, the children must do 
one of .two things, — either they must take a cold lunch, or they must 
rush home, gulp down a warm meal in the good old American fashion, 
and then hurry back to the school-room. This is very baneful during 
the period of active growth, when there should be plenty of wholesome 
food, eaten with a decent regard for the capabilities of the digestive 
tract. A longer recess at lunch-time would perhaps obviate this diffi- 
culty. Some one, supersaturated with paternalism, has declared that 
the community should provide hot lunches for its public-school chil- 
dren. We may yet come even to this I 

Bracken would have tuberculous children excluded from public 
schools, for their own good, and in order that they may not be a 
source of infection. They should have a few hours for study ; and 
much attention should be given to their physical training and to their 
out-door life. 

Probst advises that it is not necessary to enforce an absolute rule 
excluding consumptives from school ; it is highly essential that every 
consumptive permitted to attend school should be required to carry 
out minutely necessary measures to prevent the communicating of his 
disease to others ; that every effort should be made to have early 
knowledge of consumptive teachers or scholars, medical inspection 
being the best means to that end ; that teachers and older scholars 
should be fully instructed in the cause, prevention and cure of 

Certainly consumptives should not teach school. Apart from the 
possibility of their infecting susceptible scholars, the occupation is an 
indoor one, in which their chances of recovery are not good. Teachers 
should be fully instructed concerning this disease, so that they may 


proceed iiitellig'ently coiiceriiing veiitilulioii, the cleleclioii of predis- 
posing causes affecting tlieir pupils, and like measures. And certainly, 
all things considered, consumptive children liad best have frequent 
holidays and be out of doors most of the time, proper attention being 
paid to tlieir food, clothing and exercise. No consumptive should ])e 
employed about a school ; the school-rooms should be flushed with 
fresh air during intermission ; children should use only their own 
pencils or other articles which they an; liable to put in their mouths ; 
and, of course, they will not spit upon the tloor. They should rinse 
well the school drinking-cup before using; or children should have 
individual drinking cu})S, especially where the upward flow faucet is 
not available; the lloors of school-rooms should be scrubbed, and the 
desks, seats, and window ledges should be washed frefpienlly ; the 
entire school-room should be disinfected every three months ; seats 
and desks should be properly constructed to suit the size of the child, 
so as to obviate stooping and cramped positions which may compress 
the chest and prevent natural deep breathing. 

Knopf recommends that, wherever possible, instead of American 
windows, which can be opened to only one-half their extent, French 
windows should be used, or windows sliding in the wall, or tliose that 
turn on a pivot, all of which admit twice the amount of air; walls and 
woodwork should be plain, with corners rounded off, to make cleansing 
easy ; there should be plenty of indoor singing and outdoor botanizing 
and geological excursions. Public-school sanatoria for the treatment 
of tuberculous and scrofulous children are an urgent necessity in nearly 
all our large American cities. 

The logical outcome of the situation as here considered would be 
the engagement of a school doctor, or a medical school inspector. 
Medical men are now thus employed in several cities for the detection 
of infectious disease. In New York City, for a number of years past, 
these physicians have daily inspected all cases referred to them by 
teachers, of children who manifested symptoms possibly indicative of 
diphtheria, measles, scarlet fever, or other infections. Within several 
years past physicians have made weekly inspection of all children in 
the various classes. The physician, so far as tuberculosis is concerned, 
should himself detect, or may be apprised by the watchful teacher, of 
such symptoms as mouth-breathing, swellings of the glands in the 
neck, persistent, perhaps dry coughs, catarrhs and running ears ; pale 
or feverish, easily fatigued, nervous or fretful children, and very s{)e- 
cialiy those who have persistent headaches should be carefully ex- 
amined. As we have seen, tuberculosis in children manifests itself 
in bones, joints, or in the abdomen, rather than in the lungs. Joints 


that are tender, painful on pressure, that swell (white -swellings), 
undue fatigue of arms or legs, diftieulty in swallowing and in breathing, 
accompanied perhaps by pain on {pressure in the vertebrae of the neck; 
"girdle sensations," referred to other jiarts of the trunk, with pain upon 
pressure of vertebne; frequent urination and irregular movements of 
the bowels, accompanying i)ain in tlic linnbar spine ; a distended and 
painful abdomen, Avith vomiting and persistent diarrhcea. — such mani- 
festations as these must be immediately attended to. 

John Brisben Walker has described admirably the Department of 
Physical Culture at the St. Louis Exposition. This form of exercises 
is now no longer confined to universities. It is happily extended in 
great measure to public schools. The idea here is not of competition, 
of hurrah and brag, display and scliool advertisment, but of truly 
bringing the child to an understanding of its body and advancing it in 
that physical training which will give it, not skill in games, but a per- 
manent stock of health and efficiency. Fortunately, some ten thousand 
teachers, from all parts of the country, were able to observe this work, 
in which the schools of the great city are now engaged. Besides being 
instructed, most of these teachers are no doubt having the exercises they 
have seen reproduced in their own schools. The most lasting lesson 
was found in the collection of photograjjhs on the walls of the gym- 
nasium building, which suggested all sorts of possibilities in the way 
of ''setting uj)"" the hitherto j)erhaps feebly developed body of the 

^^'hat is here emphasized is that no violent competition for the few 
is needed, but constant, steady development for all. Even a class- 
room may make a fair gymnasium if there is no better obtainable. 
Work may, indeed, be performed without a})paratus or with only a 
few inexpensive sticks and ropes. Among tlie practices which count 
nmch for the habit of public-school children is the interruption of 
studies at periods during the day for " two-minute exercises." At a 
signal the class drops its text-books, rises to its feet, stretches its arms 
to expand its lungs, and so goes through a few health-giving exercises. 

I cannot complete this chapter without an "apjjreciation " of the 
work of an elderly lady who was principal of the public school in Xew 
York City, where I did my first work as medical school inspector. 
I was of the original corps of appointees, some six years ago. The 
work was at that time new and not popular in every school. This 
gentlewoman, upon my first call, informed me that she saw no 
occasion for my presence there. For many years her teachers had 
been instructed to bring to her ailing children, whom she had at once 
sent home. There were no children for me to see that dav ; and I left 


THK S('II()(U>-('HILD 


fooling that 1 really liad no business at large. When I canio nexi day 
she showed me a chilcl that was not ill, so far as I could sec. I cx- 
|>lained I wanted to see only children wlio wer(» jjossibly suffering 
from infectious diseases. Well, its father was an alcoholic, ''and 
wasn't that catching?" slie wanted to know. 

Within a few days, however, we got along beautifully. She r(>cog- 
nized that my coming did not greatly disturb the school routine and 
discipline, and that 1 relieved lier of r(^si)oiisibility ; and I soon found 
reason to admire the work of this excellent and masterful teacher of 
little cliihtreu. 

Part of the training she inculcated was such drilling as is here 

set forth as being something new. I several times saw from the 

platform the exercises which were gone through with by the assembled 

children. These, my dear old friend had many years ago instituted 

in her schools ; and they have been copied and used in other schools 

with great success. The children, even the smallest, pointed to the 

various parts of tlieir bodies, naming them and tlieir functions, all 

si)eaking in unison the while, and with delightful cadence : •• I have 

two eyes, two ears, one nose, and one mouth ; my eyes are made for 

, seeing, my ears for hearing, my nose for smelling," and so on. And 

' they went tlirough various drills, standing erect, throwing their arms 

above their heads, backwards, outwards, and the like, with excellent 

I co-ordinated precision. 

j And while ''seeing New York," and perchance studying the 

.Subway Tavern, the sociologist can do no better tlian to visit the 

I public school near by, the destinies of wliich are controlled by Mr. 

Doty and his admirable assistant. Miss Hayes. The former of these 

is a terrifying man in appearance, with his hair brushed up and his 

I piercing blue eye. No truant boy could meet that eye and live. But, 

bless you, for all that, there never was a softer-hearted man ; nor one, 

I imagine, so easily taken in by a plaintive yarn. But the wonder of 

his school is this. It is in the Italian quarter, and most of the children 

are of ignorant parentage, who come for the lirst time, knowing not a 

word of English, or anything else than Italian. To make Americans 

of these children of six and upwards, to teach them the English 

^language and through them to educate their parents, — does the reader 

'know of any greater task, or one so unassumingly achieved? 

And then that other school, in which I attended a recejjtion the 

day before Christmas — how the principal at one point announced, 

"Children, Dr. Ruber wishes you a Merry Christmas," — how I there- 

ijupon began to remove my overcoat, preparatory to res|)oiiding with 

a speech, while the principal, not seeing, went rigid on with the cere- 


monies ; and how I sat down again foiled and blushing, to the uncon- 
cealed delight of the assemblage. 

I cannot, myself a public-school boy, speak too highly of them, so 
admirable a part of our national life, conceived as they are in the 
spirit fundamental to our Constitution, educating so well those upon 
whom we must rely for the perpetuation of our institutions. Shame 
upon those spineless and cheap specimens who would decry our 
excellent public schools — 'twas not for such as these our fathers 
fought and bled ! 



"The prudent man foreseeth the evil and liideth himself. The simple pass 
on and are punished." 

The adolescent period is a constant source of predisposition, not 
only to tuberculosis but to disease in general. We have noted that 
consumption begins to manifest itself with deplorable frequency about 
the fifteenth year. With puberty comes an oftentimes radical menial 
and physical transformation. So that the boy or girl, if not carefully 
watched, may deviate from even the most perfect health to a well-nigh 
permanent tendency to disease. Especially is this so with the feminine 
organism, unable at this time as it so frequently is to bear anything 
that would interrupt or interfere with its activity. The generative 
organs undergo great changes, and with these changes the whole 
moral and physical nature is altered. Perversions of any organ or 
faculty may then evidence themselves ; and once started are apt to 
continue. Then other factors, such as constipation, want of sleep and 
excessive work at school, assist in establishing literally a permanent 
predisposition. Thus are developed the list of affections which are 
included in the generic name hysteria. Among the purely physical 
affections are chlorosis (green sickness) and aniemia (in which the con- 
dition of the blood is abnormal). And under such circumstances 
tuberculosis, especially of the lungs, is a matter of easy devolopment. 
Here again we recall that consumption is more common at, and shortly 
after, the years of puberty than in previous years. 

This same period of puberty is also, with regard to boys, of most 
difficult management, especially with regard to the sexual appetite, 
and it is not made any less so by many advisers, who are presumably 
well-intentioned. The boy needs most desperately to have his mind 
directed. The working boy is safe in the daytime ; in the evening 
night-schools or wholesome amusements may engage him ; and if he is 
tired enough to go to sleep at once on retiring, it is well with him. 
On Sunday afternoons, debarred through theological influences, libra- 
ries and museums are generally closed to him : wliolesome amuse- 
ments (after morning church hours) such as obtain in continental 
cities, are denied him ; baseball and other manly and splendid sports 



aro not permitted tlie boy wlio has no time for play during the week. 
Til us do he and liis fellows group themselves about alleys, street 
corners and congested thoroughfares and get themselves suggestioned 
in all sorts of bain^fnl ways. 

The ])oys of the better-off, who go to high-school and college, ex- 
ercise sntliciently ; and liere the wise i)rovision of college athletics 
comes into play, keeping the minds of the young men free from ener- 
vating impressions (Coughlin). 

Sexual abnormality, as also perversions of all the appetites, is sub- 
versive of nervous and circulatory tone ; it is depressive of the func- 
tions of tlie organism ; it incites to structural affections. As every 
physician knows, the adjustment of this matter is extraordinarily diffi- 
cult ; and it is made no less so by sucli as are bigoted or stupidly 
inexperienced in dealing with tlie real conditions. 

The excessive use of cigarettes among boys and young men is cer- 
tainly predisposing to consumption ; for tobacco is an irritant of the 
mucous membranes, rendering them dry and inviting catarrhs. 
Inhalation is especially pernicious, not only because of the hot 
smoke but also in the deterioration in the quality of the air thus 

I should strongly advise young men in business to join militia 
regiments. It is amazing tlie amount of health, both physical and 
moral, to be got out of such service. Of course, this suggestion is 
for the physically fit, not for the tuberculous ; even if such cases were 
not excluded in advance by tlie regimental surgeon, strenuous exercises 
of the sort here executed are not for the latter. Let the young men 
go into a good regiment. From the very beginning tliere is a superb 
sense of well being. He is introduced to an admirable system of 
calisthenics. He assumes the position of a soldier, and perhaps for 
the first time in Iiis life enjoys a delicious sense of physical symmetry 
and completeness. For at least an hour and a half — the length of a 
drill — he stands very straight, his shoulders thrown back, his lungs 
expanding fully, his head erect, cliin up and eyes to the front. His 
movements are timed and measured ; and he enjoys the mental rest 
of doing implicitly wliat he is told, and of having some one else for the 
time Ijeing do his thinking for him. Here is an extraordinary satis- 
faction. There are exercises he has to take. Soon he is given a piece 
to carry, which seems to him to have the weight of a young pine-tree, 
and which at first he manipulates with the airy grace of a dancing 
bear balancing liis staff. After the drill he goes liome, bathes, sleeps 
soundly, and awakens with an appetite, a sense of physical well-being 
and a clearness of mind such as are perhaps entirely new and most 


happy experiences witli him. Besides, lie becomes of a company of 
a hundred splendid fellows — sound, manly, wholesome men. Among 
such his mind and body have got to be right. 

The weak-lunged, or he who is likely to be alfecled by the pre- 
disposing causes we have detailed, would do well to protect himself. 
To begin with, he should lead the physiological life. He should rise 
betimes, bathe well, eat slowly three meals of wholesome food daily ; 
should be in the sun and the open air a great deal; should drink 
generously of water, at least between meals ; should avoid dusty, damp, 
or foul air ; should work only in rooms where there is fresh air ; should 
go to bed early and sleep at least eight hours. He should wear all- 
wool underclothing the year round, thick in winter and lliin in the 
summer. The night wear should be of wool, changed from that of 
tlie day, of course ; woollen socks should be worn in ])ed if the feet 
are cold. Warm footwear and stout, watertight shoes, preferably with 
cork soles, should be worn. He had better let tobacco alone, and 
should take alcohol very moderately and never witliout a bite of food 
at the time of drinking. There should be fresh air for him, and lots 
of it. Some people seem to have an antipathy for this benefaction not 
unlike that of the tramp for soap and water. He is not to be one of 
these. Fresh air abounds over all the surface of God's earth, except 
in the houses which man has built. The people who pass their time 
out of doors know nothing of coughs and colds. Not fresh air but 
want of it is the cause of many diseases. It is nature's disinfectant ; 
there is no better. Living outdoors enables one to digest coarser 
food and to do more work without fatigue than is })Ossible indoors. 
Pure air means oxygen, and this means pure blood ; and this in 
turn means well-balanced metabolism, — the conversion of oxygen and 
wholesome nutriment into healthy tissues, so that a virile body is the 

Next to be considered is exercise, of which there are all sorts, — 
rowing, swimming, riding, golf, tennis, boxing, croquet (for those of 
feminine tendencies), walking, etc. Walking is my preference. I 
consider it the best of all exercises. Professor Blackie, after the 
many years since his work, " How to Get Strong," was first publislied, 
still extolled this exercise above all others. It is of all perhaps 
the most inexpensive. No paraphernalia. DonU you like it? Read 
Robert Louis Stevenson, who quotes Hazlett : "Give me the clear 
blue sky over my head and the green turf beneath my feet, a winding 
road before me, and a three hours' march, and then to thinking! 
And he must have a winding road, the epicure." Poor Stevenson 
— to have appreciated this, and yet not to have been able to enjoy it ! 


One crisp spring morning I stood on the veranda of a hotel at 
Lake Hopatcong. Near by was a German matron, rotund and of 
most pleasing features, her two children playing about her. Presently 
there came upon the breeze the rise and fall of men's voices, at first 
indistinct and then sufficient to hear the song: 

"Halli, hallo, halli, hallo, 

Bei uns geht's immer. je langer. je schlimmer ; 
Halli, hallo, halli, hallo, 

Bei uns geht's immer a-so !" 

And , from the sound of the first note this good gentlewoman's 
face took on a glow and a suffusing of the eyes, until presently, with 
splendid swing, green sprigs in their Alpine hats, a body of men on 
a holiday marched out of the woods near by to the hotel steps. 

Thoroughly to enjoy and to get the most good out of this exercise 
of walking, you must throw your shoulders back, and your chest out. 
head erect, lips closed ; no mouth-breathing ; make it a five-mile clip. 
Trolleying is excellent, too ; the way to do is to get off and walk when- 
ever you come to a stretch of country that is especially enticing. 

We ought to breathe through the nose. Subsidiary cavities are 
provided within this organ in which the air is filtered, warmed and 
moistened in its passage to the lungs ; otherwise, as in the pernicious 
habit of mouth-breathing, the air gets into the lungs cold, raw, and 
often dust-laden. 

Usually men who work out of doors get all the exercise they need. 
But people who work in factories should get some fresh air in the 
evenings if they can't get it at any other time. Night air is not bad, 
as some people think. — although it is not as good as the air when the 
sun shines. " There is no other air for us to breathe at night but 
night air." The housewife should make it a rule to go out of doors, 
walking or riding in street-cars, at least one hour every day. 

The thing to remember about exercise is to stop when fatigued, 
no matter how much or how little has been taken. The phthisical 
are especially prone to overexertion. 

After exercise comes bathing. The skin has important functions ; 
it respires, secretes, and excretes. Therefore we should bathe well 
in order to keep the skin in as normal condition as possiljle. A 
cold sponge-bath to the waist on rising is, in addition to the advan- 
tages mentioned, a good tonic for weak lungs. If this is done the 
bath-room should be warm, and vigorous friction with a rough towel 
should follow. A cold bath in a chilly room would very likely occa- 
sion in a weak constitution shock, followed by depression. In such 
cases tej)id water should be substituted for cold. 


It is said our English brethron take cold tub-baths (at the tem- 
perature of running water) on rising, even on the coldest mornings. 
This practice is probably not so general as Ave are led to believe ; no 
doubt it is indulged in only by eccentrics, of whom there are not a few 
on the tight little island. A Birnungham (England) i)hysician advo- 
cates instead a tub-bath on rising at the temperature of the body 
(98.5° F.) in a bath-room at a temperature of about 70 degrees. This 
advice is surely rational and wholesome. The feeble might stand 
while taking a cold sponge-bath in a bath-tub in which there is very 
warm water up to the ankles. 

We have dwelt upon the effects of inordinate alcoholism ; it cannot 
be too greatly condemned with regard to tuberculosis. However, to 
those in health a moderate use of alcoholic drinks of good quality 
seems to be distinctly beneficial. 

Tea, the tipple of women, may have perhaps as baneful effects as 
inordinate alcohol.' Catarrhs and other affections of the nose and 
throat must be cured. Otherwise the respiratory passage will be 
contracted, there will be oxygeii-hunger, upon which will follow weak 
lungs and narrow, undeveloped chest. Enlarged tonsils, adenoids, 
nasal '• spurs,'' and like mechanical obstructions must be removed. 

Singing is excellent exercise to develop the limgs, — though, of 
course, not essential. If one does sing, and can at the same time 
maintain cordial relations with his neighbors, his limgs will bo all the 
better for it. Among the German soldiery, there is, I understand, 
plenty of concerted singing on the march. 

The weak-lunged should get into the habit of taking long breaths 
and of expanding the lungs freely; good results would follow the 
practice of the following gymnastics for five minutes three times a day, 
on rising, before eating at noon, and at bed-time (Savage) : 

It is very simple and no machine is required. First, any clothing 
that would interfere with the free expansion of the chest should be 
removed. We breathe about eighteen times a minute, men a little 
more slowly than women. The exercise consists simply in breathing 
more slowly than usual for five minutes. Let a man breathe ten 
times a minute or fifty times in five minutes, timing himself by the 
clock. And let a woman breathe twelve times a minute or sixty times 
in five minutes, timing herself by the clock. Long, deep breatlis of 
fresh air must be taken. To do this, one must stand erect, soldier- 
wise, the shoulders thrown backward, the chest thrown out, and the 

' A great specialist cures many of his cases of heart-disease in women "by 
requiring the tea-kettle to be taken from the stove." 


arms jjrossed well against the side. Otlier gymnastics than these 
should be counselled by the physician or the physical trainer for 
each individual. It is quite essential that pure air should, if possil^le, 
reach the innermost recesses of the lungs. We must recall that 
breathing is not so much a matter of inspiration and expiration as it 
is a matter of the interdiffusion of gases. There are in the normal 
process three kinds of air, — the tidal air, which is exchanged in each 
breathing, the complemental air, which is forced out after deep mspira- 
tion. and resitlual air, which remains after the fullest expiration. Res- 
piration really means the conveyance of oxygen to the furthermost 
tissues of the body. Normal respiration is certainly essential to health. 
Feeble respiratory movements (in the thorax) react upon tlie general 
systemic condition. Breathing gymnastics will certainly remedy re- 
spiratory insufficiency. And in addition to their direct effect they 
will have an excellent hitluence upon the nervous system, especially 
of the young. 

Of course, enough clothing nuist be worn to keep the body warui^ 
but there must not be so much that it will constrict the chest and 
interfere with free respiratory movements. "Put your chest-pro- 
tector on your feet''' is an absurd way of stating it ; but the meaning 
is that if the feet are kept warm and dry many a disease of the 
respiratory tract will be avoided. In order to complete the record 
I set forth the usual medical wail against the tightly-laced corset, 
tiglit neckwear, tiglit shoes, etc. I know that no woman will take 
these things into a moment's consideration. The adoption of the 
rainy-day skirt is reconnnended. 

A few more points : The teeth and mouth should be scrupulously 
clean. Medicines should certainly not be taken except upon the phy- 
sician's prescription, — $02,000,000 is the annual price paid in these 
United States for patent medicines (no physician's prescription re- 
quired, alack). I think tlie consumers of them were harmed inversely 
as the proprietors were benefited. During convalescence after ener- 
vating diseases — infiuenza, pneumonia, typhoid, especially after fevers 
— the ])atient should be very careful indeed. To rest before and after 
meals is essential to good digestion for those who are weak. Excite- 
ment should be avoided. When the choice can be made, one should 
live in a dry and sunny house, avoiding narrow and crowded streets. 
Take a vacation, — one day in every week. Finally, doiit neglect a cold. 

C H A P T E U \' J 1 1 


BenvnUo — Tiike thou some new infection to ttie eye, 
And tlie rank poison of tlie old will die. 

Romeo and Juliet, Act I, Scene II. 

The search for immunity from disease began in the early days of history. In 
fact, Galen used the flesh of the viper as an antivenene, while Mithridates fortified 
himself against disease by taking all the then known antidotes. He also experi- 
mented upon condemned criminals, and finally succeeded in rendering himself and 
them immune to snake-bite by taking the blood of animals which had been fed 
upon venomous snakes ; Andromachus, physician in chief to Nero, as well as 
other notables, resorted to the same expedients. Finally, Dioscorides advised those 
bitten by mad dogs to drink the blood and eat of the liver of the animals which 
had bitten them. — Wainright. 

We liavG in general terms considered that as most of us do not 
€ontract consumption despite tlie great prevalence of tli(> disease, 
there must be established in the unaffected some sort of natural or 
acquired immunity. The study of this condition of immunity has 
occasioned in the ambition of great physicians — Maragliano, von 
Behring, Trudeau, and many others — to find a means by which 
practically all of us may be rendered immune to this tuberculosis. 

In this aspect tuberculosis may be likened to smallpox. No doubt 
there is in the minds of many a vague sense of disapproval regarding 
such efforts as are being made to find a serum by means of which 
people may be vaccinated against the former. These are reminded 
■of the attitude toward Jenner's eflforts with regard to smallpox. In 
his day this infection was regarded as an inherent humor which must 
€ome out in every man. As no one could escape it, it was better to 
have it, and be done with it. Anyway, Jenner had no business med- 
dling with the course of nature, — it was downright sacrilege, as many 
an unrighteous fatalist declared. Against this and like reasoning it 
was difficult indeed to get established a procedure altogether uni)rece- 
dented, such as vaccination. Yet to-day who outside an insane asylum 
can conceive a return by choice to ante-Jenner conditions, when small- 
pox decimated cities and towns, wiped villages entirely off the map, 
and left every other survivor hideously pock-marked ! No doubt a 
sentiment against vaccination for tuberculosis will exist for generations ; 
tut it is conceivable that the efforts of Maragliano and Iiis colleagues, 



and of their scientific descendants, will result in procedures which will 
make tuberculosis as rare as is smallpox. With regard to the infection 
itself, it needs no extraordinary spirit of prophecy to foresee such a 
result. Undoubtedly, however, no radical or universal extermination 
of the disease consumption can be hoped for until such powerful pre- 
disposing factors as poverty, alcoholism, and the like, can be done away 
with. If these conditions can be controlled tuberculosis will become 
in its plague aspects as much a memory as is smallpox. 

Many observers have found that injections of serum from an im- 
mune animal into another liave caused the destruction of bacilH intro- 
duced under the skin. Although the same test can obviously not be 
applied to man it has been found that the agglutinative pow'er of the 
human blood (its power of arresting the motility of micro-organisms 
and of causing them to cohere in groups or masses) is raised by in- 
jections of serum from an immune animal into the system of a healthy 
man. From this it is reasonable to conclude that the defensive sub- 
stances of the blood liave been increased or fortified by the injection. 

Maragliano considers that he has cured cases with an antitoxic 
serum which he has prepared, and that these cases have remained free 
from tuberculosis a number of years. It seems evident that such cases 
must /lave acquired an immunity to the disease ; otherwise they would 
have been subject to relapse. The serum besides being injected has 
been introduced by the mouth into the digestive tract. Maragliano 
considers that innnunization in this manner is possible, although there 
are some who hold that the defensive materials are altered and not 
assimilated in the alimentary canal. He has shown also that the pro- 
tective elements of the serum pass into the milk ; so that von Behring's 
idea would seem feasible of introducing the immunizing sui^stance 
along with the milk of inmiune animals. These methods thus far 
considered constitute "passive immunization." 

Active imnmnization is seen in clinical cases when the healing of 
local tuberculosis is followed by an increase of the defensive powder as 
measured by the agglutinative property in the blood, and in which a 
second attack of tuberculosis does not occur. To secure this experi- 
mentally, material must be introduced which will secure the same 
reaction by the system as it exhibits against the living bacilli; but it is 
not necessary to introduce the bacilli, nor is it, of course, justifiable 
in human beings. After many trials and experiments Maragliano 
has prepared a material which, all danger of infection excluded, 
will cause, when inoculated under the skin, a tuberculous phlegmon. 
By means of these inoculations immunizing resources are undoubtedly 
established in animals. Such inoculations have resulted in the pro- 


duction of antitoxic, bactericidal and agglutinating- materials, so that 
animals have been immunized to the point of rendering ttiem in- 
sensible to intravenous injections of virulent cultures which inevitably 
killed the controls (healthy animals whicli served as a standard of 
comparison). Finally, Maragliano has come to use these injections 
upon man, inoculating into the arm, at a point which soon presents 
a small circumscribed area of tuberculous ulcer, with suppuration 
that is entirely sterile. The temperature usually runs a fever course 
for two or three days, after which all lOanifestations disappear. The 
proof of immunization in these cases is derived from tlie increase of 
the agglutinating power. 

Von Behring, whose discovery of the antitoxic serum used against 
diphtheria has resulted in the saving of so many precious young 
lives, has also been a factor in tlie evolution of an anti- tubercu- 
losis serum. He has rendered calves immune to tuberculosis by the 
intravenous injection of dried cultures of the Koch bacilli. Some- 
times one injection suffices to this end. Sometimes several are neces- 
sary. As a rule there is no marked reaction to these injections. And 
after long exposure to tuberculosis (even after the injection of virulent 
tubercle bacilli) when they are killed their bodies show thai they 
are free from the chsease, while control animals become infected. As 
with Maragliano these phenomena are found to be based upon an in- 
creased a^lutinative power of the blood resulting from the injections. 
Von Behring has found that while calves show no marked reaction 
against these injections of dried cultures, older animals sometimes 
react in such a way as to endanger their lives, contracting as they do 
pulmonary congestion and oedema and sometimes pneumonia. There- 
fore, for immunizing purposes, von Behring chooses young calves. He 
is not yet ready to apply his method to human beings, but he believes 
that the time will come when the human race can be protecied by 
these inoculations and an efficient means be obtained for extinguishing 

this disease.* 

The greatest danger to calves is from infection while very young. 
This is also the case with the infant, from living in the same room with 
persons affiicted with consumption, from impure food, and the like. 
Another analogous observation is that calves infected by the presence 
of tuberculous cattle in the same stable may not reach the expres- 
sion of the infection in pronounced tuberculosis for years. 

Von Behring has undertaken experiments concerning the possi- 
bility of inmiunization by the milk of immunized cows, but these are 

1 Billings and von Behring. 


as yet iiu()nii)k'te and afford no data upon which definite observations 
can be based. 

Trudeau has made many valuable experiments v,ith regard to im- 
munity. He has used as his agent a living culture of the Koch 
bacillus, which had become much attenuated by long cultivation upon 
artificial media. This culture had been obtained by Trudeau twelve 
years before, directly from a consumptive, and had then been passed 
through a rabbit, and was from that time grown on artificial media, 
chiefly glycerin-peptone bouillon. The culture finally came to grow 
more rapidly, showing no marked change, however ; and it was just 
as effective at the end as it was originally. It showed a gradually 
diminishing virulence for guinea-pigs, and after the first six years, in 
ordinary doses, it did not kill rabbits, and in guinea-pigs produced 
only very slow lesions, or in other cases did not kill the animals 
at all. Trudeau administered increasing doses of this material to 
healthy guinea-pigs, and subsequently inoculating these animals with 
a virulent culture of it, was able to demonstrate a distmct difference 
between the lesions produced in these animals and in control animals, 
which had not been immunized, and to which the same doses of the 
virulent material were given. In general, in the immunized animals 
the lesions at first appeared to be more extensive than in the non- 
immunized, but subsequently the former showed retrograde changes, 
while in the latter the lesions advanced steadily in the usual way 
until they were fatal. 

Trudeau differentiates very definitely toxic and bacterial immunity. 
A certain degree of toxic immunity can be produced, he considers, 
but not sufficient to protect animals against inoculation with living 
virulent bacilli. He could accustom his animals by gradually increas- 
ing doses to bear witli impunity amounts of toxic products of the 
tubercle bacillus which at first would have proved fatal. But this 
toxic immunization did not protect the animal against the invasion 
of its tissues by living virulent bacilli when subsequently inoculated. 
It was only when he began to use living cultures as a protective inocu- 
lation that he met with such results as indicated that the living germ 
is essential to wliat success has been attained in the production of 
artificial immunity. He inoculated living bird tubercle bacilli in rab- 
bits, and secured a marked degree of artificial immunity. In these 
rabbits, which had previously received the preventive injections of 
living bird bacilH. the virulent inoculation at first gave rise to a violent 
reaction of the tissues, which ended generally in cure, while the tuber- 
culous process, similarly induced in the controls, was steadily progres- 
sive, though at first it was accom{)aiii('d by little or no local reaction. 


The works of these men and of Koch, Thoiiiassen, de Schwemitz, 
McFadyean, Pierson, GiUiland, Neufeld, and very many others, will 
surely result eventually in definite procedures which it requires no 
great spirit of prophecy to foretell will alleviate human suffering 
perhaps more than any other single agency since the world began. 
Maragliano declares that his system of vaccination has even now 
been perfected to the degree that it is absolutely innocuous. It could 
be practised in families where tuberculosis is prevalent, in factories, 
and in infected centres, such as the "lung block." "Since milk, the 
blood serum, the blood, and probably also the flesh of iiiniume ani- 
mals can furnish the human organism with elements of resistance 
against tuberculosis, why should not these be used as food and furnish 
along with the normal nutritive material immunizing material.? Why, 
instead of ordinary milk, should we not use the milk of an imnmne 
cow ? Why, instead of ordinary meat, should we not eat the flesh of 
immune animals P" 

With regard to other diseases, as smallpox and diptheria, im- 
munizing measures are now a matter of course ; and in their accom- 
plishment laboratories, health departments, scientific institutions, and 
great business enterprises are working together upon a rational scien- 
tific basis. No doubt tuberculosis will ultimately be dealt with in the 
same way. 

" Antistreptococcus sera" are really a curative rather than a pre- 
ventive agent. We have found that as the disease tuberculosis pro- 
gresses various forms of cocci aid the Koch bacillus in its pathogenic 
work. It is the admixture of these cocci which results in virulent 
types of the disease. And the Koch tuberculin would no doubt be 
curative if it had the tubercle bacilli alone to contend witli. There are 
various sera directed against these cocci, to be used later in consump- 
tion, and some physicians have reported very favorable results which 
they attribute to their use (Bonney). 


Part VII 


The essentials in the home treatment of consumption in small 
towns, country places, and suburbs of large cities, are : 

1. The confidence of the patient. 

2. The masterful management on the part of the doctor. 

3. Persistence — benefit is usually a matter of months, complete 
arrest a matter of years, absolute cure a matter of many years. 

4. Sunshine by day ; fresh air by night. 

5. Rest while there is fever. 

6. Bread-stuffs, and milk, meat, and eggs. 




Then give place to tlie physician. — Ecclesiasticus^ 
"The hest occuiialioii for a patient is to labor to get well." 

The physician will take every possible means to establish an early 
diagnosis, recognizing the gravity of the disease, and the fact that 
with each day's delay in treatment the patient's chances of regaining 
healtli are progressively jeopardized. He must be a masterful man, 
dominating the situation. Knowing tliat benefit is a matter of months, 
arrest of years, cure of many years, he will map out the course accord- 
ingly. His will be the generalship, the recognition of the many ele- 
ments to be considered, and the material at hand with wlii(;h the dis- 
ease may be combated. Tlie patient must be made to rest confidently 
upon Ills strength and his judgment; and the patient's mind must 
become permeated with trust in his latent resourcefulness. His con- 
sultations must always and unfailingly be an inspiration. 

There must be something of a subconscious bond or compact to 
which sympathy will be tlie contribution of the physician and obedience 
that of the patient. The latter, particularly in this disease, is weak and 
lacking in reserve energy. He will need support and suggestioning 
of health and vigor, not only when he knows lie needs these things, 
but even more so when he imagines he does not, — like many who 
need to pray, not so much when they are unfortunate as when tliey 
are becoming prosperous. The physician will study the mental con- 
dition of the patient ; he will recognize that in many such, especially 
Avomen, the emotions and the will are apt to be unstable. He will 
deal severely with frivolity; will encourage the despondent; will with 
great and redundant patience instruct the ignorant. His directions 
must be clear and definite; concerning them the patient must never 
be left in doubt. It is essential that he shall explain the nature of the 
disease to the patient. It is criminal to speak mildly of an " apical" 
or of a pulmonary catarrh, and soothe the feelings of the patient, with 
the result that tlie latter may, through not understanding the gravity 
of the disease, neglect herself, with fatal results. It will not be agree- 
able for the physician to know that a consumptive has said of him in 
the last weeks of her life: "If Dr. X. had but told me the truth, 
I might have been well to-day." For such an evasive diagnosis as this 



no consuinptivo will observe the rigid regimen essential to recovery, 
especially in the case of a man ; nor will such an one renounce his 
favorite habits and pleasures ; nor his vocation, if needs be ; nor his 
time and money to achieve his cure ; nor will he leave, if called upon 
to do so, his own people and his familiars. 

The diagnosis of consumption, if made early, is not discouraging ; 
it is not now, as it used to be, ec{uivalent to a death-sentence ; in all 
human probability the conscientious and obedient patient, who has the 
disease in its incipioncy, will get well. And this will be so, moreover, 
in many cases of fairly advanced disease. 

Upon being told of his malady the patient may become dread- 
fully affected ; and here enormous tact is required on the part of 
the physician. The patient will look him anxiously in the face, and 
he must compose liis features to a clear-eyed, calm and gentle sympa- 
thy, and his voice must be both firm and kindly while he is meeting 
the patient's quivering lips, the white, tense, dilated nostrils, and the 
swimming eyes, over which he presently puts his trembling fingers. 

However, following upon this initial shock, the psychology of the 
patient is almost invariably that of the volunteer soldier. When the 
idea of going into battle first confronts the latter, he will have a sense 
of terror no matter how established his courage may be ; but presently 
this emotion will certainly give way to that of exultation and of a belief 
in ultimate victory in the fight which must be made. 

The patient must be obedient to his physician, and persistent in 
every detail of the treatment enjoined upon him. He w-ill be 
confident of his recovery, — a state of mind happily prevalent among 
consumptives ; for such patients are proverbially sanguine and optimis- 
tic. He must understand that his improvement and final recovery will 
depend largely upon his own conduct. He must consider, before he 
undertakes any business or other matter, how his chances of getting 
well will be affected thereby. He must make it a habit to converse 
with no one except his physician or his nurse concerning his disease ; 
nor will he adopt the therapeutic suggestions of his solicitous friends. 
If he have lost faith in his physician or his nurse let him straightway 
get another. However well he may consider himself he must continue 
under liis physician's observation until he is dismissed. 



Pathological anatomy has never perhaps given any more decided proof of the 
cure of a disease than it gives in cases of pulmonary tuberculosis. 

We consider here the general principles upon which are founfiod 
the cure of this disease. The layman who reads this book must, if 
he has occasion, consult his own physician for details ; the medical 
reader is referred to appropriate chapters for scientific essentials. 

The first practical consideration will be the disposition of the in- 
fective material ; this we liave dwelt upon. Then the consumptive 
will keep away from others who are suffering from such infectious dis- 
eases as diphtheria or scarlet fever ; for an admixture of the germs 
of these diseases with that of tuberculosis results in the mixed infec- 
tion which renders fatal so many cases of the latter. The consump- 
tive patient will be careful not to reinfect himself, to which end he 
must associate intimately as little as may be with other sufferers. 

As regards others he will observe the golden rule, and must take 
the greatest care not to infect his fellows. It were well for him not 
to work in dairies or about cattle, nor should he prepare or otherwise 
handle foods. 

The next consideration is that of rest, at least durmg fever. He 
must not endure the slightest fatigue or overexertion. To the end 
that he may rest well the home in which he lives shall be fit and com- 
fortable. His bedroom should be the largest, sunniest, and best ven- 
tilated in the house. Carpets and curtains should be as scarce as 
possible compatible with the aesthetic sense. I shall here sketch a 
specimen room which I saw at the Baltimore Exposition. Its«esthetic 
and very wholesome appearance appealed even to my unemotional 
masculine eyes. Its floor was of hard wood, and there were just rugs 
enough to give an appearance of comfort. There was a Morris chair, 
well-cushioned ; also cane-bottomed chairs ; a dressing-table, neatly 
covered with thin, clean linen, upon which were placed " frizzing," 
appliances for " doing up" the back hair, and other mysterious para- 
phernalia essential to the feminine toilet ; a sofa with pillows (none of 
them plush) ; a brass bedstead, over which by means of a stand was 
a tray with dishes containing an appetizing meal ; a small stand by 
the bed, having upon it a book, clock, etc. ; a scrap-basket, a wash- 
stand, with tooth- and nail-brushes, a mouth-wash, a thermometer 




rosliiii: in a glass upon clean absorbent cotton, towels, etc., and a few 
simple pictures of a restful character, such as represented landscapes, 
sheep, and the like. There was in this room no such cheerless 
abomination as antiseptic furniture. 

Tlie aspect of the room should be to the south, if possible : it 
should be large and easily ventilated, and as far as may be from the 
other rooms without producing a sense of isolation or of disturbing 
the home relations or the play of the family affections. Tlie bed 
should be at least a foot from the wall. The temperature will be 
60°, and windows will to this end be open constantly. The patient 

will not remain within several feet 
of a radiator or a hot-air register ; 
lie must not breathe hot air. 

Rest should be out of doors as 
much as possible. When the air 
is cold the jiatient may wear warm 
headgear ; he in a y be wrapped 
comfortably in abundant clothing 
or sleeping-bags, with hot-water 
bags or I3 o 1 1 1 e s, or liot bricks 
wrapped in strong paper for the 
feet. Emaciated patients may sit 
upon rubl:)er - rings or cotton or 
oakum pads, covered witli gauze, 
such as may be easily destroyed. 
Porches, verandas, fire-escapes,^ 
yards, the roofs of houses, may all 
be utilized in this way. Morris 
chairs, or steamer cliairs, or small 
cots may be used, with screens or 
tent-covers to keep off snow and wind. Patients may rest in gardens 
during many hours. They may walk to parks or they may be taken 
thither in hand carriages or wheel chairs. 

The next })rinci})le of treatment is that the patient shall every pos- 
sible moment breatlie fresh air and be in the sunsliine. Among the 
many blessings which ])ure air confers are the rest and repose it in- 
duces and the ravenous appetite it occasions, whicli makes possible 
the abundant feeding essential to recovery. No atom of oxygen, the 
life-giving gas, should be lost. If I were a poet, "which I'm not," I 
should certainly write a poem in praise of oxygen. The theme is 

Fig. 39.- 

-Courtesy of Dr. J. W. Braniian, and 
the Xcw York Medical Ifcws. 

■'Tell it not in rjath": for 'tis a violation of tlic law to (Miciiiiiber tire-escapes. 


an inspiring one. This, tlie litl'-l)('sl()\ving, llio liCe-niaintuining gas, is 
tlie most useful and the most abundant of all the clcmenls (as we still 
call lliem). Its combination with olhor substanc(^s — oxidation — 
makes heat, and that is Avliy tlie sentient body is generally warmer 
than the atmosphere. All animal and vegetable life d(>p(?n(ls U})on 
oxygen. Under the sun's benignant influence, plants give out this 
gas, which thus freed is respired in animal life. The capillaries carry 
it to the uttermost cell in the organism, giving power and warmth 
and liealth, — in fact, life itself. It is more important than food to 
the economy. Without the latter one may exist for moidlis ; wittiout 
the former one cUes within a few minutes. Oxygen has a tonic effect 
upon the system. It dilates the air vesicles, increases chest expansion, 
gives greater lung capacity, accelerates the blood-flow and e(|ualizes 
the circulation throughout the body. The tendency to local stasis in 
the lunofs is thus avoided. 

Fig. 40.— Couch in a garden. 

Pure air and the blessed sunshine, — the tubercle bacillus cannot 
withstand these. Scientific data would seem superfluous here. Still 
one may note that a high temperature used to be maintained in the 
houses in English zoological gardens of certain animals from the tropics. 
Now they let these animals go out even in winter into the fresh air, 
and the mortality is considerably less. Hillier states that among 
closely confined milch cows tuberculosis is principally found ; among 
cows kept in the open air in Jersey tuberculosis scarcely exists. The 
well-fed stalled ox is more liable than his fellow fed on a half-starva- 
tion diet on the barren moorland. Tul)erculosis is rare among sheep, 
w^hich are practically never housed. 

Consumptives should be in the fresh air - twenty-four hours out of 
the twenty-four." The day air is better for them when the sun is 



shining:, but the night ah" is good, and it has the advantage, in cities at 
least, of being freer from irritating particles. 

As regards the value of pure air read the eloquent testimony of the 
physician, Daremberg, who was himself a consumptive : 

" No one knows the happiness of the consumptive who quits his 
tainted chaiiibcr to live au grand air if he has not himself experienced 

the benefits of this change. After 
having passed several months be- 
tween the four walls of a small room 
in Paris I arrived on the French 
Mediterranean coast, and, after the 
advice of Henri Bennet, I stretched 
myself out all day in the sun. At 
night I lay with my windows open. 
As Voltaire says, ' The hope of re- 
covery is already lialf a recovery.' 
Soon my powers revived. I could 
walk, make short excursions, find 
pleasure in existencCo I discovered 
that the sun of my life had not 
yet set. I saw it rise each morn- 
ing with deliglit, and each day 
linger too sliort a time to allow me 
to enjoy to the full the pure air, 
the bright light, the blue sea, the 
heavens, the earth — everything. 
It is good to feel one's self reborn. 
" This life in pure air, night and 
day, stimulates the appetite, im- 
proves the digestion, suppresses the 
fits of coughing, facilitates expectoration and the respiratory move- 
ments, invites calm sleep, and when the consumptive has an excess of 
evening temperature, that excess passes almost unperceived by him. 
Generally botli fever and sweats gradually disappear." 

Some years ago a poor man came to me, — a worker upon a cement 
boat that made tri])s to the city from up the Hudson. Tliere was 
irrepressible spirit in him — and tliere still is, I am glad to say — 
and much honhommic amt love of life. Every time I saw him he de- 
clared himself better, — which I knew he was not. His was a classic 
case of the disease ; and all the symi)toms were aggravated by such 
factors as the cement dusi he had to iidiale and the heaviness of the 
barrels he had to lift. While under my care he was getting progress- 

FiG. -41. — The "Aerarium." A practical 
method of sleejjing outdoors. Put the head of 
a cot hcd through window and protect by a 
long doul)le awning so arranged as to keep up 
a rising current of air without draught. This 
plan is to be followed only upon the physi- 
cian's advice. Courtesy of the Lapalme- 
Iloffman Co., Waterbury, Conn.) 



ively worse, until one night I was called to go to him. From tlio Coot 
of a street on tlie East River, to which I was directed, I leaped in the 
darkness from heat to hoat until I reached the cabin in which he lay, 
— a small canal-boat cal)iii, the windows of which were sedulously 
closed. The air baffled ad(M{uate d('Scrij)tion. Tliere were several 
men playing poker; they had jnst eaten a meal of steak and onions; 
they were smoking villainous tobacco; I think tliere was an odor of 
bad whiskey, but I could not definitely isolate it. I could, however, 
distinguish that of creosote which my patient exhaled while lying in 
his bunk. (In those days not to prescribe creosote was tantamount to 
malpractice.) I realized at once that my patient must inevitably die 
if something radical was not done. 
So I had him thereafter sleep 
under the stars, no matter what 
the condition of the weather might 
be. His head should be protected, 
his body well covered, and his 
feet warmed in intensely rold 
weather. Clothes-horses and other 
contrivances should screen him 
against snow and bitter winds. 
Awnings should protect him against 
rains. Never again should he slee[) 
in that cabin. These rides he 
obeyed. He sees me now occa- 
sionally. Certainly his disease is 
arrested ; and it seems likely that 
he will, in very fair health, attain 
a goodly age. His associates bear 
me a grudge. They wish I had 
let him alone. As things are now 

they are out of pocket by his prolonged existence, for he is the best 
poker-player among them, can sit longest at the game, and has, in 
the long run, appropriated a large proportion of their earnings. 

Another case is that of a young woman who made getting well the 
business of her life, for the time being. Slie had her cot put on a 
porch outside the house. An umbrella, securely fastened, protected 
her head whenever it snowed, and it happened from time to time that 
when she awakened her blanket would be covered with the night's 
snow-fall. These cases are not now unusual. 

While many people in health are " hugging fires" consumptives 
walk or ride, if" possible; or they recline, wrapped up and sheltered, 

Fig. 42.— Side view of Aerariuui. (The La- 
palme-Hoffman Co., Waterbnry, Conn.) 



of course, in the open air, during as many hours as may be, through 
ah changes of temperature, fearing neither rain, sleet, nor snow. 
The rain, however, they had best avoid. If the patient is so ill that 
he cannot ])e out of doors, his bed is drawn close to the wide-open 
windows. Weak patients should be wheeled out into the air directly 
from their rooms. To this end it might be possible in many houses 
to cut down the Avindow to the level of the porch or of an .outside 
platform. When indoors, day or niglit, the consumptive's windows 
should be freely opened. Such treatment never has untoward results. 
The head should be well covered ; the feet should be w^armed if neces- 
sary. In warm weather the head and shoulders must not be kept in 

Fig. 43.— Dr. Dunham's bed. Stiovving how head may project out of window. This plan is to 
1)6 followed only uiioii the physician's advice. 

the direct rays of the sun. Sun-baths — the nude body being exposed 
to the direct or concentrated rays of the sun — nmst be taken with 
caution and only by the physician's instruction. High temperatures 
may thus be induced. 

An important role is not now assigned to any particular climate in 
the treatment of consumption. Patients are not sent thousands of 
miles to get well, as used to be the case. It has been found that 
almost any salubrious climate will be effective. In one respect a 
change from a low altitude to a very high one is unfortunate, in that 
the patif'tit must oftentimes for the remainder of his days live in the 
latter climate, the rarefied air of which induces a "physiological emjihy- 


sema." The consumptive who does not do as well as he would like 
is apt to change his climate frequently. There is always distress during 
the travelling, which is, moreover, positively dangerous when there are 
cavities and a propensity to hemorrhage. In any event the patient 
must rest well at home for a few weeks before attempting any journey ; 
nor will he go to any place without definite information concerning 
it, or of the certainty of finding accommodations. 

After oxygen comes the necessity of plenty of nutritious food-stuffs, 
and of good digestion, so that all the fuel that is taken in may be 
assimilated and converted into healthy, germ-resisting tissues. De- 
tails concerning diet will be decided upon in individual cases. In gen- 
eral terms it should be such as will give the largest amount of nutrition 
with the smallest amount of labor for the alimentary tract, — roasted or 
broiled beef, mutton, lamb, fresh vegetables and fruits, cereals mixed 
liberally with cream, koumiss, plenty of sugar and good butter ; and at 
or between meals six or more eggs and from one to three quarts of 
milk distributed through the twenty-four hours. Indigestible things, 
such as sweets, pastries, dainties, must be avoided; these interfere 
with normal metabolism, — a i)erfect change of oxygen, fluids, and food 
into tissue. Between meals, at any rate, plenty of water will be drunk. 
There should be half an hour's rest on a bed or reclining chair before 
and after the principal meal, at least ; nor must the patient eat when 
in a state of nervous excitement. 

Lack of food or wretched food, and irregularity in feeding, — these 
factors are enormously prechsposing to consumption among the poor. 
Then many things are dreadfully cooked ; to this fact many experi- 
enced nurses testify. 

I hesitate to mention the use of alcohol. In certain cases, con- 
cerning which the physician must decide when he knows the tempera- 
ment of his patient and that obedience can be assured, small amounts 
of alcohol, in wines, or egg-nogg, or sherry and q^^, etc., will be found 
beneficial. To give free rein to alcohol will surely be disastrous. 
' As regards medicines: Let no patient use any without his physi- 
cian's directions. There are certain serums which physicians may 
administer by injection or otherwise with good results. Beyond these 
there is at the present time no specific which will cure consumption. 
One of the saddest pages in medical history is that upon which is 
written the deaths of consumptives who need not have died, but who 
became progressively worse upon sure-cures, such as had been advised 
by solicitious friends, or had been testified to in vicious advertisements. 
Patent medicines, of which the formulae are not distinctly given, should 
not be taken by consumptives. Many of these have alcohol as a basis, 


and thus give a sadly fictitious and temporary sense of well being; 
tliey bring relief one day, relapse the next — and progressive decline.' 

Not more reprehensible, on the other hand, are the counsels of 
Dowieites, " faith-curists,'' Christian scientists, and the like, who 
would have the consumptive disregard his disease as a figment of the 
imagination. Tliese inijiosters go about unwhipped of justice for 
much suffering, much family bereavement, many deaths that have 
come about through their baneful counsels, born of complacent ignor- 
ance, of all stupidity most execrable. 

3Iany consumptives need medicines. Their various organic func- 
tions have to be regulated according to the individual necessity, and 
the complex relations of the tissues and organs. In one case the 
kidneys need a medicament, in another the circulation, in another the 
nervous system, in another the stomach. It was Henry Ward 
Beecher who declared that near by many a grave are vegetable and 
mineral substances the virtues of which, if they had been rightly used, 
would have deferred the occupant's burial. This is good sense and 
good science, according, as I think, with the facts of life which are 
presented in the opening chapters of this book.^ 

It must be evident, upon reflection, that drugs are a means of cure 
as essential and as divinely appointed as any other agency for restor- 
ing health. They have certainly — as much as anything is certain — 
been put in nature to be studied and used intelligently ; and medical 
science has systematized and formulated the world's accumulated 
knowledge of them. But it is absolutely necessary that, in tubercu- 
losis at least, they shall not be used haphazard. The uses of them 
are matters which lie wholly within the physician's province, — particu- 
larly as regards this disease. Especially must any drug which spoils 
the appetite or the digestion be discontinued. 

We are now in a position to count upon the thumb and fingers of 
one hand the fundamental principles in the treatment of consumption : 

(1.) The disposition of the infective material. 

(2.) Rest. 

(3.) Fresh air and sunshine. 

(4.) Pure food and drink in abundance. 

(5=) The use of medicines as directed by the physician. 

' Appendix B. 

^Tlie " ihousand-souled" understood well such facts as these, as we may judge 
from the Friar's apeech in Bcmieo and Juliet. Shakespeare might, by the way, have 
supplied the evolutionists with one of their chief tenets, — that life is the constant 
adjustment of infernal relations to external relations. 



It is impossible to extirpate all tubercle-bacilli, therefore it is indispensable so 
to strengthen and harden the body that the absorbed germs cannot take hold 
upon it. — Imperial Board of Health of Germany. 

The subject of the sexual tendency with regard to tuberculosis is 
as important for the physician to consider as it is difficult to discuss. 
We need but allude to it here. Obviously in the management of con- 
sumption every element which would tend to weaken the system 
should be eliminated so far as possible. The Scriptural statement 
that "he who thinketh in his heart"' upon sexual things hath already 
committed the equivalent at least of a sexual act is figurative in a 
sense ; nevertheless, it is practically quite as true as if there had been 
physical consummation. For the mere thought itself has led to the 
secretion of physical elements, with the result that the system has 
become impoverished to the extent of this abstraction from its tissues. 
This is why, conversely, Sir Galahad's strength was as the strength of 

The consumptive is rather more prone to sexual excitement than 
the average normal individual. ^lany things occur to one in explana- 
tion of this : the lack of occupation ; the many hours passed in enforced 
idleness ; the nervous tension and the general excitement under which 
many consumptives labor ; the erethism which may be induced by the 
high temperature and the influence of the tubercular toxins within the 
body ; the superabundant sense of well-being which the forced feeding 
induces ; in many cases the feeling that the disease is likely to be fatal, 
and that life might as well be enjoyed to the limit while it lasts, and 
like considerations. With regard to these matters the physician will 
see that susceptible patients have as few opportunities lor isolation as 

Judicious bathing is exceedingly important in the cure of consump- 
tion. Upon general principles a daily sponge on rising, at least to the 
waist, with a brisk rubbing afterwards, is essential. The bath-room 
should be warm. The temperature of the water should not make one 
chilly. It may begin with 95° or 90° Fahr., and may be gradually 
reduced until a lukewarm or cold bath may be taken with comfort. 
By this time perhaps a cold shower could be endured. A coarse 
towel should be used vigorously, — by an attendant, if })0ssible. There 



sliould bo some rest at'Uu" i\w l)ath, from fifteen minutes to half an hour. 
Wcclvly tlicrt^ sliould be a warm batli, with thorough cleansing of 
the body; wliere there is much sweating this l^ath should be taken 
twice a week. 

The scientific advantages of bathing are to enrich impoverished 
blood elements; to deepen inspiration; to enhance nutrition; to 
further metabolism ; 1o eliminate excreta ; to obviate blood stasis: to 
reduce temperature ; to l)ring about a sense of mental as well as 
physical well-being. 

In htemoptysis baths should be omitted (certainly the daily ones). 
AN'liile the patient is lying down the various parts of the body should 
be cleansed and rubbed in succession. When also tliere is pleurisy, 
or after a night-sweat, or when the temperature is below 97°, a dry 
rub should be used judiciously, instead of a bath. And during fever 
the bath is best taken in the afternoon rather than in the morning.^ 

It is very essential that the consumptive should have his exercises 
graduated by his physician ; especially is this so of lung gymnastics. 
Concerning prophylactic exercises we have dealt in another chapter. 
AVe note here that certain judicious exercises will expand the lungs 
and increase much needed air-space. 

Indications against exercising are subnormal temperature, one 
degree below ; fever, no exercise at all if the temperature is 100° 
F., and bed inexorably if the degree is 101° F. ; rapid pulse and a 
tumultuous heart ; weight much below par ; far advanced disease ; 
fatigue or shortness of breath u])on exertion ; or when tliere is blood 
in tlie sputum. The physician will not permit exercise where there is 
a far-advanced cavity, or a dilated right ventricle. In consumption 
the organism is often on the verge of bankruptcy, and may be "easily 
bankrupted by an excessive amount of physical exercise." Again, 
" excessive muscular action consumes energy and throws products of 
combustion into tlic circulation" (Flick). In all such circumstances as 
these rest is essential ; exercise may prove fatal. 

When respiratory exercises are required of the patient, the 
physician will, of course, see that there are no hypertrophies, exos- 
toses, or obstructions to free respiration. The man or woman who 
must work will take every possible chance forest; there should be 
no ruiiniiig or lifliiig of heavy weights; stooping should be avoided. 

The patient's clothing should not constrict his neck or chest; it 
should not imj:)ede respiration. He should not wear constantly 
enough clothing to keep his skin moist with perspiration. Overcoats 

^ Appendix C. 


and wraps are to be used lor outdoors ; the underclotliing should be 
woollen all the year round, — thick in the winter, of light weight in the 
sunnner; or in Aviiihsr wool or silk may l)e used, atid in sunnner silk, 
or silk and linen, or silk and cotton. 

Sleep, nature's soft nurse, is perhaps of all luedicainenls the best, 
if it be taken warmly covered at the tempera! lU'e of the air without 
the house. In the country one had best go to bed very early in order 
to finish sleep (nine hours of it, if possible) before sunrise. Then 
he may bask in the early sunbeams and lie listening for an hour to 
the lark and the bobolink. If he can, he had best build a WTen's 
nest within sight of liis bed, so that lie may be encouraged by the 
abounding song and the pulsating joy of life which this splendid little 
optimist manifests. If in the city, on the other hand, he must not 
sleep or live in dark rooms opening on shafts, or in basements. 

Tobacco is irritating to mucous membranes ; probably no catarrh 
has ever been cured in an inveterate smoker. Tobacco throats are 
certainly predisposed to infection. The weed should be used as little 
as possible. Ho^vever, in many cases where the habit is essential to 
comfortable living, and lias been practically lifelong, it must be con- 
doned ; it must then be confined to moderate limit. Smoke must not 
be inhaled. Cigars and pipes are less harmful than cigarettes. 

Cougli is nature's effort to get rid of deleterious matter. Never- 
theless one sliould cough as little as [)Ossible, especially at meals ; and 
as far as may be only in order to expectorate tlie products of intlam- 
matioii ; he should invariably in coughing and sneezing turn aside his 
head and hold a handkerchief , before his face. Sometimes talking 
increases the coughing ; this suggestion is offered only to men, who, 
of course, only stand in need of it. Should there be a hemorrhage, 
the j)atient should lie very quietly until a physician arrives. 

The consumptive should avoid crowds, smoke, irritating vapors, 
dust, and dampness. His house should be built not upon damp, 
clayey soil, but upon porous, gravelly, elevated dry soil, or a slope, if 
possible, witli a southerly exposure. 


Part VIII 


C'est dans le pouvoir liuiiiaiu de faire disparaitre du iiioiide tons 
les maladies parasitaires. 



Let lis go nut into the sunshine. — D'Axnuxcio. 

Tent-life assures the maximum of fresh air and sunshine ; and, 
because of its comparative cheapness, is more available for the 
vast majority of consumptives than permanent and more soUd 
structures, particularly as tlie latter are at present very few and have 
hopelessly inadequate accommodations for these sufferers. Besides, 
it has been found that many patients really do better in tents than in 
the wards of buildings. Those who keep their fever while sleeping 
indoors are prone to be without it when the night as well as the day 
is spent in the open air. 

I can here but outline the features of some among the many 
excellent devices for the outdoor treatment of consumption, referring 
the reader to Appendix E for details of construction and cost. 

Tent-life is the method which will first be pursued by communities 
to segregate their consumptive poor and afford them rational and en- 
lightened treatment, or for charitable associations having tliese ends 
in view.^ 

If possible, when many patients are to be taken care of, there 
should be a central administration building for dining, etc., and for 
the housing of advanced cases, which would be in the midst of a tent 

In tent construction certain things have always to be kept in view. 
The ordinary rain-proof canvas tent is also air-proof, — so that sides, 
ends, and roof must be kept open, except when rain or snow or 
heavy winds have to be excluded. " The tent without special care 
may become a hindrance instead of a help in the treatment of tuber- 
culosis." In the winter months there should, if possible, be some 

^For the 30.000 consumptives in New York City there are availahle at present 
less than 2000 hospital or sanatorium heels ; for the 22,000 of the State there are 
but 193 beds. " Since of this total of 193 beds, 118 are for local use only, in Buf- 
falo, Rochester, and Westchester County, for the estimated 18,250 State cases out- 
side of these three places, there were available 75 beds, or one bed for every 244 
cases." — (From the Charity Organization Society's invaluable pamphlet on "City 
and Country Care of Consumptives. Some Methods of Housing.") 




means of heating the tent while the patient is rising and retiring for 
the night. The patient's eyes should be protected from the glare of 

Fig. 44.— Tent-life at .Saranac Lake, New York. 

light, which is a drawback of some tents. Good ventilation is es- 
sential ; otherwise the tent is ai)t to become damp and cold in inclem- 
ent weatlier. 

Fig. 45.— Tent at Country Bnineh of the Rush Hospital for Con.sumptives, Philadelphia. 

Professor Fisher, of Yale, became coiisuiii])tive : and. not wishini. 
to leave his work, he devised a tent lor his own home use (Fig. 46. 



The neighbors thought him non compos for living in this tent. However, 
he got well, after which he presented his device to the State of Maryland, 
stipulating only that it should be used in the treatment of a like suf- 
ferer. Its floor is ten by four- 
teen feet and its walls are eight 
feet high under the eaves, from 
which rises a pitched roof to a 
central cupola. It is raised a 
yard above the ground, and is 
provided with a very ingenious 
system of ventilation. ' 

The tent constructed by Dr. 
C. F. Gardiner is very exten- 
sively used in Western sana- 
toria. It is a modification of the 
Sibley Army tent, and is of a 
conical shape, the walls being 
arranged to unlace and turn 
back for airing, with vertical 
sides rising four feet above the 
ground. The board floor has 
an air «pace beneath, and air 
inlets protected by hinged doors 
so as to be opened or closed as 
desired. There is a ventilator 

at the apex of the cone. All of the openings may be closed to heat 
temporarily the tent for rising or retiring. There is a sheet iron cyl- 
indrical stove, the pipe of which is carried above the top into the air. 
This tent has neither centre-pole, pegs, nor guy-ropes, and stands quite 
firm like a house. It is " not an experiment, but has been used now 
some six or seven years in various parts of the country, and found to 
be practical and efficient in the treatment of tubercular cases, its main 
feature being the automatic supply of outdoor air, with a ]jroper de- 
gree of warmth to insure comfort in cold weather." 

The Tucker tent (Figs. 48 and 49) is an individual structure used 
at the Association Health Farms of the Denver Young Men's Christian 
Association. Its ventilating features are excellent. Its cost is from 
seventy-five to one hundred dollars. 

The tent devised by Dr. H. L. Ulrich is a simi:)le and serviceable 
structure •• within the reach of the poor man's purse and intelli- 
gence'' and which may be put ujj in any yard or empty, unused lot. 
Its cost is about tweiitv dollars. 

Fig. 46— Prof. Fisher's tent. 



The sloeping-box devised by Dr. Millet, of Bridgewater, Mass., is a 
one-story structure, erected some distance above the ground. The 
entrance is through a door at one side, reached by a stairway. There 
is a large window on either side. The south end is open, closed only 
when necessary by a pulley-drawn curtain. The back of the box to 
the north is closed by two pairs of heavy wooden shutters swinging 
horizontally, the lower lialf of each pair hinged at the bottom and the 
upper hinged at the top so that this end can also be thrown completely 

An Adirondack tent-honse is described by Dr. Hermann M. Biggs. 
It is a simple, serviceable model, which can be used by three or four 
inmates during most of the year with perfect comfort. Its cost would 
be from one hundred and fifty to two hundred dollars ; it is well- 
ventilated, and can be comfortably warmed in moderately cold weather 
by means of oil-stoves. 


At Muskoka there is a type of frame cottage witli shingled roof and 
board floor, the walls being either board or canvas. A porch is built 
on the south side, practically all of which can be thrown open. The 
upper part of the interior is ventilated by means of small windows 
under the eaves. A ventilator opens from the roof. The room is 
heated by a small stove and lighted by electricity from the central 

The pavilion-tent, or the tent-cottage, a device of Dr. Holmes, of 
Denver, Col., is used in the Metropolitan Hos|)ital on Blackwell's Island, 
New York. Twelve of these structures, accommodating one hundred 



and forty-two patients, are an important featnre of the institution's 
treatment. Various devices and improvements liave made them " prac- 
tically storm-proof and as comfortable in stormy weather as an ordi- 
nary building.'" A double circuit of steam-})ipes around the side of 
the tent insures warmth in winter ; in three of the more exposed of 
these tents stoves have been placed for additional heating. 

The temperature in 
these tents ranged be- 
tween 20° and 30° F. 
most of the winter during 
both day and night. The 
women have live d in 
them at tliis temperature 
throughout the winter, 
improving in health and 
e n j o y i n g themselves. 
They were not compelled 
to sleep in these tents ; 
there were always empty 
beds in the wards, and on 
several of the coldest 
nights a few of them went 
inside, but the majority preferred to remain outside, and said so fre- 
quently. They were, of course, warndy dressed, having heavy flannel 
petticoats, mittens, hoods cover- 
ing the head and neck, and were 
abundantly supplied with 
shawls, steamer-rugs and 
blankets. We shall see that 
these experiences are duplicated 
in the tuberculosis camp on 
Ward's Island. 

Dr. H. B. Masten provides 
an ingenious arrangement for a 
tent sanatorium. The dimen- 
sions of the cottages are twelve 
by nine and a half feet with a 

height of ten feet. The side walls are built five feet from tlie ground 
with lumber and heavy building paper. The remainder of the frame 
is covered with twelve-ounce canvas. The door opening on the 
veranda has a large glass panel in its upper half. Above the veranda 
roof each cottage should have a transom, and this, together with a 

Fig. 48.— The Tucker tent. 

Fig. 49.— The Tucker tent. (Interior.) 



hinged window in the near wall, is always to be left open except 
when the patient is at toilet. This will provide plenty of ventilation, 
as it is difficult to make the air of a tent impure. The floors should 

1 to 12. Tent Cottages. 

13. Bath Houses. 

A. and B. Ends of Veranda enclosed in glass. 

C. Chimney and Ventilaling Shaft. 

D. Canvas Curtains. 

Fig. .50— Dr. H. B. Masten's tents. 

be double, of hard pine, with a layer of paper between, and kept 
polished with a mixture of paraffin and turpentine. This prevents 
splintering and avoids all cracks, affording no place for the lodgement 
of germs. The interior should be painted in a soft green shade. The 

Fifj. .SI— A Dncker tent-house. 

furniture should consist of a single bed, dresser, mirror, two chairs, 
and a small table with a glass or marble top. Each cottage should 
have an electric bell connected with the main office. The bath-house 
should be built of brick, with hard-linished walls painted green. 


The front half should consist of a wrilmg-rooiu, and the rear slionld 
contain the bath and dressing-rooms, together with various kinds 
of baths. The dressing-room should contain three lavatories, one to 
be used only for cleansing the teeth. 

The sewage and the water from the bath-rooms is conduclcd to 
water-tight tanks, and the water disposed of by subsoil irrigation. 
The residue from the tanks is spread on the ground in the sun at a 
considerable distance from the building. 

The Ducker Company, of New York City, have in answer to my 
request kindly sent me this picture, which is of a building seventeen by 
thirty-three feet. Twelve patients can be comfortably accommodated. 
The lower half of its sections is covered with wood clap-boards, and the 
u[)per half, including the gables, with canvas. Over the canvas roof, 
in which there are ventilators, is a large canvas fly. There are regis- 
ters in the floor admitting a free circulation of air which passes out 
througli the roof without draught. The windows on the sides and 
ends fall down into the casements below and the canvas awnings can 
be raised at any time, making the whole interior " like out of doors." 
The cost of the building approximates $750. 

A very interesting structure is the outdoor shelter, or " pavilion," 
which can be turned so that the sun rays may be enjoyed for as many 
hours as possible, and rain, snow, or cold wind may be warded ofT. 

Dr. P e 1 1 e g r i n and Architect 
Petit, of Paris, have indeed de- •* .^' 

signed houses erected on rotating i 

platforms which can be made to 
face in any direction. The platform 
is supported b y t w o concentric 
walls, and the axis of rotation is 
occupied by a shaft through wdiich 
pass the water-pipes. A gas-engine 
moves the platform, which may be 
harnessed to clock-work. The 
latter may be so arranged as to 
enable the house-front to follow fig. 52-Revoiving shelter. (Hiiuer.) 

the sun during the day. 

My good friend. Dr. Peters, is a genius who has gone into the 
practice of medicine. He has discerned the possibilities of '' super- 
annuated trolley-cars for consumptives." Pine Ridge Camp, near l^rovi- 
dence, Rhode Island, of wiiich he is the superintendent, was estab- 
lished in 1903. There was, to begin with, an administration building, 
dhiing-room and kitchen, several cabins, twenty tents, and trolley- 



cars. The cosl of the eiifire plant was two thousand five hundred 
dollars. Patients paid something — as they could, from one dollar a 

Fig. 5.S-0)(i streetcars as living quarters for the consumptive. Pine Ridge Camp, 
Rhode Island. (Courtesy of Dr. W. H. Peters.) 

week — for their maintenance. The cost of the institution per capita 
has been four dollars and fifty cents a week. The deficiency was 
made up by the contributions of citizens. 

Fig. .M— Interior of old lean-to. Sleeping quart^ers, Loomi.s Sanatorium Annex. 

Trolley-cars that had outlived their usefulness were used as an 
experiment. The bodies of the cars, which were in excellent condi- 



tion, were taken from tlieir trucks and set up on a I'oundation 
eighteen inches from ilie ground, each being furnislied with a cot-bed, 
stove, table, and chairs. The i)atients are tlius made very com- 
fortable. The trolley-car is the consumijtive's ideal sleeping pavilion, 
capable of perfect ventilation, and gleaning all the sunshine that is 
going. It is claimed to be far ahead of the average cabin or shack, 
and the cost is much less. These cars arc very lieavy. They are 
finished in hard-Avood, with windows and door-frames made to 
stand the severest weather. Double-walled cabins or shacks, accom- 
modating two patients, approximate one hundred and fifty dollars in 
cost. Dr. Peters found the average cost of discarded cars to be 

Fig. 55.— a mountain home. (Journal of the Outdoor Life, Trudoan, New York.) 

twenty-five dollars, and no doubt many companies would be glad to 
donate their unused cars to so worthy a charity as a consumptive 
home. This the Providence Traction Company has done for the 
Pine Ridge Camp. 

The " lean-to" (Fig. 54) is developed from the idea that patients 
not only do well by being all day out of doors, but that they do even 
better by being practically out of doors throughout the twenty-four 
hours. Dr. King, the physician-in-cliief at the Loomis Sanatorium, 
Liberty, New York, " havhig in mind the old-time Adirondack ' lean- 
to camp, built of a frame-work of poles covered with bark, provided 
the carpenter of the sanatoriun) with a rough sketch from which, with- 
out further instruction, he built a shed with an overhanging roof, open 



in front, with tlie ends so constructed tliat they can be opened or 
closed as occasion demands." In Appendix E is described succinctly 
the manner in which this •' lean-to" has been developed out of the 
orljiiiial idea, the successive improvements upon it, and the cost of this 
admirable structure. Dr. Iving believes that this plan meets the re- 
quirements for open-air cure more completely and satisfactorily than 
most others (including tents). 

At l^ake Placid, in the Adirondacks, an experimental camp has been 
planned on three sides of a hollow square fronting a camp-fire, with 
chimney and fireplace in the covered portion directly opposite the 
camp-fire (Fig. 55). The main roof is raised two feet above the roofs 

Fig. 56— Nathan cottage, Adirondack Cottage Sanatorium. 

of the sleeping-rooms, allowing free passage of smoke when the wind 
blows from the camp-fire. This raised roof covers only the open 
s{)ace in the middle of the building, the roofs of the sleeping-rooms 
being tight. Tlie structure is, in fact, a liouse with one side left off. 
This experimental camp accommodates six persons, each having his 
own room (twelve could be acconmiodated in an emergency), to cost 
one thousand two hundred dollars, with but three hundred and fifty 
dollars extra for e(iui})ment. This would make the cost per head a 
little over two hundred dollars. The patients are in the open air all 
the time, but sheltered from storms. Small enclosed brick buildings 
could be used for those remaining all winter in the woods. It is con- 
sidered that a State tuberculosis camp for poor patients upon this 


plan would be cheaper and better than that of brick or stone sana- 
toria ; the sum required for the latter would provide for five times as 
many patients during at least six months of the year. The 'u\vd is 
to have open camps, in suitable localities, grouped around central 

The cottage which Mr. Max Nathan has generously had erected is 
an admirable type of the single permanent building in wliich a few 
patients may Hve. The newest of its sort in the Adirondack Cottage 
Sanatorium, its cost was in all about live thousand six hundred dol- 
lars. Messrs. Scopes and Feustman were the architects. 

The handbook of the Charity Organization Society contains an 
excellent plan for a municipal sanatorium, providing for pavilions, 
central buildings, and one hundred and twelve tents, wdiich are to be 
arranged in streets, with wide spaces. 



To formulate the objects of such a dispensary my own experience and thought 
would suggest the following : 

(1) As complete an investigation of the patient as possible, including history, 
physical and bacteriological examination, and, when the diagnosis is doubtful, the 
tuberculin test and an X-ray examination. 

(2) Investigation of the patient and his surroundings at his home, including 
the hygienic condition of his domicile. 

(3) Instruction both of the patient and his household in personal and dom- 
iciliary hygiene, and the safe disposal of the sputum. 

(4) The free supply to poor patients of pocket- and house-spittoons. 

(5) Securing entrance into sanatoriums for curable cases, and into consump- 
tives' hospitals for incurable ones when they cannot be properly treated at home : 
or, when neither is possil)le, to treat the patient at his home as well as the condi- 
tions will permit. 

(6) Aiding poor patients to oiitain suitable food and other articles necessary 
for their proper care. 

(7) Affording opportunity to physicians to send their poor ])atients for diagnosis 
when desired, as well as advice and assistance in treatment. 

(8) The examination and oversight of patients who have returned from sana- 

(9) Opportunity for the scientific investigation and study of tuberculosis and 
various methods of treatment. 

(10) Clinical instruction to students and physicians in the examination of 
tuberculous patients. — Otis. 

In a recent symposium in the Medical Section of the NeAv York 
Academy of Medicine the work done in the chnics of the New York 
Health Department and of the New York Nose and Throat Hospital, 
in the Gouverneur and Vanderbiit dispensaries and at Bellevue, was 
set forth by Dr. Knopf, Dr. Barton, and others. All these stations 
were established (none earlier than the fall of 1903) exclusively for 
the purpose of treating poor consumptives and of preventing the 
spread of the disease among their intimates. 

The treatment in these stations has for its essentials : The instruc- 
tion of the patient concerning the disposition of the infective agency ; 
and the assuring of the patient, so far as is })ossible, the benefits of 
rest, sunshine, and good food. The work done by the physicians and 
nurses in the dispensaries is supplemented by visiting nurses, who 
visit the patients' homes, further acquaint them with the nature of tlie 




disease and its infectious or conimunicable character, and explain the 
simple methods by which infection in the home is to be avoided. And 
elementary rules and advice, printed in various languages, are provided 
in the dispensaries and distributed by the visiting nurses, for the pa- 
tients' better understanding of the situation. 

In connection with the work of these institutions four propositions 
are worthy to be reflected upon : 

1. Consumption is pre-eminently a disease of humanity's sub- 
merged strata. This is a fact, as patent as any in the history of man- 

2. Consumption is contracted mostly by those suffering from/ 
malnutrition and starvation. As details (yet very important ones to > 
an appreciation of the situation) one should note the indigestible qual- 
ity of the food as commonly prepared and cooked by the wives of 
poor workingmen, with consequent excessive fermentation and devel- 
opment of toxhis. There is here provided ideal pabulum upon which 

Fig. 57.— The Health Department of New York City. Clinic for treatment of communicable 
pulmonary diseases. (Courtesy of Dr. Knopf and Messrs. Wm. Wood & Co. ) 

the bacillus and its allied micro-organisms may nourish themselves and 
multiply. This bad cooking is, incidentally, as potent a factor as any 
other in driving men to drink; and if the W. C. T. U. would take it 
upon themselves, in place of at least one among their already multitudi- 
nous activities, to teach their sisters how to cook, there would be less 
occasion to blame men for becoming drunkards. The chaotic indul- 
gence of the appetites and the exhaustion resulting from excessive 
sexuality among the wretchedly poor are also factors which must be 
considered ; we must not here forget Malthus. 

3. The communicability of tuberculosis depends almost entirely 
upon the house. And such is certainly the case when the house is 
dark, dirty and germ-inviting, unventilated, with damp walls, inade- 
quate drainage, and horrible plumbing conditions. 

4. In 98 per cent, of all cases of consumption home treatment 
must be depended upon (Osier). The sanatorium treatment is ideal, 



but for obvious reasons it cannot and probably never can be utilized 
generally in the cure of the consumptive. 

In view of such considerations as these, it is likely that the work 
described in this symposium will be found epoch-making in the light 
against the gn^at white plague. 

These institutions should be maintained in all large cities. In 
order to assure their thorough efficiency they should not be parts of 
general dispensaries, but should be devoted only to this disease. 

With a view to presenting aspects as ideal as may be of a tuber- 
culosis dispensary. I review at length Knopfs paper, read at this 
meeting, upon the " Clinic for Pulmonary Conmiunicable Diseases of 
the Health Department of the City of New York" (Fig. 57). This is a 
one-story structure composed of a registration-room, a drug-room, 
a waiting-room for women, one for men, two dressing-rooms for 
patients, two examination-rooms, an X-ray-room, a laryngological- 
room, a dressing-room for nurses and one for doctors, and toilet facili- 
ties for patients and employees. Throughout this building, which is 
situated at Fifty-fifth Street and Sixth Avenue, there are tiled floors, 
all corners being rounded off. and all the rooms light and well-venti- 
lated. A pneumatic cabinet is in course of construction, and no doubt 
a hydrotherapeutic installation will be forthcoming. All the furniture 
— desks, tables, benches, chairs, stools, closets, etc. — is made of wdiite 
enameled iron, easily cleaned and disinfected. The desks and tables 
are covered with plate-glass. 

The objects of this clinic are : Early recognition and diagnosis of 
cases of pulmonary tuberculosis ; the care of patients applying for 
treatment ; the attention and observation at their homes of the in- 
digent needy and ambulatory cases, including those under the care of 
charitable organizations and all those discharged from the public in- 
stitutions of the city ; the removal to a sanatorium or a hospital of 
cases requiring such care ; the provision of a " clearing-house" to 
which all cases of tuberculosis may be referred : and the extension 
and strengthening of the sanitary control of tuberculosis among the 
poor by the Department of Health. 

In order to furnish the patient with information concerning his 
mode of life, his duty towards himself, to his immediate environment, 
to the physician, and to the public in general. Dr. Knopf prepared for 
the Clinic's patients a table of instructions, among which are the fol- 
lowing : " Be hopeful and cheerful, for your disease can be cured, 
although it may take some time. You may improve steadily for 
months and lose it all by carelessness. Report to the Clinic when 
directed. Report immediately if you have fever, intestinal trouble, 



diarrhoea, constipation, pain, increased couf.'-h, or reddish expectoration. 
If you are too ill to come to the Clinic, send word. If you arc in doubt 
about any matter concerning your method or mode of living-, ask your 
doctor. Your cure depends upon obeying all instructions faithfully." 
These instructions are translated into (German, Italian, Hebrew, and 
later will be translated into Bohemian, Russian, and probably into 

This Clinic was formally opened March 1, 1904, since which 
time, up to May 15, 1905, seven hundred and ninety-four patients, of 
whom five hundred and sixty-five were males, have applied for 
diagnosis and treatment. The total number of visits by ambulatory 
patients average thirty-three a day. Of the seven hundred and ninety- 
four patients the first sputum examination revealed the presence of 
the bacilli in one hundred and fifty-five cases ; in three hundred and 
thirty-one the first examination of the sputum was negative, but the 
symptoms and physical signs were evident enough to make the diag- 
nosis positive : seventy-two patients were referred to sanatoria or 
special tuberculosis hospitals ; one hundred and sixty-four w^ere re- 
ferred back to their private physicians or to general dispensaries as non- 

We observe from these figures that it is not safe to rely upon bac- 
teriological examination alone, or to wait for the inauguration of treat- 
ment until the bacilli are found. Again, a social factor is revealed in 
the statement that sixty-eight patients gave wrong addresses, of whom 
fifty-five w^ere positively diagnosed as suffering fi'om pulmonary tuber- 
culosis. Among the reasons wliich may have prompted these appli- 
cants, no doubt the most frequent w'as that they did not wish their 
neighbors, friends, or boarding-house keepers to know that they were 
suffering from consumption. 

Among the other papers read in this symposium was that of Dr. J. 
A. Miller, who described the dispensary treatment at Bellevue Hospital. 
The patients were carefully examined, — the temperature, pulse, respi- 
ration, chest measurements, and weight having been taken. If they 
were found consumptive the name and address were taken and given 
the nurse for visitation : and the sputum was sent to the Health Board 
for inspection. Printed circulars and other information and instruction 
were given them, and the diet dwelt upon. Milk and eggs were pro- 
vided if applicants were too poor to buy them. Pocket sputum boxes 
were given the patients, who were to return once a week for treat- 
ment. A thorough investigation of home conditions was made and 

^Appendix G. 


reported by a special nurse, who tried to arrange the whole domestic 
economy of the patient and to demonstrate practical disinfection. 
Proper education of the patient and of his family with regard to 
hygiene and the prevention of the spread of the infection was attempted, 
and circulars of information were given. A study of the social and 
economic conditions as obtained in each case was made, and upon 
this was based the management of each case. Milk and eggs were 
provided from the hospital store. Tents and cottages w^ere placed 
upon the hospital grounds, and the institution kept in close touch with 
sanatoria and charitable organizations, such as the Charity Organiza- 
tion Society. During seven months there were one hundred and sixty- 
six cases. The nurses made four hundred and eleven visits to their 

Dr. J. L. Barton, of the Throat, Nose, and Lung Hospital, considered 
that patients in tlie incipient stage, and those whose vitality was not 
utterly exhausted, not only improved, but got well; that organized 
clinics with trained district nurses will do more to eradicate the dis- 
ease than can be done in any other way ; that hospitals should be 
provided for those having no means ; that advanced cases are likely 
to be centres of infection ; that the greatest cause of the spread of 
tuberculosis was malnutrition. 

Dr. John Huddleston considered that since the inception of the 
dispensary treatment in New York City more than five thousand 
consmnptives were believed to be under control, and these people, 
properly treated and instructed, were being made centres of instruc- 
tion rather than of infection. 

Though a part of the general dispensary of the Presbyterian Hos- 
pital in New York City, the tuberculosis work instituted by Dr. 
Shively in its heart and lung clinic is perhaps the first in that city 
upon modern lines. 

The dispensary of the Post-Graduate Hospital in New York City 
has some unique features. It is in charge of Dr. Russell, who accepts 
for treatment adults in any stage, provided the disease is uncomplicated 
and that the patients are able to report twice a day and secure at the 
dispensary suitable food, clothing, and shelter. An emulsilied mixed 
fat is dispensed. The hours are arranged in the evening for the con- 
venience of working men and women. Irregularity of attendance or 
failure to obey directions is followed by dismissal. There is a session 
on Sunday mornings at nine. 

The iirst dispensary for the exclusive treatment of consumption 
was inaugurated, it seems, by Dr. Cahnette, — the Emile Roux Dispen- 
sary, in Lille, France. '' The Germans," states Knopf, " came next with 


their Polyklinik fiir Lungenkranke." In Edinburgli there is a flourish- 
ing institution, established through the efforts of Dr. R. W. Phillips. 
Throughout Europe, and in some South American republics, there are 
dispensaries for the treatment of tuberculosis, hi Havana there is an 
excellent dispensary, established by the medical department of the 
United States Army for the treatment exclusively of tuberculosis. In 
many American cities — Boston, Baltimore, Philadelphia, New Haven, 
Scranton, Minneapolis, Chicago, Worcester, Providence, and in Canada 
— admirable work of this sort is being done hi behalf of poor consump- 
tives. The trustees of the Western Reserve University, in Cleveland, 
Ohio, claim the honor of having established the second antitubercuiar 
dispensary in the United States. Co-operating with the medical 
faculty in this work are the Association of Nurses and the Associated 
Charities of Cleveland. The question of a dispensary in connection 
with the work of the Canadian League for the Prevention of Tuber- 
culosis is being, agitated in Montreal. 

The Henry Phipps benefaction has its dispensary in the heart of 
Philadelphia. It was established despite great opposition, the fear 
behig that the inhabitants of the city might become infected by reason 
of its proximity. In 1899 a law was passed forbidding the erection 
of hospitals or homes for patients with contagious diseases in the 
built-up portions of cities. But Dr. Flick succeeded in having it 
amended to admit of the construction of the institution which Mr. 
Phipps's gift made possible. Flick well said : " The prejudice against 
having a hospital in the midst of a city is foolish. Such an institution 
is a safeguard to a community, not a menace." I for my part think 
such a prejudice is much worse than foolish among a people who are 
alleged to live in conformity with Christian principles.^ 

^For the invaluable rules for the patients of this dispensary, see Appendix G. 



It', tliiMi, those who are engaged in this most gracious ministry — the care of the 
sick — adtl to their healing art some knowledge and some enthusiasm for the science 
of philanthropy, which, after all, no less than the science of medicine, underlies 
their art, they will surely exert what will be very nearly a preponderating influence 
in the relief of distress, and in that larger, more attractive undertaking, of which 
we are becoming dimly conscious, — the working out of a better social order, in 
which there shall be less of sickness ; less of suffering ; less of premature decay 
and death, — more of healthy living ; of wholesome, rational enjoyment of life. — 

It is to Miss Lillian Wald that New York City is indebted for ttie 
inception of its plan of district nursing wliich now obtains. 

Soon after tliis lady's self-a])pointed work as a nurse began she 
came into contact with some of the dreary hardships of East Side hfe. 
She studied certain seemingly irremediable ills, until she was fully 
convinced that many of them could be prevented by some prac- 
ticable method of bettering general conditions. Realizing that a 
thorough knowledge of existing conditions was the first step to this 
result, she determined to live among the people whose needs were so 
great and so little recognized.^ Being joined by Miss Brewster, they 
spent together two months at the college settlement in Rivington 
Street. Here they worked and planned with an energy so tireless 
and an enthusiasm so vital that other earnest women began to gather 
around them. At first these two were able to cover nearly the whole 
area on the East Side, now divided into many districts. By degrees 
the great efficiency and the spirit of neighborliness which they dis- 
played began to be realized and appreciated, and from branch to 
branch of a family, from friend to friend, from house to house, from 
street to street, the knowledge and confidence spread; and the calls 
for them increased until they had to invoke the services of coworkers. 
So that to-day the field of their activity covers nearly the whole 

Miss Wald is now head-worker of the nurses' settlement, which 
has its headquarters on Henry Street. The varied and tremendously 
out-reaching phases that have "sprung up in response to needs of all 
kinds cannot be here described. The department of district nursing, 
which is under the charge of Miss Hitchcock, alone would require a 

^ Boulelle. 


long article for its description. A district nurse must undergo a pro- 
bation, during which, besides technical skill acquired at the hospital, 
her qualifications essential to this special work are gauged. She must 
be heartily in earnest ; free from hysterical enthusiasm, such as is a\)i 
to be short-lived ; tactful, firm, patient and courage-compelling. If she 
be qualified she may enter upon her duties as soon as there is a 
vacant place for her to fill. The reason that she is not at once em- 
ployed is that new districts cannot be added until the very modest 
salaries of the nurses assigned to them can be paid. There is no 
general endowment fund. The compensation is forthcoming through 
some individual or society sensible of these services to the community. 

A catholicity of spirit is strikingly attested in the list of supporters. 
The Society of Ethical Culture, the United Hebrew Societies, the Pres- 
byterian Church, and many other organizations supply these nurses, 
and the recognition of this broadness of view is shown in the confi- 
dence of all physicians in touch with this work. Miss Wald and her 
colleagues have the cordial co-operation of the hospitals and of the 
Health Department. The steadily growing trust and affection of the 
people themselves may be realized when we read in the report of 
1903 that one thousand seven hundred and four patients were treated 
at their own request or that of their friends ; one thousand five hundred 
and sixty-three more were reported by physicians of the neighborhood ; 
six hundred and twenty-seven by charity agents ; and one hundred 
and twenty-seven by the Health Department. Thirty-one thousand 
five hundred and sixty-eight visits were made, exclusive of two thou- 
sand seven hundred and seventy-six friendly calls upon patients. 

In every household the nurse makes her efforts felt in visible manual 
service, such as dressing wounds, cleansing utensils, and kindly assist- 
ance. Whatever she does, she does not only in the way that is most 
simple and effectual, but she shows how it is done. To slovenly 
households she proves that cleanliness and order are conducive to cheer 
as well as health. To homes where extreme poverty has not been 
able to drive out instinctive neatness she brings methods that save the 
time and strength of the homemaker, and in many families with a 
modest competency she brings great relief to worn mothers, who see 
with almost incredulous gladness that the children they were so loath 
to trust to any one's care but their own are receiving such relief as 
they themselves would have proved powerless to give. 

Miss Wald evidences the advantages to the sick of the co-operation 
of the district nurses with various charitable societies : " Relief may 
come from various sources, and can be secured through the nurse or 
visitor without unpleasant effect. 1 have known frequently a sick 


person receive milk from the New England Diet Kitchen, ice from a 
fund, groceries from a society, bedding from the settlement, physician 
and supplies from the dispensary, cot and delicacies from a neighbor- 
ing club, and flowers from a guild, — all summoned by the district nurse 
and not differing, except in degree, from care received by the well-to-do.'" 

Tliere are now many district and visiting nurses' associations in 
this country, — in at least fifty-three American cities ; this does not in- 
clude nurses engaged by individuals, or nurses who are on their 
own account devoting themselves to the visitation of consumptives in 
their liomes. Miss Grace Forman, of the Vanderbilt Clinic, New York 
City, has done excellent work, as has Miss Jean Hopkins, of the 
Bellevue Clinic, and Miss Reba Thelin, visiting nurse of the Johns 
Hopkins Dispensary. A society of professional and charitable men 
and women is doing notewerthy work in Chicago. In Boston the 
district nurses co-operate with the Board of Health. A national 
society or federation of district nurses will no doubt be forthcoming to 
consolidate and make more efficient this excellent work. London has 
its training home for district nurses, who do splendid work, and this 
is so, no doubt, in other European cities. 

Miss Nutting, of Johns Hopkins Hospital, has presented a number 
of valuable data, which she has collected after communicating 
with some twenty-five societies. The cost of treating tuberculous 
patients in their homes and in hospitals is compared. It costs not less 
than one dollar a day to care for one patient in a hospital ; generally 
it is up to two dollars and over. One patient so treated would there- 
fore cost to maintain from four to six hundred dollars. Hospitals reach 
the consumptive few, nurses the consumptive many, and " if we have 
any hope of reaching even a moderate proportion of the 98 per cent, 
of tuberculous patients who, Dr. Osier says, must be treated in their 
homes, the provision of a sufficient staff of nurses in each city, spe- 
cially devoted to this particular work, would seem to be a necessary 
initial step.'' 

To the homes of consumptive patients milk (the best to be had), 
from one to two and a half quarts daily, and eggs, from four to eighteen 
within the twenty-four hours, are sent, according to the patient's con- 
dition. To these staples meat, fruit, and other articles are occasionally 
added. These needs are largely met through diet kitchens, relief 
societies and benevolent people. It is hoped that students of domestic 
science will become interested in placing within the homes of the poor 
simple facilities and easily comprehended instructions how to live and 
how to prepare plain, healthful, cheap food. An extremely important 
feature of the visiting nurses' work in Boston is the reporting by the 


nurses who visit obstetric ])atients and report to the district doctor any 
symptoms suggestive of tuberculosis in an expectant mother. She is 
examined, and arrangements are, if necessary, made to put the baby 
at once upon modified miliv. 

Without variation the news comes from every nurse and every 
society that " the patients are nearly always in an advanced stage be- 
fore we are brought to them. Here much relief and comfort can be 
Jjrought ; improvement or cure is rarely to be expected. Much can, 
however, be done beyond tlie actual alleviation of the condition, work 
so dear to the heart of the nurse, the achievement of which has been 
for so many ages her sole thought." Even though the patient may not 
be saved, the rest of the family may be safeguarded from further 
danger of infection. The nurse, above all, is an educator, — a con- 
sideration of fundamental value to the community. 

Edward T. Devine, Esq., groups visiting nurses into four classes, — 
the nurse : the instructive nurse ; the incidental nurse ; the pseudo- 

The nurse takes definite professional responsibility for cases of 
sickness, just as do private nurses engaged for family work. 

The instructive nurse may do any or all of this and necessarily 
does some of them ; but she is primarily nursing the family rattier 
than the patient. It is an essential part of her work, not so much to 
care directly for the patient, but to show other members of the family, 
or neighbors, or the patient himself, how to do this. The teaching of 
sanitation and cleanliness is her strong point. 

The incidental nurse is a trained nurse who is, however, engaged 
in tasks of various kinds, for which the training and experience of a 
nurse are a valuable preparation. She may be the matron of an in- 
stitution, or a visitor of a charitable society, or a missionary, or a 
settlement worker. She makes incidental use of her equipment as a 
trained nurse. Herein she has great advantage over others who have 
not had the same or some similar training. 

The pseudo-nurse is one who, although appearing in the guise of a 
nurse, and securing entrance to the home because she is a nurse, never- 
theless is, primarily, a missionary bent on conversions to her own par- 
ticular creed ; or a settlement worker out for the purpose of drumming 
up recruits for a social club or an educational class ; or tlie investigator 
of a charitable society seeking facts in regard to the alleged distress of 
the family ; or, in short anything else than what she appears to be. 
" For the instructive nurse, and for the incidental nurse, we may have 
entire respect and regard, for both make it perfectly evident upon what 
particular errand they have come. But the pseudo-nurse— who is the 


nurse only in order to receive admission : only in order to gain con- 
fidence : only in order to establish an influence with the family — stands 
upon a somewhat less reputable footing." This is unquestionable 
and very true. 

I saw at tlie Baltimore Exposition a visiting nurse's kit, — a bag 
containing scissors, forceps, and artery clamps, bichloride tablets, 
green soap, nail brush, a hypodermic syringe, a thermometer, safety 
pins, matches, a sputum cup, paper napkins, a medicine glass, a drink- 
ing cup, a chart, and circulars for the instruction of consumptives. 

From time to time we hear of nurses — it must be evident from the 
reading of this section that there are few — who will not take cases of 
consumption, being fearful of the disease. For those among the laity 
who are afraid, or selfish, setting a preposterous and inordinate value 
upon their own existences, we have only sentiments of amusement and 
scorn. But the nurse is like the soldier. When the latter lacks courage 
lie is lit only for hanging — not deserving even the honor to be shot. The 
work of the nurse is not a business ; it is a profession, a consecration. 
However, to the vast army of the unafraid among nurses, it must be 
evident that the danger from visiting consumptives is not great, and 
is easily avoidable. It is essential that the nurse preserve her health, 
her strength, and her powers of resisting infection. She must have 
pure air, good food, and wholesome exercise. She would do well, if 
she sweeps and dusts the rooms of consumptives, to use an aspirator 
(the Fraenkel contrivance, for instance), or several thicknesses of 
sterilized gauze. To be constantly close to the patient is unwise ; the 
breath alone is very rarely dangerous ; but the fine droplets of sputum 
and the coughing may be. If she have a " cold," or has had pneumonia, 
or grippe, or pleurisy, or any enervating disease, she should give up 
caring for the consumptive, transferring her work to a vigorous 
professional sister. 

While attempting to give the work of the trained nurse its just due, 
let MS not forget the beautifully self-abnegating, if not strictly scientific, 
work which has been done and is, I hope, still being done by the Sal- 
vation Army. The disruption in this organization robbed it, I fear, of 
much of its beneficent influence ; and if my fear is justified, it is cer- 
tainly a calamity for civilization. There does not begin to be space 
enough in this book for a just estimate of this work. I set forth but 
a detail : 

Two Salvation Army '• lassies" would hire a dirty two-roomed 
apartment in the slummiest of tenements. They would at once set to 
w^ork scrubbing its floors, banishing its cobwebs and its soot, white- 
washing its walls, — making it a model of decent, homely cleanliness. 


Then, at a cost of a few dollars, they would put in a small stove, a 
clean bed, a rough table, two or throe chairs, and a few cheap kitclien 
and other household utensils. The women of that tenement would 
visit them after their neighborly fashion. The lassies would then 
waste no time expounding the genealogy of King David, or turning 
the thoughts of their visitors to higher, nobler things, but would 
rather show them practically how much of life's necessities they could 
buy for a dollar. They would teach them how to cook decently for 
their husbands. Above all, they would put heart into them. I am 
fond of imagining the poor Nazarene going unseen with these lassies 
in their work among these, His owm people. 



In ono of the last letters that he ever wrote, suffering and almost dying himself, 
Robert Lonis Stevenson said : 

' ' I have been getting some of the buffets of late ; but have amply earned them — 
you need not pity me. Pity sick children." 

The French Government has demonstrated a very deep and 
rational understanding of some of its domestic problems. For instance, 
it lias nobly undertaken, on a splendid scale, the care of the tubercu- 
lous or scrofulous children of its people, for whom it has established 
in various parts of France large and excellently equipped hospitals. 
Several of these institutions are on the sea-coast ; and there these puny 
sufferers are assured the benefit of the sea-air and of ozone ; lots of sun- 
shine, plenty of pure food-stuffs, — bread, meat, milk, and eggs ; careful 
nursing ; and altogether adecjuate medical care of their " white-swell- 
ings" of the joints, tuberculous affections of bones, and of the many 
other conditions requiring the physician's attention. Thus, instead of 
early deaths, or, what is worse, of the prospect of growing up weak- 
lings, most of tliese children are vouchsafed happy futures and strong 
constitutions thereafter resistant to infection. And hygienic habits are 
inculcated in them which they are sure to disseminate after their 
graduation. In this manner are secured to the State many worthy 
and virile citizens, who would otherwise be lost to it ; and there are 
surely none who serve it more faithfully or more gratefully. Here 
is certainly a movement worthy the consideration of the statesman 
and the political economist. 

John S. Ward, Jr., Esq., a member of the board of managers of the 
New York Association for Improving the Condition of the Poor, was 
in France in the summer of 1903, where he visited many of these 
institutions. His observations were all the more interesting from the 
fact that there was at that time no hospital in the United States which 
was exclusively set apart for children suffering from tuberculosis. 

At Berck-sur-Mer, near Calais, the City of Paris maintains the 
Hospital Maritime, whicli institution was founded in 1861, has grown 
up to cover a large amount of land, and contains seven hundred and 
fifty beds, all of which are occupied. A nominal charge is made ; and 
it costs per day for each patient a sum equal to forty-five cents, which 

includes light, heat, medicines, food, wages, incidentals, and the cost 



of transporting the childivn to and from Paris. Every tuberrulous 
manifestation is treated here ; but this hospital is primarily for the 
treatment of other than lung tuberculosis, the sea air being not gen- 
erally beneficial to those suffering from pulmonary diseases. How- 
ever, as we have noted, the lungs are generally not the primary seat 
of the disease in children. The patients vary in age from three to 
fifteen years, and the average period of their stay is one year, although 
some are there for only three months and others as long as three 
years. An average of about twenty-nine per cent, are discharged as 

A unique feature of the hospital is the large double-deck railway 
trucks which are used to carry the children, if necessary, from the 
institution to the very water's edge. Here such children as are help- 
lessly bedridden have their beds gently transferred to the truck, 
whence they are taken to the beach, where they may during many 
hours enjoy the beneficent sea-air. At Berck are also the hospitals 
Rothschild, Bouvril, the Parmentier Cornu, and the Cazin Perrechaud, 
in which the cost of maintenance is considerably loss, for the reason 
that the thirty nuns who nurse the two hundred children serve with- 
out price. 

The sanatorium at Pol-sur-Mer is situated three miles from Dun- 
kirk. It receives two classes of children, — those sent from the hos- 
pitals of Lille or other manufacturing towns in the north, suffering 
from surgical tuberculosis, rickets, or other definite diseases, and con- 
valescent or debilitated children who are admitted during the summer 
months, either to complete their recovery or as a prophylactic measure. 

Another sanatorium is in course of erection at Zuydcootc near by, 
and it is proposed that here the elder convalescent children shall be 
trained and encouraged to become farm-hands and agricultural labor- 
ers in order to keep them away from their unhealthy surroundings at 
home, chiefly in mining or industrial districts. 

At Hendaye, on the Bay of Biscay, near the Spanish border, the 
City of Paris maintains the second of its institutions. On account of 
its benignant and warm climate a few pulmonary cases are here 

At Ormesson, Villiers, and Noisy, in the vicinity of Paris, and 
within a short distance of one another, are free hos[)itals for children 
having pulmonary consumption, maintained by a charitable organiza- 
tion— L'ffiuvre des Infants Tuberculeux. The building at Ormesson 
is splendidly equipped. It receives boys from three to ten years of age 
in the incipiency of the disease, and has accommodations for one hun- 
dred and twenty-eight. 


At Villiers-sur-Marne there were in 1902 consumptive boys ranging 
in age from ten to seventeen, to the number of two hundred and ten. 
The society which maintains this establishment recognizes the possi- 
bihty tliat patients wlio return to unfavorable surroundings will develop 
again the symptoms they had lost. A colonie sanitaire has therefore 
been established as at Zuydcoote, where convalescents are taught 
gardening and farming. Great hopes have been entertained that this 
would be a means of attracting young lads to a country life and of 
getting them away from hurtful town surroundings. Unfortunately it 
is found almost impossible to retain them ; the town influence is too 
strong in them, and they never settle down happily to country life. 

The hospital at Noisy is for girls only ; here, as at Villiers, an 
endeavor has been made to interest the older children in outdoor occu- 
pations, but again with small success. Town instincts are as firmly 
rooted as in the boys. 

At Villepinte, near Paris, there is another hospital which receives 
consumptives from three to thirty years of age. This institution is a 
godsend to the incurable — those who are doomed to die — for such 
patients are not received in hospitals generally, there being no room 
for them. There the last days of the afflicted are made as comfortable 
as may be. Other hospitals near Paris are those at Forges-les-Bains 
(for convalescent children), and at Bois-Colombes. 

Mr. Ward on his return put his association in possession of much 
information upon which it might, if it seemed meet, proceed to erect a 
sanatorium for New York City children suffering from non-pulmonary 
forms of tuberculosis. To such work as this the association would be 
no stranger : for it has already had for many years a fresh-air home for 
poor women and children on Coney Island, called Sea Breeze. Of 
such children there are probably four thousand, three-fourths of whom 
live in tenements. Among these there were one thousand one hundred 
and eighty-four deaths in 1902. 

In February of 1904, then, a large sum was appropriated for the 
maintenance by this association of the first American experiment in 
providing treatment at the seashore for children sufi'ering from non- 
pulmonary forms of tuberculosis, and a series of tents were put up at 
Sea Breeze by way of experiment. 

And when the winter of 1904-05 came on, rather than return these 
children to overcrowded tenements, where their tuberculosis must 
very likely have recurred, they were transferred to a portion of the 
permanent structure at Sea Breeze. Here, one very cold day, Dr. 
J. W. Brannan, of New York, visited them. He came upon a number 
playing in the snow. Mitts were dangling by strings about their necks ; 


but they were not in use. While chafting with them, tliey told him 
they had to go into the building to get their temperatures taken. He 
went in with them. The windows were wide open. He wanted to 
keep on his hat ; but as no one else was covered, he removed it. His 
hands were gloved. He took off his gloves. The children affection- 
ately took his hands, one on each side. They said his hands were 
cold ; he found theirs to be warm. Then he felt the hands of others, 
and made the same observation. The windows were open wide 
l/n-oughout the twenty -four hours, except for half an hour mornings and 
evenings, when the children dressed and undressed. These children 
were tuberculous ; but, except for the surgical manifestations, one 
would never have imagined it. Dr. Brannan (he s])oke in discussion 
of a very interesting paper by Dr. L. R. Williams, before the New York 
Academy of Medicine) had not in his professional life seen curative 
results comparable to these. They were rosy-cheeked children with 
one exception, — a white-faced child. " She came yesterday," was the 
explanation made by one of her companions. And in general terms 
the surgical lesions progressed wonderfully toward complete recovery. 
Statements were made by Dr. Homer Gibney and others to the same 

Unquestionably there is need for not one but many such hospitals 
for tuberculous children. And of several that are now building we 
have space to mention but one or two. These institutions, among 
other blessings, provide that children upon whom it is expected to 
operate in city hospitals will receive such nourishment and other 
means of invigoration that they may be rendered (it for the ordeal ; 
and children, who have been operated upon in the city hospitals, are 
taken care of during their convalescence. 

The work done in New York City by St. John's Guild, while not 
directly concerned with tuberculosis, nevertheless lias to do with so 
large proportions of such cases that it has an interest for us here. 
This charity maintains two " floating hospitals" and a seaside hospital 
for sick children. The former are fitted with accommodations to take 
both sick children and their mothers and the well children, who must 
go alone, on fresh-air trips down New York Bay and back. Their 
purpose .is to combine with the needed fresh air and salt-water bathing 
such medical aid as vvill in very many cases protect them from dis- 
eases incidental to childhood. In addition, these hospitals are of great 
use as floating ambulances to bring to the seaside hospital children 

^ Results here are probably better than in French institutions, for the reason 
that in the latter the windows are nearly or wholly closed in cold weather. 


who need treatment, prolonged sometimes for weeks. The child is 
taken in hand by the physician as soon as it comes upon the floating 
hospital, and when it reaches the seaside structure, which is to be its 
temporary home, treatment is instituted which generally results in its 
restoration to health and strength. Many such infants are scrofulous, 
or have tuberculous infections of bones and joints, such as we are 
here concerned with. The surgical observation is pertinent, that 
operation in such cases is never radical. A single operation does not 
cure the child of its disease, as we may infer from a consideration 
of its nature. After operation the most wholesome conditions possible 
are essential to complete recovery. 

A detail of the floating-hospital work is the modified-milk depart- 
ment, which i)rovides daily from thirty to one hundred and seventy 
bottle-fed infants with milk, prepared according to the formulae ordered 

Fig. 58— At the country saiiatoriutji o£ the Montefiore Home. (Courtesy of Dr. Alfred Meyer.) 

by the hospital physician. This involves the preparation every day of 
from five to thirty gallons. The permanent hospital of the Guild is 
situated upon an excellent beach at New Dorp, Staten Island. 

One afternoon I was a delighted guest of Dr. Alfred Mayer and of 
Dr. and Mrs. Rosenberg in the " country sanatorium" of the Montefiore 
Home, which institution provides for tuberculous children as well as 
adults. I certainly can give no better impression of sanatorium life 
among children than to sot forth excerpts from The Review, published 
by them, under the guidance and with the advice of Mrs. Rosenberg.' 

At the sanatorium at Stony Wold in the Adirondacks women and 

^ Appendix D. 



boys (none over twelve) and girls from eight to eleven, suffering from 
tuberculosis, are taken care of. Children " are much more b(,'nerited 
by the open-air treatment, which they insist upon taking in a more 
energetic manner than the older patients, — sliding down hill, riding on 
the logs with lumbermen, building snow houses, and enjoying them- 
selves in ways fomiliar to children. A competent teacher gives them 
daily instructions, classes being held each morning in the library." 

In Boston, a shack twenty by foi'ty feet, lighted by ton windows, 
which are open day and night, has been biiill al W'ellesley lliils. 'i'hc 
children sleep between blankets in flannel caps and niglil-gowns, and 
wear woollen bed-socks. In the daytime they wear llannel under- 

FiG. 59— The country sanatorium of the Montefiore Home. 

clothes, dresses, sweaters, and woollen hoods. There has not been a 
case of sore throat or cold in the head, and appetites have im])roved. 
The children are those treated in the hospital for tubercular disease 
of the joints and bones, and tubercular pleurisy and peritonitis. 

In an interesting report of the New York State Hospital for the 
care of Crippled and Deformed Children, it is noted that its present 
small building at Tarrytown can accommodate only twenty-five 
patients, and that the need of a much larger hospital is evident. 
"The State has already anticipated this demand by appropriating 
$5000 to buy a suitable site, and no doubt before long further appro- 
priations will be made to build and equip a hospital in which five 
hundred patients may be accommodated." ' The residence of many 

^New York Medical Journal. 


who hav(> tuberculous hip joint and spinal disease is Mkely to be several 
years. Though benefited by treatment for a few months, they would 
speedily relapse after a return to the tenement-house life or to their 
isolated homes in the country. It is the intention of the managers in 
this hospital to keep their patients under treatment long enough to 
effect a permanent cure in all cases where the environment is unsatis- 
factory at home ; and this means years for many of them. It is cer- 
tainly unwise economy on the part of the State to treat a child with 
tuberculous joint, for example, for a few months, and then to discharge 
it prematurely, with the certainty that the disease would relapse with 
an accompanying increase in the deformity. The various excellent 
day schools, which have been established in New York for the educa- 
tion of the crippled and deformed children, who are not received in 
public schools, present distressing evidences of prematurely discharged 
hospital patients. The ideal hospital for the treatment of such cases 
among the children of the poor should aim at both care and treatment 
until a cure is effected. This means education as well as surgical and 
medical care. 

The example set by this State hospital has moved the Governor of 
Ohio to appoint a commission of prominent citizens " to report upon 
the feasibility and desirability of caring for, treating, and educating 
crippled and deformed children.'' This commission has recommended 
the expenditure of $200,000 for the establishment of a hospital to be 
erected on a fifty-acre plot of ground. From other States come inquiries 
and requests for information and advice, and in Minnesota the work 
has progressed most favorably. 

Mr. Tubby, an English orthopaedic surgeon, has suggested that 
there should be a system of country hospitals for the care of surgical 
tuberculosis in children. There are plenty of hospitals in cities where 
cliildren can receive proper treatment, but provision for the further 
care of these little patients has been lacking. Mr. Tubby's plan is 
that each urban hospital should be merely the central receiving station, 
where the diagnosis should be made, and tlie active treatment applied. 
The patients should thereupon be sent to the nearest branch hospitals 
for convalescence. Each rural hospital should have its local medical 
staff, the entire system being supervised by the chief surgeons of the 
urban hospital, of which the rural institution should be a branch. In 
these latter, which need not be equipped with elaborate paraphernalia, 
the children could convalesce under beneficent and cheerful sur- 
roundings far better than if they were sent back to their tenements 
from the over-filled city hospitals. 

Part IX 


Over the doors of the wards and hospitals for consumptives, 
twenty-five years ago, might well have heen written these words : 
"All hope abandon ye that enter here," while to-day, in the light 
of the new knowledge, we may justly place at the entrance of the 
modern sanatorium the moi-e hopeful inscription, "Cure sometimes, 
relief often, comfort always. " 






The purpose of these public institutions is both therapeutic and educational. 
In a large per cent, of the cases brought under treatment reasonably early the dis- 
ease may be arrested and the patient again put upon his feet. But more than this, 
he is sent out an enthusiastic and trained missionary of the fresh-air doctrines and 
of the necessity and methods of preventing the spread of infection. They serve 
another purpose in that, by removing from the homes, especially of the poor, the 
I source of infection, and that during the period of danger, they lessen the spread of 
disease. Thus they serve the triple purpose of prophylaxis, education, and eflicient 
treatment. — Beport Indiana State 3/cdieal Association. 

I HAPPEN to be writing this in the Christmas season, and so am 

moved to consider the sanatorium to be what in essence it really is, — 

ij something of an expression of that merciful Spirit which, twenty cen- 


: ,^]i»Lit%t.i'-ri' rin'jj 

S ^llj >fl~Ta-l*l 

111.. tiU. .Sanatorium ut Guerbersdorf. 

turies ago, amid brutal and decadent surroundings, manifested a 
benignant altruism and a humane consideration for the suffering and 
the afflicted. The sanatorium is in effect a place where those who are 
consumptive may find rest, may live amid fresh air and in the sunshine, 
and may have wholesome food in abundance. Here the recovery of 
most of the sufferers from this disease is confidently expected, at least 
m the incipient stage ; after which they return to their families to take 



up aiiiiin, with restored liealth and strength, their life work. Those 
who do not g(^t well are vouchsafed peace and comparative comfort 
for the rest of their days. And this latter is, I think, a very great 
thing. It is dreadful to die untimely ; but that is not so dreadful, to 
my thought, as to be suffering constantly while one has breath in his 
body, to be dragging out one's life in anguish of mind, starving, amid 
wretched surroundings, and where the God-bestowed sunshine cannot 

There is, in one of these sanatoria, a place set apart called " Hearts- 
ease." It is for those who are not expected to recover, Tliere such 
sufferers, so long as they can see, may contemplate nature, God's 
beautiful garment ; so long as their faculties remain with tliem, they 
may aj)preciate His beautiful flowers ; may hear the music of His 
birds ; may have the nourishment He has provided. Life is so un- 
speakably precious a thing, I think, that those who must perforce give 
it up prematurely, ought to be vouchsafed all the happiness possible 
for them, so long as they have consciousness to enjoy it. 

Finally, such institutions safeguard to a very great degree the health 
of tlie remainder of the community, so far as this communicable dis- 
ease is concerned. We shall see, morover, that wherever they are 
situated the general healtli of the surrounding community is better 
than is ordinarily tlie case ; and tliat such conmiunities are thereby 
greatly advantaged in material prosperity. 

There are now very many sanatoria in all cjuarters of the world, 
— in both North and South America, in every European country, 
in the Orient, and in Africa, I cannot begin to describe even a few 
among them. In the following pages I essay but to present the salient 
points of some of those which are typical, and shall begin with the 
work at Saranac Lake — the first of its sort in this country — a tale as 
fascinating and as full of the milk of human kindness as the best 
Christmas story that was ever written,^ 

^ Concerning American institutions, see Appendix I, and the Directory of the 
C. 0. S. , and the N. A. S. P. T. 


Fig. 61.— Tubercle bacilli, with pus-cells, in sputum. 
From a case of tubercular inflammation of the lungs. The 
bacilli stained with fuchsin. (Delafield and Prudden.) 



History is |)hil()sophy teaching by»example. — BoLiNfiBKOKE. 

If in tliis sentiment we interpret philosophy as the love of learning 
which has for its objective human betterment, then no history of the 
American people — no history of humankind, indeed — can be complete 
which does not make some statement of the inception and progress 
of the work of Dr. Edward L. Trudeau. 

Thirty years ago, having been found to be consumptive, this phy- 
sician went into the Adirondack wilderness to try to prolong his life. 
In those days almost nobody ever expected to recover from this dis- 
ease. " Nothing, indeed, would then have seemed more improbable 
than that I should have lived to avail mvself of the great lionor of ad- 

FiG. 62— The Sanatorium at Saranac Lake. 

dressing you on such an occasion as this, or that anything which could 
occur in a life spent in those remote and primitive surroundings might 
be considered by the management of the Phipps Institute at all worthy 
of your attention to-night." ' 

In 1873 there was little medical interest in tuberculosis, nor did the 
laity know^ much about it, except that it was thouglit to be always 
inherited and almost invariably fatal. There was then little special 
hospital accommodation for the consumptive. Most hospitals admitted 
a few cases to their general wards when they had empty beds. There 
were a few homes for consumptives in existence, but no institution 
was presumptuous enough to announce that its object in taking these 

^ Dr. Trudeau's address. 




patients was anything beyond affording tliem a place where they might 
die. The giving of cod-hver oil, creosote, and anodyne cough mix- 
tures, and the keeping of the wards at a given temperature (the 
windows being generally kept tightly closed to prevent the patients 
taking cold), were practically the only attempts at treatment. The 

climatic treatment was within 
the reach of only the well-to-do, 
and they w^ere not generally 
sent away until their physicians 
and they themselves became 
alarmed at the activity of their 
symptoms. The poor and 
those Avlio depended upon their 
daily work for their support 
were left to their fate. The 
Adirondack region w^as in 1873 
a real wilderness visited during 
the summer months by a few 
sportsmen. Here Dr. Trudeau 
met Dr. Alfred Loomis, who, 
despite his critical condition, 
encouraged him in his determi- 
nation to r e m a i n at Paul 
Smith's during the winter. 
" My good wife cheerfully acqui- 
esced in the plan, in spite of 
the gloomy prognostications 
of many medical friends who 
tried to dissuade me from so rash a step, and it was entirely due 
to her courage and determination that we settled down, in 1874, to 
face the severity of an Adirondack w'inter, forty-two miles from a 
railroad or a physician, and completely cut off for weeks at a time by 
the deep snows from any communication with the outer w^orld.'' The 
spring found Dr. Trudeau much improved, to his no small wonder. 

The village of Saranac Lake consisted at that time of a saw-mill and 
half a dozen guides' houses. For fully thirty winters Dr. Trudeau 
has lived in this region. Long before this time Dr. Brehmer had 
begun to work out the princij)les on which the sanatorium treatment 
of tuberculosis is based, and Dr. Trudeau was anxious to test his 
methods, the more so as the urgent need became apparent of supply- 
ing at Saranac Lake a place where persons of moderate means could 
be properly cared for. 

-Dr. Kdward L. Trudeau. 


Thus, gradually, the idea of shirting a sanatorium for working men 
and women, at a cost to them less than the exi)ense of operating it, 
began to crystallize in his mind. And here we may note in passing, 
concerning this beneficent institution, that one essential reijuircment 
in the candidate for admission is that he shall not have sufficient means 
for his maintenance there. 

Dr. Loomis promised the support of his great name and examined 
applicants in New York free of charge up to the time of his death. 
The first subscriptions were given by Mr. and Mrs. Anson Phelps 
Stokes, " whose ever-helpful interest, as well as that of many of my 
personal friends, has never failed me through these years." Soon 
$5000 were collected, and having bought a few acres on a sheltered 
hillside, with money donated by guides and residents of the village 
the erection of two small buildings was begun in 1884. Since segre- 
gation of patients was the aim in view, the cottage plan was adopted. 
The first cost $350, and consisted of one room, heated by a wood 
stove and lighted by a kerosene lami). It had a small covered piazza, 
W'here, " after much persistence and eloquence," he persuaded his 
first two patients to sit most of the day at rest. From this beginning 
the institution has gradually and steadily developed.^ And the prin- 
ciples of treatment upon which it was founded have become generally 
accepted over our entire country. The latest cottages are substantial 
yellow brick and stone structures, eminently adapted for the open-air 
treatment. Lighted by electricity, heated by hot water and having 
fireplaces, supplied with baths and running water, each room opens 
directly on a covered veranda, upon which the patients' beds are easily 
pushed wlien ordered temporarily to remain in bed, as well as to sleep 
out at night upon occasion. 

Year by year obstacles were overcome and needs were supplied as 
they developed, — more land, an abundant water supply, good drainage, 
electric lighting, a crematory for the disposal of infectious material, an 
open-air recreation pavilion, many more cottages, a library, a chapel for 
religious services, an infirmary for the proper nursing of the very sick, 
and an administration building suited to the enlarged needs of the 
growing community. All these came into being until a small village of 
twenty-two buildings, entirely free from any encumbrance, has grown 
up about the little one-room cottage which still stands as a reminder 
of the institution's humble beginning. New problems had constantly 
to be solved. Sooner or later after admission patients would exhibit 

^ The village of Saranac Lake itself has grown to be a town of four thousand 



coiiiiilications of the disease — hemorrhage, pleurisy, tubercular pneu- 
monias, acute exacerbations — so that oftentimes a promising patient 
would be transformed into a bedridden invalid, who needed for Aveeks 
or months constant day and night nursing and attention. In the 
beginning there were no nurses available, nor money to procure them. 
There was no resident physician, nor was there a salary to offer 
him ; " so that during the smnmer I had to do the medical work of the 
institution as best I could,'' to this end driving from Paul Smith's, 
fourteen miles (uich way. But the problems were finally solved. A 
coiJSumi)tive physician came to the sanatorium to live, and gave liis 
services in return for board and lodging ; and the gift of the Hall and 
the Childs Memorials provided buildings to which the very sick could 
be transferred at once from their cottages when acutely ill. 

The requisites for admission have been that the applicant should be 
in the earlier stages of the disease, with a fair chance of restoration to 

Fig. (54.— Porch at Faianar I.akt 

health, and that his pecuniary circumstances shojuld be such as to pre- 
clude the possibility of his paying the prices asked at the hotels and 
boarding-houses in that region. Five dollars a week has been for 
twenty years past the cliarge, despite the greatly increased cost of 
operating the institution. There is now a deficiency of about four dol- 
lars a week on each patient. Every one is on the same basis, there being 
no private patients and no graded rates. There are no extra charges 
except when the patients are so ill as to be confined to bed and taken 
to the infirmary, thus requiring constantly the services of a nurse, 
special diet, etc., when the additional regular infirmary charge of five 
dollars a week is made. There is a small free-bed fund, the income 
of which is applied to defray the expenses of patients whose resources 
have entirely given out. 


During the first years of Dr. Trudeau's work he had much difficulty 
in filling the few beds in the institution, and on many occasions it took 
all his eloquence and persuasive i)o\vers to prevent tlu^ desertion of his 
patients. Since then the education of the public as to the value of 
sanatorium treatment has little by little become apparent, so that of 
late years there has always been a long waiting-list. Not on(» in twenty 
applicants can be taken, and many like institutions would be recfuired 
to accommodate all who seek admission. 

The saving and prolonging of lives at the sanatorium has been by 
no means all that has been accomplished. The hundreds of patients 
discharged during the past twenty years have been so many mission- 
aries who have scattered over the land, imparting to others the simple 
but all-important knowledge as to protective measures and hygienic 
mode of life which they have been so practically taught in the institu- 
tution. And, besides all this, " by affording a scientific demonstration 
that a fair proportion of tuberculous patients can be cured and restored 
to lives of usefulness, the sanatorium has had an influence in bringing 
about a new attitude of hopefulness towards the disease which lias in- 
spired the building of similar institutions." 

The sanatorium has been throughout essentially an Adirondack 
charity, having owed its support almost entirely to visitors who come 
to the St. Regis and Saranac Lake region in search of pleasure, rec- 
reation, or health. Two fairs held each year — at Paul Smith's and the 
Saranac Inn — have supplied a goodly share of the funds necessary to 
meet the yearly deficit in running expenses. 

It is wholesome, indeed, to read how the financial difficulties 
attending the progress of this institution were overcome, — how physi- 
cians, nurses, and laymen gave of their strength and their skill and 
their fortunes to this end. '' Though the sanatorium has never had 
money enough to pay for the services required to do its work, this 
institution has received throughout all these years the kind of devoted 
service which no money can command, and which has made its work 
a benediction to those it has sought to relieve." 

The narrative of the scientific Avork done at Saranac Lake by Dr. 
Trudeau and his assistants, the difficulties they had to contend witli, 
reads like a chapter in a romance. There is now firmly established a 
laboratory, wdiose opportunities for original investigation have always 
been freely placed at the disposal of any medical man desiring to do 
scientific work in the investigation of tuberculosis. In another section 
we have dwelt upon Dr. Trudeau's researches with regard to the pro- 
duction of artificial immunity. During the past twelve or fifteen years 
he has published twenty-one papers and his colleagues sixteen, setting 


forth the work accoiiipUshcd in his laboratory, which is the first in 
this country devoted exchisively to this purpose. 

Not only in the sanatorium and the laboratory has the tuberculosis 
situation been coped with. The village of Saranac Lake has been con- 
stantly cahed upon to adapt itself to new conditions. An ever-increas- 
ing number of invalids, from the well-to-do to the penniless, have made 
the town practically a cottage sanatorium on a large scale. For the 
rich there are now beautiful and even luxurious homes, designed and 
built with a special view to the requirements of the invalids, and for 
carrying out the open-air treatment in the vigorous climate of the 
Adirondncks. And these features are also more or less developed 
even in the humble boarding-houses w-hich abound. An efficient 
health board has instituted modern methods of guarding against 
infection. Sanitary rules and regulations are exposed in public places, 
and enforced as far as practicable in the town, and disinfection and 
fumigation of rooms recently occupied by the sick is made compulsory. 

The residents of Saranac Lake have not been unmindful of the 
poor consumptive. The district nurse, whose expenses are defrayed 
by the benevolent, is constantly occupied in instructing and nursing 
those who are too sick to care properly for themselves ; " and Avhen 
death comes, as it often does to the lonely consumptive far away from 
home and without friends, the same charitable spirit which has tried 
to relieve his lot provides him with a decent burial. How^ little those 
who so often speak disparagingly of Saranac Lake, because it harbors 
so many invalids, know of the burden of human misery, not its own, 
which this small and remote town has ministered to as best it could 
for so many years." 

A bureau of information is supported by the institutions in the 
town, and assists rejected candidates to find cheap boarding-places, 
and a free dispensary is maintained at the town office of the sanatorium 
where medical advice is freely given by Dr. Trudeau's associates. 

Among the many merciful works which have been done at Saranac 
Lake is the Reception Cottage, which has been established and is 
maintained by Miss Mary R. Prescott.^ Here a few acutely ill or 
advanced cases, wlio cannot be taken at the sanatorium, are often 
refused at the boarding-houses, and who are in need of constant 
nursing which they cannot afford to procure, are taken and cared for 
at a very moderate cost. 

Among Saranac Lake's illustrious visitors was Robert Louis Ste- 
venson, wiio spent the fall and winter of 1889 in Mr. Baker's cot- 

^ Appendix F. 



tage, which has since become an object of historic interest. " In its 
little sitting-room Stevenson received the visits of many i)rominent 
men, who journeyed to Saranac Lake to see liiin. and it was in lliis 
room, on a cold winter night, by the light of the wood fire in the big 
fireplace, while Stevenson sat on a chair placed on top of the table, 
which had been mov(^d into a corner, that Richard Mansfield delighted 
the great author with his weird and grewsome impersonation of Dr. 
Jekyll and 3Ir. Hyde 

"To a temperament like Stevenson's, wliich shrank from the grim, 
inexorable facts of life, and lived in an ideal world, painted and peo- 
pled by his own vivid imagination, who craved sunshine, blue skies, 
and tropical seas and verdure, Saranac Lake hi winter, with its ice and 
snow, its gray skies, and its ever-pres(Md and iil)i(|iiit()ns problem of 

Ht i Uli 


Fifi. 65.— The Fresc'Ott Reception CottiiKe. 

human suffering and sorrow, did not especially appeal, but he acknowl- 
edged to me, and in his writings also, tliat liis health was much bene- 
fited by his stay there, 

" He naturally looked with repugnance on the exact and uncom- 
promising methods of scientific research and animal experimentation, 
and we had many heated arguments on this subject. I finally per- 
suaded him one day to visit the little room in my cottage which was 
then my only laboratory. He had just written for Scribncr's a short 
essay entitled, ' The Lantern Bearers,' in which some of his beautiful 
thoughts had as a text a game he and the other boys played, and 
which consisted simply of walking along the beach on a dark night, 
hiding under their coats a lantern, which was only fiashed at each 
other as they passed as a signal. I was intent on sliowing him my 


animals and culture tubes, and the ravages which are caused by the 
tubercle bacillus in the organs of animals, and was trying to impress 
upon him the possibilities which lay in these experiments in advancing 
our knowledge of a germ which kills one in seven of the human race, 
when suddenly I noticed that he looked pale, was not listening, and 
was edging towards the door as fast as possible. As soon as he got 
outside he turned to me and said, ' Trudeau, your lantern may be very 
bright to you, but to me it smells of oil like the mischief.' It was 
evident that neither of us could fully appreciate the brightness of each 
other's lantern, though we both tried." 

The tuberculosis problem, as it has been developed at Saranac 
Lake, has been carried on from the first practically along the three 
lines which must in the future be followed, — namely, study, prevention, 
and treatment. In the town and at the sanatorium, by education of 
the invalid, by the health board's regulations, and the disinfection of 
infected surroundings, by the intelligent care of the very sick in the 
sanatorium infirmary, and in tlie boarding-houses and at the recep- 
tion cottage, prevention lias found its practical application. Treat- 
ment has made for itself a brilliant field in the development of the 
sanatorium methods and the application of these methods to patients 
in the town, while the study of tuberculosis in its scientific aspects has 
proceeded in the laboratory, in which latter department of the work 
increased knowledge must be hoped for in the struggle with this 

Thus in this remote Adirondack region has the problem been 
practically met. During their own work. Dr. Trudeau and his associ- 
ates have witnessed the general spread of the new knowledge '" and 
its application by others to the needs of great communities all over the 
land, the building of many private sanatoria, and the growing feeling 
of hopefulness which of late years has enlisted the co-operation of 
the State, the philanthropist, the medical profession, and the laity." 



The establishment of private sanatoria has yielded most valuable service in the 
treatment of the disease. — Mnrykuid Tuberculom CommiKslnn. 

Tjie Tuberculosis Infirmary on Blackwell's Island, New York City, 
affords an excellent example of what can be done in the way of sana- 
torium construction in the face of great difficulties. The need of a 
special hospital where the modern treatment of the disease miglit be 
carried out has long been apparent in New York City, where the 
'number of consumptives vastly exceeds the limits to which such suf- 
fering can be accommodated in its general hospitals. For a long lime 
the city shrank from the large initial ex))ense necessary for eslabli.sliiiig 
such an institution. However, in October, 1901, two buildings on the 
grounds of the Metropolitan Hospital for the Insane a! (he north end 
of Blackwell's Island became available through the transfer of the 
city's insane to State institutions. Here was an opportunity to estab- 
lish without large outlay a hospital for consumptives, which was seized 
by Commissioner Folks almost immediately after taking oflice in Jaim- 
ary, 1902. These buildings could be adapted very satisfactorily. No 
large appropriation was available, although considerable alterations 
were required. The work was, however, begun by the hos|)ilal 
employees with the materials at hand. Soon the smaller, a structure 
of two stories, was put in condition to receive patients. The walls 
were painted, the floors polished, and the antiquated plumbing re- 
paired. ■ By the end of May, this building housed one hundred and 
eighty-three patients. Soon a part of these were moved into a porlidii 
of the much larger building, a three-story gray-stone structure, wliicli 
had been renovated. The plan was to occupy one of the three tlnors 
at a time, leaving the others to undergo necessary altcralioii. initil the 
entire building could be adapted to the purpose in view. 

The larger building was altered in the following mamicr: There 
were no open wards, but single or double rooms, opening on a wide 
hall. This insured a certain amount of privacy to persons usually 
deprived of it in general institutions, and prevented the disturbing ot 
some patients by the coughing of others. A clear stretch of three 
hundred feet of hall, ten feet wide, was made, at either end of which 
windows were placed, occupying almost the entire end wall space. 



These windows added greatly to tlie light and ventilation of the entire 
lloor. Next, all interior wood-work, all the doors and door-frames, 
were removed, leaving a series of open arches and rounded corners on 
either side of the hall, from end to end. The entire floor was thus 
made one large air-space. The cubic air-space per bed was about 
two thousand feet, and the entire interior was refmished, and given 
several coats of white paint. Most of the flooring was renewed and 
polished. There was a marked contrast between the gloom of the 
original building and the light and cheerfulness resulting from the 
renovation. The better spirits induced by the pleasanter surroundings 
more than compensated for the comparatively expensive renovation. 
The temperature at this institution is kept at sixty degrees ; windows 
are constantly open. The situation on the north end of Blackwell's 
Island, between the two channels of the East River, is perhaps the 
best for purity of air and general liealthfulness that can be obtained 
near the city. The value of this institution to the large number of 
its consumptives without resources for private treatment is incalculable. 
The patients have ample air-space on the liospital grounds. All the 
" bad cases'' have been placed on the top floor by themselves in both 
buildings. This has certainly contributed to the well-being and good 
spirits of the stronger patients, who are thus completely separated 
from tlie depressing features of the ordinary hospital environment. A 
number of the cases, on becoming convalescent, have been put upon 
the hospital pay-roll, — an excellent policy, for the men are still under 
some medical supervision, and are not endangered by doing too heavy 
work, or such as is done under unhealthful conditions. 

A platform, fifteen feet wide and one hundred and thirty feet long, 
has been built along the south side of the building, where patients may 
promenade when the ground is wet or damp, or be carried out in re- 
clining cliairs into the sun.' 

St. Joseph's Hospital for Consumptives is owned and conducted 
by the Sisters of St. Francis. It occupies an entire block, bounded by 
St. Ann and Brooks Avenues, in the Bronx Borough of New York 
City. Nearly all its three hundred beds are occupied by the sick poor, 
mostly " advanced cases," who are admitted irrespective of creed, race, 
or nationality. 

The Riverside Hospital, on North Brothers Island, is maintained 
by the Department of Health of New York City, and is used as a 
tuberculosis hospital. Here, if necessary, such patients may be de- 

^On dismissal the patients are provided with a list of medical suggestions with 
regard to theii' future well-I)eiiig. (Appendix G.) 



tained as appear to be a danger lo the coniinunity lliroiigh refusal lo 
go to liospitals, or on account of persistent, neglect of tlic necessary 
precautions against infecting otliers. Wlien certain of tlicse patients 
liave recovered their liealth sufficiently, I understand such suitaljle 
work is offered them as is to be done on the Island, and they are put 
on the city's pay-roll. 

The Montefiore Country Sanatoi:iuni was begun in 1897. In 1901 
the present new buildings were opened at Bedford Station, West- 
chester County, on an elevation overlooking a beautiful valley. Tlie 
grounds comprise one hundred and thirty-six acres, on which patients 
are let out to work at farming. Efforts have been made to confine 
the number of patients to those in the incipient stages of the disease, 
although no extreme line is drawn. At the time of lis dedication this 
was the only free sanatorium for consumptives in the United States. 

Fig. 66. — The IMontefiore Countrv Sanatorium. 

Partially cured patients are constantly being sent Ikjuic. The land 
is becoming well-tilled, so that its productive power is constantly being 
augmented. There is sufficient pasturage for a herd of twenty cows, 
••and the crops of hay, rye, corn, and oats have been of superior 
quality, and the tlourishing condition of the farm is a source of pride 
to all." There is also a prolilic garden, from which fresh vegetables 
are supplied in abundance during the summer, and line autumn crops 
are in anticipation to be stored for winter use. Tliese results are 
achieved in large measure through tlie work of the more robust 

" The relations of the sanatorium and its officers with the citizens 
of Bedford and the surrounding country-side grow more cordial and 
neighborly as the nature of the mission of the institution becomes 
better understood. On the Fourth of July the inmates were treated to 
a fine Independence Day parade, with many well-conceived historic 



floats. The i)ro('OSsion was oigaiiized by the villagers as a testimonial 
of esteem and in appreciation of tlie good-will of the directorate for 
ihe iidial)ilants of the locality/'' 

Dr. Rosenberg, the medical sui)erintendent of this institution, de- 
clares tliat tlie number of cases classed as " not imi^roved" would be 
very greatly reduced, and most of them ultimately transferred to the 
columns for "apparently cured'' or " improved" in his classification 
if the large number of withdrawals against the advice of the staff could 
be prevented or lessened. This state of things is due to the insistent 
claims of dependent families or relations left behind in the city ; to 
homesickness — sometimes unconquerable — and to the allurements of 
metropolitan life, particularly to young adult males. 

-Tli>> M<iiiti:'tiore ( 'niintrv Sanatorium. 

The Stony Wold sanatorium is situated at Lake Kushaqua, Frank- 
lin County, New York. It is primarily intended for incipient cases 
among working girls. Some children are admitted. This excellent 
yet still very incomplete institution was formally opened in 1903. The 
president is Mrs. James AV. Newcomb. 

It is largely through the efforts of the '• auxiliaries"' that the build- 
ings have been completed and equipped to the extent they are at 
present. Their total membership numbers upwards of twelve hun- 
dred and fifty. Several of these organizations have each undertaken 
the support of more than one patient; while one has four patients 


as its guests, and aiiotlier has started an endowment lund lor tin? per- 
petual care of its room. The work being undenominational, all creeds 
are represented among the patients. There is a farm which it is in- 
tended will be systematically developed. Upon it many articles of diet 
required for the sanatorium can be produced for less tlian the market 
cost. The development of the farm will also make possible the estab- 
lishment of a dairy. 

Across the entire front of this institution is a very long porch, from 
Avhich Mounts Marcy and Whiteface can be seen in the distance, with 
Lake Kushaqua lying just below. 

The New York State Hospital for tiie treatment of incipient pul- 
monary tuberculosis began to receive patients on July 1, 1904. Dr. 
Trudeau selected the site at Raybrook, Essex County. Dr. John II. 
Pry or is the superintendent. 

This institution was established in accordance with an Act of the 
New York Legislature.' The trustees are empowered to receive 
patients who have no ability to pay. Those only are admitted 
who have been for at least one year preceding the date of appli- 
cation citizens of the State. Every person desiring free treatment in 
this hospital must apply to the local authorities of his town having 
charge of the relief of the poor, who sliall thereupon issue a written 
request to the superintendent for his admission and treatment. It 
must be stated in writing whether the patient is able to pay for his 
care, and all these statements are to be filed in a book kept for tliat 
purpose in the hospital. \Vhenever there are vacancies caused by 
death or dismissal, the superintendent issues a request to an examin- 
ing physician, appointed in accordance with the terms of the Act, in 
the town from which the deceased or removed patient came, for the 
examination of another applicant from that town. 

The Looniis Sanatorium, founded by Dr. Alfred L. Loomis, who 
died before the project was far advanced, is situated two and a half 
miles from the village of Liberty, in Sullivan County. The elevation is 
two thousand three hundred feet above the sea-le\el. The winters are 
dry, cold, and exhilarating; the summers cool and refreshing. Dr. 
Herbert Maxim King is the physician-in-chief. It has a school for 
nurses, the pupils of which have, to a considerable extent, been drawn 
from the convalescents. The i)urpose of this institution is to admit 
only incipient or moderately advanced cases, and the basis of treat- 
ment has been climatic and hygienic. It was the first institution to 
utilize the X-ray for purposes of diagnosis in pulmonary diseases. 

* Appendix G. 



The charges are ten to twenty dollars per week. No free patients are 
taken. There has never been any effort made on the part of the man- 
agers of this institution to make it a source of profit, but everything has 
been calculated to make it, if possible, self-supporting. There is a 
charitable annex which holds thirty patients at the rate of five dollars 
per week. The amount paid for medicines varies greatly with the need 
of the patients. This reduced rate does not cover the expenses of the 

at Loomis Sanatorium, fiL'lu i.:iiitnts 

annex, which has been met by means of contributions from outside. 
There are many more applications than the annex can accept. 

Before discharge in those cases which are " apparently cured" or 
have their " disease arrested," a system of exercise tests is given " in 
order to determine, if possible, the fitness of the individual for return- 
ing to his home and work," — an excellent procedure.^ 

^ Concerning the lean-to used at this institution, see Appendix E. 

■Ct V 



This institution " may he taken as a model for what may be accomplished in 
this line." — Marijland Tuberculosis Commusion. 

The Massachusetts State Sanatorium at Piutland is upon ground 
twelve hundred feet above sea level. It is built on the pavilion plan 
and will accommodate about two hundred and fifty patients. The 
primary purpose of this institution is to arrest the disease, and. if 
possible, to extirpate it ; therefore, only such patients are admitted as 
are deemed " not too far advanced to admit of reasonable hope of 

Fkj. 70. — The Massarlmsetts Stato Sanatorium. 

radical improvement.'" It is not a home for the hopelessly sick ; for, 
great as is the rocognized need for homes of refuge for advanced con- 
sumptives, such service is manifestly incompatible with the even more 
needed service of rescuing lives that can be saved only by sanatorium 
treatment. For hopeless cases tliere should be separate hospitals, 
esjiecialiy in the vicinity of great cities. Those who do not improve in 
the sanatorium after a stay sufficiently long to test the effects of 
treatment are advised not to remain, and their friends are expected 
to arrange for tlieir removal to surroundings primarily devoted to or 
better adapted for their comfort. 

There is a uniform charge of four dollars per week. There are no 
extra charges, and absolutely no tips are permitted. There are no 



private patients and private rooms are allowed only lur i)hysical 
reasons. Only residents of Massacliusetts are admitted. Drs. Vin- 
cent Y. Bowditcli and Herbert C. Clapp, of Boston, are- supervising 
physicians ; and tliey decide tlie duration of the stay of patients. Dr. 
Walter J. Marclay is the superintendent. Examinations for admission 
are made in various cities in the State. 

It is suggested to physicians applying in behalf of i)atients that only 
those be sent whom it is hoped to cure, or in whom tliere may be 
amelioration of symptoms sufficient to insure their becoming wage- 
earners again. " It is, moreover, an educational institution where the 
patients are taught the simple but important laws of hygienic living, 

Fig. 71.— Taking the air at the Massachnsi-tts State Sanatorium. 

and as such is a factor in the foundation of preventive medicine.'" In 
order that patients with unfavorable symptoms may not have to make 
a long and distressing journey, only to find themselves ineligible for 
admission, physicians are advised that cases suitable for treatment are 
those in which there may be signs of incipient disease only. The 
physician would greatly facilitate matters by sending with his patient 
a record of his morning and evening pulse and temperature, taken 
for a week before application, together with a brief but careful state- 
ment of the physical signs and general symptoms in the case. 

The average length of stay has been but six months for each of four 
hundred and eighty-four patients, exclusive of ninety-two who for 


various reasons remained less than a month. Further accommodations 
for an increase up to four hundred patients are considered imperative ; 
as also new land and a barn, so that an economical supply of pure 
milk for the institution may be assured. 

Provision has been made for the addition to the sanatorium of four 
brick cotta'res, two stories in height, to accommodate not more than 
thirty-five patients each. One of these cottages may be used as a pro- 
bation ward, where about thirty newly received patients may be treated 
for a brief period, and the proper classification and treatment deter- 
mined. Another of these cottages may become an infirmary for 
twenty or thirty patients during such days or periods as they may need 
treatment more nearly resembling that applied in hospitals. The 
estimate given in this report for the coming year was $100,000 for 
maintenance, $10,000 for an additional one liundred and thirty acres, 
and $15,000 for a farm building. 

In this institution a dietitian is employed, who is thoroughly 
trained in domestic science ; she also attends to many of the duties 
of a steward. Dr. Marclay considers that open wards are preferable 
to individual sleeping-rooms, not only upon grounds of economy of 
construction and administration, but also because the nurses have 
better control of temperature, ventilation and care of patients.^ 

^ Invaluable rules for the regulation of patients are set forth in Appendix G. 


The captain of the ineii of death. — .1oh.\ Bi-nvan. 

Olr Government maintains two sanatoria, one at Fort Stanton, New 
Mexico, and another at Fort Bayard, in the same State. Dr. Paul M. 
Carrington is in charge of the former. Himself but two years ago a 
consumptive, he is now to the best of his knowledge entirely cured, 
ruddy-cheeked, and weigliing some two hundred pounds. 

Fort Stanton, formerly a garrison post, is controlled and operated 
by the United States Public Health and Marine Hospital Service, one 
of the many bureaus of the Treasury Department. Seamen employed 
in the United States merchant marine, keepers and crews of light- 
houses, officers and men of the revenue cutter service, and the Coast 
and Geodetic Survey, and officers and men employed on Government 
vessels other than the Navy, may enter. Admittance is through 
the United States marine hospitals, which are maintained at practically 
every river, lake, and ocean port in the United States and among its 
possessions. In these hospitals are treated sick sailors, who are gen- 
erally without homes or legal residence in any civic community. 

From the marine hospital the consumptives, no matter in what 
stage, are sent at the Government's expense to Fort Stanton, where 
they may remain until cured ; or, if they die, are decently buried. 
Thus does the Government vouchsafe to its wards relief and often 
permanent cure. And, in segregating them, it wisely diminishes the 
tendency to the spread of tubercular infection. 

At Fort Stanton these men have rest, outdoor life, and nutritious 
food, by which their bodies may be strengthened to the degree of com- 
bating and disposing successfully of the bacillus and the results of its 
activity. An ample herd of dairy cattle is kept on tlie reservation ; 
horses are bred ; chickens, pigeons, hogs, and Belgian and other hares 
are bred and raised ; and there is a herd of range beef cattle which, 
within a year or two, will supply all the meat required. A large tract 
of land is devoted to the production of hay, grain, and garden vege- 
tables and fruits. It is expected that by such means as these this insti- 
tution will in time become practically self-supporting. It has its own 
ice- and cold-storage plants, a fully equipped steam laundry, and a 




modern system of pluuibiiig, vvater-works, ana sewage. The men 
are out of doors practically all the time. About half of them sleep 

in tents, which are very i)Oi)ular; for cases in tents do better than 
those living in wards. The remainder have beds in specially ventilated 


dormitories, which they are not permitted to occupy except when 
they are asleep. Their male nurses are required to keep them out 
of doors in the daytime. All the tents arc floored, sided, and have 
small sheet-iron stoves ; and every one of ttiem was occupied during 
the whole of the winter of ]90-'5-04, when the temperature was the 
lowest in many years. In only a few instances was it found necessary 
to remove tent patients to buildings. 

At Fort Stanton the sun shines on an average three hundred 
and forty days in the year ; and nearly every one of those days is 
pleasant enough to be enjoyed out of doors. The summers are cool ; 
the winters mild. The altitude is 6,150 feet; the precipitation from 
but fourteen to seventeen inches, partly snow. All the year round 
the atmosphere is very dry. The heat is never enervating: and there 

Fi«. 78— Fori Siaiitnn, New Mexico. 

is always a cool breeze. The conditions for sleep — a great tissue- 
builder — are ideal. The temperature on winter nights is almost 
invariably at freezing-point. And low temperatures are beneficial for 
such patients. Dr. Carrington has not seen a case of pneumonia since 
the station was begun. The atmosphere seems free from pathogenic 
germs, and wounds of all kinds heal readily and without infection. 
Moreover, it is noted that on the appearance of winter mixed infection 
cases invariably lose their distinctive character. 

The sanatorium consists of a group of buildings, constructed of 
stone and adobe, situated on the Rio Bonito (beautiful river), in a 
grove of cottonwoods and willows. The buildings are arranged on 
four sides of a square — •' the parade ground'' — which has been con- 
verted into a blue-grass lawn, contrasting pleasantly with the brown 
of the surrounding hills. In all this work are manifested the good 


taste and ability of the architect, Mr. J. Ross Thomas, himself a 
'• thirtl stager." Upon the verandas and under the trees are invalid 
chairs. In winter the physicians require that the patients sit out of 
doors in the sun, in the lea of a building, perhaps. Reclining chairs 
may be seen, placed in several inches of snow, containing patients 
muffled from head to foot. 

To occupy the minds of these men certain amusements are pro- 
vided. Exercises tending to undue exertion and such as are exciting 
are guarded against. There is golf and croquet. An excellent library 
of books and magazines has been provided by Miss Helen Gould. 
There is no reading-room ; all reading must be done out of doors. 
There are concerts in which patients proficient in entertaining take 
part. On the verandas cards, chess, checkers, and the like, are 
played. Periodical trips are taken, picnics for a day, or perhaps fish- 
ing or hunting parties, which camp in the surrounding mountains for 
weeks. Many patients are allowed to own and ride horses ; many may 
do light work, such as weeding, gardening, distributing food, tending 
fires, etc. All are closely watched, however, by the surgeons in com- 
mand, to prevent overfatigue. 

Certain of these exercises have been found exceedingly beneficial 
by the physicians, breaking up adhesions as they sometimes do, and 
increasing lung capacity. There are breathing exercises, by which 
means practically all increase their chest expansion early in their stay, 
generally several inches. A difficulty encountered daily is that 
patients unaccustomed to restraint, except while aboard ship, soon tire 
of the essentially rigid regulations of sanatorium life. Alcohol is for- 
bidden, except medicinally for appropriate cases. Many consider this 
a hardship not long to be borne by those who have been for many 
years steady and hard drinkers. (Whiskey is sometimes smuggled.) 
It is indeed difficult to keep men, accustomed as they are to the license 
of seaport, lake, and river cities, interested, amused and satisfied in 
tliis arid region. Unfortunately for the station's statistics, the men 
who leave to return to cities are usually those with fair or good 
chances of recovery ; and some cases, favorable wdien discharged, 
have returned after several months only to swell the mortuary 

The Fort Stanton ^jhysicians find that their patients, especially 
those wlio have had hemorrhages at sea level or in low altitudes, are 
less liable to this symptom after admission. They attribute this good 
condition to decreased barometric pressure. 

Every effort is made to prevent the infection of healthy employees, 
and the reinfection of the cured and the convalescent- Sputum para- 


pliernalia, intended for destruction after use, are burned in brick 
crematories, several of wbich arc located at convenient j)oints on the 
grounds. JMetal sj)utuni cujjs are disinfected daily in a specially de- 
signed steam sterilizer. No j)atient can spit on the ground and remain 
at Fort Stanton. Here, as at Saranac T.ake, the experiment of inject- 
ing dust from consumptives' quarters into guinea-pigs has afforded the 
same convincing demonstration. 

It is essential to note Dr. Carrington's opinion that results in 
permanent febrile cases, especially those in which there is a wide 
range of daily temperature, are not better than in less favorable 

At Fort Bayard, an old army post, is located the United States 
General Hospital for the treatment of officers and men who have 
contracted tuberculosis in the servict^ of the government. Up To the 

fall of 1903 this institution, which had been in existence six years, 
was under the direction of Dr. D. M. Appel, a major and surgeon in 
the regular army, who went to Fort Bayard a consumptive in the 
second stage. He is now on active duty in the Philippines, in very 
good health. At present this hospital is under the command of Deputy 
Surgeon-General Edward Comegys. Officers are sent to Fort Bayard 
on sick leave immediately tuberculosis is diagnosed. If their chances 
of recovery are good they are retained on the active list and kept at 
Fort Bayard until cured and able to return to duly. If the indications 
are that they will never be able to accept regular tluty, they are retired 
for physical disability, and as retired officers are entitled to treatment 
in this hospital while they wish to remain there. The percentage 
of cures has been from 8 to 10 per cent. 

1 For results of treatment, see Appendix H. 



"T wish to make one statement, and I confess tliat I do it with a feeling of 
deep humility. As perhaps many of you know, I am interested in a summer home 
some seven miles from Raybrook. On learning that a State hospital for consump- 
tives was to be established at that place, with many of my neighbors I began to 
protest. I have written minatory letters to the Governor on the subject. Doctor 
and Mrs. Newcomb have shown us here a different spirit. They have set us an 
example by bringing this institution to their own home. You can't serve your 
fellowmen unless you are willing to touch them."" — Bishop Potter. 

St. Joseph's Sanatorium, at Silver Citj', New Mexico, is under the 
management of tlie Catholic Sisters of Mercy. Dr. Bullock is the medi- 
cal director, and there is an advisory board of physicians of authority. 
It was establislied in 1901. The two buildinars are arransred about a 

Fio. T.^i— St. .Tospph's SaTiatorinm, Silver City, New Mexico. 

court after the old r'alifornia Mission style. The older structure is 
used for patients requiring special care. The newer is one story high 
and one room in breadth, with porches outside and inside, upon whicli 
each room opens by French windows. The result is really a succes- 
sion of cottages, liaviiig all the advantages and none of th(> disadvan- 
tages of the cottage system. Each room has its fireplace. Tht^ main 


building has a larao reercatioii hall with many windows. Tliciv are 
arrangements lor liydrothorai)y, and a laboratory. The dining-room 
and kitclien, in a separate building, arc reached by a covered way. 

In the future, cottages in wliich families can be accommodated 
will be built around the main structure, so that tlie invalid may be 
accompanied by one or more members of his family. A ''daughter"' 
institution, designed for patients of limited means who can pay but 
part of the regular rate, will be created out of the profits accruing 
from the operation of this sanatorium. Tims the two sanatoria, both 
" closed " institutions, and under one management, will bear the same 
relationship to each other that Falkenstein and Ruppertshain do in 
Germany. An unhmited growth is not, however, contem|ilaled for 
St. Joseph's. Patients must be few in number in order that their care 
may be properly individualized. 

The sanatorium is outside the business centre of the city — a min- 
ing community — on rising ground protected from the i)revailing north 
and west winds by hills, and overlooking a wide range of country be- 
yond. The mountains of old Mexico are within sight. Fort Bayard 
is but nine miles distant. The climate of this region makes it ideal 
for invalids the year round. The altitude is 6000 feet, the average 
annual rainfall 12.3 inches, the mean annual temperature 54° F., 
the absolute humidity 46, tlie relative humidity 171. There are 37 
cloudy days in the year, and the dew-point is 29. The air is dry 
and sterile. 

Only sucli cases as present a fair prospect of recovery are re- 
loived. The institution is for the cure of the disease ; it is not an 
asylum for hopeless cases. Other than incipient cases are taken, how- 
ever ; for it is recognized that frequently long-standing tuberculosis is 
susceptible of great improvement or complete cure. Cases of persis- 
tently high temperature and uncontrollable pulse, or other symptoms 
of a progressively fatal nature, are excluded. Open-air life, rest in 
febrile cases, regulated exercises, driving, measured walks over known 
inclines, diet and hydrotherapy, with symptomatic medication, make 
up the treatment. The charge of |100 a month is found to be the 
minimum at which St. Joseph's can supply the invalid's requirements. 
The advisory board may however recommend, to be admitted at $75, 
such patients as are specially favorable for recovery. The number of 
these is obviously limited. Never, liowever, has any one been turned 
away. Monthly scientific reports are sent to the patients" home pliy- 

Dr. Bullock considers that -if Silver City, climate and all, could 
be transported East, it would shortly become the most famous of sum- 


mer resorts." He finds that patients do best in the fall, winter and 
spring months. Those who have done well in the winter will con- 
tinue their progress during the summer. " Those who have failed 
during the winter will, as a rule, go all to pieces during the sum- 
mer. As for new-comers, the contrast with the home climate is so 
great at any time of the year that they apparently do about as well in 
the summer, though they gain weight more rapidly as cool weather 

Dr. Bullock thanks Dr. H. M. King, the president of the advisory 
board, " who made the long trip across the continent for no other 
pur])ose than to assist at the birth of a new sanatorium." And a 
'- great debt is due the Sisters of Mercy for their devoted services. 
In the face of every obstacle — and our discouragements have been 
many — they have been unswerving in their loyalty." 

'^ The Home," of which the Rev. Frederick M. Oakes is superin- 
tendent, in Denver, Colorado, is conducted under the auspices of 
the Episcopal Church. Many professional men — doctors, lawyers, 
clergymen, teachers, students — whose salaries and incomes are cut off 
by failing health, live here, as far as may be, under the circumstances 
of life to which they have been accustomed, for at least one-half the 
price possible in any other place in Colorado. There are four build- 
ings : St. Andrew's House, for men ; Grace House, for mother and son, 
or husband and wife ; the Emily House, for v.^omen ; and Heartease 
for the very sick. They are connected by glass and covered porches, 
— ''the cloisters." From the porches, beyond vast plains, are to be 
viewed Pike's Peak, Mt. Evans, and Long's Peak. 

The National Jewish Hospital at Denver had its inception in the 
following condition of things, as related in the statement of its Secre- 
tary : " Denver has always been the Mecca for consumptives. Hither 
thousands have hurried, from year to year, to seek the health-restor- 
ing properties of its wonderful climate. Many of them were sent by 
physicians anxious to be rid of such profitless patients. Poor they 
left, poor they came, — penniless, unknown strangers in a strange land. 
Unfortunately, unable to exist on air alone, they fared but little better 
in their new home. Without means, they congregated in the slums, 
in the close atmosphere of the river bottoms, of the smoke of the 
smelters and locomotives, and therefore were not benefited by the 
change. The little that could be done for them by the handful of , 
Jewish people in Denver was unavailing, and many died for want of 
the necessarj^ care who could have been saved ; others more often 
for want of the proper food, and frequently without the touch or 
help of a loving hand to soothe their last hours. It was this condi- 


tion which gave the Jewish people of Denver the idea dI a hosjiilal 
for consumptives, — a free institution for inchyent sufferers. It re(piin'<l 
many years of unselfish, unremitting labor to gain even the first par- 
tial success. The men and women of Denver bore the brunt of the 
work ; they carried on their shoulders the burden of raising money 
for buildings and maintenance ; but it was simply impossible for a sin- 
gle community to maintain unaided an institution to take care of the 
sick of other cities," 

The building was soon raised ; but for ten years it stood empty, 
until now it is " a monument of deeds, one that marks no creeds." 
It is the one haven in that city where only the indigent sufferers may 
come. Under such conditions the hospital has become too small to 
answer the constantly increasing demands upon it, so that it has be- 
come necessary to limit admittance to those whose recovery may 
reasonably be hoped for. New buildings are sadly needed. The 
present building is but a wing of the originally planned structure. It 
is located far enough out on the plains to get the full advantage of the 
pure, sweet air ; near by is the beautiful city park. There is from it an 
unrivalled view of the Rocky Mountains, a semicircular sweep of two 
hundred miles of the most picturesque mountain scenery in the 

The features essential to a well-equipped sanatorium are here to 
be found. Expert physicians treat every phase of the disease. There 
is moderate diversion and entertainment, — cheerful and unrestricted 
social intercourse, games and music. 

We observe again that no money or compensation whatever can 
be accepted from the patients. This hospital is absolutely for the indi- 
gent, and it has been truthfully said that the Jews of America have 
here "added another to the grand monuments that have marked the 
lilDerality of that race through all ages." All ol'licers, directors, trus- 
tees, physicians and managers, in fact all except the actual working force 
within the hospital, give their time and services gratuitously. 

In a noble and eloquent address President Grabfelder stated : '• It 
is pitiful in the extreme, and full of distress to tliose more closely 
brought in contact with suffering, when we are compelled to deny 
admission to worthy persons because ot our inability to acconnno- 
clate those who are justly entitled to our consideration ;" and " when 
successful treatment has arrested the disease, to see the patient com- 
pelled to return to the very surroundings and conditions in which. 
in the first instance, he became a victim." 

It is noted that the financial condition of the married patients has 
generally been at a very low ebb. They are naturally anxious al)out 



the coiulilion of their lielpless families at home, "but when this natu 
ral anxiety was stiunilated by frequent letters from home, expressing 
distress and a longing for their return, it greatly retarded and often 
prevented recovery, and in many instances it so worked upon tlie 
patients that they left the hospital before it was safe for them to do so, 
resulting in complete collapse." 



"I expect to pass through this world hut once ; any good thin^, therefore, 
that I can do, or any kindness that I can show to any one, let mo do il now. Let 
me not defer nor neglect it, for I shall not pass this way again.' 

Over one thousand patients have been cared for in two Muskoka 
institutions conducted under tiie auspices of tlie Canadian National 
Sanatorium Association. It would certainly be difficult to estimate 
how effective is the influence that these patients exert after returning 

Fig. 76.— Shacks at Muskoka. 

to their own homes and communities in spreading iiilclliLrent infonna- 
tion of proper sanatory and hygienic methods of living. The secre- 
tary of this association states in his report for the year ending Sep- 
tember, 1903, that in three years the mortality in Ontario from tuber- 
culosis has decreased nearly twenty-five per cent. Thr mortality from 
this disease for a number of years previously had been steadily in- 
creasing each year. 

The Muskoka Cottage Sanatorium appears to be quite self-sustain- 
ing. The free hospital for consumi)tives, without an endowment to 
rest upon, has from time to time been in need of funds. However, 
this association has lived up to its record of never having refused ad- 
mission to a single patient because of his or her poverty. 



Proniineiit iiuMiical visitors (Voiii all parts of Canada and the 
Stairs have greatly appreciated tlie splendid location, the thorough 
e(iuii)nuMit, and the good results obtained at Muskoka. Dr. J. H. 
Elliott, the physieian-in-ehief, states that during the year ending Sep- 
tember, 1908, sixty-one per cent, of the patients were discharged ap- 
parently cured. Of the advanced cases less than five per cent, were 
apparently cured. 

In considering these results it must be remembered that patients 
are unable for various reasons to remain under treatment as long as 
necessary ; otherwise results would have been even better. Of thirty- 
three far advanced cases treated an arrest of the disease was secured 
in seven. This is of special interest and importance, thinks Dr. El- 
liott, now that the Toronto hospital for advanced cases is about to 
be opened, showing as it does tlie great possibilities in the treatment 
of those usually looked upon as past help. A growing experience 
has shown that a fair proportion of the far advanced cases may be ad- 
mitted with great benefit to themselves and without prejudice to the 
earlier cases under treatment, if a careful selection be made. " Of 
course, these cases can never be admitted to the exclusion of the more 
favored ones, and it is only possible to accept them when we liave a 
number of vacant beds, our aim being as much as possible to main- 
tain the sanatorium as a curative and educative institution, and not 

Dr. Charles D. Parfitt, the physician in charge of the free hospital 
for consumptives at Muskoka, reports that during the year the real 
aim — to cure inci})ient cases — has had to be made subservient to the 
pressing needs of the public. A great number of hopelessly advanced 
cases were precipitated upon the hospital without any previous appli- 
cation for admission. For humane reasons they were not turned 
away. The res])onsibility for this large number of advanced cases, 
considers Dr. Parfitt, rests largely with the family physician, altliough 
he recognizes the impossibility of getting patients from the wage-earn- 
ing classes with as early disease, as from those more prosperous. But 
the family physician has it in his po^ver to urge his patient to cjuit 
work and place himself in the sanatorium at a much earlier period 
than when lie usually comes. The likelihood that a case will progress 
towards recovery should, in Dr. Parfitt's opinion, form the basis on 
which patients are admitted, rather than priority of application. If 
this basis were ado|)ted a greater number would pass through the hos- 
pital with benefit c(uickly obtained, and the range of usefulness of the 
institution would l)e increased. Patients who are considered physi- 
cally able have been given light work to do, either in or out of doors, 



— an advantageous i)laii, as many have shown a marked improveiiiciit 
while being regularly employed. And liie aim has been lo lind work 
for graduate patients who, being unable to remain longer as i)atienls, 

Fig. 77.— Shack at Miiskuka. 

are thus enabled to prolong their stay, live under sanatory conditions, 
and become at the same time self-supporting. To this end it is urged 
that if some industrial interest could be added to the hospital its use- 
fulness would be greatly enhanced. 



Tuberculosis primis in sladiis semper curahilis 



Give him ;iir. h<>"ll striiitxlit be well. — Shakespeare. 

In 1840 George Bodingtoii. "an obscure country j)ractitioner," 
living in Sutton Coldfield, Warwickshire, England, published an essay 
on -'The Cure of Puhnonary Consumption on I*rinciples Natural, 
Rational, and Successfnl." in wliich he dwelt on the importance of a 
generous diet, fresh air day and night, together with systematic arrange- 
ments with regard to exercise and general treatment, and the watch- 
fulness daily — nay, almost hourly — over a patient by a medical 
superintendent. He insisted on fresh air, declaring that cold is never 
too intense for a consumptive patient ; the apartment should be kept 
well aired, so that it should resemble the pure air outside, pine air 
being used in the treatment as nmch as possible. There have been in 
England special hospitals for consumptives, — namely, the Royal Sea 
Bathing Infirmary for Scrofula at Margate, established in 1791 ; the 
Royal Hospital for Diseases of the Chest, in London, in 1814 ; and the 
Brompton flospital for Consumptives, in 1841. But Bodington estab- 
lished in Sutton the first sanatorium in the world wlii'h was based 
upon the principles he set forth ; and for several years previous to the 
publication of his essay, he had here practised these princii)les and 
had effected many cures. However, upon their publication, his views 
met with most bitter and contemptuous opposition. He was regarded 
as a lunatic; his patients were driven from his institution, which "by 
the irony of fate he was compelled to turn into an asylum for the re- 
ception of the insane." 

In 1855 Dr. Henry McCormac, of Belfast, published a book on 
somewhat similar lines, and had " to bear every kind of persecution 
to which a man in his position could be subjected."" In 1861 he ad- 
vocated what are now established principles in a paper on the "Abso- 
lute Preventability of Consumption." At about this time the same 
doctrine was preached by Bennett, of Mentone, and by the late Sir 
Benjamin W. Richardson, who embodied liis views in "A Sanitary 

Now^ (1905) there are many sanatoria for consumptives in the 
British Islands — at Brompton, Ventnor, Cotwold on the Norfolk coast 




— some seventy in all. The majority are, however, for paying pa- 
tients, and there is urgent need of providing accommodation for the 
poor consumptive. 

The Slierwood Forest Sanaturium, built by the Nottinghamshire 
Association for the Prevention of Consumption, is a wooden structure 
erected for workingmen at a total cost of £5300, about £220 for each 
bed. In this sum are included drainage, electric lighting, water sup- 

FiG. 78. — Shenvood Forest Sanatorium. (Hillier. ) 

ply, roads, and all otiier sources of expenditure, much of which is in- 
curred once for all. Consumptives of limited means in this county 
and adjacent districts are eligible. The institution is situated on a 
pine-clad slope, four hundred and seventy feet above sea-level, and 
facing a wide expanse of heather and bracken. Tliere are fifty acres, 
half woodland, half moor, which are continuous with a wide tract of 
similar country stretching northward for miles towards Rufford and 
Ediuiiistown. The building, on the edge of the wood, faces soutli- 
southeast. It is J. shaped. A central block, containing offices, rooms 
of tlie staff, and some small wards, separate the male from the female 
wing. Each wing accommodates seven patients, — a private ward, bath, 
and cloak-rooms. Verandas running along both south and north sides 
of these wings enable the patient to lie on the side most sheltered from 
the wind in winter and the very warm sun in the summer. 

"Several have slept there comfortably during the severe snow- 
storms of February," writes Dr. W. B. Ransom, the lionorable secretary 
of this association. There are now twenty-three patients, two nurses 
and four servants. There are two visiting medical officers who come 



daily and are paid a salary. The corporation of Nottingham has 
contributed £1000 towards the sanatorium's funds ; that of Mans- 
field, £200. The remainder has been contribuled privately, and 
chiefly from those interested in individual applicants.' 

Among comfortably equipped sanatoria for i)ayiug jxitionts of mod- 
erate means there is the London Open-Air Sanatorium at AVokiugliam, 
which stands in eighty-two acres of pine woods on the borders of 
old Windsor Forest; the soil is saudy, the altitude two hundred and 
fit!y-two feet above sea level. The building stands in the centre of 
the grounds with an open glade immediately in front of it. There is 
a central administrative block, two separate bedroom blocks on either 
side of the central block, and behind a dining-room and kitchen block. 
There is a separate laundry. The bedroom blocks are divided into 
ground and first floor, the latter being reached by a wide and conve- 
nient staircase. All the bedrooms face south, and the '■vindows open 
almost from floor to ceiling. There are sixty-four patients, each of 
whom has a separate bedroom. There are outside sun blinds and 
light inside curtains, hung at some distance from the window. Each 
bedroom contains, in addition to the ordinary bedroom furniture, a 
cane couch, on which the patient may rest quietly in his own room 
during the day. The dining-room is large and airy, with windows 
opening to the ground ; the kitchen has every modern cooking ap- 
pliance ; there is electricity ; the grounds are open to use of patients ; 
there are open-air shelters, electric lighted. The staff is made u|) of 
a resident medical officer and an assistant. Two London physicians 
examine applicants. Patients pay three guineas a week. 

The Ventnor Consumption Hospital, or "TheKoyal National Hos- 
pital for Consumption and Diseases of the Chest," was founded by Dr. 
Arthur H. Hassall in 1869 on the southeastern coast of the Isle of 
Wight. Originally formed of a single block it now consists of eleven 
or more, together with a handsome chapel. The climate is mild and 
the atmosphere, being practically that of the ocean, is germ-free. Its 
temperature ranges between 80° and 25° F. The site covers more 
than twenty acres '• in one of the loveliest and most sheltered spots 
of the Undercliff." Each patient, no matter what his circumstances, 
has a separate bedroom. The houses are well sheltered from unfa- 
vorable winds, constructed upon sound principles of sanitation, and 
surrounded by gardens. There are large sitting-rooms, lovely land- 
scape and sea view, plenty of light and sea air, effective ventilation, 
and good drainage. There is, however, an absence of verandas and 

For construction details, see Appendix F. 


reelining-chairs. Those in an early stage of tuberculosis, such as 
atiord a roasonablo expectation of cure or of marked alleviation, are 
eligible. Each ])alient must pay $2.50 a week in part payment of the 
cost of maintenance. The institution has an annual expenditure of 
$55,000. tlie greater portion of which is raised by voluntary subscrip- 

Early in 1902 Sir Ernest Cassell gave to the King £200,000 to be 
used for whatever charitable purpose might seem best. It was de- 
cided to erect a sanatorium for consumptives ; and to this end physi- 
cians were invited to submit essays and plans in competition for the 
erection of a sanatorium. Dr. Arthur Latham, in association with 
A. William West, architect, secured the first prize. In this essay 
the main principle enunciated was that the resistance of the body 
should by every possible means be developed so as to render the 
tubercle bacillus innocuous. Latham proposed the following modifica- 
tion of Brehmer's essentials to cure (Part X, Chapter V) : There should 
be a continuous supply of pure air with no unnatural variations of 
temperature ; the avoidence of reinfection and of all sources of irrita- 
tion, such as dust ; good, nourishing food in sufficient quantity to es- 
tablish and to maintain the normal body weight of the patient ; 
constant supervision by a skilled physician, who so orders the patient's 
life that he avoids everything which is harmful, and takes advantage 
of everything whicli lielps the process of repair or develops the powers 
of resistance. 

Dr. Latham's requirements for a sanatorium are the following: 
All patients must have comfortable accommodations, a separate 
room being provided for each ; the sanatorium should be on an ele- 
vated and sloping site, with a sunny exposure, and well sheltered from 
cold winds ; there should be a farm at a convenient distance ; there 
should be extensive grounds, well wooded, and affording ample space 
for exercise of various kinds; the soil should be dry and permeable; 
the water supply abundant ; there should be the latest sanitary ar- 
rangements and all essential scientific equipments ; the ventilation 
sliould be such tliat the air contained within the rooms and passages 
is free from all sources of contamination and rivals the outside air in 
purity, whilst at the same time draughts are avoided. 

The buildings should be so situated and so constructed that dust 
is avoided as far as possible ; and the fittings should be of such a kind 
that inevitable dust can readily be removed. 

Arrangements should be complete for the quick and effectual de- 
struction or disinfection of all infected material. 

The buildings should be so arranged that constant medical super- 


vision can bo readily exorcised. The qnarters of tln^ iiiedical men 
should overlook the grounds. 

The bedrooms of the sexes should, necessarily, be in (hn'orent 
blocks, but there is no necessity for separating the men and women 
in the dining-room or grounds. Four classes of patients must be pro- 
vided for, both in the sanatorium and in the grounds: those who can 
}| take exercise more or less freely ; those who can only take light exer- 
cise on level ground ; those who must be isolated in their own rooms ; 
those who, though unable to take exercise, may be allowed to associ- 
ate with a few other patients. 

The acconnnodation for visitors must be limited. 

No provision, so far as the buildings are concerned, need be made 
for amusements beyond an entertainment room, which may also serve 
the purpose of a lil^rary ; such games as billiards, golf, and tennis, 
which involve much movement of the arms, or lead to excitement, 
should not be provided. 

A few^ open air galleries are of service, but nothing approaching 
the Liegehalle system should be erected. 

The dining-room and kitchen should be completely cut off from 
the patients' rooms, but no separate dining-room need be provided for 
the regular staff; the kitchen should be very modern and thoroughly 
i sanitary ; the dairy and the farm should be of a model character. 

There should be ample accommodation for hydrotherapeutic meas- 
ures, with adequate laundry and clothes-drying apparatus. 

The heating arrangements sliould be such that the temperature is 
\\ never raised more than a few degrees above the outside temperature, 
so that no sudden variations are experienced when the patient loaves 
his room, and that the humidity of the air is not sensibly diminished. 
Adequate shelter should be provided in the grounds and elsewhere 
against wind, excessive sun, or heavy rain. 

No special arrangements need be made for exercise under cover in 
bad weather, though it is as well to provide covered ways between cer- 
h tain of the buildings. 

All facilities should be provided for the treatment and clinical ob- 
servation of the patieids by the aid of laboratories and special depart- 
ments,— such as bacteriology, pathology, chemistry, physiology, and 



Speaking of the relative numerical importance of diseases in relation to child 
life, he (Dr. Menard, of Berck-sur-Mer) said, with a forgivable epigrammatical ex- 
aggeration, that there were but two which counted. — alcoholism in the parents, and 
tuberculosis. — lirifhh Mrdicnl Jonmal, June 11. 1904. 

In France there are isolated sanatoria, imt the united effort has 
been directed — most nobly, as we have seen — towards combating the 
disease in childhood. Among sanatoria for adults that at Canigou is 
the first founded in France where the principles laid down by Brehmer 
and Dethveiler were carried out. This is now done with as much 
vigor as the peculiar arrangements of tliis institution Avill permit. 
There is here a gallery for the rest cure, situated several hundred feet 
higher than the Jiiain building, in reality a hotel, in which the patients 
take their early breakfast. They then proceed to the gallery. The 
next meal, an elaborate one, is served at noon in the dining-hall an- 
nexed to the veranda of the rest cure. There is also nourishment 
between meals. Towards evening the patients descend to dine at the 
hotel and to sleep there. Many of them are strong enough to make 
this trip on foot ; the feebler ones go in an omnibus. Otherwise, the 
treatment is as in the German sanatoria. The patients rather like tlie 
change of going up and down, '' this being a pleasant interruption to 
the rather monotonous mode of Hfe in the sanatorium.'" This institu- 
tion is closed during the hot months. It is situated in a park of some 
sixty acres, well wooded, with chestnut trees, acacias, oaks and pines. 
Palms, aloes, olive-trees and cacti grow treely without artificial shelter. 

The Boucicault Hospital was founded by the late proprietor of the 
Bon Marclie ; two of its five wards have been set apart for the hygienic 
treatment of consumptives. There are here certain beds reserved 
for the Bon Marche employees. During eighteen months one hun- 
dred and twenty-five patients have been under treatment, most of 
these suffering from the more advanced stages of the disease. The 
precautions against infection and against the dissemination of dust are 
said to be very complete. The patients are clad in aseptic dresses, 
Excei)tiiig on visiting days little or no dust is brought in from outside. 
The windows are kept open day and night, and twenty-two reclining 
chairs, with pillows of oats, have been ^irovided in the garden for rest 
in the open air in tents. 

At Bligny (S(nn-et-oise) there is a sanatorium popidaire which is a 
type of iustitulicjiis for men only. 



Zwei Diiiije lorn treduldiif trapron : 
Dein eignes Leid, dnr andnni Klagen. 

Among Austrian sanatoria is that establislicd at Alland, soiiio six- 
teen miles from Vienna, for the poorer classes, in conned ion with the 
liospitals of that city, whose citizens, in the main, subscribed the nec- 
essary funds. The site is of unusual beauty in a valley in the Wie- 
nerwald. The grounds, having a southerly slope, comprise nearly two 
hundred acres, and consist of woodland, meadows, and cultivated land 
in about ecjual proportion. The sanatorium is fourteen hundred feet 
above sea level ; and about it the mountains rise to the height of two 
thousand two hundred feet above the sea, to the east, northeast and 
northwest ; so that tliere is an absence of strong wind. There is Ijut 
little dust. The soil is mainly limestone, with some clay. An aque- 
duct brings water pure and abundant. 

Tliere is a main building having a fresh air gallery running along 
its south side, and a glass winter garden in the centre. Tliere are 
quarters for medical men wlio come to study the methods of treat- 
ment. Others besides this building are scattered in the park. 

Patients are chosen at the general hospitals of Vienna, and are ex- 
clusively males in remediable stages. After a probationary [)eriod of 
three weeks they stay for three months. Certain among them are 
allowed to do gardening and other work suitable to their physical 




Allen Menschen Recht gethan 
1st pine Kunst die Niemand kann. 

In Switzerland, as in (lerinany, there are many sanatoria. As in 
Germany also the organization is excellent and the results definite. 
At Davos Platz are several institutions. This region, situated in a high 
funn<'l-shaped valley, traversed by a little torrent, the Landwasser, 
among the mountains of Grisons, has an altitude of five tliousand feet, 
an average rainfall of thirty-six inches, and a mean annual tempera- 
ture of ?>7° F. The average is one hundred and fifty cloudy days to 
the year. The valley runs from northeast to southwest. In the north 
there is a high chain of snow mountains, and to the east tlie valley 
is i)rotected by a strongly projecting mountain spur. To tlie south 
there are fields and pine woods. In an angle in the valley is Davos, 
which has a large population, many of whom are consumptives. For 
the latter, this town has some disadvantage, which inevitably exists 
in a fashionable health resort, — many consumptives congregate to- 
gether with a mixed population of tourists and other invalids. There 
is skating, tobogganing, sledding, snowshoe running, and like sport, in 
the winter; and there are concerts and entertainments in crowded 
places to a degree which may be deleterious to the health of delicate 
persons. "Many of the consumptives there are scarcely, if at all, 
under medical control, and are apt to disregard the direction of their 
medical advisers, to their own hurt and possibly to the disadvantage 
of others."' 

Here is situated Dr. 'J'urban's Sanatoriun^. There is a fine view 
to tlie south and soutliwest over meadows and the town to the moun- 
tains beyond. A garden of seven acres, with walks at general gradi- 
ents, adjoins the grounds of the Kurverein, to which patients have 
access on the payment of a subscription. Each bedroom in the main 
building has a radiator, capable of ventilation and having a ventilating 
inlet next to it ; on the opposite wall is an outlet leading to a chamber 
under the roof. 

The diet varies. One day it is rccherclw ; the next it is simple in 
character. There are six meals a day. No advanced cases are ad- 
mitted. There are extensi\'e fresh air galleries ; but afebrile patients 



take a good doal ot exercise in the open. Tlie neighborhood is care- 

, fully inapjxxl out in quarter hour walking distances. Dr. Turban has 

■ established a class of '^ Prophylactiker," made up of the children of 

his i)atienls, wlioni he educates physically and mentally, so that Ihey 

may avoid the disease of their parents. 

The Basel Sanatorium at Davos was founded for workingmen and 
poor patients by the Gemeinniitzige Gesellschaft of Basel, on the initia- 
tive of the medical profession, and with the help of public subscrip- 
tions. This is one of some ten institutions devoted to a like purpose 
on Swiss soil. 
ij In order to expose as little surface as possible to the cold air this 

sanatorium was built on a concentrated plan, of an L shape, instead 
of the extended one-sided arrangement common in the lowlands : it 
[j is in a very sheltered situation, being protected to the east and west 
by pine woods; the aspect is southwesterly. 

To the west of Davos, in the valley of Arosa, at an altitude of 
six thousand feet, surrounded by pine-covered mountains, and near 
two beautiful lakes of clear water, a majestic sanatorium has been 
built. Most of the rooms face south and southwest and open upon a 
t! wonderful panorama. The view to the south is over meadows which 
rise to naked peaks in the distance ; to the west are wooded mountain 
sides. A few rooms have balconies ; every room has its own fire- 
place ; in a covered veranda facing south are chairs for the rest cure ; 
II here the patients pass the greater part of tlie day. Many walks are 
taken over sunny meadows, or in the woods. The altitude here is 
higher, and the climate rather more stimulating, than at Davos. 

This sanatorium is situated some nine hundred feet above the 
village of Leysin in the Canton de Vaud. It is well protected from 
the cold winds, and is in a pine forest. The air is calm; and the 
Vvinds, which come rarely, are mostly from the south. From the 
, terrace Liegehalle there is presented a beautiful panorama of moun- 
i tains, forests and villages. Most of the one hundred and ten rooms 
have balconies. The ecjuipments of the wdiole institution — furniture, 
carpets, curtains, etc. — have all been selected with a view to easy and 
thorough disinfection. Around the institution are numerous sun- 
boxes wdiere patients may rest during their walks. This sanatorium 
is especially for French-speaking people. Patients of all stages are 
admitted, provided there is any probability of their benefiting by the 




riulrr the iiitnliillion of Brehrner at Goerbersdorf is this inscription (trans- 
l;ite(i Ity Kiioiif): 

Only the physician who lias studied nature, 

and has trained his mind in mathematical science, 

knows how to cure men. 

Ix Germany there are numerous institutions, and there is greater 
(Effort , better organization, and more definite results than anywliere 
else in Europe. 

The folks sanatoria came into being in 1896. Eight hundred dis- 
tinguished citizens formed a central committee, of which the Empress 
is the protectress, the Chancellor of the Empire, Von Biilow, is the 
honorary i)resident, and General Von Pannwitz is the secretary. 
This committee began the work of erecting folks sanatoria, or Volks- 
heilstatte (people's curing stations), which work has progressed so 
earnestly that tliere were in the sunnner of 1903 fifty-seven such 
institutions in full operation and twenty-six in process of building. 
Nearly eleven thousand consumptives are now thus accommodated in 
Germany. Some of these structures have been built by the Society 
of the Red Cross, some by railroad corporations, some by life insur- 
ance companies, some by individuals, and associations organized for 
tliat special purpose, and some by the Agricultural Insurance Society. 
Only incipient cases are supposed to be treated. These folks sanatoria 
are places for curing the disease. However, many second- and third- 
stagers gain admittance and are often benefited. 

The erection and maintenance of many Volksheilstatte depend 
upon the workmen's insurance system of Germany. Of these institu- 
tions the Grabowsee Sanatorium is an excellent example, being con- 
ducted on economic lines for the benefit of the working classes. Origi- 
nally erected by the Red Cross Society in 189G, it stands upon a hill 
among pine woods, about eighteen miles from Berlin. The site covers 
forty-eight acres, is twenty-five feet above sea level, on sandy soil. 
The land was obtained on a long lease, on a yearly rental of fifty 
marks. The sanatorium originally consisted of some two dozen light 
pavilions intended for use by the army, " Dockersche barracken." 
The walls were constructed of a specially prepared double layer 
thickened pa|)er. Tlie " barracken" were of various sizes, the wards 
accommodating eight ])atieids each. These buildings have been gradu- 




ally replacod by permanent slruciiiros of brick, wood and iron. an<l 
now acconiniodalo one hundred and ninety patients, al a per capilii 
cost of throe marks a day. Only men— some privah- paticnls. olii<'rs 
sent by insurance societies — are the occupants. 

Dr. Dettweiler's sanatorium at Faikonshnn has been since its estai)- 
lishment "the Mecca for students of modern piilliislotherai)hy all 
over the world," From a 
graceful appreciation by Dr. 
Knopf we learn that Privy 
Counsellor Dr. Peter Dettweiler 
took his degree in 1863. He 
was an army surgeon in tlie war 
of '70. During the perform- 
ance of his duties he con- 
tracted consumption, and, re- 
signing from the army, became 
a patient at Goerbersdorf. His 
health being restored, he be- 
came an enthu.siastic assistant 
to Brehmer. In 1873 he pub- 
lished his tirst \vork upon the 
treatment of consumption, and 
after six years' service at Goer- 
bersdorf founded the Falken- 
stein institution. Physicdans 
from everywhere — many from 
America — visited this sanato- 
rium, where they were heartily welcomed, and leariKMl the methods 
pursued there. 

Among many other achievements D.'tlweiler instituted the open 
air rest cure on the reclining chair. He founded the first sanatorium 
for the consumptive poor, which is situated at Rujjpertshain : and it 
is to his initiative that Germany is now indebted for its many institu- 
tions of this sort. He was a charitable man. of unusual coi'di.ility 
and kindness, yet strong in personality, stern antl severe Avhen occa- 
sion demanded. '• His control of his patieids was wonderful. He 
studied the soul-life of every patient; lie was his IViciul. confessor 
and physician." To his assistants he was an ideal chief, always hel])- 
ful and considerate. 

Ivnopf quotes the following from an address delivered by this great 
humanitarian: "The medical director of a sanatorium for consump- 
tives should not take upon himself the responsibility of such a posi- 



tion unless lie is fully prepared and honestly feels that he can excel 
his co-workers in strength, creative power, discretion, faithfulness, and 
duty. Otherwise, he is no better than a hired em])]oyee, too weak for 
the great and u[)lifting cause of service to his fellow-men, which at 
the end of this nineteenth century has grown to such great heights, 
and which promises so much for suffering mankind," Dettweiler 
died in January, 1904. 

The first German State Invalidity Insurance Company undertaking 
the creation of its own sanatorium for its consumptive clients was the 
Hanseatische Versicherungsanstalt fiir Invaliclitats und Altersersic he- 
rungs, of Lubeck. A beautiful site was selected in the Harz moun- 
tains, on the slope of the great Oderberg, at an altitude of nearly two 
thousand feet. The mountains and woods are a protection against 
cold winds. The institution occupies an area of some nine acres. 
There is a main building consisting of a central portion and two an- 
nexes. Apart from tliis is a machinery-room and a laundry, the resi- 
dence of the physiciaii-in-chief, disinfecting and autopsy-rooms, and 
stables ; and there is a building occupied by the employees and their 

The bedrooms for patients are seven rooms with one bed each, 
fourteen rooms with two beds each, six wdth three beds each, and four- 
teen with four beds each. Besides these there are bedrooms reserved 
for patients to be isolated. The equipment of the institution is plain, 
comfortable and hygienic. The ventilation is wellnigh perfect; the 
heating is done by .steam ; the lighting is by electricity. There is an 
excellent water supply and a good drainage system. 

In front of the building is a large covered gallery, and along the 
east and west sides of the house are the galleries for the rest cure and 
promenade exercises on rainy days. These galleries are twelve feet 
wide and more than four hundred feet long. There is a large square 
in front of the sanatorium, whicli, being specially protected against 
cold winds, is a favorite place for patients to promenade. 

As to discipline, a certain number of patients select a foreman who 
is responsible to the physicians and the general superintendent (two 
distinct olTices) for the carrying out of the general and medical direc- 
tions on the part of the patients. The treatment is hygienic and 
dietetic, and the patients are sent to the institution immediately the 
medical examiner of the insurance company detects the disease. Dr. 
Knopf notes that the walls at Oderberg are ornamented with sugges- 
tive verses, — some of which grace the pages of this book. 

At Goerbersdorf are the sanatorium founded through the generos- 
ity of Countess Pueckler, and that of Dr. Hans Weicker, both under 



the direction of the latter. Tlie former of tlicse institutions ac- 
coinniodatcs thirty patients from among the 'middle class." This 
small number is in accordance with the wishes both of the founder 
and of tlie physician, " wlio desire this sanatorium to resemble in a 
measure a family home." Dr. Weicker dines with the patients, and has 
inaugurated "zwanglose Vereinsgungen," — informal reunions where 
patients and physicians meet and where hygienic instructions are im- 

The other institution — the Ivrankenheim — consists of various 
villas distributed throughout the village. These are exclusively for the 
poor, and only incipient cases are admitted, of whom the majority 
are sent for treatment by tlie State Invalidity Insurance Comijanies 
of Germany. These companies sent twelve patients in 1894, sixty-six 
in 1895, two hundred and fifty-six in 1896, and five hundred and 
twelve in 1897. There is a division for men and one for women. 
The inmates of each villa select a foreman from among their number 
who is responsible for the order in the house, takes each temperature 
twice daily and sees that all the directions of the physicians are faith- 
fully carried out. 

Honnef on the Rhhie is protected against the cold north and east 
winds by the " seven mountains." Hohenhonnef, the site of the sana- 
torium, which was established in 1892 by Dr. Ernst Meissen, a former 
assistant of Dettweiler, is seven hundred and thirty-five feet above 
sea level, and is surrounded by a park. There are many promenades 
of various inclination, to suit the exercises graduated for the patients. 

The main building is so constructed (the two wings forming obtuse 
angles) that nearly all the rooms receive sunlight for at least a few 
hours during the day, the majority having a southwestern exposure. 
The gallery for the rest cure extends along the main front, and has 
room for a hundred rattan lounges. There are douche- and inhala- 
tion-rooms, laboratories, drug-rooms, etc. Dr. Walters considers tliis 
probably the most luxurious sanatorium for consumptives on the 
continent. "There is, indeed, a little danger lest the internal comfort 
should tempt the patients to spend too much time indoors ; but I saw 
no indication wdien I was there of such mistaken conduct, which is 
no doubt prevented by Dr. Meissen's watchful care." 

Reiboldsgrtin is picturesquely situated in a dense pine forest in 
the southern portion of Saxony, at an altitude of two thousand four 
hundred and sixty feet. The sanatorium has no habitations near 
by, and it is an hour's distance from the nearest village. The various 
buildings form a little village by themselves. The Kurhaus contains 
dining-rooms, parlors, music-rooin and kitchen. From the villa 



Wintorhoim there are covered glass galleries whicli lead to rest- 
cure verandas, to the villa Wiesenhaus, the villa Hugosruhe, the 
Thurinhaus, the Karlsruhe, and the Mathildenruhe. There is a 
park of over five hundred acres. The surrounding country offers 
many opportunities for excursions. Dr. Wolff, the medical director, 
himself an accomplished musician, sees to it that frecjuent concerts 
and theatrical entertainments are provided. There is at Zoebisch, near 
by, a little colony of friends of patients residing in the sanatorium 
grounds, with a sprinkling of convalescent patients among them, who, 
while still under the doctor's care, have graduated from the sana- 
torium and no longer require strict supervision. Near the sana- 
torium is a natural spring containing iron salts, the water of which is 
utilized for the anoemic patients. 

We have now, in a manner, reached a climax in the consideration 
of sanatoria. We are ready to appreciate Herman Brehmer and tlie 

truly magnificent results of his 
work. Being attracted by tlie 
ideas of that obscure country 
doctor in England to whom we 
have referred, Brehmer founded 
upon them the sanatorium treat- 
ment of tuberculosis. Like Bod- 
ington he had to meet much 
ridicule and opposition. How- 
ever, he persisted in spite of 
this, and succeeded finally in 
convincing the world of the 
soundness and importance of 
the methods he elaborated. In 
1859 he was permitted through 
the influence of Humboldt and 
Schonlein to open his sana- 
torium at Goerbersdorf in Prus- 
sian Silesia, whicli he raised 
from small beginnings to be- 
come the largest private institution of its kind in the world, having 
a division for the well-to-do, one for the '-middle class," and one for 
the ])oor. 

His views were not, of course, generally accepted at once; "in- 
deed, some of the grounds uj)on which they were based have since 
been shown to be erroneous." His work and that of his supporters, 
howe\er— Boliden, Dettweiler, and Otto Walther in Germany, Sir 

FiH. 80.— Brehmer at the hcfrinnins of his work. 



Hermann Weber in England, Blake and Trudcau in America — have 
established fnlly the value of the open-air treatment of tuberculosis. 

Brehmer held that certain conditions, more especially a small heart, 
made people much more liable to tuberculosis. He observed that at 
Goerbersdorf there was hardly any tuberculous disease, and that the 
inhabitants had peculiarly powerfid hearts. This he thought to be due 
to the air pressure at that altitude. He argued next that " anything 
which protects one man from falling ill must be able, if properly em- 
ployed, to cure another of the same disease," and from this argument 
he evolved the following principles of treatment : 

1. A life spent in tlie open air under conditions which give im- 
munity from tuberculosis. 

2. Complete freedom from any debilitating circumstances or any- 
thing which may lead to an exacerbation of the disease. 

3. Medical hill-climbing as an exercise when the condition of the 
patient renders this advisable. 

4. An abundant dietary in which milk, fatty food, and vegetables 
occupy an important place. 

5. Various hydrotherapeutic measures. 

6. Constant and unremitting medical supervision. 

At Goerbersdorf the old and the new Kurhaus, in Gothic style, 
have dining- and small conversation-rooms, a reading-room with a mag- 

, "i 



Fig. si. —The Brehmor Sanatorium. 

nificent ceiling, a winter garden wilh fountains, all lieatcnl by a water- 
heating apparatus. The halls and rooms are amply ventilated by 
Kosmos ventilators and other means. There are covered balconies, 
verandas, Leigehalle, several villas, meteorological observatory, and 
a chemical and bacteriological laboratory from which has emanated 
much scientific Avork. These buildings niv m a park of three hundred 



acres, which has splencUd trees extenchng to the top of the moun- 

In 1854 this sanatorium was estahlished, and there was a semi- 
centennial celebration in 1904. A jjropos of this occasion Dr. Knopf 
wrote concerning the great debt which the civilized world owes to this 
mau. After graduating in medicine he began to practise in Goerbers- 
dorf, at that time a village of some nine hundred inhabitants. The 
hygiene established by Brehmer demonstrated tliat in a well-managed 
and well-ecjuipped sanatorium one is less likely to contract tubercu- 
losis than anywhere else. There are no\v some seven hundred con- 
sumptives living in the five flourishing sanatoria at Goerbersdorf (two 
of Brelnner, two of Weicker, and one of Rompler). Nevertheless, 
the mortahfy in the village is now one-third less than it was before 
these institutions were established, and the result must be ascribed 
in large measure to the perhaps subconscious imitation of the habit of 

cleanliness obtaining in the sanatoria. 
The village has also gained in its eco- 
nomics ; it is now one of the most pros- 
perous communities in Germany and 
has trebled its population since 1854. 

This great physician, who died in 
1889, never received any recognition 
from the German Government, — no title 
or decoration such as means so much 
in that country. He had independent 
and democratic views, and was sturdy 
in their expression. However, a beau- 
tiful monument, recently erected in 
front of the sanatorium park, built by 
patients and physicians from all the 
world over, expresses the gratitude they 
feel. His was a striking personality, — imposing, energetic, with a 
beautiful head on broad shoulders and a patriarchal beard. He 
was " a true friend, an ideal physician, and a great and good man." 
Al the time of his death there were some three hundred sanatoria in 
Germany ; and there are now many more of these, for the absolutely 
poor as well as for the affluent. And in many other countries — 
tlinjiighoiit the world, indeed — the number of these benignant insti- 
tutions is constantly increasing.' 

Fig. 82.— Brehmer. 

^ The works of Cornet, Knopf, and Walters contain lists of European sanatoria. 

Part XI 


Let me conclude with a quotation from De Quincey. which puts 
in graphic language the question which so many generations have 
asked, and asked in vain, hut which we have been permitted to 
answer in part, at any rate, and to answer in hope: " If you walk 
through a forest at certain seasons, you will see what is called a 
blaze of white paint upon certain elite of the trees marked out l)y the 
forester as ripe for the axe. Such a hlaze, if the shadowy world 
could reveal its futurities, would ])e seen everywhere distributing its 
secret badges of cognizance amongst our youthful men and women. 
Of those that, in the expression of Pericles, constitute the vernal 
section of our population, what a multitudinous crowd would be 
seen to wear upon their foreheads the same sad ghastly blaze, or 
some equivalent symbol of dedication to an early grave. How ap- 
palling in its amount is this annual slaughter among those that 
should by birthright be specially the children of hope, and levied 
impartially from every rank of society ! Is the income-tax or the 
poor-rate, faithful as each is to its regulating time-tables, paid by 
any class with as much punctuality as this premature florilegium, 
this gathering and rendering up of blighted blossoms by all classes? 
Then comes the startling question that pierces the l)reaking hearts 
of so many thousand afflicted relatives : ' Is there no remedy ? Is 
there no palliation of the evil?' " It is one of the greatest triumphs 
of scientific medicine to be able to reply, Yes, the evil may be palli- 
ated and is rapidly being lessened, and for many, at least, a remedy 
has been found. 



CllAl'TER I 


"The following is the daily regime (in German sanatoria) : 
'•At eight o'clock in the morning a domestic enters the hedroom of the patient 
and closes the windows, which have remained open all night. He lights a fire 
and serves the first breakfast. After this the patient arises and is comfortably ar- 
ranged in a long chair something like a steamer chair, out of doors, generally on a 
l)rotected porch. His legs and body are warmly covered and often a hot-water bot- 
tle, if the weather is cold, is placed at his feet. 

"About eleven o'clock concentrated nourishment is brought to tlie patit>nt : a 
glass of milk, some egg-nog, or bouillon. At twelve, luncheon, after wliich 
the patient enjoys a promenade, which, varies according to the prescription of the 
physician. The promenade is made on a terrace or in a winter gard<'n connected 
with it. Afterwards the patient resumes his place in the reclining-chair and passes 
the whole afternoon in a state of absolute repose. A quiet game of cards, domi- 
noes, conversation, or reading, is not forbidden. Certain patients indulge in pro- 
found sleep, and care should be taken that this in no way interferes with the sleep 
of the night. Often at four o'clock nourishment is brought to the patient. After 
this dinner is served, and after dinner another promenade, shorter tlian that in the 
afternoon. The patient then returns to the reclining chair and remains there until 
ten o'clock in the evening, and then retires and sleeps in a flannel gown. The 
windows should be open all night. As patients improve they are allowed to 
take more exercise and prolong the promenade. In some of the sanatoria the 
beds are arranged on tracks, a plan which enables them to be wheeled out on the 
porch so that the patients can lie in the open air." — Looms. 

Sanatoria, then, are ideal places for the care and treatment of 
people "who are consumptive. 

These institutions, when well conducted, are not a source of 
danger to the community in which they are placed. In fact, they 
come in the course of time to be very beneficent and really desired. 
The death-rate from consumption in such communities, rather than 
being increased, comes to be greatly lowered, for the reason that the 
measures against infection wdiich are taught and enforced in well- 
conducted sanatoria, are learned by the population about them. Nor 
are the well likely to become infected in sanatoria ; nor the patients 
to become reinfected in tliem. Dr. Trudeau declares that in nineteen 
years no nurse at Saranac Lake, nor any of the attendants or servants, 
had contracted consumption ; and the dust taken from all the build- 
ings of this institution, except in one instance, failed to infect guinea- 
pigs. I do not believe that results so favorable could be had from 



any one of a hundred city dwellings taken at random one after the 
otlier. Moreover, tliose wlio liave been cured of consumption in 
sucli institutions as these go out well-trained medical missionaries, 
teaching others the habits of sanitation and cleanliness they have 
accustomed themselves to. 

We have found the communities of Goerbersdorf and Saranac 
Lake to be benefited with regard to material prosperity by their 
sanatoria; it has been, and is now, the same witli Falkenstein. The 
sentiment of sucli communities may be judged by tlie results of the 
following iiKjuiries : 

Several citizens of Saranac Lake, the metropolis of the Adiron- 
dacks, were asked whether there is any prejudice against the institu- 
tion on account of its nearness, one mile and a half, to the place. 


I I iT W>. ■ TT-tT^iff*^ir,ttff«? i 



ffT"'|r^i IfVlDIP : T-nrTTrTTTTITTTIII lY«ff<f^tMj'»M»«f • 

Fig. J54.— TliL- Agnes Memorial Sanatorium, erected by Lawrence C. Phipps as a memorial to 

his mother. 

The reply, in every instance, was that no objection was felt, and, 
furthermore, that the sentiment of the community, after years of ex- 
perience, might be measured by the fact that they have contributed 
many hundreds of dollars towards the purchase of land near the town 
upon which to erect a State sanatorium — the Raybrook institution. 

Inquiries were also made in the town of Rutland, Massachusetts. 
The replies were all to the effect that no prejudice exists against tlie 
State sanatorium, which is located a mile and a half distant. The 
proprietor of the largest summer resort hotel there stated that the 
institution exerted no influence in keeping summer boarders away, but 
that, on the other hand, instead of being an objection, it is an advan- 
tage to the town. 

The dangers from infection are certainly less in a sanatorium than 
in a city or town. And manifestly it is best for any city or town that 
its consumptives be jn'ovided for in some such institution where they 
will not infect their neighborhoods. ''The consumptive liospital is a 
safeguard and not a menace to the public.'" And every reasonable 
community, without regard to Immanitarian motives ^thougli such 



motives aro uiaiiifost enough), but from purely selfish consirleralions, 
would (hid (he establishment of hosjjitals for its ])oor consumidiv.'s lo 
"pay," from nearly any view-point one may care lo take of the 

• Besides lessening the dangers of infection fli(> sanatorium is by far 
the best place for the consinuptive to be in. Here he is livalcd 
much more effectively and satisfactorily than at home. He has to 
obey strict regulations; Ihe disciphne maintained in these institu- 
tions is impossibl(> in a home; he is constaidly under medical super- 
vision ; liis diet, mode of living, exercise, and his employment, if any, 
are constantly being regulated for him. And tliis is a groat rest and 
comfort to the soul and body of any sick man, to have some one else 

Fig. 85.— The townfolk of Bedford, New York, entertaining the patients in the Bedford Sanatorium 

on the Fourth of July. 

plan his life for him, leaving him to do nothing but simply obey 
orders. "Very few families have any knowledge of the strict and 
constant measures that should be in force to insure safety from infec- 
tion to other members of the family, and in almost all cases lillK^ or 
no precaution against tlie spread of the disease is taken, either by the 
patient or the family." 

We have noted that in some sanatoria leaflets of instruction are 
given those dismissed, so that tlieir lives thereafter may be ordere(t as 
much as possible in conformity with them, — an excellent measure 
which serves often to obviate a recurrence or a relapse of the dis- 
ease. "Patients in a sanatorium learn discipline, and all who wish 
to carry out the treatment at home should lirst spend some time at a 
sanatorium to learn how to manage themselves, this being the most 
important thing of all." 



The shortest hmit of sariatoriuin treatment is three months, and 
most patients should stay six months at least, if permanent benefit is 
to be derived. In charitable institutions, where there are many 
applicants for each bed, it is best that there should be a period of 
probation during which the physician should determine whether the 
patient is likely to be made well by his stay, and if it be found that 
he does not do well under sanatorium treatment, he should give place 
to another whose cure may be assured. Even under the shortest 
terms but two or three patients can be accommodated for each bed 

Fig. 8«).— These patients at Hertford increased in weight as follows (left, to right): 1, 23 lbs. in 4 
month.*; 2, 22 lbs. in .') months; 3, lii lbs. in :! months; 4. 12 U)s. in :; months; 5, 10 lbs. in IV^ months; 
f>, 12 lbs. in 4 months; 7, 16 lbs. in 4 months; 8, Hi lbs. in :\U^ months; y, l.=> lbs. in 2)^ months ; 10, 
11 lbs. in 1 month ; 11, 12 lbs. in 'A'a month.s. 

during a year. Under these circumstances it would seem best that 
only tliose who are likely to have their health restored should be 
given place. 

What are the results of sanatorium treatment? These it is some- 
what difficult to gauge. One set of reports is tabulated upon the 
basis ot cure, arrest, improved and unimproved cases. This is not 
an entirely satisfactory classilication for the reason that it is diffi- 
cult to pronounce a case cured of tuberculosis. Many of the cases 
that are classed as '• incii)i(Mit.'" for instance, have no doubt had in 
earlier years attacks of tuberculosis, 'fherc are many patients who 



have at one time or another in their hves, previous to their admission 
to a sanatorium, suffered symptoms which they have perhaps dis- 
regarded, or liave forgotten, such as fever, chills, malaise, inability to 
work, and so on, which ill feelings they have attributed to a sli'dit 
cold or to malaria or la grippe. Oftentimes such symptoms, from 
which they have recovered, have really been those of tuberculosis. 
Such cases might be classed in sanatorium reports as incipient cases 
whereas they are really arrested cases of the disease. Then again, in 
institutions, all but incipient cases are rigorously excluded ; in others 
there is wider latitude of admission, so that statistics would be cor- 
respondingly affected.' 

No particular climate is essential for tlie cure of consumption. 
The sanatoria we have considered are variously situated as regards 

Fig. 87. — Sharon Sunatoritnn. SharDii, Massacliiisetts. Sun bath in winter. 

altitude and latitude ; some are by the seashore ; most are in the 
mountains. Non-pulmonary tuberculosis (as in children) does ex- 
tremely well by the seashore. The air here is certainly less germ- 
laden than it is inland. But most of those who have coughs and 
catarrhs are pronouncedly distressed by sea air ; although some such 
patients are not, and do extremely well on ocean voyages. A dry 
inland climate is also apt to be comparatively germ-free. Many 
patients are doing well in Egypt, whither they have been sent, within 

' Some sanatorium results are detailed in Ajipciidjx H. 



Fig. 88.— Suniiii 

mil', Sharon. 

a score of miles from the desert, wliere meat suspended in the air will 
not i)utrefy for many days. A high altitude also is much more germ- 
free ; but the trou])le here is that many, perhaps most, of those who 
breathe this rarefied air cannot again return to the denser atmosphere 

of their former homes ; and a 
high altitude is dangerous in 
some heart conditions. Per- 
haps an ideal altitude for the 
consumptive is one of some 
twelve hundred feet, with many 
sunny, clear days in the year, 
as dry as may be, as free from 
dust and damp as possible, — 
one in which the patient may 
stay constantly out of doors. 
A change of climate, as every 
one knows, is good in the event 
of jjretty nearly every subacute disease, not only organic, but func- 
tional and neurosal as well. One almost immediately feels a benefi- 
cent change, sleeping and eating better, and with a vastly improved 
sense of well-being. The consumptive feels this change in perhaps 
greater degree than any other ; and oftentimes no patient needs more 
than he a change of environment. Still, Brehmer insisted, as does 
Trudeau, that a well-trained patient will do well in any climate, and 
that he will not be iujured by 
inclement weather, provided 
he lives constantly out of 
doors. " It is not so much 
u-heir the consumijtive lives as 
how he lives that is of the 
most importance f' the con- 
sum})tive " cannot be left safely 
to his own devices as to his 
mode of life in any climate. 
A life sjicnt entirely out of 
doors, in any kind of weather, 
good and abundant food and 
rest, and discipline, are the all-important factors to utilize in bringing 
about a cure." 

I again emphasize the equivalent of a criminal procedure of 
sending a i)atient ill (Hjuipped, botli with regard to his bodily strength 
and to his funds, upon long jounu^ys into places he knows not of, and 

Fig. 89.— Same camp in winter, Sharon. 



wheiv li(> is not known. No patient witli a fevor or a rapid pulso 
should take such a trip. Before sending a patient away iiis character 
sliould be considered wiih regard to the place and the people among 
whom he is to go. If lie is going to a health resort it iinist be learned 
what are its facilities for the cure of his disease, rather than those ar- 
ranged for his pleasure and entertainuieut.^ 

The cjuestion of recreation in a sanatorium is a ))ractical one not 
always easy of adjuslment. For inshuice, there should certainly be 
a library, but it is best not to have a reading-room ; and the pa- 
tients should be I'equired to take their books out in the open. We 
have noted that in one institution cards are ])rohibite(l for the reason 
that they keej) th(^ ijatients so much indoors. This amusement, with 
checkers, chess and like games, should be played on piazzas outdoors. 

Pifi. 90. — Exercises at Berlforrt Sanatorium. 

Croquet is an excellent game, requiring little exenise, and keeping the 
patients out of doors while it is being played. There should be pro- 
vided in every sanatorium plenty of means of nn-reation, in order tliat 
the mind of the })atient may be well occupied ; for a variety of rea- 
sons this is essential. It may be jjossible to engage patients in recrea- 
tions which may at the same time be jn'ofitable. There are now, for 
instance, classes in bookbinding, illuminating, and j)liotography, under 
a competent instructor, at Saranac Lake. These employiiientsare en- 
gaged in for but a part of each day. They divert j)atieids and may 
give those who do not expect to return to their former occupations 
after their cure an opportunity to learn another and perhaps a more 
healthful vocation. There have been a number of renumerative 




orders for bimling books. The work is all done by hand. Several 
patients sell many views they have taken. About one-third of the 
sanatorium patients have enrolled in these classes. 

We have seen tliat European sanatoria differ in some respects from 
American. The former are generally made upon the plan of a 
large central building in which is the dining-room and administrative 
offices, with wings leading out from either side, which contain the 
bedrooms and the baths, and along the front of which wings are 
broad piazzas. The basis ot the American sanatoria is generally a 
central or administrative building, w'hich is surrounded by cottages, 
each accommodating several patients. An essential in a sanatorium, 
in my o]nnion, is that in some way or other each patient may have a 
room, no matter how small, entirely to himself. No man can fairlv 

Fig. 91.— ijewiug-circle at Bedford Sanatorium. 

live his life, it appears to me, who has not some such place in lieu of 
the traditional castle in which he may — when he is minded to — pre- 
serve his individuality apart from the world about him. Other re- 
quirements of a sanatorium are that it should be built, if possible, 
on the south side of a hill, with woods near by. in which may be 
placed reclining chairs and sunnner houses. The soil should be dry 
and porous. There must be abundant pure drinking water. There 
should be a sight of water, — some sort of stream, or a lake. There 
should be graduated walks. Much of the land should be suitable for 
agriculture. It should be higher than the surrounding country so that 
it will be above the mists and the fogs of the lowlands. The ground 
leading from the sanatorium should be sloping, in order to insure 
drainage. There must be no ground-water. The sewerage must be 



l)erfect. Railway communication should bo so easy that supplies of 
all sorts may be had cheaply. But the site should be far enough away 
from any town to avoid dust and factory smoke. There sliould, if 
possible, be roof gardens and solaria. An infirmary — a ward, or, if 
possible, a separate building — devoted lo the care of the very sick 
should be a part of every sanatorium. And, for the possible develop- 
ment of cases of acute infectious diseases, such as diptherla and scar- 

Fii.. '.tJ— I>r. I'ottengii's Sanatorium, ^ronrovia. California. 

let fever, a separate building should be maintained. This is important, 
that the consumptives shall not have tlieir bodies taxed by other dis- 
eases in addition to tlie one from which they are suffering ; but still 
more for the reason that the germs of these acute infections should 
not aid the tubercle bacillus in the formation of the '' mixed infection " 
which makes consumption so serious a disease. 


" There is a rest." 

We liave observed that many sanatoria — in fact most — purpose to 
treat only incipient cases. Tliis seemingly brutal course is in essence 
quite humane, and necessary under existing circumstances in this 
country. It is sought in sanatoria to make curable cases well, so 
that they may rejoin their families and take up again their life-work. 
Every good institution of this sort has a large waiting-list ; and every 
incurable case it takes care of excludes, during the lifetime of that 
patient, perhaps protracted through years, several cases annually that 
might be cured. 

The remedy for this state of things is to build many homes and 
hospitals for incurable and advanced consumptives. In this manner 
are these sufferers among tlie community's poor made as comtbrtable 
as possD^le while they live, and innocuous with regard to the health 
of the remainder of the community. 

Every town or city sliould have such a home or hospital, and it 
should be adequately large. They should be suburban, these homes, 
not far from the community which maintains them ; so that from 
time to time the patients may be cheered by the visits of their 
familiars. In the City of New York, for instance, there are some 
forty thousand poor consumptives for whom, as things are at the 
present time, the State or the municipality should jirovide. The noble 
charity, St. Joseph's Home, has room for but three hundred advanced 
<-as('s. And this is by far the largest institution of its kind in the 
city, taking more cases than all the rest put together. Setting aside 
humaniiarlan aspects, on purely economic accounts, it is a govern- 
mental short-sightedness of an amazing sort that barely five per cent, 
of this number can be provided for in public institutions. This is 
not. ill I he case of New York City, tlie fault of the Healtli Deparl- 
nu'iit. The plan of this department to provide adequately for such 
condilioiis as these has until very recently been frustrated by the en- 
actment of a Slate law in every conceivable respect degrading to 
American civilization. 

It must l)e emphasized that the establishment of such hospitals 
and homes is by far the most important and essential of all com- 



munal preventive measures against tuberculosis, — for the advariced 
consumptive is the most prolific disseminator of the infection ; weak 
and helpless as he is, particularly if he be poverty-stricken and unat- 
tended, and emitting daily, as he does, billions of potencies by wliidi 
this disease may be generated in others. "The most important of 
preventive measures is the prevention of imi)lantations.'" In these 
hospitals the advanced consumptive is scientifically taken care of, 
and his emanations are destroyed and rendered harmless. American 
cities most wofully lack such institutions, which should be distribiiled 
all over the country, one in every State; in every large city; a com- 
munal one for several towns. Every reader can figure out for him- 
self that with regard to the tuberculosis situation the establishment of 
such structures is the best of all economies, both immediately and in 
the long run. 

Particularly should consumptives be eliminated, in so far as may 
be, in such public institutions as almshouses or reformatories. Their 
segregation in insane asylums and prisons is now being attended to. 
When nothing better can be done, or pending permanent arrangements, 
consumptives should be housed in separate wards of almshouses and 
similar institutions. These wards should be the sunniest and the best 
ventilated, and so managed and equipped that there need be no fear 
of the spread of infection. Or tents might be erected on the institu- 
tion's grounds. And pending further measures, general hospitals 
should have separate and special wards for consumptives. Here, 
besides the advantage to patient and community, young j)hysicians 
and nurses could receive practical education and training in the prin- 
ciples upon wliich the treatment of consumption is based. Many 
hospitals, however, are prejudiced against consumptives, because of 
an unnatural and unreasonable fear of the infection. Wtiat are hos- 
pitals for, in God's name? "Our country is full of hospitals. If our 
hospital beds were counted and a census taken of our sick people of 
all kinds who cannot be cared for properly in their homes, it prob- 
ably would be found that we have ample beds for all. Unfortu- 
nately, however, we w^ould rather keep our beds empty than admit 
cases that do not suit. Formerly, the coiisuni})tive was ex- 
cluded because he lived too long and would not get well ; now he is 
excluded because his disease is contagious. Alas, that our pride 
should sow cockle in the wheat-field of our charity ! We like to 
give aid in distress, but we like to give it where it brings glory. Our 
charity has built hospitals in great numbers and has provided hospital 
beds which easily would give relief to all suffering humanity, but we 
desire to see the people wdioin we put into these beds get well 


quickly. For the sliort sufferer we have a welcome, but agamst the 
long sufferer we turn our faces." (Flick.) 

In Germany there are Invalidenheime, several of which have been 
established by the State Workmen's Insurance Department. 

In I\iris the authorities requested the Societe des Hopitaux to 
suggest the best means for prompt, practicable isolation of the tuber- 
culous in the hospitals. It was recommended that certain quarters in 
the hospitals should be set aside for tuberculous subjects. They 
should, if possible, be in a separate pavilion ; at least there should be 
a separate entrance. The dishes, etc., should be numbered for indi- 
vidual use of the patients, and sterilizing apparatus should be provided 
for the linen and spittoons. Subjects with recognized tuberculosis 
should not have access to the other wards. Each ward should have 
several beds isolated from the rest of the room for provisional isola- 
tion of the dubious cases. There should be some establishment to 
serve as a home for the surplus tuberculous ; and the number in the 
hospitals should always be kept down by transferring the surplus, with- 
out further formality than a line from the physician in charge, certify- 
ing to the diagnosis and demanding the admission of the patient on 
account of the crowded condition of the hospital quarters. 

In England the National Association for the Prevention of Con- 
sumption has published a leaflet upon Homes for Advanced Con- 
sumptives, in which it is observed that those who are admitted to 
sanatoria in the latter stages with extensive consolidation or with con- 
solidation and much fever, usually die within a year after their dis- 
charge. F(n' such cases a distinct home should be provided. It was, 
therefore, proposed at a meeting of the committee of the Westmore- 
land Consumption Sanatorium that a conference should be sought 
with representatives of the County Council of the ten sanatoria 
authorities in the county and of the Boards of Guardians for the 
purpose of discussing some practical plan of dealing witli those in the 
county who should be suffering from consumption in too advanced a 
stage for admission into the County Sanatorium and who were without 
adequate means of isolation at home. At this meeting the impor- 
tance of isolation in such cases was recognized, and it was agreed that 
steps should be taken to establish a hospital to this end. An Isola- 
tion Hospital Act was passed, which constituted the whole county 
into a hospital district and elected a hospital connnittee. As a 
result much useful matter was set forth to the following effect: While 
tuberculous dust cannot be found in even the dirtiest houses in which 
consunq)tive3 have not lived, it is found in two-thirds of the dirty 
houses, and in one-half of the fairly clean houses occupied by con- 


sumptives, especially in tliose structures wliicli were badly lifjrhted 
and badly ventilated. And it has been found that persons in houses 
adjoining those occn|)i('d by consumptives get infected appaivnily 
by the sweeping out of accumulations of tuberculous-infected dust. 
Every case of advanced consumption in a small crov;ded dwelling is 
necessarily a dangerous source of infection. These most dangerous 
cases are generally rejected from sanatoria, which admit cases only in 
the early stage, when the disease can be arrested. These sanatoria 
are available chiefly for preventing cases reaching the infective stage 
and for training patients to manage their sputum. Some other home 
besides a sanatorium is then indispensable. Very many consumptives 
pass into the hopeless stage before they are discovered. Advanced 
consumptives eagerly enter such liomes, and the association cites 
institutions which have waiting lists of many applicants. 

During fifty years past London has been segregating its consunijj- 
tive poor in hospitals. To this plan is laigely due (he fact that, the 
largest city in the world, it has the lowest death-rate fi'om this disease 
— about tw^o per tliousand. 



Duriiii: Iho sprinsr, summer, ami autumn this work (at Bedford Sanatorium) 
has been largely iu farm, garden and orchard. The supplies were far beyond the 
needs of the institution, and the prize pumpkins, cabbages, radishes and ears of corn 
would have done credit to a country fair. The value of such a regime to the 
patients themselves (selected incipient and convalescent cases, to whom outdoor 
work could be given) is simply inestimable. The outdoor life it encourages, the 
training in a useful and healthful occupation, the stimulus that comes with some- 
thing accomplished, the reduction of the hours of loafing and brooding, all tend 
to the betterment of the patient, both physical and moral. — Alfred Meyer. 

It is orti'ii a vexatious ])robl('m how to find ofcupatioii for con- 
suiiii)tives who can do some hght woric coimuensurate with tlieir 


liMiiMii- ,.i i;,MiMi. 

iiiiiiii :it work. 

condition ; for tiiose wliosc disease has Ijeeii arrested, even tem- 
porarily : for tiiose whose liealth lias been restored, and whose 
retiu-n to former uniiealthfu! occupation sucli as stone-cutting or 
sweat-sliop work, is sought to be avoided. Morever, one ofthe diffi- 
culties of the sanatorium life lies hi the lack of occupation, as we have 

It is advisable that every sanatorium should have, for such of its 
inmates as are al)le, perhaps for but two or three hours a day, some 
light vegetable or other farming work to tlo. And for graduates of 

sanatoria, farm or open-air colonies have been and siiould be eslab- 



HsIkhL wluM'e work of a salubrious sort may l)e douc. Such a colony, 
living under proper sanitary regulations, vigorously enlbrced. cannot 
liarni any conmuinity. 

In tlie West tliis difficulty of getting- suital)le work lor sanaloriuni 
graduates is emphasized by the officers of the Jewish Sanaloriiun at 
Denver. Many of the discharged cases nuisl perforce remain in Ihe 
high altitude of the Rocky Mountain zone. It is very i)ainful to see 
such patients comj)elled to return to the very surroundings and con- 
ditions in whicli, in the lirst iiislance. they became victims of the 
ihsease. And one of the nujst serious problems whicli confronts this 
mstitution is what to do with cured cases who nevertheless require 
"the preparatory course" to fit them to return to the active duties of 
life. The purchase of a farm has been advocated near the hospital 
in which light work could be done. However, it is pertinently 
observed that very few sanatorium patients are willing for or suited to 

"i". M. C. A. heiilth farm, Denver, Colorado. 

agricultural pursuits; so that the cost of supervising such a farm has 
been found to exceed what the patients could earn. Such deficiency 
should, however, not be a deterrent factor. The Denver Young Men's 
Christian Association has established a health farm at which many of 
the consumptive young men who have flocked to that region from all 
parts of the country, and for whom sanatorium accommodation could 
not be found, find employment. There are on the gj-ounds forty-five 
Tucker tents, one for each man. There are two tracts.— thirty-four 
acres of fruit land, and sixty acres of unimproved land. Besides the 
tents there are an administration building, a water-tower observatory, 
and a tent hospital. The patient pays $25 a month. Light work in 
partial payment of this charge is provided as much as possible. 

Forestry is advocated as being of all occupations the best for those 


who have had consumption. It is an ideal outdoor occupation, 
lairly roiniwierative. "The demand for its products nmst increase in 
an ai'ilhmetical, if not in a geometrical ratio, in the years to come," 
states the Ohio Slate Tuberculosis Connnission, which has investigated 
the matter. This body sent a circular letter asking for definite in- 
formation concerning what employment might be provided for con- 
valescents. Some thirty replies established, first, the economic value 
of a cured consumptive's labor. This was thought to be equal in 
laboring capacity, at the start, to about one-fifth of that of a normal 
workman. Second, they definitely placed the responsibility for the 
effects of the labor upon tlie laborer. The medical director of the 
institution should be the daily arbiter of any wdio may or may not 
labor. Third, they decided the mininumi time tliat employment 
should be given, which is six months; two years maybe taken as 
a limit beyond which it would seem needless to go. 

Labor organizations may establish farms for consumptive union 
workmen in various parts of the United States. These, if the plans 
mature, will be located in North Carolina, the Adirondacks, in the 
Middle West, and on the Pacific coast. 

A phase of the situation, as it appears in the work of the French 
hospitals for tuberculous children, which we have noticed, is the 
unwillingness of children who have graduated from tliese histitutions, 
to do liglit farming and outdoor work, and their preference for 
returning to the slums from which they had to be taken when they 
were ill. It certainly is a strange phase of human nature when, 
having once tasted the sweet and wholesome pleasures of the country, 
one should wish ever to return to the scjualor and the unhealthfulness 
of city life. At Villiers it was recognized that patients who return to 
unfavorable suri'oundings are likely to develop again the symptoms 
they have thrown off. A colunie has therefore Ijeen established where 
convalescents are admitted and taught farming and gardening. Great 
hopes were entertained that this would be a means of attaching young 
lads to a country life and of getting them away from hurtful town 
surroundings. Unfortunately, it has been found almost imjjossible to 
retain them. The town influence has been found too strong hi them, 
and they never settle down happily to country life. At Noisy-le- 
Grand, where only girls are cared for, a similar endeavor has been 
made, with no better success, and for tlie same reason. 

In England, Hillier notes tiiat cured cases, and even advanced 
cases, whose disease is arrested (a condition which may be rendered 
permanent by the continuance of an open-air life on radical hues, but 
which is almost certain to relapse if a crowded city life is reverted to) 



should find lip-ht occupation in industrial colonics, which would bo 
uncter medical supervision. For other chronic diseases, as epilepsy, 
which is much less common than tuberculosis, industrial communities 
have long been established. Witli tuberculosis, as with epilepsy, it 
will be found that by taking a patient from his home not only arc his 
own prospects of health and life niucli enhanced, but a grievous 
burden is lifted from his familv, and the danger of infection is renajvud 

Fii.;. '.u.— NoT'lrarh runcli, Cuidiail' > Springs, Colorado. 

from them. Moreover, he can be more conveniently and economically 
treated in a community of patients. 

One of the conditions essential for the admission to such a colony 
should be a period of at least a few months spent in a sanatorium 
where a consumptive would be carefully coached in the precautions 
necessary for disinfection and the principles of the open-air life. The 
lighter kinds of outdoor work, horticultural, and the keeping of 
poultry, pigs, or bees, would be appropriate. Patients would have to 
be prepared to rough it to a certain extent ; to wait ui)on themselves 
and dwell in simple, inexpensive barracks, pavilions, or cottages. 



Apyluiiis \'(>v flu' insane should take the first place among State institutions 
with repaid In I In- rc-rulation and control of tuberculous patients. — Bracken. 

It seems tliat a disproportionate number of the insane develop 
tul3erculosis during their stay in asylums. One account states that in 
seventy-foiu' consecutive cases of pulmonary consumption, in ages 
between twenty and sixty-two years, only three liad evidence of this 
disease b(>fore admission to these institutions. It is furthermore 
observed that tliose wlio enter an asylum with tuberculosis have 
little chance of recovery while they are inmates. 

It seems that tuberculosis is apt to follow insanity. It does 
not precede the latter. Several phases of life among the insane, 
which do not obtain in normal circumstances, would explain this 
conditions of things. Many will not complain or tell of their symp- 
toms, and tluis do not for a time manifest tuberculosis. Indoor 
life, even cell life, is essential for many of them. The insane who 
can be permitted to be out of doors do not seem particularly prone 
to consumption. Many are careless in their habits, and their men- 
tality is such that they cannot comprehend instruction in prophylaxis 
concerning their disease. There is a great deal of opportunity for 
infection, because of the carelessness of the sufferers concerning 
their sputum, and of the intermingling of the consumptive with 
those who are not so. Then the tissues of many asylum inmates 
are apt to be vitiated and of lowered tone, so that they are predis- 
posed to infection, tubercular or otherwise ; this is particularly so of 
the melancholic and demented types. 

Cornet would explain the frequent occurrence of tuberculosis in 
sufferers from psychic disorders, especially where there is deep de- 
pression and an apathetic stupor, associated with a reduction of the 
vegetative functions, l)y the reflex excitability to inspired particles of 
dust. Grashcy finds that the insane who get about and do their 
work are no more subject to disease than are the healthy. Von 
Ziemssen declares that nuns who keep to the cloister are more apt to 
become tuberculous than those who have their work outside the wall. 
Increased mortality is due to opportunity for infection in such life. 
S. Solis Cohen cites Laennec's instance of a French religious order, 



showing that depivssion had inncli to do witii llir cxtiiiclioii |»y 
phthisis of all the nuns ollu-r than those whose dntics kept tlinn 
in contact with the outer world. 

Bracken finds thai the feeble-minded fre((uently develoj) tuber- 
culosis of the intestines, these individuals bein^- in the habit of swal- 
lowing their sputum. In insane asylums two sorts of tultcrculoii.s 
subjects are encountered. — those who have stdfered from the disease 
before their admission, in wdiom the condition prf)j^r(^sses slowly, 
and those who become infected after admission, in whom llic disease 
progresses rapidly. 

Dr. James Greenwood, of the Southwestern Insane Asylum, 
Texas, considers tuberculosis l^y fiir the most serious of asylum dis- 
eases. Its course is rapid in these institutions, in all situations, in 
fact, where people are confined, as in religious orders or by the re- 
quirements of law, tuberculosis has become a very serious problem. 
The asylum with wdiich this observer is connected has a tuberculosis 
record of 21+ per cent., or eighty-tive among three hundred and 
ninety-two deaths during the twelve years of its existence. Nine- 
tenths of such patients are between twenty and fifty-five years of 
age, and eleven-twelfths of the deaths from tuberculosis are found 
to have occurred during these years. 

The total death-rate per thousand in the United States for this 
period is about ten, of whicli 4.4 to 4.8 are due to tuberculosis. In 
this asylum for twelve years past there has been an average yearly 
death-rate of thirteen per thousand among the iimiales due to tuber- 
culosis alone. This is three times as many as are caused by tuber- 
culosis in the United States witliin the age linnts stated. During the 
first three of these twelve years, for which these statistics were made, 
tliere were no deaths fi-om tuberculosis, but as tlie wards became in- 
fected tlie death-rate from this disease increased until it has averaged 
eighteen per thousand for the last five years of the twelve. The 
average length of time hi the asylum of those dying from tuberculosis 
has been three and one-half years. During the last twelve months 
investigated by Dr. Greenwood there were on the female side twenty- 
nine deatlis, of which nine, or 30 per cent., were (hw to tuberculosis. 
Six of these nine cases contracted the disease in the ward where the 
most demented cases were kept. Of these nine cases eight were 
dementia, in which form of insanity the vilality is lowest. During 
these twelve months there w^ere on llie male side twenty-eight deaths, 
of whom eight died of consumption. All of these eight cases wer(> of 

Dr. Greenwood considers that there should be a special hosi)ital 



for tuberculous iusaue, so built that these patients will be given 
plenty of fresh air, while at the same time the structure may be 
easily cleaned and disinfected. 

Another important measure would be the enactment of a law re- 
quiring that all cases admitted must be free from tuberculosis, as the 
law now requires them to be free from other contagious diseases. 

Since 1901 consumptive insane patients have been separated and 
treated, to their own great advantage, and incidentally to that of their 
non-tuberculous fellow-inmates, in canvas tents, throughout the four 
seasons of the year, at the Manhattan State Hospital, East, New York 

Fig. 9f..— Tents on Ward's Island, New York City. (Coiii'tesy of Dr. .7. T. W. Rowe.) 

City. Before tliat date Dr. A. E. McDonald found the problem of 
caring for this class of patients a serious one, especially because the 
form of construction of the hospital buildings was such that no smaller 
wards or sections were available for their isolation. 

An experimental camp was therefore established, consisting of 
two large dormitory tents, 20 by 40 feet, each containing twenty beds, 
with smaller tents of different shapes for the accommodation of the 
nurses, the care of hospital stores, jjantries, and a dining-tent for such 
patients as w:ere able to leave their beds and tents for their meals. 
It was originally intended to continue the camp only through the 
summer, but when in the autumn it was found that the favorable 
ex])erience continued, it was decided to carry the experiment, on a 


modified scale, into the approaching winter. The camp at first liad 
been placed upon an elevated knoll, properly exposed to the full force 
of the summer breezes. For the winter its site was removed to the 
centre of the island, where hills and buildings acted as a wind-break. 
The number of patients was reduced to twenty, — those most ill being 
retained and the others being returned much against their will lo the 
buildings. In the accessory tents above mentioned large stoves were 
built with wire screens surrounding them to protect tlie patients, and 
with asbestos and other fire-proof material for the prevention of fire. 
Slatted wooden movable pathways were prepared, which might fur- 
nish means of passage between tents when the storms should come. 
It was found that despite high wind and bad weather a more equable 

Fig. 97. 

-Tents on the Knuiiids of the Manhattan State Hospital, East. Ward's Island, New York 
City. Revolving tent in foreground. ( of Dr. J. T. W. Rowe.) 

temperature liad been maintained and less discomfort had been ex- 
perienced in the tents than in the hospital wards most exposed to the 
force of the gale. This tent camp, in which all i)lilhisical patients 
with active manifestations are isolated, has remained in continual use 
through the succeeding winters and intervening seasons. 

Among the results obtained are the reduction to a minimum of 
the danger of infection to other patients and to employees. The 
patients themselves have suffered no injury or liardshii), but have on 
the contrary been unmistakably benefited. There has been a de- 
crease in the death-rate, both absolute and relative ; a marked gen- 
eral increase in bodily weight (amounting in the case of one patient 


to ail actual douhliiiy of Ave igl it, from eiglity-tlireo to one liundred and 
sixty pounds), and mental has, as a general rule, been the concomi- 
taiii of physical improvement among the patienls in this camp. " Com- 
mon colds" were here unknown during the Avinters. 

Dr. McDonald makes the observation that where phthisis and in- 
sanity coexist they are apt to alternate as to the prominence of several 
manifestations, — tlie mental symptoms being more i)ronounced while 
tlio physical are in abeyance, and vice versa. Under the tent treat- 
ment lie lias found a general disposition toward accord in the mani- 
fest iiii|)r()vement in liotli respects, proceeding concurrently; and 
some of the discharges from the hospital, which gave most satisfaction 
at the time and most assurance for tlie })atient's future, were of 
inmates of the tuberculosis camp. 

This innovation was, we believe, the first adopted by a hosjiital 
for the insane, and is said also to be the first instance of a continuous 
system of tent treatment anywhere. The results have been so en- 
couraging that steps have been taken to introduce the same system in 
other liospitals in New York City, in the Oliio State Hospital at Colum- 
bus, the Protestant State Hospital for the Insane at Montreal, Canada, 
the Vermont State Hospital at Waterbury, the Eastern Maine Hospital 
at Bangor; in the States of California, Delaware, Louisiana, Maryland, 
Mississippi, Oliio, Rliode Island, Virginia, and elsewhere. 

C 1 1 A I ' T K 11 V 


A separate hospital buildiiif:^ of sufficient capacity fo accommodale all its pris- 
oners suffering from tuberculosis, i)rovided with properly fitted wards, modern 
sanitary appliances, and outdoor and indoor exercise courts, isolated completely 
from the prison population proper, presents without question the solution of tlir 
problem of the treatment and prevention (jf this disease in the penal institutions 
of the State. — Ransom. 

Many factors in prison life are peculiarly conducive lo luhcrculosis. 
Most prisoners have before incarceration lived wretchedly amid un- 
sanitary conditions. Cells are traditionally dark and unwliolcsonie. 
Prison fare is poor; seclusion is enforced; Ihere is coinparalively 
little exercise allowed. Sing Sing prison has, rightly enough. 1 |)re- 
sume, been termed a veritable tuberculosis pest-hole. 

Dr. J. B. Ransom, physician to Clinton Prison, in N(nv York Slate, 
points out that a criminal class is essentially a part of the commu- 
nity, as much as is any otlier. Society is morally as Avell as lawfully 
bound to conserve the convict's health during the incarceration to 
which it has subjected liim. But for other reasons than this it sliould 
be interested in the welfare of penal populations, which are always 
tidal. The three institutions in the Emi)ire State are dischai'jjing 
annually about twelve thousand, among avIioiii women are in a very 
small minority. The prisoner should l^e dismissi'd willi a degn^e of 
healtli wliich will at least iH'event his becoming a j)ublic menace and 
burden. This is particularly essential with regard to tuberculosis, 
to the development of which a prison life and (Mivironment arc very 
favorable. From forty to hfty-five per cent, of all the deaths occur- 
ring in the prisons of the world are due to il. In many isolated cases 
the percentage has been much higher, — even eighty at onetime; in 
New York State it has reached seventy-tive per cent. 

This high mortality is, of course, not due entirely lo prison en- 
vironment. Yet most of the cases are thus engendered, because of 
the unsanitary structural arrangement of nearly all the prisons of the 
past, and many of those of to-day. They are damp and often much 
overcrowded; they lack sunshine and fresh air from out of doors. 
Then there are the age (that of convicts on commitment averages 

•>] 321 


about thirty) aiul sex, and the physical and mental strain occasioned 
by the confinement and the necessary disciplme. The nervous system 
of the prisoner is ahnost always mistable. 

The discharged prisoner is somewhat more dangerous than the 
ordinary citizen, in that he is likely to return to crowded and un- 
healthy localities, and to be wilfully careless about his personal habits. 
His capabilities for infection, if he be a consumptive, are rather un- 
usual. So that the State cannot afford, as it should not permit, pre- 
disposing conditions to exist in any of its prisons. 

The consumptive prisoner should be as well taught as regards 
personal hygiene as the graduate of a sanatorium. Many cases can 
be cured in prison, where some conditions should be especially favor- 
able ; these patients are more than usual under control, and must 
submit to necessary instruction, sanitary rules, strict isolation, ward 
and outdoor treatment, and like measures. 

The exercise of such functions as these by the State is neither 
sentimental nor paternal, but a legitimate, reasonable prerogative in- 
herent in constitutional governments. The State's authority to com- 
mit a man does not imply oblivion for him, unless he be given a life 
sentence or the death penalty. After short terms he is supposed to 
return to society more or less bettered. The State is bound, if only 
by self-interest, to assume the relation of guardian toward the prisoner. 
Therefore it should protect him from incapacity engendered by dis- 
ease, even more than should non-criminal communities, which are so 
largely supplied with municipal and town regulations. 

The State of New York is now taking action to better the condi- 
dition of its consumptive convicts. In 1889 tuberculosis prevailed 
greatly in Clinton Prison. There was no means of caring for these 
sick; no isolation, bathing, or feeding; no treatment, no precautions. 
There was no distinction between the consumptive and the well ; 
"they locked, worked, and ate together." When in hospital they 
were mixed indiscriminately. Through a vicious State law concern- 
ing prison work, these unfortunates were largely idle. Practically 
" the only saving element in the past, which had acted as a preven- 
tive to almost utter annihilation of the population, was the large 
amount of outdoor labor wdiich was afforded the men by the then 
existing system of manufacture. The new law changed outdoor work 
to shop Avork. A rapid increase in the number of tubercular cases 
resulted. Dr. Ransom reported seventy-five per cent, of his deaths 
in 1890 to be due to tuberculosis, and he then earnestly but ineffec- 
tually called the attention of the prison department to the necessity 
of isolation and special treatment of the consumptive prisoners. At 


this time, indeed, the disccase was Uttle understood. xMany opposed 
the methods of treatment now deemed essential. The disease spread ; 
conditions were even worse in Sing Sing and Auburn, the two other 
prisons of the State. Dr. Ransom liad for years been urging the 
transfer of tubercular cases to Clinton Prison, because of its excellent 
location, ^nd its isolation from the non-criminal populations. Some 
advanced cases were transferred, with excellent results. Continued 
agitation bore fruit. There came a change in the system of niaini- 
facture ; improved methods of administration, especially in the med- 
ical departments ; a more systematic transfer system. Then a special 
line of treatment was adopted. This resulted in a reduction of the 
consumption death-rate in the five years ending in 1001, so that, there 
were seventy-two deaths in the three State prisons as against two 
hundred and fifty-three during the previous five years, — a gain of 
seventy-one per cent. In 1901 the Legislature had constructed a 
new ward for the treatment of the tuberculous. (It cost $2500, — 
noble and magnanimous Legislature !) In tliis ward, which was 
attached to the prison building, were suitable acconmiodatioiis for 
advanced cases and those positively requiring ward treatment to the 
number of forty-three. Here, it was found, all classes of criminals, 
without regard to the nature of their crimes or the lengths of their 
sentences, could be treated without jeopardizing prison disci])lin(>. 
There were no insurrections: no breaks for liberty; less troiii)le than 
"from the same number of men of the same class locked in the 
regular isolation cells." Cases are now regularly transferred to 
Clinton from all the penal institutions, including reformatories, in the 
State. The consumptive prisoner is, to begin with, strip{)ed, bathed, 
and given careful physical examination. His sputum is examined. If 
his disease is in the active stage, or if he be weak and exhausted, he 
is at once admitted to the hospital ward, where his condition is daily 
recorded. He is instructed concerning the hospital regulations, his 
personal habits, his sputum, his teeth, hair, and clothing. His deport- 
ment must be orderly. He may exercise in his bed aisle, and may at 
certain hours mingle with other members of his section, and })lay 
checkers, dominoes, etc. Other patients may go through morning and 
afternoon exercises, appropriate to their condition, in an outdoor 
court, which is provided with running spring water, benches, elevated 
cuspidors, a water-closet, and a crematory for sputa. Besides med- 
ical treatment a nutritious diet is prescribed, made up of cereals, vege- 
tables, milk, meat, and eggs. 

A drawback to the work is that under ])rison conditions tubercu- 
lar patients cannot get all the open-air treatment they require. Never- 


theli'ss •• it is gi'atityiiig tuid soiiiotiines astonishing to see how these 
nuMi improve." 

The total medical ap])ropriation made for Clinton Prison is $4000. 
a small snni indeed. All the work done for these consumptives, in 
addition lo the general prison work, lias been done by the same 
medical staff as is provided for tlie other prisons, — a resident phy- 
sician, a pharmacist, and a trained nurse, the latter at a salary of $50 
a month. Of course, these conditions cannot continue and must be 
clianged, as may be seen by comparing this staff with that of other 
institutions for the tuberculous. The sanatorium at Fort Stanton has 
four medical officers, two pharmacists, and forty-one attendants. Tliat 
at Rutlaiid has two visiting physicians, four residents, one dietician 
and steward, and one superintendent of nurses. 

New York State thus leads the way in tlie establishment of a 
tuberculosis ward in its prison hospital service. Nevertheless it has 
but begun its work. It has probably a larger number of consump- 
tives in its penal institutions tlian have otlier States, because of the 
conditions existing in New York City, tlie largest feeder of its prisons. 
Besides, its prison construction is generally almost mediaeval in char- 
acter, in which respect it compares unfavorably with other States. It 
still maintains the altogether unsanitary bucket and wliitewash sys- 
tem, the dust of the latter predisposing greatly to tuberculosis. 

The condition of tlie average jail is responsible for the develop- 
ment of a large percentage of cases that were well before incarcera- 
tion. Nearly all essentials for the prevention of infection are neglected. 
Prison metliods have not resulted in the early detection of tubercu- 
losis ; milder types have gone unsuspected; latent or inactive cases, 
or sucli as are not easily recognized, have been subjected to conditions 
favoring the development of the disease. 

Dr. Ransom recommends, with regard to Clinton Prison, instead 
of tlie present makeshift, the construction of a special and adequately 
commodious hospital apart from the prison building. New York State 
has now some seven hundred consumptive convicts ; the last appro- 
priation made provides in all one hundred and iifty-four beds with 
wliich to meet every demand. Dr. Ransom would have all buildings 
comiecled with jjenal institutions especially constructed with a view 
to i)roper sanitation. They should be so jjlaced as to admit mornhig 
and afternoon light, widi high ceilings, large windows and an aderjuate 
ventilating system. The cells should be large, well-lighted, and pro- 
vided with water-closet and wash-basin ; they should be constructed 
of steel, and a washable paiiil should be used as an interior liiiish, — 
no whiit'wash anywhere. 


The law should require tlie physician of every juvenile oi- dlliei 
pt^nai institution to examine each new-coniiM' for jtossible liibereulosis ; 
and data shoidd be recorded upon blanks provided for that ])nrpose. 
If the prisoner ])e a ('onsuni})tiv(', the ])liysician sliould at diice (ill 
out such a blanic and file a coi)y with the District Attorney. Tlie trial 
may thus be hastened, as also incarceration (if there be conviction), 
so that the prisoner may at once be benefited by the special pro- 
visions made in his behalf Up to the time of trial \\c should be 
isolated. If he be accfuitted, he should be told of his condilion on 
his release. All cases found in penitentiaries and the like should In? 
isolated and transferred on the detection of the disease. Those in a 
condition recjuiring it should have outdoor work. They could, for 
instance, raise vegetables for the use of the prison, as has been done 
at Clinton with excellent results. There should be open wards for 
such prisoners. A cell seven and one-half by seven and one-quarter 
feet, with a bucket for a water-closet, is not a proper place for a con- 
sumptive. It is in the cells that much infection takes place. Dr. 
Ransom cites specifically the case of a young inmate upon whom he 
operated for a Avound. Soon after, he became sick and exhiljited 
general symptoms of acute tuberculosis. The cause of the infection 
was obscure until the cell history was looked up. Its former imnate 
was a consumptive. The cell had been thoroughly cleansed and 
whitewashed, — an ineffective safeguard, however. 

The example of New York State has been followed in Connecticut, 
Indiana, Kentucky, Minnesota, and South Carolina. Texas has since 
1899 maintained for tuberculous convicts the Wynne Farm at Ilunts- 
ville, a high and well-drained region. All the prisons of tii(> State 
transfer their tuberculous inmates, no matter in what stage, to this 
farm, which is supervised by the Superintendent of Penitentiaries. 
The strictest hygiene prevails. The men are nearly all worked at 
some light form of gardening, farming, poultry- or stock-raising. One 
hundred and eighty cases — whites, negroes, and M(>xicaiis — have, 
during the first three years, been treated under these circumstances. 
Forty-six died (24.44 per cent.). Before this system was inaugurated 
about half the deaths in the State prisons were due to tuberculosis. 
This report emphasizes the feasibility of transferring all consumptive 
convicts to a central place for treatment, the benefds to be derived in 
ttie way of reduction of the number of such convicts in the varions 
S| prisons of the State, and the practicability of light outdoor work lor 
these cases. This farm is expected soon to be self-sustahiing, apart 
from the expense of guarding the men. 



The struggle with tuberculosis is intimately bound up witli the solution 
of the most complex economic problems, and no plans will be complete which 
have not for their basis the material and moral improvement of the people. The 
struggle with tuberculosis demands the mobilization of all social forces, public and 
private, official and voluntary. — CAsiMm-PERiER. 

The whole problem of financing the tuberculosis situation is one of 
greatest difficulty. There are many considerations, — the cost of land 
and buildings ; the expense of maintaining them ; the ability of con- 
sumptives to pay wholly, or at least in part, for their treatment and 
other things essential to their cure ; the perplexing cjuestion of the 
charitable care of those who cannot, involving always the possibility 
that an unfortunate tendency to pauperism may be engendered, so 
that while perhaps the bodies of such patients are being made well, 
their characters are being undermined ; the question how the de- 
pendents of the consumptive wage-earner are to be taken care of 
while he is from work ; the extent to which private individuals or 
associations may be asked to contribute to the support of poor con- 
sumptives ; the extent to which municipal. State, and federal authori- 
ties should act in this regard, — these and many other elements must 
be taken into account ; and in considering expense witli regard to 
prevention and cure one must make comparative estimate of the losses 
which would result to the State and the community if no steps were 
taken to mitigate the tuberculosis situation. 

Expense items are set forth iin other chapters and in appendices. 
I can but detail here Mr. Folks's estimates concerning sanatoria and 
their adjuncts for the poor of New York City. Four hundred and 
fifty thousand dollars would be required for a satisfactory institution 
to accommodate five hundred patients. The cost of maintenance in 
various institutions is as follows : The average yearly i)er capita cost 
of patients at Saranac Lake is nearly $500. At Rutland the average 
daily expense is $1.42 per capita. Tlie average number of patients 
at this rating has been one hundred and seventy-seven. The per 
capita expense would no doubt be much less than this for five hun- 
dred patients, as supplies could be bought more advantageously in 
larger quanlitics. At the Bedford Sanatorium, with an average of 



one hundred and thirty-four patients, the per diem cost lias been 7G 
cents. The raising of produce on the farm assists in reducing the 
cost. The Loomis Sanatorium, at Liberty, reports a per capita cost at 
the Annex, which is on th(^ ward i)lan, of $1.21 per day. This is based 
on the care of thirty patients ; a larger number would no doubt reduce 
the per capita cost. The St. Joseph's Hospital, with an average of 
three hundred and forty-five patients, reports a per capita daily cost of 
80 cents. The Seton Hospital, with an average of one hundred and 
ninety-five patients, requires a per capita cost of 79 cents. The Metro- 
politan Hospital, on Blackwell's Island, with an average of six hundred 
and twenty-three patients, requires a per capita daily cost of 74 cents. 
For the institution contemplated for New York City jMr. Folks would 
estimate a per diem cost of $1 for five hundred patients, or a total 
for the year of $182,500, — an amount which might be reduced if suf- 
ficient land were provided to permit the carrying on of dairying, 
poultry-, vegetable-, and fruit-raising on a large scale. This cost of 
maintenance includes food (whicli must be abundant and good), 
clothing, bedding, salaries, medical supplies, light and fuel, and ordi- 
nary repairs. 

The Ohio State Commission would build sanatoria in various 
regions within that State. To begin with, $200,000 should be appro- 
priated for a site and the erection of properly equipped buildings. 
The average stay of patients would be six months ; so that the insti- 
tution should be capable of caring for one hundred and fifty patients 
daily, and three hundred a year. By the addition of tents many more 
could be taken care of. It is recommended that no })atient shall be 
accepted under fifteen or over forty, nor any but incipient cases ; that 
a tract of some hundred to tw^o hundred acres be secured, much of 
which should be suitable for agriculture. 

Dr. Holmes very aptly compares the struggle of a tuberculous 
patient to a nation defending its life or its honor. Similar questions 
are presented for solution, and identical conditions are to be met. 
War between nations and war against disease are often declared with 
little warning. In either event the defenses are frequently found 
in a weak condition, the finances at low ebb, and the strongholds in a 
neglected state. The nation that fails to prepare for war in time of 
peace can make but a feeble resistance when danger is threatened. 
An army sent to the front is certain of defeat unless plans for furnish- 
ing supplies have been carefully formulated. Disaster results if the 
line of communication is broken and the supplies cut of. Such a 
catastrophe means an indefinite siege, with indescribable privation and 
suffering. On the other hand, the equipment and supplies nay be 


inexhaustible, and yet if the commanding otlicer lacks judgment he 
may lead his brave men into dangers that mean inevitable defeat. 

The great army of tuberculous patients furnish memorable object 
lessons. Many a patient for a time makes a good fight ; yet for lack of 
conservative judgment or on account of overconfidence, what seemed to 
be a certain victory is turned into a sudden defeat. In warfare against 
disease the campaign should be well studied before rushing to meet the 
enemy. The course pursued should depend on the resources at hand. 
Good judgment and cunning stratagem are essential. Before a cam- 
paign is undertaken an attempt should be made to estimate the ap- 
proximate cost ; every elfort should be made to procure the necessary 
funds ; the field for operation should be selected with a view of securing 
the most favorable conditions and the strongest defenses ; the source 
and nature of the supplies should be well considered, and a com- 
mander chosen to direct the forces whose experience and judgment 
are above reproach. " When these precautions are not taken defeat 
is inevitable. How many tuberculous patients plan a campaign with 
skill and judgment? Too frequently they leave all judgment at home. 
They take with them a good supply of bravery, but few or no other 
supplies ; they frequently choose a battlefield with no natural defenses, 
and are often unskilled in proper methods of utilizing their available 

With regard to the part which life insurance companies might 
take in the financing of the tuberculosis situation, we must not lose 
sight of the fact that these are essentially business and not philan- 
thropic institutions. Any action which they would take would 
rightly enougli be upon grounds of self-interest. We note that the 
Prudential Life Insurance Company of America alone loses ten thou- 
sand policy holders yearly from consumption, involving a loss of 
$110,000, or $110 per capita. Mr. F. K. Hoffman, the actuary of this 
company, declares that the financial interest of his company in 
the tuberculosis problem amounts to four-fifths of a million dollars 
per annum ; yet he answers with a decided negative the question 
whether industrial insurance companies should contribute to the erec- 
tion and maintenance of sanatoria. " Once the companies were to 
engage in this form of direct assistance to afflicted policy holders, they 
would soon be confronted with numerous })ropositions to make equal 
provision and grant e(iual consideration to policy holders suffering 
from other diseases,"' etc. He states, furthermore, that such a com- 
pany represents the interests of all the policy holders, and not of any 
special class, however unfortunate or afflicted, and rightly observes 
that life insurance companies have no funds available for charitable 


purposes. As it is, his company receives Irorn each policy holder 
dying from consumption an average amount of $24, and it must pay 
at every such death an average of $134. German insurance com- 
panies, as we shall see, have taken up the work of sanatorium treat- 
ment of their consumptive policy holders. Within two years (1«{)7-H) 
these companies had spent more than one million dollars for tlu' 
establishment and maintenance of sanatoria for consumijlivcs pre- 
viously insured by them. Rut Mr. HolTman points out that these 
companies are branches of the government insurance system, and arc 
not private companies. Under the German system every irorhndu 
must be insured. 

The next chapter is devoted to the splendid way in which the 
German people have faced the probletn of financing the tuberculosis 
situation. I would here set forth Illllier's opinions, based upon this 
system, concerning the same problem in England, He emphasizes 
two points : that the consumptive himself is to be provided for ; and 
some provision must also be made, while he is incapacitated, for those 
dependent upon him. As regards the latter point there is bound 
to be impoverishment sooner or later, whether the consumptive be 
taken early from his work or left a year or two longer until work or 
cure are impossible. Evidently the prospect of eventually restoring 
his wage-earning capacity should more than compensate for the 
temporary money loss entailed by his early removal. It is indeed 
"only the hand-to-mouth way that the public have got into of re- 
garding every question in relation to the working classes, which has 
led to an economic fallacy about the ruthlessness of removing the 
consumptive wage earner from his work." 

In England the principle of subsidy through the poor rates, friendly 
societies, and private charity, largely predominates over the more 
rational and business-like German methods. Can the German method 
be transplanted to England and to other countries ? Is the consump- 
tive to continue " to be sent home on a sick allowance and a weekly 
bottle of medicine from some dispensary, to spit on the hearth and 
cough his time away amid the family, doomed himself and probably 
infecting others ?" To counsel compulsory insurance among the Anglo- 
Saxon races is probably too Utopian for practical consideration at 
present. Funds must continue to be looked for from friendly socie- 
ties, corporations, boards of guardians, county councils, and private 
philanthrophy. Even in Germany sanatoria are by no means entirely 
provided for by the State Sick Insurance Department ; they are con- 
tributed to from many other sources, of which private contributions 
are by no means the least. Indeed, " what is required is to bring to 


boar upon tlie extinction of tiie diseases due to tuberculosis all the 
agencies which we can command." ' 

How may money be had to fight tuberculosis irrespective of State 
appropriations ? Flick declares there are men and women everywhere 
who are willing to do much for charity and philanthropy, " provided 
it is clear to them that the money which they give is judiciously 
expended and yields fruit in practical results. If the right effort is 
made, the money which is necessary can be raised." Tuberculosis is 
a disease which comes home to every one at one time or another — 
somewhere in his family or among his friends — so that practically 
every member of a community will consider an appeal. There is in 
Canada a method of raising money for such purposes as this which 
might be engrafted upon our American system of State government. 
This is the enactment of a State law under which any community may 
get a certain amount of State aid, in proportion to the amount of w^ork 
which the community itself does. If a community would establish a 
sanatorium for consumptives, it could under this system draw from 
the State an amount of money proportionate to that which it has 
itself raised ; and for every patient treated it would get from the State 
a certain percentage of maintenance money for each day of his treat- 

^ Sir William Broadbent, the chairman of the Council of the National Associa- 
tion for the Prevention of Consumption. 


CllAi'TEU Vll 


We consider it. our imperial duly to impress upon the Reichstag the neces- 
sity of furthering the welfare of the working people. We should review with in- 
creasing satisfaction the man i fold successes with which the Lord has hlest our 
reign, could we carry with us to the grave the consciousness of having given our 
country an additional and lasting assurance of internal peace, and the conviction 
that we have rendered the needy that assistance to which they are justly entitled. 
Our efforts in this direction are certain of the; approval of all tlii; federate Governments, 
and we confidently rely on the support of the Reichstag, without distinction of 
parties. In order to realize these views a hill for the insurance of workmen against 
industrial accidents will first of all be laid before you, after which a supplemen- 
tary measure will be submitted providing for a general organization nf 
industrial sick relief insurance. But likewise those who are disabled in con- 
sequence of old age or invalidity possess a well-founded claim to a more ample 
relief on the part of the State than they have hitherto enjoyed. To devise the 
fittest ways and means for making such provision, however difficult, is one of the 
highest obligations of every community based on the moral foundations of Chris- 
tianity. A more intimate connection with the actual capabilities of the people, and 
a mode of turning these capabilities to account in corporate associations, under 
the patronage and with the aid of the State, will, we trust, develop a scheme to 
.solve which the State alone would prove unequal. — Message of fhe Emperor 
William I. to the Reichstag in November, 1881. 

The German people have grappled nobly with certain economic 
problems related to the tuberculosis situation. These problems are 
vastly important of consideration, especially that one which seeks to 
obviate pauperism for the consumptive, and to prevent his becoming 
an object of charity. A system by which every laborer and servant is 
obliged by law to become insured against sickness, accident, and old 
age, the companies being controlled by the Government ; a system by 
which in one year eighty-two thousand insured men and women W(>re 
treated in sanatoria, so that seventy-one i)er cent, of them n-lnnicd to 
their work "with strength and hope won back ;" a system wliich with 
all these results has vouchsafed to the consunii)tive his self-respect, 
is certainly worthy of study. 

Procedures have been evolved out of the imperial mandate just 

quoted under which the workman, incapacitated by sickness, accident, 

infirmity, or old age, has a legal right to a measure of provision, Jjotii 

for himself and family, which sav(\s liim from being compelled to rely 

upon public charitv. The means by which this end lias been attained 



are based upon compulsory insurance on the part of the workman 
and his employer, under a system of administration in which the in- 
sured are represented. Under this system there are three forms of 
insurance, — accident, sickness, invalidity and old age.' 

(1) In accident insurance the premiums are paid entirely by the 
employer, and in case of death resulting an allowance is made to tlie 
survivors from the day of deatli. For widows and children this 
allowance is fifty per cent, of the yearly earnings ; for dependent 
parents, twenty per cent. During tlie first thirteen weeks an injured 
man is supported out of the sick fund, presently to be described ; and 
if by that time he is not sufficiently recovered to resume work he re- 
ceives an allowance during his disablement, up to sixty per cent, of 
his yearly earnings, or free hospital treatment during the whole cure, 
besides an allowance for his family. This accident insurance is 
extended to working people engaged in industry or agriculture, to 
officials whose salaries do not exceed $500 a year, and to small 
employers. The employers are united in trade associations and 
contribute to the insurance funds proportionally to the wages paid, or 
to the number of hands employed, as well as to the risks of accident 
in the various occupations. 

(2) In insurance against sickness the workman pays two-thirds 
of the premium and the employer one-third. In the event of sickness 
the allowance is made for thirteen weeks, or the sick man receives 
free hospital treatment and half the sick pay for the support of the 
family. Similar help is provided for women in childbed for four 
weeks ; and in case of death the funeral expenses (t\venty times the 
daily wages) are paid. The sickness insurance is managed by local 
sick associations, (jf which there are a number of organized branches. 
One of the many indirect advantages of this system is that not only is 
the man i)aid, but, feeling that his family is provided for, this knowl- 
edge jjrevents him from leaving the hospital too soon, and he enjoys a 
mind at rest, — a decided essential to recovery for every form of acci- 
dent or sickness. 

(3) In insurance against infirmity and old age, there is a fund 
which is contributed to conjointly by the Empire, the employers, and 
the employed. The Empire contributes to each annuity the fixed 
amount of fifty marks ($12.50) per annum, and pays as well the 
contribution of the workman himself while he is serving in the 
army or navy. The employer and the employee contribute equally 
and in proportion to the wages earned. The payment of these latter 




contribulions is really made by the 0Mi])l()yer, who every week aflixcs 
stamps to the card of the msured. Tiicse slaiiips are issued l)y the 
Imperial Insurance Department, and in paying'- I lie wages of the ciii- 
ployed tlie employers are entitled to deduct the workiiiaiTs share of 
these contributions. Tlie eidire charges of the workman's insurance 
on the year's average are as follows : 

Sick insurance . . 
Accident, insurance 
Invalidity insurance 

Total . . . 




Employed ! Emr'ire 
marks. marks. 








From this it will be seen that the workman actually does not i)ay 
one-half of the whole charges. Indeed, he gets back considerably 
more in compensation than he contributes for his insurance. These 
three branches of National-State Insurance supplement one another, 
and form a complete organization, which goes far to relieve distress 
thrown upon the entire family in the case of sickness, incapacity for 
work, or death of the workman. The effect is more far-reaching even 
than this. The social status of the workman is raised to a higher 
plane than that attained perhaps in any other State. In place of de- 
pendence on almsgiving he claims as a right from the State that relief 
in case of sickness for himself and family which the State has helped 
him to purchase, and not left him to beg. Out of the funds of the 
workman's insurance, grants by way of advances are made for im- 
proving the dwellings of Avorkmen, and for supporting improvements 
of public interest. "One million marks are exi)ended daily in Ger- 
many from this branch of provision for workmen alone, whilst the accu- 
mulated funds already exceed one milliard marks (S250.()00,00U), one 
hundred million marks of which liave been spent in constructing 
workmen's dwellings and special establishments for sick, injured, 
invalided, and convalescent working peoi)le, public l)alhs, and similar 
institutions, for the benefit of the working classes. As, however, the 
circumstances which tend to disturb the good relations between em- 
ployees and employed are everywhere much the same, the hope is 
natural and well justified that the consideration and forethought 
which the Gernian laborers owe to the beneficent sacrifice of tlieir 
employers will find an echo in other civilized countries for tlie welfare 


of tl)o liLiman race and the consolidation of social peace and con- 
cord.""^ The workmen's insurance has also done much to improve 
the general conditions of life for the workman and his people ; and 
the consideration that in case of sickness and incapacity for work he 
is entitled to an indemnity from the insurance funds, largely allays 
anxiety. The policy on the part of the controllers of the fund is to 
prevent danger from sickness and accident, and this policy, which has 
inspired much of the work of the State Sick Insurance Department, 
is described by a short formula constantly cjuoted, " The prevention of 

As sickness immediately makes a call upon the common fund, the 
various local branches or sick clubs not only address themselves to 
restoring the sick to health, but endeavor to prevent by every hygienic 
and other beneficent measure the occurrence of disease. Thus, by 
the aid of the State Sick Insurance Department, millions of pubUca- 
tions, such as the " Tuberkulose Merkblatt," have been distributed 
among the working classes and to the officials of the sick clubs and 
unions, and have attracted much interest. 

The three unions engaged, under the patronage of the Empress, 
in fighting consumption — the German Central Committee for the Es- 
tablishment of Cure Dwelling-homes for Consumptives, the Berlin- 
Brandenburg Union for tlie same purpose, and the People's Cure 
Dwelling-Home Union of the Bed Cross — have provided sanatoria for 
consumptives. The catalogue of the St. Louis exhibits of the German 
Imperial Board of Health stated that in 1904 there existed in the 
Empire more than ninety lung sanatoria, with altogether eight thou- 
sand beds, of which two thousand five hundred were for women 
patients. On an average of four patients for each bed, about thirty- 
two thousand patients have thus enjoyed the benefits of the sanatoria 
in a year. The expense of building and furnishing these sanatoria 
amounted, according to a moderate estimate, to more than 40,000,000 
marks (nearly $10,000,000). The building of new sanatoria was 
being planned, and some of these were to be opened for patients 
within the year. As a basis for building expenses, the sum of 5000 
marks for every bed is calculated. 

Tile Imperial Insurance Department has advised the insurance 
institutions to "avail themselves of the favorable opportunities offered 
by the exertions of these unions, and in cases of consumption, where 
the insured is capable of recovery, to demand the aid of the sick 
clubs and communities concerned, for the preservation of the work- 



man's self-support, by granting a treatment for that i)urposc in sana- 
toria which will, if the result answers tiie lioped-for cxpeclalions, 
lessen the annuities they are charged with."" The favorable ex|tfi-i- 
ences up to the year 1899 led to an extensive support of the endeavors 
of the insurance institutions. It was felt that here was a question 
not only of guarding the family from inniiediate distress, but also of 
eitecting a timely removal of members of the family who might infect 
the others. These efforts, together with the improvement in the 
general condition of tlie working classes, brought about by the whole 
organization of the State Sick Insurance Department, have already 
brought the tubercular death-rate in Prussia from 31 per 10,000 in 
188G to 19 per 10,000 in 1901. 

One lesson which the experience of the State Sick Insurance 
Department has taught above all others is the necessity for sending 
consumptives to sanatoria at the very earliest stages of the disease, 
if the best curative and economic results are to be obtained. In 
addition to sanatoria for consumptives, and home dwellings, many 
other institutions for the benefit of the working classes have been 
promoted by the Workmen's Insurance Department. Accident stations, 
centres for sick nurses, and institutions for convalescents have all 
been erected. Loans at a low rate of interest are granted for the 
purpose of making railroads ; for the encouragement of cal tie-raising; 
for laborers' colonies, public baths, improvements, etc. :\Ieanwhile 
the vitality of the workmen is improving, and the birth-rate among 
them is the highest in Europe. Moreover, the tendency to save has 
been increased by the compulsory insurance system. The working 
people have their representatives on the boards of the sick clui)s and 
insurance institutions, who sit and vote side by side with the em- 
ployers and the officials of tlie Empire. And " the results will in the 
future be still more effectual when these plans have stood in Ibrce 
through several generations, and liave become the flesh and blood 
of the population."^ 

^ Herr Klein, an Imperial Councillor. Bielefeldfs paper is invaluable. 

Part XII 


The great work of sanitary reform has been, perhaps, the 

noblest legislative achievement of our age, and, if measured by the 

suffering it has diminished, has probably done far more for the real 

happiness of mankind than ail the many questions that make and 

unmake ministries. 





I often think it, comical 

How Nature always does contrive 
That every boy and every girl 

That's born into the world alive 
Is either a little Liberal 

Or else a little Conservative. 


MoDERATisTS are few and far between. The extreiiios of the pendu- 
lum characterize the temperaments of most men. On the one hand, 
there are those who are for having everything regulated by the Gov- 
ernment. And certainly there are many things which would be bettor 
conducted that way. However, there are ultra-i)aternalists who do 
now, and certainly will, occasion much damage if the measures ilicy 
have brought to pass or which they advocate become i)ermanent. For 
instance, the abolition of the army canteen has untiuestionably worked 
woe, brought about as it was by the W. C. T. U. in the interests of 
drunkenness and vice. Then there is the scheme to discourage "race 
suicide" by means of the gratuitous distribution of perandmlalors. 
And the proposition recently advanced to furnish breakfasts to school 
children must upon sober reflection impress both the political econo- 
mist and the judicious humanitarian as being about as vicious a pro- 
ceeding as can be conceived. It has been well observed with regard 
to such extremists, " What a good world this would be were it nut 
for its virtuous people." 

On the other hand, there are the laissez-faire-ids — those comfort- 
able folk who discern in the trend of things eternal not perspira- 
tion, but potentiality ; it is they who wonder why the universe needs 
so much managing, why the Almighty needs so constantly to bt> ad- 
vised. Yet, upon momentous occasions, as when woman's honor is 
destroyed by cadetism, and is dispensed by the check system, these 
laissez-faire-ists will jump out of their easy chairs and strike in a way 
to amaze their opposites. All this is by way of noting that the meas- 
ures which will be set forth in these chapters are, I think, temperate 
and judicious ; for they have been formulated by reasonable men 
who have learned experience through many years' work in the held 




It is tlu' j)r()viiice <if' the Legislature to procure the safety of the community, 
even if it interferes with the freedom of indiviciual action. — Hobbes. 

The work of Dr. Hermann M. Biggs in the field of preventive 
medicine is of world-wide appreciation, as having manifestly resulted 
in the saving of many lives and the alleviation of much human suffer- 
ing. The administrative measures, which have been put forth by the 
New York City Health Department during his able advisorship of 
some fifteen years past, are now gratefully adopted, so far as prac- 
ticable, by many civic counnunities. Certain measures which he has 
found essential to the control of tuberculosis by municipalities are here 
reproduced from his writings : 

1. The compulsory notification by the physician in charge, and 
the registration of all cases. The information here gathered is held 
to be contidential. And there is no official surveillance, as in the case 
of more acutely infectious diseases, such as diphtheria and scarlet 
fever. "It is assumed and stated positively that in all instances 
where the consiun})tive is under the care of a private physician, and 
the latter will undertake to give such instructions as are necessary to 
prevent the transmission of the disease to others, no furtlier cog- 
nizance of tlie case will be taken by the health authorities after the 
registration." However, if the consumptive has the disease in an 
infectious stage, has no home, is without a physician, is living in a 
lodging-house or in a poorly furnished tenement, or is receiving 
charitable medical advice through some public institution, then there 
should be no ({uestion of the propriety of official action. 

2. The sanitary authorities should afford facilities for the early 
diagnosis by bacteriological examination of the sputum free of cost. 
In many incipient cases the symptoms are not sufficiently definite to 
permit a jiositive diagnosis by the general practitioner, although the 
exi)ert may easily arrive at a })ositive conclusion. It is essential thai 
a diagnosis be made at the earliest possible moment. And since 181'4 
the New York City Health Department has provided facilities for 
sputum examinations, with results very valuable to physicians, to the 



sick, and to the aiithoritios. Dr. FUji^js notes the curious (act tliat 
many physicians in private practice, wlio are unwilling'- or reluctaut to 
report cases directly, without hesitation send specimens lor examina- 
tion with all the facts whicli are necessary for registration. It is only 
on this condition that examinations are made. There are now in 
New York City two Imndred depots where outfits, hiaiiks. etc.. lor 
the collection of specimens of sputum may be obtained and w here 
the specimens may be left for the department collectors. 

3. Information concerning the disease should be given In the 
public by printed circulars and by the public press. The sanitary 
authorities have important educational duties to jjerlbrm. 

4. Consumptives should be visited in their homes Ijv physicians 
or trained nurses, who would instruct the families and patients in 
regard to nece.ssary precautions. The nurse should gather inlbrmation 
concerning the sick person, the social condition and financial income 
of the family, the number of persons in il and their wages; "the 
number of cases of tuberculosis which have occurred, the probable 
source of infection in the individual, the sanitary condition of the 
premises, the amount of air-space for each person, the character of 
the light and ventilation, the precautions being observed, and tlie 
possible need of any further interference on the ])art of the 

If it becomes evident for the good of the conununity that a patient 
should be removed to a hospital or a sanatorium outside of the city, 
the patient should, if possible, be induced by persuasion to go: but 
if he persistently refuses institutional care, forcible removal must be 
resorted to in instances where it is evident that tlio health of the 
community is jeopardized. It is to the Riverside IIos])ital on Xorlli 
Brother Island that many such cases are taken from New \(>vk 
City, — an excellent institution, comparatively palatial for those lor 
whom it is intended. 

5. Rooms or apartments which have been vacated by consump- 
tives, either by death or removal, should be disinfected or reiu)vated 
after trained medical inspectors have been sent to inspect lliem. In 
dirty and filthy premises, where the walls and ceilings are in bad condi- 
tion, renovation should be required to be done by the owners. If 
essential for the purpose the apartments maybe vacated, or if already 
vacant the occupation by others must be i)roliibited until the renova- 
tion has been completed. Fal)rics which cannot be disinfected l^y 
formaldehyde on the premises should be removed by tlu^ authorities, 
subjected to steam disinfection, and returned. 

Dr. Biggs sets forth a serious difficulty which arises from '-the 


freciuent chang-o of residence of some families containing consumptives, 
and as tlie families become constantly poorer on account of tlie finan- 
cial loss and expense entailed by the illness, they move continually to 
a poorer and poorer class of tenements. It is often impossible to 
trace them, or to obtain information of their change of residence, so 
that proper disinfection of the apartments may be insured. The 
owners of the property may of course be recjuired to furnish informa- 
tion of the removal, but there is danger lest this course may eventu- 
ally entail some hardship on the poor consumptive in rendering it 
more difficult f(ir liim to fmd lodgings. This is the most troublesome 
problem to solve which we have found in New York. I do not feel 
sure that eventually notitication by the owner of the removal of a 
consumptive will not be necessary, as the only solution of this 
difficulty." • 

6. There should be provision for repeated visits by trained nurses 
to cases in tenements when the patient cannot be removed to an in- 
stitution, so that changes of residence, the manner in whicli the con- 
sumptive takes precautions, etc., may be learned. 

7. Suitable food, especially milk and eggs, should be supplied to 
destitute families by the authorities or by others, such as charitable 
societies, whicli undertake supervision in .such affairs. Some of these 
cases present very difficult economic problems. For instance : " A 
family consists of a mother, with moderately advanced consumption, 
and five small children. The father is dead. The income of the 
family from all sources is insufficient to maintain it properly and fur- 
nish the mother with suitable food. But the apartments are well 
ventilated and sufficiently commodious, they are neat and clean, and 
the mother makes every effort to obey every instruction and heed 
every suggestion. She insists on remaining with her children, and 
her presence is necessary to keep the family together. Undoubtedly 
the mother would be better off in an institution, and then, too, the 
cliildren would be removed to an institution for children, and would 
be better protected from the danger of tubercular infection. But then 
the children grow up as institutional children, which is most un- 
fortunate, and. furthermore, there is no sufficient sanitary ground 
for the forcible removal of the mother. Under such conditions, 
for the present at least, I believe the authorities should provide, 
or see that there is provided, such food or other assistance as is 

' Othpr p:initarians very stronsrly advocate compulsory notification by the owners 
of houses. 


If, however, the apartments are dirty and not well kcpl. or an- 
small, dark, and badly ventilated, and like anfavorablc coiKJilions pro- 
vail, then the mother should be removed to an iiistiluiioii, if neces- 
sary by force, and the children otherwise provided for. Kvidenlly 
each such case must be decided after a careful consideration of the 
facts; no uniform regulations can here be laid down. The auliiori- 
ties should, however, recognize their responsibilities to provide assist- 
ance in many cases, and should have means at their disposal for this 
purpose. If this assistance is dispensed by other authorities than the 
health authorities, it should be under the latter's direction and super- 

8. The sanitary authorities should provide, or see that there are 
provided, and should supervise, three classes of institutions for con- 
sumptives : 

(a) Free dispensaries, from which suitable cases should be referred 
either to a sanatorium or to a hospital, as seems necessary. 

(6) Hospitals for the care of advanced cases. It is not necessary 
that all such hospitals should be directly under tlie control of the 
sanitary authorities, although the latter should exercise a general 
supervision. In large cities the authorities should have control of at 
least one well-equipped institution for such advanced cases as it may 
be necessary to remove forcibly and to retain in the institution against 
their will. Among such cases, in addition to those just considered, 
are those which are discharged from other institutions because they 
have there been found undesirable patients for various reasons. From 
the sanitary stand-point these are of all cases those which it is most 
essential should be provided with institutional care. Homeless, de- 
pendent, friendless, dissipated, and perhaps vicious, such consumptives 
are likely to be the most dangerous to the community. If not cared 
for in an institution, they are wandering from place to place, living in 
lodging-houses or sleeping in hallways or wherever cover can be 
found, careless concerning their sputum, disseminating infection 
wherever they visit. Such cases nmst at any cost be provided for by 
the sanitary authorities, and, if necessary, they nmst be removed to 
. and detained in proper institutions. The same procedure should 
obtain for cases living in lodging-houses, or those who are imnates of 
public institutions not having facilities for their care. The experience 
of the New York City Health Department has shown that difliculty is 
rarely experienced in management of these cases if the accommo- 
dations which are provided and the food and care given are of a 
superior character. These measures can, of course, be taken only 
where the sanitary authorities have full uower and control, and the 


patients can be retained only in institutions over whicli tliey have 
direct authority/ 

(c) The sanitary authorities having to deal with the prevention and 
care of tuberculosis should have available proper sanatoria in favor- 
ably situated country districts for the care of early and incipient cases. 

9. The sanitary authorities should issue regulations applicable to 
public institutions as to the care of consumptives. Such patients 
should not be admitted promiscuously into the wards of general 
hospitals. All public institutions caring for such patients should be 
recjuired to provide separate rooms or wards. These regulations 
should apply not only to general hospitals, but also to hospitals for 
the insane, penal institutions, homes, asylums, and the like. Suitable 
regulations should ])e formulated in regard to cases occurring among 
the teachers or pupils in the public schools, as to employees in 
factories, workshops, and mercantile establishments, and as to occu- 
pations of a nature which are likely to disseminate the disease. 

10. The sanitary authorities should enforce the prohibition of 
spitting in public conveyances, in public places, and upon the side- 
walks. Dr. Biggs considers that here lies the keynote of the whole 
question of the prevention of diseases of the respiratory organs, not 
only tuberculosis, but pneumonia and other diseases as well ; that all 
classes of the people should be educated to a recognition of and i 
belief in the fundamental importance of the proper disposal of the 

A number of additional measures of minor importance nave been 
in operation. There is a semiannual census of cases under treat- 
ment in public institutions in New York City. It has been the custom 
for some three years past to communicate with the attending physician 
in cases which have been reported, and to inquire whether the patient 
is .still under treatment, and if so, whether improvement has taken 
place or not, and whether the physician has any objection to a visit 
being made if the patient be not at that time uiuhu' the physician's 
observation. If the physician replies that the patient has passed trom 
his observation, and he has no objection, tlie department makes an 
effort to locate the patient and determine his condition. 

^Tlie leuality of fhis measure may l^e questioned. Bui the health board's 
position is no doubt souni]. The advanced and uncared-for consumptive i> a 
menace to the In'altb of his neiiihbors. With legard to smallpox — an analogous 
disease in rdalioii lo possible effects upou llie couununily — the Federal Supreme 
Court has decided that oue must be vaccinated, willy-nilly, by the properly consti- 
tuted authorities, and in New York City for many years ])ast sufferers from small- 
pox ami other infectious diseases have i)een lawfully lemoved from their iKUues. 


Sectional maps have been prepared which show vwvy hoiisc-lol 
in the borouqh of Manhattan on a scale suriiciciitly huve lo indicalc 
all the cases of Inberculosis, and llic deaths from lliat diseas(>, whiih 
have from the beginnin,y- of lliis work come nnder the ohscrvalioii of 
the department; the topographical distribution of the disease has thus 
been demonstrated.' 

The department has had house-to-house insi)ections made in tene- 
ment districts by women physicians in the search for uinvporied cases 
of tuberculosis. Quite a large number have been found in this way, 
especially among the foreign population. Great care has been taken, 
as far as it was possible under civil service regulations, to oiitaiii 
trained nurses and physicians who speak foreign languages, — French, 
German, Yiddish, Russian, Italian, and Polish. 

Dr. Biggs discusses several questions with regard lo his jjlan of 
administration, as here outlined. — 

1. Is such a scheme feasible? It has been in force in Xew York 
City — the second largest in the world — some fifteen years past, and 
experience has conclusively demonstrated its feasibility and jjracfica- 
bility. Since such is the case in this large city, smaller cities should 
have no difficulty in establishing and enforciiig similar regulations.- 

2. Are there serious objections to the enforcement of such meas- 
ures as these? There was very great oi)position to lliem in the 
beginning, so that many difficulties were for this reason occasioned. 
But experience has shown that the obstacles are largely imaghiary ; 
that the harmful results, which were predicted as certain to Ibllow, 
have failed to niaterialize. Practically no serious difficulties are en- 
countered in carrying on the work. The difficulties with regard to 
tuberculosis are really less serious than those encountered in con- 
nection with the acutely contagious diseases. There has come to 
be hearty approval by the majority of the medical profession, and 
acquiescence by the remainder. 

3. What may be reasonably exi)ected from the enlbrcement of 
such measures? There has been a more rapid fall in the tiiberculims 
death-rate in New York City tlian in any other great city in the world, 
and this notwithstanding the tact that the conditions in many respects 
are much more unfavorable. In no other city is there sueh diversity 
of population as exists in many of the wards of the l)orough of Maw- 
hattan, in some places six to eight hundred— even one thnusand — 

' Fig. 37, page 147. 

'Tfie department lias a recorct of 90 per cent, of the consumptives of the 
boroughs of Manliattan and the Bronx before their deatli, thougii in many inslauco-s, 
of course, it is only a sh(irt time ])etVjre death. 


people to the acre, wliereas tlie most densely populated districts of 
Paris, Vienna. I.ondon, and Prague have only four hundred or less 
})ersons to the acre. And this dense population is in great measure 
foreign-born, old tongues and old customs being retained, so that 
the difficulty in reacliing these people is unusual. During the last 
ten years there has been a decrease of forty per cent, in the death- 
rate in children under fifteen from pulmonary tuberculosis and tuber- 
culous meningitis, and a decrease in the total tuberculosis deatli-rate 
between 1887 and 1902 of forty per cent. 

Dr. Biggs does not intend to indicate that the whole of the re- 
duction in the death-rate from tuberculosis in New York City has been 
the result of the measures directed especially against this disease, for 
many other factors have undoubtedly contributed to it, but he does 
believe that the very great and rapid fall in the tuberculous death-rate 
is the direct result of the application of these measures, and that the 
next fifteen years will see an equal reduction. If "the necessary de- 
ductions of our scientific convictions" be accepted, we must conclude 
that tuberculosis is of all the important infections certainly the most 
preventable. " I am not only prepared to accept fully the deductions 
from the known facts in regard to this disease as to the possibilities 
in its prevention, but would regard the experience of New York City 
as furnisliing conclusive proof of the truth of this conclusion. 

" This is the great urgent sanitary problem of the new century. In 
no otlier direction can such large results be achieved so certainly and 
at such relatively small cost. The time is not far distant when those 
States and municipalities which have not adopted a comprehensive 
plan for dealing with tuberculosis will be regarded as almost criminally 
negligent in their administration of sanitary affairs and inexcusably 
blind to their own best economic interests."" 



It is true that the rich and those in cornfortahle circumstances liave it in fheir 
power to escape the disease, if they have the wit to do so. But how ahoiit llie 
poor,— they who, Hke dumb cattle, are driven by their necessities into the very 
face of death? Consumption claims most of its victims from that class, ami they 
have neither the power nor tlie i<nowledg(' to escape its clutches. Does not the 
Government owe them a duty? If consumption is contagious, it can he exter- 
minated, or, at least, its ravages much curtailed ; it consequently behooves every 
government to take up some other position in the matter than one of passive neu- 
trality. — Flick. 

In the year 1900 there was appointed a New York State Tenement- 
House Commission, wiiose investigation led to the conchision that tiie 
excessive mortality which prevailed among the poor of the metropolis 
was due largely to want of fresh air and to unsanitary toilet arrange- 
ments. The presence of many unlighted and unventilated living-rooms 
was found to have a direct bearing on the great loss of life through 
pulmonary consumption and infantile disorders. Of tlie seventy thou- 
sand deaths occurring annually, twenty-five thousand were among cliil- 
dren under five years of age, while eight tliousand resulted from 
phthisis. There w^ere forty-one thousand rases of infectious disease 
reported annually, of which ten per cent, terminated fatally. The 
prevalence of infectious disease was rightly attributed to tlie use of 
unsanitary toilets and sinks, from which inleciioii was spread by Dies 
and in other ways. There were nearly nine thousand uncovered 
toilets, located for the most part in the thickly populated wards. In 
the streets of these wards the practice of exposing food for sale on 
push-carts and street-stands has been common. The Connnission 
therefore decided to recommend that unsanitary constructions in old 
tenements should be remedied. As a result a tenement-house act 
was passed, which led to the establishment of the Tenement-PIouse 
Department in New York City. Robert W. de Forest was the first 

The work of this department is well set forth in its report, in two 
substantial volumes, which covers the eighteen months beginning Jan- 
uary 1, 1902. The tenement-house act was by no means a mere 
extension of principles embodied in existing legislation. It was new 



in spirit and purpose, and liad for its ol)J(Mt the improvement of the 
moral as well as the pliysical environment of tlie tenement popula- 
tion. It provided for tlie suppression of prostitution in tenements, 
and only the citizen familiar with municipal conditions for a decade 
past can know what this means. Besides, the act raised the standard 
of future building construction, and called for the alteration of unsani- 
tary houses erected under former lax rules. The functions entrusted 
to this new department were extremely varied and extensive. They 
included supervision of all tenement building operations, compelling 
alterations in forty thousand unsanitary structures. There were, to 
begin with, eighty-two thousand inspections to be made. Every tene- 
ment-house in the city was to be inspected once a year, while houses 
in which the apartments averaged a rental below twenty-live dollars 
a month were to be investigated monthly. 

The department w^as clothed with ample powers, as was essential 
in the interests of the health of humanity's submerged strata in this 
community. It can at once, and peremptorily, stop work on new 
buildings and vacate old ones. No new tenement can be occupied with- 
out its permit. All ow'ners (or their responsible agents) must report 
their names and addresses, and certain other information, to the de- 
partment's registrar. It may enter the private apartments of two- 
thirds of the city's population. It lias a force of four hundred 
employees and a budget of half a million dollars. 

The part of the report which describes the organization of the 
department and its methods of work is very interesting, if for no other 
reason than that tlie system instituted by 'Sir. de Forest and his col- 
leagues makes evident tlie practical impossibility of blackmail by their 
subordinates. Such excellent workers as Lawrence Veiller, the lead- 
ing expert on housing reform in the United States ; Webster C. Bush, 
former Commissioner of Buildings in Brooklyn ; Charles B. Ball, former 
Chief Inspector of Plumbing in the District of Columbia : Prof. Wm. 
R. F^atterson, former Statistician of the State Board of Control of 
Iowa, and Miss Kate H. Claghorn, of the Federal Census, were j\Ir. de 
Forest's associates. • 

The work of the department has been excellent in every conceiv- 
able way. And the public has evidently been convinced of this, for 
subsequent attempts to emasculate the tenement-house act in the 
Legislature have aroused spontaneous and altogether effective protests 
from every honest and decent quarter. 

The thousand odd photographs taken by this department repro- 
duce the ghastly conditions in which many a wretched family was 
situated. And the picture showing the condition of things after the 


(k'partniont's activity are in llie reverse degree most gralilyiiig, as is 
here seen. In December, IDOo, Mr. de Forest reported to Mayor Low : 
" Tenement conditions in many instances have been found to be so 
bad as to be indescribable in print ; vile ])rivi(>s and privy sinks; foul 
cellars full of rul)bisb, in many cases of garbage and decomposing 
fecal matter; dilajjidated and dangerous stairs ; i)iumbing pipes con- 
taining large boles emitting sewer gas tlirougliout the liouses ; rooms so 
dark tbat one cannot see the people in tliem ; cellars occui)ied as sleeping 
places ; dangerous bakeries without ])ro[)er protection in case of lire ; 
pigs, goats, horses, and other animals kei)t in cellars; dangerous old 

Fig. '.»y.— The cellar of a macaroni factory. In the pan in the left-hand corner is a mixture of 
macaroni. On wet days this macaroni was dried in this cellar alongside the goats. The cellar was 
tilled several feet high with accumulations of filth. House vacated by the riepartmcut. 

fire traps without fire-escapes: disease-breeding rags and junk stoiv.l 
in tenement-houses; halls kept dark at iiiglil, endangering the lives 
and safety of the occupants ; buildhigs wilhoul ade.piate water supply. 
The list might be added to almost ind(^liuitely. 

'^ The cleansing of the Augean stables was a small task compared 
to the cleansing of New York's eighty-two thousand tenement-houses, 
occupied by nearly three millions of peoj)le representing every nation- 
ality and every degree in the social scale 

"The task that confronted the department was not, liowever. 
limited to this. Without organization, without employees, with all its 
problems before it, it was on the very day that it came into existence 



confronted with an organized and vigorous attack in ttie Legislature 
upon the fundamental principles of the law for whose enforcement it 
was created. 

" liiving accommodations for sixteen thousand seven hundred and 
sixty-eiglit families, or eighty-three thousand eight hundred and forty 
persons, have been provided in sanitary, comfortable, and decent 
houses, each one of which has been built according to law ; notorious 
evasion of and non-compliance with the laws has given place to their 
complete, uniform, and imjjartial enforcement ; the evil of prostitution 
has been practically abolished in the tenement houses ; three hundred 

Fig. 100. — A hall and sink as the Department 
found them. 

Fig. 101.— The same hall and sink as the 
Department left them. 

and thirty-seven thousand two hundred and forty-six inspections have 
been made. 

" The registration of forty-four thousand five hundred owners' 
names has been secured, thus fixing the responsibility for bad condi- 
tions in the tenements ; contagious disease has been checked and 
prevented; thirty-tv;o thousand eight hundred and twenty-five citi- 
zens' complaints have been investigated and the conditions complained 
of remedied. The existing tenement houses have been frequently and 
systematically inspected."' 

We may here emphasize that this Tenement-House Department is 
in constant contact with property holdings of enormous value, and 
with a vast number of people of varied interests. Its relation with 
the public apparently presented opportunities for blackmail on a large 


scale. And general municipal experience in this counlry cerluinly 
gave no assurance that, even if corruption could be avoided, this 
particular department would be competent to enforce effectively and 
impartially a law so complex as the one by which it was established. 
•'Indeed, most of the flagrant evils which this new law sought to 
remove had grown up through past corruption and inefficiency in the 
Building, Health, and Police and Fire Departments. When, for exam- 
ple, the State Tenement-House Commission of 1900 made an inspection 
of six hundred and eight tenement-houses in })rocess of construction 
under the jurisdiction of the old building department, violations of 
law were found in all but fifteen of the buildings."'^ Mr. de Forest 
and his associates recognized that in their work they would have to 
face adverse influences. Honest administration of the department was 
not sufficient ; tact and ability of the highest order were also essential. 
If this act was to remain permanently on the statute books, the value 
of the work would have to be very thoroughly demonstrated. That 
this was done no one will cjuestion who examines their re})ort, to 
which the reader must be referred for a detailed examination of the 
methods pursued. Suffice it to say that the work of these gentlemen 
has not only firmly established the cause of housing reform in New 
York, but has " demonstrated clearly that corruption need not exist 
in any of the large city departments." 

The Tenement-House Act made this department an entirely new 
branch of the city government. Before its creation the duty of 
enforcing the laws with regard to cleanliness in tenement-houses 
rested with the Health Department, which could not, however, because 
of insufficient appropriations, carry on a systematic house-to-house 
inspection. The health authorities could but investigate citizens' com- 
plaints and keep watch upon houses in which recent cases of infection 
had occurred. A large proportion, therefore, of tiie city's tenements 
had fallen into a position of neglect which certainly resulted in a great 
waste of life among the occupants, particularly among infants. And 
for more than a generation the crowded, filth-polluted tenement dis- 
tricts have been regarded as a source of danger to the cominunity 
at large because in them were lodged, and from them were spread, 
epidemic diseases ; so that no more important function was entrusted 
to this new department than that of maintaining an effective sanitary 
inspection service. This work is threefold: all tenements are in- 
spected at regular and frequent intervals; citizens' complaints are 
investigated ; houses in which infectious diseases have occurred are 

^ Editorial in New York Suiu August 4, 1904. 



Fig. liiJ.— Advertising siLTU constructed in front of 
the only windowsof six rooms, shutting out all light 
and air. 

thoroughly overhauled, hi pursuance of orders issued by the depart- 
ment during the eighteen months covered by the report, twenty-one 
thousand five hundred and eighty-four repairs were made to plumbing, 

thirteen thousand six hundred 
'; and seventeen water-closets 

were cleaned, twenty-nine thou- 
sand and ninety-six walls and 
ceilings were put in proper con- 
dition, and forty -five houses 
were vacated as unfit for habi- 

Under the present system 
the complainant, if a tenant, is 
in no danger of having his name 
disclosed to the landlord ; so 
that nearly thirty-three thou- 
sand complaints were received, 
of which but seventeen per 
cent, were found to be without foundation. 

From the Health Department morning reports are obtained of the > 
cases of infectious disease "closed" on the preceding day, sucli being j 
cases wliere the infection is ended and the premises have been dis- 

This Tenement-House Department has an ingenious but simple 
method of card filing which enables it to keep a constant lookout for 
houses with a high record of 
legal violations of infectious dis- 
eases. Thus organized, this 
service is a model of its kind. 
It has banished forever the 
danger of epidemics and has 
checked the ceaseless waste of 
life resulting from filth-con- 
taminated dwellings. The city 
has been made clean in the ob- 
scure recesses of its buildings 
as well as on its thoroughfares, 
as is demonstrated by the fact 
that there has been a fall in 
the death-rate from 20 per lOOn in 1901 to 18.18 in 1908. 

Besides the duties already enumerated this department was 
charged with that of keeping fire-escapes free of encumbrances. It 

Fig. 103.— The same premises niter thr liepait- 
ment had acted. 



was to keep a record of deaths, of sickness, and of arrests ainon^r 
the tenement population. Weekly statements were to be suliniilted to 
it bv the pohce, and by all dispensaries, hospitals, and charities in the 
city. A special bureau was i)rovided for this statistical work. Thus 
much material would be collected ttiat would tend to disclose the 
influence of housing environments, as the health, the morals, and the 
'conomic welfare of the tenement po])ulation. 

This tenement-house law of 1901 is the UrUi which has been en- 
acted for New York City. Four previous laws failed to accomplish a 
complete reform, chiefly because they were framed with reference 
to a lot unit of twenty-five by one hundred feet, which prevailed in 
Manhattan borough. The dumb-bell 
tenement was introduced through a 
prize competition in 1879, and perhaps 
it was as good a type of multi-family 
house as it was practicable to build on 
a site of these dimensions, where land 
values are high. The dumb-bell was 
in effect a double house, with the space 
between its front and rear apartments 
occupied by halls and water-closets. 
Each floor contained four apartments, 
two of which faced the street and had 
four rooms each, while two, facing 
the back yard, had three rooms each. 
Along the middle of each side of the 
building was an indentation of the wall 
about twenty-eight inches wide and 
fifty to sixty feet long, the purpose of 
which was to provide light and air to 

the five rooms on each floor on either side of the house which had no 
windows on the street or the yard. The wall of the adjoining house 
might, or might not, have a corresponding indentation. In either case 
the result was . high, narrow sliaft, open at the top, but without any 
intake of air at the bottom. Instead of admitting fresh air and sunlight, 
the shaft became a stagnant, semi-dark air-well, which promoted the 
spread of disease and acted as a flue in case of fire. 

The dumb-bell made evident the futility of hoping to build in 
Manhattan a sanitary and '-paying" tenement on a twenty-five foot 
lot. The most radical innovation of the new tenement-house law 
was that it practically abolished this unit and made the erection of 
dumb-bell tenements impossible. This law introduced a wide court, 


Fig. 104.— The bottom of an old-law 



with an intake of air at the bottom, and increased the area of the 
yard. As originally passed it provided that a non-fireproof tenement 
might be carried up six stories on a plot forty or more feet in width, 
but only five stories on a site with a smaller frontage. However, it 
was soon found that a five-story house could not be made to pay on 
the high-priced land of the congested neighborhoods, and, at the 
instance of the department itself, the law was amended in 1902. 

Non-fireproof tenements, six stories high, may now be constructed 
without reference to the size of the lots. However, the requirements 
with regard to light-courts and yards demand a comparatively large 
site in order to obtain the most economical and profitable arrangement 

of floor plan. The sites now preferred 
have a width of from twenty-seven and 
a half to fifty feet and a depth of one 
hundred feet. It is still possible to get 
four apartments on a floor in a twenty- 
five foot house, but the number of 
rooms has been reduced from fourteen 
to twelve. This size lot is used only 
where a larger site cannot be pieced 
together, and upon it but five per cent, 
of the tenement-houses erected during 
the period covered by this report were 

The typical new-law tenement seen 
in Manhattan is not only a larger house 
than the discarded dumb-bell, but its 
apartments are larger, containing five 
and four rooms instead of four and 
three. The law requires a water-closet 
to every ajjartment. As space has to be set aside for this purpose, the 
extra room and cost ret{uired for putting in a bath are relatively small. 
Consequently nine-tenths of the new houses have completely equipped 
private bath-rooms, removing the popular distinction which formerly 
existed between a flat and a tenement. 

A salutary result of the activity of the commissioner and his 
associates is that many structural alterations have been made by 
owners of property without pressure from the city. The latter have 
learned that investors will not buy unless a search is obtained from 
the department showing tliat the tenement offered conforms to the 
law. Furthermore, it was early discovered that the improvements 
yield a handsome speculative return, because of the increase of rents 

Fig. 105. —A portion of the hottom of a 
new-law court, showing- tunnel for circu- 
lation of air. 


which they permit. Tlie net profit realized in the case of a typical 
five-story tenement amounts to between $2()()() and $4000. Profes- 
sional enterprise and capital have consequently been enlisted in the 

Fig. 106. — A living-room as tli.- r^'iiiii l hmhi fmnul it. 

service of housing reform, and the remodelling of unsanitary tene- 
ments on speculation has become one of the principal features of 
activity in the real estate market. 

This new law has in fact practically effected llie abolition of the 
tenement-house proper, leaving two grades of multiple dwellings, the 
flat and the apartment house. A tenement is a multiple dwelling 
which has neither passenger elevator nor separate toilet and baths in 
each apartment. A flat lias separate toilet and baths but no elevator. 
An apartment-house combines all these conveniences. They are all 


Fig. 107.— Same room as the Dcparinu-ni I'.fi u. 

tenements in the language of this law. By it every apartment must 
have a toilet, and for the reason given baths have been added to the 
toilets ; so that few houses are now erected without private baths. 


The observations here set forth concerning housing conditions for 
the poor in New York City will be found pertinent concerning urban 
Ufe generally in the United States, where the urban population is 
twenty-six millions, while the population outside of cities of ten thou- 
sand inhabitants and over is about fifty-four millions. And the urban 
population is increasing at a rate mucli more rapid than that of the 
rural. Of the total increase between 1900 and 1903 nearly one-half 
was in tlie cities.^ 

Practically all tlie large towns in this country will have to be 
rebuilt during the next generation, and it were well if architects, 
builders, and their associates would most scrupulously consult sanitary 
authorities during their work. 

' Insurance Engineering. 




How should we combat bad sanitary conditions in homes? 

1. By an educational health campaign in the homes, carried out by the board 
of health and a staff of trained visitors. 

2. By a compulsory notification of cases in all cities. 

3. By enlarging the powers of health boards, so as to deal efficiently with the 
question of disinfection of the houses occupied by tuberculous patients. 

4. By attention to housing of the poor, proper control of tenements, and the 
regulation by law of the number of persons in each house. 

6. By placing upon the landlord the responsibility of providing.', under the 
control of the board of health, a clean, wholesome house for a new tenant. 

6. By the wholesale condemnation of unsanitary streets and blocks and llie 
rebuilding of them by the municipality. — Osler. 

The virile and achieving personality of Dr. Lawrence F. Flick has 
potently impressed itself with regard to the health of another great 
city. This physician Avas in his earlier years, like many a colleague 
who has taken up this w^ork, himself a consumptive. Upon his re- 
covery he determined to relieve, in so far as in him lay, other like 
sufferers. After many years of conscientious labor in those parts of 
Philadelphia w-here the disease was most rife, a philanthropist of great 
fortune established at his instance the Henry Phipps Institute for the 
Study and Prevention of Tuberculosis. And this institution, with 
this master physician for its director, is now a tremendous factor in 
the alleviation of the sufferings of very many thousands. Froni Dr. 
Flick's writings I here educe certain observations concerning the 
tuberculosis situation in cities : 

In large cities both domestic and working life differ very materially 
from such life in other places. Every living-place is crowded. There 
is little or no air-space between houses. Streets are narrow — some- 
times without exit — having "blind alleys." There is nmch traffic. 
Because of many fires a vast amount of unwholesome and irritating 
matter is thrown into the atmosphere. Filth accumulates, the excreta 
— both human and animal — of many thousands nmst be disposed of. 
Much dead organic matter or worn-out inorganic matter is scattered 
about. In workshops there is inadequate air space. In country 
places there are such conditions as these, but they are all scattered 
over so large a territory that evil consequences are not so likely ; and 



in cities not only is the infectious agency more prevalent, but predis- 
positions are much likelier to obtain. 

The prevention of tuberculosis is pre-eminently a governmental 
function. There are many things necessary whicli the individual can- 
not do because he has transferred his rights in the premises to the 
government. He cannot by himself prevent another from contami- 
nating a place whicli they both occupy. Neither can he compel the 
other to disinfect this place. And when the citizen changes his habita- 
tion he has no way of informing himself as to tlie sanitary condition 
of the house into which he purposes moving. 

One of man's inalienable rights is that of personal security, of 
legal enjoyment of life, limb, body, health, and reputation. In the 
interest of peace he intrusts this right to the government under all 
circumstances except when he is in imminent danger. He is, there- 
fore, with tills exception, absolutely dependent upon the government 
for its maintenance. And, when it is infringed upon, his only remedy 
is to invoke the aid of tlie law. 

But, generally speaking, the law has not yet created machinery 
c|uite adequate for the protection of the individual against disease. 
In many quarters disease is still looked upon as a dispensation of 
Providence. This is not the fault of the law, but the fault of scientific 
men, arid of men learned in the law, who have failed to engraft upon 
the law the teachings of science. Of all diseases tuberculosis is the 
one best worked out in every detail of preventability. It, therefore, 
offers an excellent basis for building up legal machinery for the pre- 
vention of disease. 

In general, boards of health have thus far accomplished very little 
because they have been badly constructed. Their measures have 
been unpopular because they have been inexact and arbitrary. Com- 
munities are likely to do a great deal and to give up a great deal for 
their own and the general good provided it is clearly defined what 
they are to do and what they are to give up. The public must 
understand what is being done. 

Registration is essential. Notification should be by the house- 
holder as well as by the physician. The whereabouts of every con- 
sumptive should be known. The contamination of places and things 
must be prevented. 

In the problem of the prevention of contamination by a munici- 
pality many factors — sociological, economical, and political — must be 
considered. The municipality should provide special liospitals for all J I 
dying consumptiv(>s, who would otherwise infect their environment at 
home. While preparations are making to this end, patients might be, 



niaintained in the vacant beds of existing li()S})iials. If tiiere are any 
such beds they stiould be in separal(! wards and under separate 
nnrsing, although they need not be in a separate building. 

Municipalities should go into tlie business of treating consumptives 
in the curable stage. It is legitimate to do tliis in order to prevent 
the spread of the disease. To this end municipal dispensaries and 
sanatoria should come into being. Only in these institutions — espe- 
cially tlie latter — can be niaintained such discipline as is essential for 
successful treatment. This cannot be done in tlie homes of most 
consumptives. The- object is the prevention of the disease, and the 
cure (which might be in itself, too parental in cliaracter for a city to 
adopt) as an incidental means to an end. And the municipality is 
justified further in removing a tubercular subject from his home in 
order to prevent the spread of the disease. 

How then, it is asked, is a comjH'ehensive scheme for the pre- 
vention of tuberculosis to be introduced into munici))aliliesy '• Who 
shall take the initiative? The medical profession as a body cpiite 
naturally is expected to take the first step, because it knows most 
about the matter. The legal profession, however, likewise has a duty 
in the premises, and should help to construct the machinery neces- 
sary. The legislators and executive officers of a munici[)ality, although 
perhaps unconscious of the fact, have a grave responsibility upon 
their shoulders in such a crusade against the great white plague. It 
is no longer possible for a man to plead ignorance of his duty in this 
matter and be justified, for the truth has been preached from tlie 
house-tops, and every one has had an opportunity of hearing it. 
Science has demonstrated that tuberculosis — the disease which claims 
more victims, produces more misery, destroys more happiness, creates 
more poverty and crime, interferes with the public weal to a greater 
extent than any other disease which has ever been known to man — is 
preventable, and has clearly outlined the metliods by which it can be 
prevented ; therefore every man and woman who has knowledge upon 
the subject, holds position in the learned professions or in political 
life, or has extraordinary wealth, owes a duty which he or she cannot 
evade. It will not do for any one of us to say, ' I am not my ])rother's 
keeper,' for to stand by and see our brother slain by a disease when 
w^e have it in our powder to interfere is just as culpable as to stand by 
and see him slain by a foe in any other form.'' 

It remains to set forth such isolated data concerning administrative 
control in cities as have not been emphasized. Every large city should, 
exclusive of the needs of the State to which it belongs, have its own 
sanatorium and hospital for consumptives. 


Knopf considers that every city should have an efficient health 
department, a building department, a tenement-house commission, a 
street-cleaning department, and a board of education ; that all of these 
agencies should combine in rendering the city in as sanitary a condi- 
tion as possible, in combating centres of contagion, in keeping the 
streets free of dust, filth, and smoke, in preventing the construction 
of unhealthful and unsafe dwellings, and overcrowding in homes, 
sweat-shops and factories, and in making the public schools well 
ventilated and wholesome. 

Under such co-ordinate action as this, houses occupied or which 
have been occupied by consumptives would be registered as well as 
the names of the sick of this disease ; cuspidors would be directed to 
be placed on stairs and in the hallways of tenements, factories, work- 
shops, and public places ; the streets would be flushed frequently, and 
wet always before cleansing, to mitigate the dust nuisance ; the wash- 
ing of the clothing of consumptives in public laundries would be 
regulated ; as would also the lighting, ventilation, and height of houses, 
and the number of the stories, the height of ceilings, the water supply, 
the width of the courts, blind alleys, and the width of streets ; food- 
stuffs, — meats, fish, milk, and vegetables ; and the inspection of possi- 
bly infectious merchandise. The city would see to it that parks, gar- 
dens, recreation piers, open spaces in general, would be numerous. 
Unsanitary dwellings would be improved, or condemned and removed. 
Whole blocks, like the " lung block," would be razed and supplanted 
by parks. 

Cornet considers that " if the municipality has the right to regu- 
late the cleansing of glasses and of the beer apparatus, the hours of 
business for saloons, the closet arrangement, the height of the rooms, 
etc., it is certainly its riglit, in far higher degree, as well as its duty, to 
regulate the disposal of the infectious material of the most wide-spread 
of all contagions.'" Saloons should be made wholesome and sani- 
tary. Many saloons are dreadful centres of infection. I think it 
would be difficult to exaggerate the importance of this procedure. It 
can and should be done, although for several reasons — chiefly such 
as obtain in local politics — the undertaking would be about as heroic 
a one as can be conceived. I understand that many cells in police 
station-houses are in exceedingly filthy condition. They should be 
made very clean. Not only is the " rounder" confined in these, but 
many an iimocent man has ])een kei)t in them overnight upon pre- 
posterous charges-, recognized as such by the judge on the morning 
following. Any citizen, rounder or otlu^rwise, presumed as he is by 
the law to be innocent until liis guilt is })r()ved in court, should not 


have to pass the night in a filthy and verniiu-riddeii cell. And it 
should be civic policy, at least, to acquaint the weak and the ( riminal, 
in so far as may be, with decent conditions. 

In other parts of the world administrative control of tuberculosis 
is becoming realized. In Saxony, in Norway, and in South Australia 
there is compulsory notification. In Norway a law was passed for the 
notification of persons with tuberculous disease in a sufficiently ad- 
vanced state to be disseminated with the spit or any other dischargers. 
Every physician who has such a case for treatment is compelled to 
report it to the health officer of the district. "Should the health 
officer find that either the habits of the patient or the state of his 
dwelling give special ground for apprehending transmission of the dis- 
ease to others, the case shall be brought before the Board of Health, 
in order that this body may decide on the steps to be laken. If the 
patient or his connections fail to act in concurrence with the orders 
given by the Board of Health, and it is found impossible to procure 
the patient nursing conducive to counteract the spread of the disease, 
the Board of Health is empowered to give orders for his or her re- 
moval to a hospital. Husband and wife may not be separated, how- 
ever, should they express the wish to remain together." ' 

Sir John Moore proposes the following excellent scheme of admin- 
istrative control for homes of the peasantry and in town dwellings: 

(a) (1) Compulsory notification; (2) verification of diagnosis by 
bacteriological examination of sputum ; (3) removal of patients to 
hospitals ; (4) periodic inspection and disinfection of the homes of 
the tuberculous. 

(6) The provision of hospital accommodations (isolation hospitals, 
sanatoria, consumption wards, etc.) for (1) early cases; (2) advanced 
cases, to provide comfort for the dying and to secure safety for the 

(c) The vigorous and absolute segregation of tuberculosis cases in 
workhouses, asylums, and other public institutions. 

(d) Education of the public concerning the prevention and man;ige- 
ment of tuberculosis. 

(e) Improvement of the housing of the working classes and of the 
very poor, especially in towns. 

^ Holmboe, 



" Public health is the foundation on which reposes the happiness of the people 
and the prosperity and power of the country." 

In these communities the dispensary is essential. Here young 
medical men and nurses get the experience which fits them to deal 
scientifically with the disease. These institutions, in addition to their 
manifold excellencies already set forth, should be equipped to give 
baths, sterilize clothing, and do laundry work.^ 

Where there are none, hospital accommodations sliould be provided 
forthwith. A good beginning might be made by fitting up an ordinary 
dwelling-house. Such buildings need not be elaborate or ornamental. 
They should be simply constructed and plainly equipped, and should 
be conducted in conjunction with dispensaries for ambulant cases. 
Then the medical staff of either can be used for the otlier. 

Sanatoria should next be established for curable cases who need 
either comparative or absolute rest. Practically the vast majority of 
poor consumptives can only thus regain their health. Conditions for 
cure are liardly attainable in the homes of the poor. Treatment is 
too expensive for them. There nuist be good food — this costs about 
four dollars a week — and a comfortable, clean, uncontaminated home. 
To keep this so would cost at least a dollar a week. When medical 
attendance, medicines, nursing, and other things are added, some ten 
dollars a week are consumed, and this expense would be from week 
to week for from six months to several years. 

The Reception Hospital at Saranac Lake is a purely local institu- 
tion, yet its plan will interest either individuals or communities Avho 
would build small hospitals. Of course, the plan would have to be 
varied to fit the type of structure to be erected, be it an infirmary, 
a hosi)ital, or a sanatorium. The plan of this reception hospital is 
excellent. It had to stand tlie test of competition, and tlie erection 
was superintended by very experienced pioneers in this work. It 
must be remembered that it was built to meet conditions peculiar to 

' An excellent feature adopted in Cincinnati is that a physician especially quali- 
fied for such work is engaged for certain hours of the day to examine suspected 
cases on any physician's retjuest. Thus numy incipient cases are detected. 



Saranac Lake ; ' it was for -' tuberculosis patients who come with fjie 
expectation of admission to the sanatorium, but because of acute or 
advanced ihness are refused admission and are unable to receive 
suitable care at a cost within their means." 

Tliere should, when practicable, be separate sanatoria for early 
cases and for more advanced cases. Tliere would then be better re- 
sults and cheaper administration. All early-stage cases need but com- 
parative rest. They can do some work and can gradually acquire a 
capacity for doing a great deal. They will need few attendants. They 
can contribute something toward their own support by light farming. 
As all are of a class and progress rapidly toward recovery, they exer- 
cise a stimulating influence upon one another. With more advanced 
cases mixed in with the early cases the whole institution has to be run 
in accordance witli the needs of the former, and consequently at much 
greater expense, and with the necessity for a larger medical and nursing 
staff, and a more elaborate domestic equipment. And " those who 
can work will not want to because of the example of those avIio can- 
not work." Besides, cases which are doing badly will have a de- 
pressing influence upon the others. 

Communal sanatoria, which may be maintained conjointly by 
several contiguous counties, could be located anywhere Avithout special 
regard to altitude and climate. Societies could be organized to this 
end, and they should interest themselves in tlu; sanihiry improvement 
of dwellings, workshops, schools, and offices. They should create a 
wholesome public sentiment. 

The sterilization of houses is troublesome and costly, and so it 
will often not be done except under either moral or legal pressure. 
Where there is no health department, legal pressure cannot be brought 
to bear. But in most instances in small communities moral pressure 
will bring about the result. When the conmiunal mind becomes suf- 
ficiently enlightened people will refuse to live in contaminated houses 
until they have become cleansed and until the landlord can siiow a 
clean bill of health. Disinfection of houses should be insured by the 
purchase of suitable apparatus, — a movable macliine would be desir- 
able, which could be used by several communities in common. 

Compulsory registration, being a government function, cannot be 
resorted to in these communities. However, through the instrumen- 
tality of dispensaries and similar agencies, to which the consumptive 
will resort, it will be possible to get gradually almost a complete cen- 
sus of cases and of infected houses. 

* Page 255, and Appendix F. 



"The mainfenanre of the health of tlie imHvidual is tlie chief requirement of 
the healthy growth of the State." — German Exhibit, St. Louis Fair. 

The State should erect hospitals and tent colonies for its in- 
digent consumptives, and hospitals for its tuberculous children. In 
some States, as in Massachusetts and New York, these things have 
been done ; in others, movements are in progress to this end. Com- 
missions have been appointed to investigate the subject, as in Ohio. 
Legislative consideration of the reports of such commissions has re- 
sulted in the making of appropriations for the purchase of suitable 
land, and for preliminary plans and specifications from which to erect 
the necessary structures. Among the States which have thus pro- 
gressed are Maine, Rhode Island, New Hampshire, New Jersey, Penn- 
sylvania, Michigan, Indiana, Illinois, and Minnesota. 

As we have seen in detail, no State need go outside its limits to 
find a suitable situation for a sanatorium, nor for a home for advanced 
cases, nor for a tent farm to which its indigent consumptives may re- 
pair. Certain general climatic features are obtainable in any State. 

Child labor should receive legislative attention in many States. 
Nothing less should be arrived at than the standard labor law framed 
by the National Consumers' League, which embodies the best features 
of the Massachusetts, the Illinois, and the New York laws. No child 
under fourteen may work for wages during school hours or after seven 
in the evening, nor may any child under sixteen work for more than 
eight hours a day or after seven. For the latter an educational test 
is required. 

That it is the duty of the State to provide, at least in a measure, 
for its consumptive poor, is a proposition hardly questionable. In 
general terms it does this for its blind, its feeble-minded, its epileptic, 
and its insane. Surely, then, it should do so in greater measure for its 
consumptives, because of the greater distress and economic losses 
which the tuberculosis situation entails.' 

* There are between twenty-six thousand and twenty-seven thousand insane in 
the thirty-nine greatly overcrowded public and private asylums of New York State. 
The annual increase in the number of the insane under State care is between 



How should the Stato assume this task? The lMichil,^■ul Slate 
Board of Health advises tliat hi every uuuii(ii)alily, and especially in 
townships, there should he a puhlic health hind to he drawn \\\uu\. 
under proper restriction, hy the health board, whenever and howev.-r 
tlie public interest thMuand. Such a finid could be ci-eated by the 
voters of every city, village, or township in a manner sinnlar to thai 
in which funds are provided for school |)urposes. 

Flick puts tlie matter very clearly. Prevention of disease is 
a legislative and executive function. The former should be in the 
hands of legislatures and councils; the latter sliould be carried out 
by the executives of States, cities, and towns. There should be heallh 
departments independent of all other departments, and snbject to the 
chief executive only. Every law concerning pnlWic health should 
be executed by this department, and nothing should be done except 
under the sanction of the law. All this work will have to be ibr- 
mulated and systematized by the joint action of scientilic physicians 
and well-trained lawyers. Eminent men of both professions should 
more frequently be sent to legislative bodies. Until tliey are, '' we 
probably will have to continue to grope along with onr semi-barbaric 
methods, with a certainty of failure, to the disgust and discontent of 
the people." Certain it is that the tuberculosis problem is of so great 
perplexity tliat the resources of tlie best of health deijartments will 
be severely taxed in the achievement of an adequate solution. 

Within the province of a State department of health ' would come 
the adopting of the following measures in addition to, or in reinforce- 
ment of, those already considered with regard to cities: There should 
be anti-spitting laws, and with these laws there should be also re- 
quirements that spittoons must be placed in buildings and other situa- 
tions where spitting is proliibited. Unquestionably men hare lo s\n[ 
sometimes, if they are not to choke, and no man should be expected 
to swallow his excreta. It is much worse than absurd that, as has 
happened in New York City, private citizens have been arrested for 
spitting on elevated-road stations, when the corporation owning these 
stations has not provided spittoons, with the contemptuous disregard 
of a law requiring them to do so, which has become characteristic of 

seven and nine hundivd, almosf enough to suggest the construction of a new 
hospital every year. The Lunacy Commission, consisting of one medical man. 
one lawyer, and one layman, have tlie entire supervision of ail these institu- 
tions, as well as the direction of the expenditure of some live milhon ili>!lars 
yearly. (Dr. F. Peterson.) 

' In New York a State commissionership (one man) has replaced the Healtii 


these bodies. Citizens have been arrested ; but there is no record 
that corporations have been brought to task. 

In cities, towns, and villages, except cities like New York, where 
regulations are enforced, there should be provision made for the free 
examination of the sputum of suspected cases and the free disinfec- 
tion of the houses of consumptives, and inspectors and disinfectors 
should be engaged for such work. 

Factor}^ and workshop inspections should be very rigid. Spit- 
toons must be provided. Sufficient air space should be prescribed 
for each workingman. Printed notices should be posted in all work- 
shops. There is no question that the State is entitled to take such 
steps. It has long ago assumed the right of protecting the workmen 
in certain callings against the dangers associated with them, and of 
exercising sanitary supervision in such premises : such measures as 
these should be extended to the ijrotection of workmen in their work- 
shops. Stringent laws concerning child labor should be made and 

There should be legislation looking to the erection of habitable 
and sanitary tenements. State schools for the blind, the deaf and 
dumb, the epileptic and the insane, and reformatories should be in- 
spected frequently for the detection of tuberculosis which may have 
developed in inmates, and snch cases when found should be segre- 
gated or transferred to institutions devoted especially to this disease. 

The business of milk inspection should be gone into scientifically 
and adequately. 

The State should, after the manner of the federal authorities, take 
care of and provide for its consimiptive employees. 

The State should attend to the disinfection of railway cars, and 
railway companies should, if possible, be induced to provide special 
cars for consumptive passengers. The Kentucky State Board of 
Health has adopted excellent rules, to which the roads running through 
that State^ have cheerfully agreed. 

The State should compel a railroad to furnish a special car, with a 
physician and a trained nurse, for the transportation of consumptives 
to sanatoria and liospitals. Large numbers of these patients are car- 
ried yearly to the Adirondack region in the regular sleeping-car, with 
its plushes and draperies. Such a car has already been provided on 
one of the Western railroads. Under ordinary circumstances of 
travel, however. I do not consider this measure either necessary or 

' A])[)eii(lix A. 


Salus ])(ipiili suinciiia t'sl lox 

We should certainly liave a national department of public lir;ill!i. 
with a cabinet secretary at its head. In lieu of this there is ikiw the 
Public Health and Marine Hospital Service, of whirh Dr. W'.iitei- \\v- 
man is the Surgeon-General. 

In a public address Dr. Wynian has ably set tnrth the nature of 
his office. The scope of its activities is essentially inclusive of iill 
civilization. A case of yellow fever in Santiago, for instance, or one of 
Asiatic cholera occurring in the Mediterranean, or one of bubonic 
plague in the Orient, becomes known in Washington practically within 
the minute of its discovery. ''The nations of the earth are more 
nearly related than ever before in our history. All tlie world becomes 
one neighborhood, so far as relates to distances. In no manner 
has this been better shown than in the warfare against contagion. 
International congresses, conferences, and conventions are frequently 
bringing the nations together as one family in the struggle against 
these foes of mankind.'* Here is a connuon ground upon which 
all nations can meet, — an object worthier the expenditure of energy 
and money than for war and armaments. Certain it is that a nation 
advances from barbarism to civilization according as it eschews the 
latter and devotes its attention to the spiritual and physical betterment 
of its people, to the education of its children, to their emancii)alion 
from child labor, to the cultivation of the arts and the sciences. 

Dr. Wyman's sentiments were in accord with U. Casimir-I'i'rier 
to the effect that the struggle with diseases, esi)ecially of the irifeclioiis 
sort, is intimately bound up with the solulion of the most complex 
economic problems. Manifestly this is conspicuously so of tuber- 
culosis, as we have seen, so much, indeed, that this disease, which 
leaves its mark upon practically the whole of the race, is an index by 
inversion ofhuman progress. The latter will advance in jiroporlion 
as the former, with its accompaniments of poverty, wretchedness, and 
the insidious brutalities visited by man upon his fellows, becomes 

Dr. Wyman declares that the fundamental |)rinci|)les of such inler- 



national congresses as he has mentioned must originate in scientific 
investigations and in laboratory work. " And liand in hand Avith 
science must go religion, that nations may develop conscience and a 
sense of justice toward one another/' to the end that the dreadful 
infections which decimate mankind may be effectively coped with. 
Surely, surely. There must be religion ; but it is absolutely essential, 
as we will presently see, that our religion shall ring true. 

In order to obtain practical results along such lines as these, good 
laws and effective administration are rec{uired. No matter how 
earnest the individual citizen may be in such propaganda, however 
zealous in setting an example by observing precautions himself and 
living in accordance with scientific precepts, he cannot achieve much 
when conditions exist which can be remedied only by governmental 

With regard to the Marine Hospital Service Dr. Wyman states that 
each State and Territory has a health department which co-operates 
with the Surgeon-General to tlie end that knowledge of hygienic 
principles may become widely diffused. It were well, indeed, if in 
this co-operative organization could be included many non-govern- 
mental institutions and associations which are maintained solely for the 
purpose of fighting the great white plague. In such manner could a 
national movement against this disease become unified and its potency 
increased in manifold proportion. 

Dr. Wyman dwelt upon the popular diffusion of sanitary knowledge. 
In local politics the electorate should be taught and influenced to vote 
for enlightened and educated candidates ; and the latter should have 
sufficient conscience to be uninfluenced by sordid or other mercenary 
considerations in dealing with questions of the health of the com- 
munity. He instanced the excellent and intelligent work of labor 
unions with regard to public sanitation. The American Federation of 
Labor, with a membership of some two millions, has interested itself 
energetically in the tuljerculosis situation ; has set itself to finding out 
why, while parks, monuments, and all other excellent things are being 
constructed, less favored localities, such as tenement-house districts, 
should not also receive due attention. Tenements, as well as the 
handsomest structures, should be sanitary. The rich can abundantly 
provide for themselves in this regard ; wherefore, the dwellings of the 
poor sliould receive first consideration. There is absolutely no reason 
worth discussing why there should be slums ; we should have slumlcss 
citicx. And if the health of the individual is vouchsafed, if his organism 
be made to meet adequately the hard facts of life, if he be made 
strong to work for and maintain his own, his neighborhood mast 

FEDERAL JUR[SI)l(Tin\ ^^jj, 

inevitably be bettered by the strength vouchsafed liim. And if (hiis 
strengthened he have virility beyond these pliysital needs, lie may 
develop his psychic capabilities with the result that his own happiness 
and that of his famihars and of his own community nuist inevitably 
be advanced. 

We note that the tariff", which the essentially embryonic wisdom 
of our law-givers at Washington sees fit to maintain and preserve, 
requires a heavy tax upon "instruments and apparatus necessary for 
the recognition and study of tuberculosis and many other bacterial 
diseases, and, except recently, and for a favored few, upon books in 
which, and in which alone, can be Ibimd records of research uijon 
which the means for the suppression of tuberculosis nnist be based."'' 

The Federal Government should see to it that innnigrants who are 
physically defective should be excluded. We debar those who have 
trachoma, leprosy, favus, insanity, epilepsy, idiocy, and those tainted 
Avith certain venereal diseases. With regard to tuberculosis, the mat- 
ter is a much more difficult one, for there would be many incipient 
cases that cannot be detected, and certainly it will not. in my o|)inion, 
be humane to exclude cases of tuberculosis, unless the disease were 
advanced to the degree that the immigrant would become a i)ublic 
charge. On the other hand, it is not the part either of wisdom or of 
humanity to permit sufferers to further swell our tenement-house poj)u- 
lation, at present the most congested in the world, and to eke out 
their miserable lives in sweat-shops. Dr. McLaughlin points out that 
the physically defective immigrants are those who remain in the sea- 
board cities, while the robust penetrate to the interior of the country, 
where in due course of time they make homes for themselves and 
become merged in their communities. During the last decade those 
of the defective class have been increasing in population more than 
ever before among immigraiits to this country, and this increase under 
these circumstances involves a serious danger to the public health of 
cities. In great measure this danger takes the form of tuberculous 
disease, which is fostered by the dense herding of ill-conditioned and 
underfed people. It is not selfish and inhuman, as some pseudo- 
philanthropists allege, to bar such manifestly defective immigrants. 

The Federal Government should certaiidy see to it. in so far as 
may be, that the food sold to its people shall be pure and luitritious. 

^ "That every physician in the United States should pay a tax to the few 
makers of microscopes in the United States, and should he dc-harred from the 
possession of the very much better instruments which are manufactured abroad, 
seems almost incredible. The duty is a protective one and yields little or no 
revenue." (Dr. W. T. Councilman.) 



The ingredients of a patent medicine sliould be required to be stated 
upon the bottle label. Whiskey and other stimulants should not be 
permitted to be sold until governmental tests have been made con- 
cerning wood alcohol or other poisonous material. Foods that are 
adulterated with paraffin or gelatin, and like materials, should not be 
sold under misleading names, and should have the ingredients of the 
things sold stated upon their labels. But it is particularly with regard 
to milk and meat that federal law should be stringent. For instance, 
the dishonest use of formaldehyde by milkmen is a constant source of 
danger. It has been assumed that a little of this chemical does not 
do much harm ; however, it is unpleasant to think of using milk so 
treated which might be a week or ten days old. 

With regard to governmental inspection of meats Cornet's investi- 
gations are authoritative. He found that in the year 1893, of six 
hundred and ninety-five thousand eight hundred and fifty-two adult 
cattle in the Prussian slaughter-houses sixty-two thousand three hun- 
dred and twelve, or eight per cent., were tuberculous. In the Berlin 
slaughter-house alone, from 1883 to 1892, fifty-six thousand tubercu- 
lous swine were slaughtered. " What an enormous sum of money," 
he complains, " passes to foreign countries in order that this deficiency 
in the meat supply, due to tuberculosis, may be made good, only to be 
replaced in great part by importation of tuberculous cattle ! In 1894 
one hundred and fifteen million of marks worth of cattle, deducting 
the exports, were imported into Germany, an amount which could be 
greatly lowered. Tuberculosis among cattle has become an inter- 
national calamity, and its limitation a burning international question." 

Part XIII 


One God, one law, one element, 
And one far-off divine event. 
To which the whole creation moves. 




I have hope and wish that the nobler sort of i)hysicians will advance their 
thoughts, and not employ their time wholly in the sordidness of cures ; neither 
be honored for necessity only ; but that they will become coadjutors and instru- 
ments of the divine omnipotence and clemency in prolonging and renewing the 
life of man. — Bacon. 

Upon the general practitioner, that man who still survives despite 
the specialistic tendencies of modern medicine, must fall the brunt (jf 
the light against tuberculosis. Most cases will come to him first for 
advice and treatment; and generally at a time when they are curable 
if their condition be recognized. Wherefore, every family physician 
in existence should, in addition to his general training, be a specialist 
in the treatment of consumption. If he do not feel proficient, he 
should take up some dispensary or post-graduate course in the diag- 
nosis and treatment of this disease. For it is by far the most fre- 
cpient he comes upon. In few others will good and timely action 
bear so much beneficent fruit and so much gratitude from the patient 
and the patient's friends. In no other case will the mournful results 
following upon lack of diagnostic skill and conscienceless neglect be 
visited so disastrously upon him. The family physician must be very 
skilled in the symptomatology and diagnosis of consumption, so that 
no valuable time may be lost in instituting proper treatment. He 
will lind that to arrive at correct conclusions is no easy matter. 
Usually by the time the bacillus has appeared in the sputum, or 
physical signs are distinctly manifest, the case has passed the huipient 
stage. He must reach conclusions from a judgment of many factors. 
One among these w ould mean nothing ; several of them taken 
together would be suggestive ; a number of them combined would 
be conclusive. 

Having established his diagnosis, having told the patient what his 
disease is, he will then institute treatment upon the broad lines 
here laid down. He will visit the home of the patient, and explain 
rules for the guidance not only of the sick man, but also of all his 
family and of those with whom he comes in contact. He will instruct 
the nurse, eitlier lay or professional, with regard to the bedroom of the 
jiatient, the wholesome cooking of his meals, the ordering of his daily 




life. The carpenter may have to be called in to construct a comfort- 
able veranda, or perhaps a roof-garden, upon which the patient shall 
pass most of his day. A tent may have to be constructed in the back 
yard or on the lawn. 

The convalescent from consumption must be watched unceasingly 
and repeatedly instructed ; reinfection is always possD^le. Another 
environment should bo sought, and another occupation if the former 
one have been one in which consumption is easily contracted. Such 
personal habits and baneful manner of Ufe as tend to the disease 
must be changed. For many months after the disappearance of ob- 
jective sym]jtoms must this scrutiny be continued. Tlie bodily nu- 
trition and strength and a right proportion in weight must be estab- 
lished and maintained.^ 

The family physician should ponder carefully before sending a 
patient any great distance from home. He should have certain 
knowledge of the region and the sanatorium or other institution to 
which he would have a patient go. There is a directory which will 
give him certain information to this end. He should bar medical 
hotels and unguaranteed boarding-houses for such patients. He nuist 
be certain that there will be a competent colleague to whom he may 
refer his patient in the locality where the latter is to live. Treatment 
by letter is unreliable ; such treatment exclusively is altogether un- 
scientific, unwise, and unjustifiable. 

The general practitioner must be a public-spirited man. He must 
interest himself in the communal prevention of tuberculosis in ways 






per cent. 




per cent. 



5 feet 

5 '• 1 inch 

5 '• 2 inches 

40 i 







5 ■• :', •' 


5 •■ 4 •' 

5 •• 5 •' 


5 •• 6 '• 


5 '• 7 " ... 


5 •• 8 •• 


5 •• 9 '• 


5 •• 10 " 

5 ■■ Jl ■■ 

6 •• •' 


6 •• 1 ■• 



here set forth. He may l)e luLsuiKlerslood, — unduubtctlly lie will la- 
but he will conthiue indifferent. On the one hand, he will he 
accused of " drunmiing up trade" for himself, when, if tin- |)uhlic 
W'Ould but think, it would be plain that the more a physician advises 
preventive measures agahist a dangerous disease the less income lie 
is likely to have. On the other hand, if the practitioner docs not 
concern himself Avith the communal danger from an infection. Ihc 
man who sounds tlie warning note, and all the rest of them, will 
want to knoAV, ''in no uncertain tones," why the sordid doclor, 
concerned only with his own scltish ends, [)ays no allcnlion lo Ihe 
public needs. 

Emphatically, the family physician must notify his cases of ion- 
sumption and get them registered. Tf his lieallh board be of Ihc sort 
which exists in New' York City, his cases will not be interfered with, 
nor need either he or his patients be even embarrassed in the slightest 
degree. If the case have no private physician, if it be a " hosjjital or 
a dispensary case," the patient should be glad of the ministrations 
Avhich the health board can enlist, and lie should not begrudge the 
safeguarding of the communal health wdth n^ference to his illness. 
Any other consideration than this is not humanilarian ; it is in reality 
only blind, stupid brutality. A physician who will not subscribe to a 
course so plainly rational and beneficent should never liave taken the 
Hyppocratic oath. In any event, he has not suflicient intelligence for 
the practice of medicine. Every medical man should co-operate with 
and hold up the hands of his healtli board. But is his health board 
corrupt and inefficient? Is it unworthy of professional conlideiicey 
Is it impotent because of the "pull" enjoyed by some rum-shoi) 
boss, or his sleek congener wdio has " vested interests" whicli nnist 
not be disturbed ? Then, in God's name, let him combine (com- 
bine is the word) with his colleagues, and see to it that at least one 
feature of American municipal government shall not be corrupt. 

And while he is looking after the interests of others let him at- 
tend a little to his owai. In England the physician who is recjuired to 
notify his cases for registration is paid a small fee, — two or three 
shillings for each living case he reports. Why not? In Maryland 
one dollar and a half is paid the physician as a proper remuneration 
for the measures of prophylaxis which he exercises in each case. 
Other than this, nowhere else in America, so far as 1 know, is the 
physician paid for such services. Why shonldn't he be paiil for them 
in every community ? Is not the laborer worthy of liis hire ? 



Here in yimr great couiiliy, in which there is so much initiative, hei'e ought to 
})(' horn a great movement for the practical apphcation to normal daily life of all 
the scieiiiilic trtiths which we now possess for training the organism to struggle 
against tul)ercul()sis. — MaraGLIANO. 

Next to the iiilluence which the family physician must exert, that 
of education is most potent. And here the lay press is an indispensa- 
ble factor. An astute physician has observed that the layman is 
likely to throw circulars of information (he gets so many of them in 
every mail) into the waste-basket unread and unappreciated ; while if 
h(^ comes ui)on the same matter in the columns of a daily newspaper 
he will assimilate it with due respect. And this observation applies 
also to magazines, almanacs, and like literature. Generally speaking, 
the information contained in good newspapers is, in my opinion, safe 
and sane. Evidently pains is taken to have data verified by men 
best posted upon this subject ; and the press at all times, I believe, 
puts its columns of reading matter at the service of the antituber- 
culosis propaganda. It is therefore the greatest pity imaginable that 
many journals, including those professed to be of a religious sort, 
contract to })rint advertisements manifestly of baneful and often of 
fatal effect upon the wretched consumptive. Among these many 
advertisements a specimen is that of " Kochine, '' a bogus concoction, 
in which the name of the great scientist is wrongfully and perniciously 
manijmlated. Many of the " alcohol-free " remedies mentioned in 
Appendix 1] are such as are recommended by politicians and clergy- 
men. Certainly of all conditions the most pitiable is that of the con- 
sumptive who responds to such meretricious advice. In view of the 
fact that alcoholism is a most potent predisposition to consumption, 
such advertisements as the following should certainly never appear, 
no matter how large the check paid for its appearance, or how needy 
the journal which accepts it: Duffy's Malt Whiskey. (An endorsing 
clergyman's i)icture.) " Cures coughs, colds, most forms of grippe, 
consum])tioii, bronchitis, pneumonia, catarrhs, dyspepsia, and all 
kinds of stomach troubles. It never fails to build up a worn-out 
system, to soothe the tired nerves, to bring perfect health to the 
whole Ijcing." 



Lectures should be given io the laily on this suhjrct. In .\.\v \ Ork 
City this is done, as is no doul)t the ease in many oilier (diiiiiiiiiiilics ; 
and school-teachers should certainly be iiistrnclcd regarding an 
elementary knowledge of this disease in children, and the propjiylaxis 
whenever consumption is ascertained to be in families liaving children. 
In New York City posters explaining the nature of consumption are 
put in the school books, to the end that possibly the i)arenls may in 
this way appropriate some knowledge of the (hsease. Older siliool 
children should be instructed in principles of hygiene, so llial physio- 
logical living will become natural to them. 

And it is not enough to draw the attention once Io these nialteis ; 
the knowledge of them inns! become a practical habit among llie 
people, who must become thoroughly accustomed to the fad Ihiil 
there is nothing needlessly mysterious about this disease. 

The efforts already made in ))ublic education are bearing linil. as 
evidenced by the large number of States which have undertaken, by 
means of commissions appointed, systematic investigation of tuber- 
culosis. The work of several of these commissions we have already 
noted. In Vermont the importance of bringing home to the people a 
sense of their peril is indicated in the statement that it shall be a part 
of the duty of the commission to adopt and make use of means to 
educate the people of the State with respect to the cause and nature 
of tuberculosis and the means that may be taken by the people them- 
selves for its prevention and cure, to the end that its large death-rate 
may be reduced to the lowest possible limit. It is, however, an 
instance of the shortsightedness of legislative bodies, in this State as 
in others, that the fringes of the great problem can only be touched 
because of the very small appropriation available. Here, as in other 
States, it has been arranged to hold public meetings in every county, 
at which lectures will be delivered, outlining simple precautionary 
measures, indicating radical treatment, and anticipating foolish 
prejudices,— particularly that consumption is among the active fatal 
" contagious " diseases. 

Education is, in fact, the key-note of the whole business. The 
things that are to be feared are those which are not comprehended ; 
terror almost invariably disappears in the face of knowledge. And 
certainly such should be the case with consumption. He who knows 
the dangers, the sources, and the nature of this disease need never 
fear it. 



For iiiy own part I cannot lielp tliinkinp; that the first and best of all objects 
of charity is the improvement of the low quarters in our great cities, which can- 
not fail to be seed plots of disease as well as of barbarism and misery. — Goldwin 

As a work of wliolesoiiie huiiiaiiitariaiiisni a recent benefaction of 
Mr. Henry Phipps, and the nielhod of its use, must certainly excite 
the Avarmest admiration of all reasonable and good men. He has 
made a gift of one million dollars for building improved tenements in 
New York City. For the management of this matter an organization 
of excellent citizens has been formed, and the chairman of its execu- 
tive committee is Mr. Robert W. de Forest, whose achievements as 
the first Tenement-House Commissioner of New York City have been 
inadequately noted in this book. Otliers among these citizens are 
Messrs. Charles S. Rrown, Alfred T. White, Myles Tierney, and Dr. 
E. R. L. Gould, the president of the City and Suburban Homes Com- 
pany, which builds model tenements, — all members of the tenement- 
house committee of the Charity Organization Society. 

Mr. Phipps would organize a society for the purpose of building 
tenement-houses in New York City, preferably in Maidiattan Borough. 
The tenements, for the building of which liis gift is made, are ex- 
pected to earn about four per cent, on their cost, after allowing a 
proper amount lor maintenance and repairs. These earnings are 
intended to accumulate and to be used from time to time in erecting 
more tenements. The rooms should not be 7^entcd at a price below the 
market 2J rice, for it is not desired to discourage individual investors 
from building tenements on a purely business basis. Building opera- 
tions might thus be ciiecked, rents raised, and injury be worked in the 
end to the working people. In periods of high cost and great infla- 
tion, the work should go very slowly or be stopped ; where there is 
great depression and lack of employment, the work of building should 
be active. One building should, to begin with, be finished and rented, 
so that its efficiency may be judged, and so that the buildings which 
follow may be in accord with the initial experiment. There should 
be all the light and air possible in these buildings ; they should be 
fire-proof and thorougldy sanitary, willi as much air-space as may be 




around tlieiii in which the children can play. I'ndoiihlf.lly this 
beneficent plan will hel[) to furnish a standard below which no \n\u\- 
lord, no matter how calloused, will find if prolilablc lo l)uil(l and 
conduct his property. 

A plot has already been secured for the fu'st l)iiildiii;:. II is in- 
tended that there shall be light in every room, proper sanitation and 
ventilation, steam heat, a gas range, and a toilet to every apart ineid. 
There shall be good material in construction ; and here again the 
builder who is unscrupulous may find that it will not pay him lo erect, 
in this city at least, of the " Buddensiek" type, a nmiihi-r of 
which collapsed before completion. 

Mr. Phipps's first tenement is given up to two, three, and four- 
room apartments, with a bath-room only in the four-room suites. 
For the others there are tub and shower baths in the basemi'uf, one 
for every six families. Two other plots are to be purchased. The 
expected income from these three is $4(),()()0 a year. In three years 
this accumulated income will buy another building. " The accunm- 
lative power of money used in this way," states Dr. Gould, '• was 
strikingly shown by tbe Franklin fund." The great Benjamin more 
than a century ago left $5000 to accunmlate for the benefit of am- 
bitious artificers and craftsmen. The principal now amounts to 
$411 ,000. It has been calculated that at 4 per cent. Mr. Phipi)s"s fund 
would, in a little more than a century hence, amount to $64,000,000. 

In a valuable comment upon this work, the Evening Fost^ says 
that the trustees of Mr. Phipps's gift would make no mistake if tiiey 
devoted some portion to homes for colored people. "Their plight is 
grievous. Only the worst buildings are open to tliem, for which they 
are charged higher rents than are asked of white people, on the ground 
that negro occupancy of a house causes it rapidly to deteriorate in 
value. Now, the negroes are great home-lovers. With all their 
defects, they are cleaner, as a class, than many of our foreign innui- 
grants, and they make remarkably few appeals for i)ublic funds. Yet 
decent colored people are often forced into disreputable associations 
for lack of other quarters, and their need of good tenements is 

In the city of Washington model tenements are being built and 
conducted by the Washington Sanitary Housing Company. Here 
again the word philanthropy rings true. This company's work is 
based upon principles of relief of baneful conditions. However. I 
am glad to note that " charity is here controlled by business i)rinci- 

1 January 14, 190.J. 


pies, the only sound method of its ministration." ' Two-story houses 
are built containing three- or four-room flats, witli bath-room and sani- 
tary plumbing, on sites formerly occupied by unwholesome shaclvs. 
These flats are rented to those who cannot pay the $10 or $16 rent oi 
other available houses. Tlie rents are $7 or |8 a month. Proper care 
of the houses is assured by setting aside one month's rent each year for 
interior repairs. The difference between the cost of necessary repairs 
and this rent is given to the tenant as a rebate ; hence the incentive 
for making the repair bill as small as possible. " The financial possi- 
bilities of the enterprise are shown by the payment of the four per 
cent, dividend annually, and, in addition, the accumulation of a hand- 
some surplus. The company has borrowed money to complete a row 
of houses and seeks to sell additional shares to liquidate its indebted- 
ness and still further extend its operations. No trouble should be had 
in selling to the citizens of Washington lumdreds of shares. Sub- 
scriptions mean philanthropy, improvement of the city, and financial 
return. The officers and directors of the company include men of 
such national and international reputation as Sternberg, Foster, Kober, 
Pinchot, and Riggs, — sufficient guarantee of the integrity of its work- 
ings. The success, sociologic and financial, of this enterprise should be 
widely known. Such examples herald the time when charity will 
cease to cover a multitude of sins in the way of further degradation 
of the people it would aid." 

Goldwin Smitli, both intellectual giant as he is and earnest believer 
in the fatherhood of God and the brotherhood of man, has, in the 
twilight of his beautiful and eventful life, undertaken a practical re- 
form for the benefit of the vvorkingmen of Toronto, his adopted city. 
He has purchas(Kl a block of land, upon which he will have con- 
structed a number of homes with modern improvements and affording 
ample breathing space, to be leased upon moderate terms. And this 
measure of relief has wisely been placed upon a sound business basis. 

In England the solution of the housing problem "has been largely 
assisted by philanthropy and private efforts, and the name of Lord 
Rowton will ever be honorably associated and remembered in connec- 
tion with one of the most important social movements of the present 
generation." - Rowdon houses are large lodgings erected in various 
parts of London. In them are combined the advantages of co-opera- 
tion on a large scale with something of the comfort of a modern club. 
They are clean, airy and light. The cost for each individual is oidy a 
trifle more than is paid in the cheapest city lodging-house, and the 

' American Medicine, Jnnuaiy 14, 1905. ' Hillier. 


physical and moral gain is great; moreover, commercially the lodging- 
houses are a success. They therefore have an assured future and 
already many cities are providing similar institutions for the poorer 

It may be that the discerning man of means will see in these matters 
of housing improvement some decidedly convincing reasons for 
investment of his capital in accordance with sound business principles, 
in such manner that he may well earn a righteous profit and be at 
the same time entitled to the high opinion of his fellow-men. Here 
he would be engaging in ''philanthropy with four per cent.," — an 
altogether just and wholesome sentiment. It is evident, when we con- 
sider all the factors which make it possible for tuberculosis to destroy 
so much human life and happiness, that the construction of decent, 
healthful homes is a work than which there is none more grateful for 
a man to be engaged in.' 

' Possible investors should not fail to read the Evening Post's editorial, January 
14, 1905. 



To combat consumption as a disease of tlie masses successfully requires the 
combined action of a wise government, well trained physicians, and an intelli- 
gent people. — Knopf. 

Much private and associational work is essentially allied more or 
less with governmental activities ; in many respects the former supple- 
ments and fortifies the latter. 

Great efforts are making to mitigate the appalling conditions under 
which many little children have to labor. To many such even the 
most rudimentary education is denied, while their bodies are becom- 
ing prematurely weazened and decayed, " feeble in frame, their 
intellect shrunk up and dry like a tree. Their children are feebler 
still." There is now a powerful National Child Labor Committee, 
with headquarters in the United Charities Building in New York City, 
which has opened correspondence with organizations and people inter- 
ested in child-labor reform throughout this coimtry, and is prepared 
to co-operate with any local movement. The National Consumers' 
League, having its office in the same building, by eliminating sweat- 
shop prices for goods, is accomplishing much to secure for poor work- 
ing people comfort and decent remuneration. 

The day nursery, in which the child is taken care of for a small 
fee while the mother does a day's work, is a feature worthy of con- 
sideration. The child is likely to be much better taken care of in the 
nursery, and the strength of the mother is to a large degree conserved 
by this means. 

The United Hebrew Charities has done an extraordinary amount 
of work through its committee on tuberculosis, in visiting and reliev- 
ing its consumptive poor, and in persuading many to make use of such 
hospital and sanatoria facilities as are available. This is one of the 
most effective of the many like institutions in this city, some of which 
we have described. The methods, whicli are typical of all such bodies, 
are : the placing of applicants in charge of a special agent ; careful 
medical examination to secure correct diagnosis ; instruction of con- 
sumptives by means of pamphlets, etc., and particularly by verbal 
guidance, concerning the disposition of sputum ; the cleanliness of 
the person and the home ; proper diet and exercise ; cessation of 




unhealthful occupations ; removal to more sanitary neighborhoods ; 
general obedience to the recommendations of the City Board of 
Health. Excellent medical treatment is secured in sanatoria when 
possible ; sufficient necessary and wholesome food, particularly milk 
and eggs, is supplied ; transportation to a more desirable climate is 
provided, whenever indicated by the medical examination ; positions 
in country towns and outdoor work are found for applicants. 

The health requirements of school children have, in the city of 
New York at least, received great attention. In the summer time the 
playgrounds and the schools are open throughout the day. In many 
schools the rooms are utilized for purposes of play. Swhnming tanks 

Fig. 108.— Roof -pavilion at the Rush Hospital for Consumptives, Philadelphia. 

are being placed in schools, and many other features calculated to 
make school children vigorous and healthly are provided. 

We have not yet in New York City pavilions for poor consump- 
tives, such as have been established in Paris by M. Boucicault ; but no 
doubt such institutions will come in time. A number of recreation 
piers have been established on the North and the East Rivers, where 
mothers and children may spend the day and the evening under very 
salubrious conditions. Particularly are these piers grateful in the sum- 
mer season. On occasions, during very hot spells, the people have 
mercifully been permitted to sleep on them throughout the night. 

Most house-tops in New York City are level, and many of them, in 
the very poor districts, are used as breathing spaces and for sleeping 


on warm nights. I am surprised, however, that roof-gardens have not 
become a general institution. Here is a basis for the construction of 
a perfect solarium upon every house. Every city roof could be railed 
off and easily transformed into a delightful summer-night resort. 
Even in this regard charity has made itself felt, for the Plant, Fruit, 
and Flower (Juild aims to put these reminders of country life upon the 
tenement fire-escapes and in windows and back-yards of the poor. 

There are now^ many small parks in New York. There should be 
a great many more, with gymnasium appliances, swings, courts and 
tracks for athletic exercises. A park is being projected at the seashore, 
either on Coney Island or on Rockaway Beach, where the poor may 
enjoy the healthful advantages of sea air. Already, as we have noted, 
there is at Coney Island a hospital for tuberculous children. 

There is in New York City an institution, no doubt duplicated in 
many other cities, called the Diet Kitchen Association, which saves 
many lives by giving nourishing food, chiefly milk, to the sick poor on 
the presentation of requisitions given by house and visiting physicians, 
by dispensary district nurses, and other workers. During the heated 
term this association jirovides modified milk for sick babies, and thus 
helps to reduce the high death-rate among the poor of this city. This 
Society, as does also the Strauss benefaction, co-operates with the 
Board of Health, various other charity societies, and forty other 
organizations in the war they are waging against consumption. 

The condition of many city tenements is so unutterably bad that 
the saloon becomes the preferred habitat of many a miserable fellow 
during much of the time when he is not working or sleeping. It 
is an institution too deeply rooted to be removed. There is no use 
in getting vapid concerning it. I am of the opinion that the saloon 
can be made a fairly wholesome institution, as it is in many a con- 
tinental city, where things are conducted in accordance with wis- 
dom accumulated during the centuries. There is no abolishing it ; it 
is the poor man's club. What ! because others are virtuous, shall 
there be no more cakes and ale ? Shall not the poor man, in the 
name of the Thousand-Souled, take his ease in his inn ? I have had 
occasion to observe (during my sociological studies) that there are 
clean, tidy, decent saloons, where men drink moderately of wholesome 
li(fuor. They can all be made so, and the poor man will get no harm 
from such if he w^ill take temperately of good spirits, and if he will 
be determined always on a " Dutch treat."' and set his face against 
the vicious American habit of " treating round."'" There are many 
worse places than a good saloon for a poor man to be in. I write 
here in general terms, not concerning the consumptive. He should 


not go to the saloon; alcohol in any form is not good for him. Be- 
sides, he is a source of infection in the saloon. 

Labor organizations have come to play an important role in the 
fight against consumption. The United Garment Workers of America 
and the Central Federated Union have joined the New York Charity 
Organization Society in the preparation of circulars to be distributed 
among their members, which provide valuable information concerning 
the prevention and cure of consumption, and which inform sufferers 
where free treatment can be had, if necessary, in dispensaries and hos- 
pitals. In Chicago, labor unions have taken up the fight. Office 
janitors, cigar-makers, garment-workers and others are co-operating 
with the authorities to this end. Labor organizations, as we have 
seen, are contemplating the establishment of farms for their consump- 
tive members in various i)arts of the country. 

A School of Philanthropy was established seven years ago in con- 
nection with the Charity Organization Society, in which many social 
workers have been trained. Mr. John S. Kennedy has recently 
founded a professorial chair, which will be filled by Mr. Edward T. De- 
vine. This chair will be allied with the Department of Economics at 
Columbia University. Mr. Devine, upon his api)ointment, expressed 
a weighty sentiment, which compels reflection : " The science of phi- 
lanthropy is related to the social aspects of civilization in like manner 
iis the science of medical prophylaxis is concerned with the physical 
life of man." No doubt the future will prove this idea to be an 
exceedingly potent one with regard to the tuberculosis situation. 

The activities here described have developed mainly in and about 
the metropolis. Similar activities now characterize very many com- 
munities both in the Americas and in the Eastern world. 

The National Sanatorium Association, the pioneer movement of the 
kind in Canada, was incorporated by a special act of the Dominion 
Parliament in 1896. It is a purely philanthropic organization, and 
every dollar which is contributed to its treasury goes to aid consump- 
tives without means. Its trustees are selected from among its mem- 
bers who have contributed $100 at one time, or who pay a subscription 
of $5 or more per annum. Representation on the board of any 
nmnicipality contributing to the association's work is provided for. 
Distinguished gentlemen, whose president is Lord Strathcona and 
Mount Royal, are its members. The services of these trustees are 
absolutely free, as are those of the association's treasurers and solic- 
itors, and also those of the visiting and consulting physicians, who 
make regular professional trips to the sanatorium and the hospital 
conducted under its auspices, and perform many other duties con- 



nected with the work. The examining physicians donate their fees to 
the association, for needy jjatients. 

The primary object of the association is to establish public institu- 
tions for the treatment and cure of consumptives, and to do everything 
possible to check the spread of this disease in Canada through educa- 
tional and legislative measures. Over thirty local associations are 
organized in the municipalities of Ontario. It is planned to establish, 
in addition to those already in existence, sanatoria at various other 
points throughout the Dominion of Canada, so that patients may have 
every advantage in the change of climate, and may be so disposed of 
that the highest percentage of cures may be effected. About twenty 
acres of land have been purchased outside of Toronto, overlooking 
the city. This is an ideal building site for the receiving home for con- 
sumptives, and buildings will be erected as soon as circumstances will 
permit. Under statute enactment every municipality in Ontario may 
make an agreement with this association whereby its institutions shall 
treat the former's patients, and such municipalities may pass by-laws 
or issue debentures to raise money to assist the association in this 
work. From all parts of Canada, " from Prince Edward's Island to 
Yucatan, from Herschel's Island in the Arctic Ocean,*' from Newfound- 
land, and from Canadians now residents of the United States, come 
manifestations both sentimental and material of the wide interest 
created in this work. This association has, moreover, done a tre- 
mendous educational work in the distribution of literature concerning 
the prevention of consumption. A travelling secretary visits the towns 
and cities of the Dominion, to promote additional interest in the work 
of the association and the cause it represents. 



We must care for the consumptive in the right place, in tiie rig^ht way, and at 
the right time until he is cured ; instead of, as now, in the wrong j)lace, in the 
wrong way, at the wrong time until he is dead. — Pryor. 

This society, both in its larger scope and because of its Committee 
on the Prevention of Tuberculosis, furnislies a model upon which to 
base other activities in this field. Mr. Devine, its very experienced 
secretary, points out that in no two places would the plan or work of 
such a society as this be quite the same.^ A general rule would apply, 
however. A representative membership, not only of the medical 
profession but of other interests and activities, and especially of ex- 
isting agencies concerned with the public health and practical })hi- 
lanthropy, is an initial advantage in enlisting the co-operation of all the 
forces in the community and the interest of all classes, and is a con- 
stant safeguard against partisan views. Local conditions must deter- 
mine whether the resulting body shall be independent or under the 
auspices of some existing organization. Both methods have resulted 
well. In Chicago such an association is in affiliation with the Visiting 
Nurses' Association ; in St. Louis, it is a Committee of the Civic 
Improvement ; in New York it is as we have indicated. 

On the other hand, the Boston and Scranton societies are inde- 
pendent bodies. Sponsorship of an organization of recognized impor- 
tance in social work may be desirable, if there are no conditions im- 
posed which might hamper the future development of the subsidiary 
body. On the other hand, the purpose of the new enterprise should 
be sufficient of itself to commend it to the public. The work to be 
undertaken is also determined largely by local conditions. The gen- 
eral features of a comprehensive campaign being agreed upon, the 
newly formed body should enter upon such work as had not been 
undertaken by any existing agency. A thorough survey should be 
preliminary to any plan of action. Tlie work of other organizations 
should not be dupHcated, though it should be whole-heartedly en- 
couraged. In developing the campaign, older organizations may be 
induced to undertake such parts as are specially appropriate to them. 

^The Directory of the Charity Organization Society. 



Collateral work should bo done to secure adequate and ample develop- 
ment of health department activities. Where there are no municipal 
departments, the society should try to supply the lack, preferably by 
having such an office established liy government. 

An organization of this sort will work for the development of the 
dispensary, the outdoor structure, the hospital and sanatorium phase 
of the subject, and will seek to influence to this end all sorts of 
enterprises both governmental and private. It should engage without 
limit in educational work. Indirect matters will concern it, such as 
movements for improved housing conditions, for better sanitation in 
factories, workshops, stores, and schools, for playgrounds in the city, 
or for the improvement of other of the multitudinous conditions such 
as are set forth in these pages. Upon such lines as these, considers Mr. 
Devine. an organization for the prevention of tuberculosis should be laid. 
To return to that one in New York which has proved its efficiency, — 

The Committee on the Prevention of Tuberculosis, appointed by 
the Charity Organization Society, was organized in June of 1902. Its 
initial membership was sixteen representative physicians and sixteen 
laymen specially interested in the social aspect of the disease. 

A competent secretary, a district nurse, and a statistician, who 
were to devote their entire time to the committees, were engaged, and 
the services of a large body of volunteer workers and of the expert 
agents and visitors of the society were enlisted. It was emphasized, 
to begin with, that here was not a movement against consumptives, 
nor one that would be permitted to increase their hardships. Educa- 
tional work concernhig the real nature of consumption was to be 
done to the end that popular phtlusiophobia might be dispelled, as 
well as for the larger benefits that would result from a diffusion of 
correct information concerning the disease. 

The objects of the committee were succinctly set forth as follows : 

1. The promulgation of the doctrine that tuberculosis is a com- 
municable, preventable, and curable disease. 

2. Tlie dissemination of knowledge concerning the means and 
methods to be adopted for the prevention of tuberculosis. 

3. The advancenient of movements to provide special hospitals, 
sanatoria, and dispensary facilities for consumptive adults and scrofu- 
lous and tuberculous children among the poor. 

4. The initiation and encouragement of measures which tend to 
prevent the develoi)ment of scrofula and other forms of tubercular 

An appeal was made for funds, which were to be expended mahily 
for the following objects : 


1. Research into the social, as distinct from the medical, aspect 
of tuberculosis : for example, into the relations between the disease 
and overcrowding, infected tenements, and unhealthy occupations, and 
also into the influence upon recovery of improved. diet and hygienic 

2. Education. The publication of leaflets and pamphlets, the 
giving of lectures, and the promulgation in every possible way of the 
fact that tuberculosis is a communicable and preventable disease; the 
widest distribution of the results of scientific research in this field, 
and of the results of modern treatment both in sanatoria and at 

3. The encouragement of movements for suitable public and 
private sanatoria both for advanced and for incipient cases ; for adults 
and for children ; for free care and also for the care of those who can 
pay moderate fees. 

4. The rehef of indigent consumptives by the provision of suit- 
able food and medicines, by the payment of rent when this is neces- 
sary to secure adequate liglit and air, and by transportation and main- 
tenance at a distance, when, in the judgment of the committee, this 
is essential. 

The labors of the committee are directed not only towards the 
amelioration of the condition of the large class of consumptives, but 
also towards the benefit of the comnmnity as a whole, in which there 
is encouraging reason to believe that tuberculosis may be practically 
eradicated. The work of the connnittee is not intended to be tem- 
porary merely, but its continuance and effectiveness will depend upon 
the public encouragement and support received. 

For research and publication the committee uses much of its funds. 
In the relief of special cases existing agencies are asked to co-operate, 
but any donations which individuals are willing to make for this 
special purpose lessen the burden upon organizations that are already 
overtaxed by cases of need arising in large numbers from the class 
of consumptive poor. 

The committee's activities have conformed with this prospectus, — 
how well must be judged by an examination of the Handbook which 
it has published. Nor will one come upon its last page without a 
hearty appreciation of the tremendous work which has been done and 
continues to be done by these humane men and women. 


'•The Truth shall make you free." 

This exposition was held in January, 1904. The programme 
stated it to be "an objective presentation to the people of Maryland 
of the history, distribution, varieties, causes, cost, prevention, and cure 
of tuberculosis." But no one could realize how meaty was this state- 
ment had he not gone to Baltimore to enjoy the presentation. I 
set down liere some of the exceedingly agreeable hnpressions of my 
visit. For details, I refer to the comprehensive and very interest- 
ing report of the commission under whose auspices the exposition 
was held. 

Tliere was a logical order to this exposition. It began with statis- 
tics taken largely (but not altogether) from the literature of the sub- 
ject. The unenviable prominence of tuberculosis among causes of 
death, its relations to other diseases, to race, age, sex, occupation, 
heredity, marriage, food and drink, dwellings, wages, insurance, 
economic considerations, — these and many other data were set forth, 
generally by means of charts, in preference to exposition by dry 
figures. For instance, the causes of death in tuberculosis Avere 
demonstrated by means of a circle, about 150° of which repre- 
sented asthenia, 10° hemorrhage, 3J° pneumonia, 3J° kidney compli- 
cations, and 3° peritonitis. It was noted that all races are exceed- 
ingly chary about reporting cases for registration. Naegeli's now 
famous demonstration, that tuberculosis exists in greater or less degree 
in practically all of us, was graphically presented. 

There was this whimsical table representing Baltimore " street-car 

Car rides ! 248 

Passengers 8156 

Separate deposits of sputa 994 

Sputa per car 4 

Crowded cars 41 

Counted deposits 125 

Sputa per crowded car 3 

Wet cars 49 

Crowded sputa on wet cars 52 



Sputum per oar 1 

Cars crowded or wet 90 

Counted sputa 177 

Sputa per crowded and wet car 2 

Cars neither crowded nor wet 158 

Separate deposits 817 

Per car 5.17 

Times spitting witnessed 30 

Conductors seen to spit on car . . 2 

Motormen seen to spit on car 5 

Pools are counted as one deposit. Motormen are depositors of 

Factory, tenement, and sweat-shop exhibits from a number of 
cities came next. New York City easily led this grewsome proces- 
sion, and "it seemed to have a banner so large as to obscure all 
the rest. 

The exhibit of State and municipal prophylaxis was a most re- 
freshing one, as was also the demonstration of the work done by 
organized charities and by volunteer associations in various parts of 
the country. An enormous amount of work was thus shown to have 
been accomplished both in this country and in Canada. The Charity 
Organization Society of New York made a particularly forceful 

In exhibits of sanatoria the State of New York, the West, our 
Army and Navy, Canada (especially Muskoka), England, and the con- 
tinent of Europe, were all represented. There were pictures of 
sanatoria situated in wooded groves, upon hill-sides, upon plains, with 
snow-capped mountains in the distance, upon Alpine crests, so snow- 
surrounded that it was not easy to distinguish the building. There 
appeared small structures so imbedded in snow that they looked like 
Eskimo huts; and tidy cottages comfortably ensconced among green- 
wood trees. Buildings of stone and wood, of part wood and part 
canvas, shacks and simple tents, were shown. The German sanatoria 
seemed, of all, the most elaborate and the most expensive. In them 
are embodied the idea of having most of the plant comprised in one 
huge building, in contradistinction to the American cottage plan. The 
Weicker Sanatorium, at Goerbersdorf, most picturesquely situated iu 
the midst of a densely wooded region ; the Dettweiler institution, 
with its auxiliary pavilions, looked like an Arabian Nights palace; 
and the Brehmer Sanatorium appeared a piece of architecture magnifi- 
cently conceived and much more costly, I believe, than any sana- 
torium which we, with our vastly preponderating resources over those 
of Germany, can boast of. 


A very valuable feature of the expositiou was the demonstration 
of what can iDe done in the way of home treatment, the plan which 
must, after all, be applied in most cases of the disease. If tlie race, 
indeed, is ever to " down"' tuberculosis, the result must be brought 
about by sanitation in the individual home, the unit of our civilization. 
It was shown how the roof-garden, the fire-escape in the tenement, 
and the v(>randa in the country house, could be utilized in fresh-air 
treatment. The sun-bath system of Dr. Millet was shown. All sorts 
of sputum receptacles, outdoor beds and cots, protected chairs, with 
rests for warming-pans for the feet, variously devised outdoor cover- 
ings, food preparations, and methods of keeping milk pure, were ex- 
hibited. Neatest of all, a room was arranged by nurses to be the 
type of such as consumptives should occupy. 

A very interesting part of the exposition was the " mural decora- 
tions,"' as a hospitable colleague called them. They were handsome 
charts, of dull red cloth, upon which were imprinted very pregnant 
and suggestive legends. These legends adorn many of the chapters 
of this book. Among tliem was a sentence from Hippocrates in the 
original. Remembering that I could once make such translations I 
began to reproduce this. But a sense of the melanclioly brevity of 
human existence having come upon me, I appealed to a Baltimore 
colleague, who rendered it thus: '"The disease which proved most 
dangerous and produced the greatest number of deaths was consump- 
tion." There was also one from Sophocles, which, my friend said, 
meant: "The gods always play with loaded dice." This did not 
seem quite correct, for I recalled that, although the gods were not a 
particularly straitlaced lot, they generally played fair. So a learned 
divine whom I had just met was appealed to. He assured us that the 
correct rendering was, "The gods always throw the cubes impartially.'' 

The history of tuberculosis was exhaustively set forth. And the 
cases containing books, plates, and portraits were most delectable 
pasture for literary browsing, at least for the medical man. This sec- 
tion was arranged, I believe, by the connnittee on books and por- 
traits, — Dr. Osier, Dr. D. R. Lyman, Dr. L, V. Hamman, and Dr. H. 
B. Jacobs. 

Upon the walls were portraits of intellectual men, those who 
either are or have been of the University faculty, — Elliot, Schouler, 
Brooks, Sylvester, Newcomb, Williams, Oilman, Remsen, Adams, 
Rowland, and Gildersleeve. It appears to me that as one progresses 
southward in this country the dignity portrayed in the faces painted 
is tempered more and more with a kindliness and urbanity of 


Over the platform of McCoy Hall, whore lectures were given every 
evening during the w-eek, a huge representation of the seal of the 
university w-as placed, and above this was the motto, " Veritas vos 
liberabit" — a most impressive motto for this University from which 
has gone forth so much that has made for well-being and happiness. 
I was greatly impressed with the largeness of the audiences. For 
instance, on the evening of my first hearing the lectures, when Dr. 
Adaini spoke, the thousand odd seats and all the available stancUng- 
room were occupied. And this audience was reduplicated earlier in 
the week, wdien Dr. Flick, Dr. Ravenel, Dr. Salmon, Dr. Knopf, and 
others lectured. These were certainly mucli larger audiences in pro- 
))ortion, and in fact, than are likely to attend a medical discourse 
in our cosmopolis of three or four million people, the most of whom 
sadly need lecturing upon the subject of this exposition. 

This tuberculosis exposition was certainly most successful, and 
its aftermath, no doubt, has been and surely will continue to be fruit- 
ful. Like educational enterprises have been conducted in many other 
communities. They should be lield in every city and town in the 
country. The larger cities should have permanent tuberculosis ex- 
hibits. To these ends, however, there have to be masterful executives, 
as are Dr. John S. Fulton and Dr. Marshall L. Price, who arranged, I 
understand, this memorable Baltimore Exposition. 

In the fall of 1905 a National Tuberculosis Exhibition will be held 
in New York City. 



Let us raise a standard to whicli the wise and tlie upright may repair, leaving 
the issue in the hands of God. — Washington. 

On an evening during the exposition just sketched, some two- 
score piiysicians met in the " Donovan Room" of tlie Johns Hopkins 
University, — a fitting place, the walls being adorned with the portraits 
of great men, copies of their writings and their poems, memorials of 
their achievements, Avhich were wholly and altogether beneficent. 
The reason of this special meeting lay in the idea to found a rep- 
resentative American association for the study of tuberculosis and 
for the prevention and cure of the disease. There were already 
several such organizations in this country, which, after the genial and 
venerable fashion of medical enterprises, were in antagonism one with 
another. As a result, European bodies devoted to these ends, who 
were anxious to put themselves in correspondence with American 
endeavor, were puzzled with whom they should communicate. 

This was a minor but an important reason among others why it 
was desirable to found an organization wliich would be representative 
of absolutely the best traditions in the medical profession, and of its 
best New-World thought in this particular field. 

Preliminary arrangements were made at this time, when Dr. 
AVilliam H. AVelch, who was chairman, was empowered to appoint a 
committee. And these gentlemen were to report at a second meeting 
in Philadelphia in March of 1904, when some hundred physicians 
were gathered from many parts of the United States. Dr. William 
Osier presided on this occasion. 

Not only the medical but the manifold sociological and economic 
aspects of this subject — so world-embracing in its scope — were dis- 
cussed, and the sentiment that was ])ervasive of this meeting was 
again one of practical humanitarianism. To a second committee was 
delegated the business of preparing a constitution and by-laws upon 
which the new association should be founded. 

And again, as at Baltimore, the deliberations of this body were 
conducted amidst an inspiring environment in the Philadelphia College 



of Physicians, an institntion impressive in its traditions, dignified in 
its material appointments, and its ivy-stained, time-softened archi- 
tecture. While I sat there, the late afternoon sun mellowing' the 
assembly chamber, 1 could not but reflect upon another historic 
occasion, held more than a century ago, hi another structure but a few 
rods away. In both was manifested a like lofty s[)irit. The former 
body deliberated concerning the emancipation of a nation, though no 
man hoped otherwise than that many lives would have to be sacrificed 
and that much suffering must inevitably ensue. The latter was con- 
cerned with the w^elfare of a race, and its confident deliberations ware 
to the end that much anguish of body and of soul should not come 
to pass and that many millions should not die untimely. 

At a third meeting, in June of 1904, at Atlantic City, the National 
Association for the Study and Prevention of Tuberculosis was defi- 
nitely founded. Dr. Trudeau, whom all delighted to honor, was 
made the president. Dr. Osier and Dr. Biggs the vice-presidents, 
Surgeon-General Sternberg the treasurer, and Dr. Jacobs the sec- 
retary. It was said that among the several hundred men present, 
perhaps one-third had been sufferers from consumption, and were 
now very robust proofs of the curability of this disease. These men, 
Trudeau, Flick, Bullock, and others, were now devoting their lives 
to the restoration of their afflicted fellows. Many parts of the country 
were represented. Among the speakers was a physician from the 
Black Belt, who declared with gratification that at last something was 
being done in his section to help the consumptive negroes among 
whom he practised. 

In May of 1905 the thoroughly organized Association had its second 
animal meeting in Washington, — an event, I believe, truly epochal in 
the history of civilization. In that splendid capitol, a fitting setting for 
such enterprise, several hundred physicians, scientists, and devoted 
laymen, under the presidency of Dr. Trudeau, manifested in their 
deliberations the same combination of altruism and sane endeavor 
that has evidenced this movement from its incipiency. 

There were sociological, clinical, climatological, pathological, and 
bacteriological sections, in wliich memorable papers were read and 
discussed by men of the first rank in their life-work. Among these 
addresses was that on Channels of Infection in Tuberculosis, by Dr. 
William H. Welch. One seldom hears, even among those whose 
calling it is to stir the heart and the emotions, so lucid and earnest a 
speaker, nor one so eloquent as this physician, who spoke upon a 
purely scientific subject, — an extempore address which, however, like 
a Beethoven number, would have been marred by the loss of a single 


note. i\or is one likely ever to have seen an audience so tensely 
interested as that which burst into tumultuous applause at the end of 
this masterpiece of logical exposition. 

Dr. Trudeau, in his address, declared, — 

" The ' great white plague' has ever been so gigantic and hopeless 
a problem that until recent years men have accepted the holocaust 
of human life which it has ever claimed, and the terrible suffering it 
entails on humanity, as an inevitable decree of fate, and have either 
looked on with Oriental fatalism, or turned their heads and passed by 
on the other side with a hopelessness born of despair and of igno- 
rance as to the etiology of the disease." 

But now consistent, rational, concerted activities were to proceed 
in the expectation that consumption might become, even in the life- 
time of many who were present, an affliction as rare as those which 
in other ages have been the scourges of the race of men. Thus, then, 
was begun the w^ork of this beneficent organization ; and no well- 
wisher for his kind will contemplate it without a stirring and grateful 
realization that it promises to be nothing short of monumental in 
human history. 

Part XIV 


Science is the pillar of fire which lights the way. 


The method of science has permeated all regions of thought and 
animated all of the commercial, industrial, political, social, and 
religious activities of men. Whether we welcome it, deplore it, 
or indifferently acquiesce in it, the fact seems undeniable that the 
method of science and the doctrine of evolution are the most effective 
sources of the intellectual enterprise of our day. 




"To ward off the calamity of disease and to prevent the spread of a pestilence 
is to increase the sum of human happiness and to elevate tlie race." 

The following authoritative report upon this subject was presented 
at Washington before the National Association for the Study and 
Prevention of Tuberculosis by Dr. A. C. Klebs, whose associates were 
Drs. J. H. Musser, F. Billings, J. C. Wilson, and H. R. M. Landis. 

The diagnosis of phthisis, of that well-developed stage of pulmo- 
nary tuberculosis, offers no ditiiculty whatever. The symptoms are 
well marked and typical, the pulmonary signs easily discoverable. The 
expectoration contains bacilli. The clinical picture is so typical that 
mistakes in diagnosis cannot well be made, even by the superficially 
trained observer. But this stage of pathological development in the 
great majority of cases is reached only after very long periods, daring 
which all signs and symptoms are less typical, less marked from that 
time on when infection took place. During this time, which marks 
the true incipiency of the malady and which anatomically is character- 
ized by the formation of few isolated tubercles in lymph glands or 
lung tissue, no or only vague general symptoms exist. — none on which 
to base a positive diagnosis of the disease. Investigation has shown 
that such infections are of very frec|uent occurence, and that only in 
a comparatively small percentage of these cases does the disease de- 
velop further. However, this percentage is sufficiently large to make 
tuberculosis the most destructive of all diseases, and the demonstra- 
tion of its frequent and spontaneous arrest, and of its curability by 
certain therapeutic measures at an early period of its development, 
must induce efforts of recognition long before the stage of phthisis is 

The discovery of the tubercle bacillus in the sputum of patients 
suffering from the disease constitutes a diagnostic means of indispu- 
table accuracy. However, the consideration alone of the fact that 
tubercle bacilli can appear in the sputum only after the caseificalion 
and breaking down of a tubercle situated near a bronchus or bronchi- 
olus makes it certain that tuberculous changes occur previous to the 

This chapter and the one followintf will probalily interest only the physician. 



appearance of the bacillus in the sputum. This is borne out also by 
the clinical observation of a recognizable stage of iuberculous lung in- 
volvement before bacilli are found in the sputum, and the adoption of 
the term "closed," designating this stage, in opposition to "open" 
— i.e., ^vith bacilli found in the sputum, — can be recommended for a 
more general introduction. 

From the therapeutic stand-point the diagnosis of pulmonary 
tuberculosis in its closed stage is of the utmost importance, the 
chances of permanent recovery diminishing proportionally with the 
postponement of rational therapeutic measures. These measures, 
being on tlie whole nothing but a radical change in the patient's mode 
of hfe, will also interfere less with the patient's usual occupations the 
earlier the diagnosis is made. Hence, also, for this reason, the para- 
mount importance of an early diagnosis. The physician who declines 
to make a positive diagnosis of tuberculosis on account of the absence 
of the bacillus in the sputum only, assumes a very grave responsibility, 
and great caution in this respect cannot be urged sufficiently. When- 
ever certain signs and symptoms justify a suspicion of the disease, 
without there being positive evidence, it is wise to instruct the patient 
carefully as to his mode of life, to watch hhn closely, and to repeat the 
examination at stated intervals. 

As regards the examination, it may be said in general that a close 
and careful investigation of constitutional as well as local manifesta- 
tions by the simplest methods will often reveal sufficient evidence for 
a positive diagnosis. The search for bacilli in the sputum has unfortu- 
nately brought about a neglect of these methods. 

The history of the patient may or may not contain useful informa- 
tion. It ought to be carefully investigated in every case. Predisposing 
moments, such as cases of tul)erculosis in the family and among inti- 
mates, or unliygienic mode of life, dusty and confining occupations, 
must all be taken into consideration ; their absence in one case, on the 
other hand, must not discourage further examination. 

Tlie symptoms of incipient tuberculosis will rarely offer anything 
typical. We may have a very early hoarseness or a condition resem- 
bling that of chlorosis or neurasthenia, of bronchitis or dyspepsia. 
Cough may, or may not, be present. Haemoptysis, in the absence of 
other causes, among all the symptoms which may be found in the 
history, is one of the greatest significance. Physical signs are some- 
times absent for weeks after the haemoptysis. Vague as all these 
symptoms may be, and characteristic of various morbid conditions, 
they assume diagnostic value only when considered together with the 
results of a careful physical examination. 


Here inspectiori, first of all, will have to reveal conditions of stat- 
ure and physical development, which in their deficiencies we know to 
be indicative, if not of the disease itself, at least of a predisposition to 
it. Length and weight of body (p. 374), circumference and degree of 
expansion of chest, are data of importance, and in their correlation 
give indication of the bodily coiuhtion and state of nutrition. Still, we 
must not depend on finding often the classical habitus phfhisicns, the 
paralytic thorax, if we are to make an early diagnosis of tuberculosis. 
However, these data, as well as the determination of symptoms, are of 
iireatest value if for nothing else but a guidance in subsequent exam- 
inations, and for that reason should not be neglected in any case. 

Of great importance is the temperature. Even a slight rise of 
temperature in the afternoon, if other causes can be excluded, ought 
to arouse invariably our suspicions. Very often this is overlooked, 
and to shield against such oversight great care in the measuring of the 
temperature is to be recommended. Whenever possible a two-hourly 
record for a period of several days ought to be taken, a good thermom- 
(>ter to be placed in the mouth with tightly closed lips and held there 
for at least five minutes, the patient in a room of even temperature. 
It will also have to be remembered that in some tuberculous patients 
the rise of temperature appears only after some exercise, — in women 
before and at the time of menstruation. 

The physical examination of the chest by inspection, palpation, 
percussion, and auscultation, if carefully and properly performed, will 
give more direct evidence than other methods. It may be said Iiere 
that the newer methods of examination, notably that with the Roent- 
gen rays, cannot, at least in their present state of development, claim 
superiority over the results obtained by the above-mentioned methods. 

Attention will be called here only to a few signs indicating limited 
lung involvement. On inspection very often a retardation in the res- 
piratory movements over the affected lung portion can be observed, 
especially over one apex. This retardation is more pronounced in a 
more recent involvement of the corresponding area of the limg (Tur- 
ban). Foci of greater extent diminish the excursions of the diaphragm 
of the affected side. This can be demonstrated on the fluorescent 
screen, but equally well and without apparatus by the observation of 
the diaphragmatic excursions by means of Litten's shadow. 

The vocal fremitus in early pulmonary tuberculosis gives little in- 
formation. It may be increased or decreased over areas of pleural 
thickening ; over pleuritic exudations it is always diminished. 

Painstaking percussion and ausculation of the chest over all parts, 
and always comparing the two sides, is of the greatest value. The 



use of the blue pencil for marking the border lines and determining 
the excursions of the lungs cannot too strongly be urged. Strong per- 
cussion, on the whole, should be avoided. Marked dulness is but 
rarely found over portions of the lungs in incipient tuberculosis. How- 
ever, the percussion will elicit sometimes a significant retraction of one 
apex as compared with the other. 

In judging the results of the examination by auscultation, it should 
always be remembered that many of the signs are subject to consider- 
able variation, depending on the time at which the examination is 
made. Rales, which we can easily discover in the morning, will regu- 
larly be absent during the afternoon. Also on damp and rainy days 
we will find them when they are absent in drier weatlier. Also do 
we find in women pulmonary signs accentuated at the time of men- 

All these circumstances must be considered before a final judg- 
ment of the case is given. 

Although every portion of the lung (including the lingula over the 
heart dulness) should be examined with the stethoscope, particular 
attention will have to be paid to the upper portions of the lungs and 
also to the lower borders and the axillary regions. 

As the earliest auscultatory sign in early pulmonary tuberculosis 
we can regard the rough and the slightly diminisiied respiratory mur- 
mur. The former must not be confounded with the sharp (puerile) 
respiratory murmur, which is more a sign of increased function than 
of swelling of the mucosa. Both are vesiculary sounds. The rough 
character is produced by a succession of murmurs, following each 
other too rapidly for aural differentiation. Is the succession less 
rapid, then we speak of an interrupted respiratory murmur, which 
suggests much coarser changes. Thus the rough murmur changes the 
character of the respiratory sound. It loses its " smooth" quality and 
becomes " impure and roughened" (Sahli.) When these adventitious 
sounds become audible besides the vesicular murmur, then we can 
speak of rales. The rough murmur is produced by slight inflamma- 
tory changes in the bronchioli, the air passing over an uneven surface 
and through a sliglitly narrowed lumen. It is principally audible dur- 
ing inspiration over tlie apices and below the clavicles. This murmur 
precedes the appearance of rales (not tlie case, as a rule, with the puer- 
ile murmur), and thus is the earliest auscultatory manifestation of 
tubercular involvement of the air-passages. Distinct attention should 
tlierefore be paid to it. Tlie appearance of rales over tlie apices (also 
in the axillary region) is next to it in importance. Rales indicate 
catarrhal conditions. With them the intensity of the vesiculary mur- 


mur is usually diminished, which is also produced by the more pro- 
nounced swelling- of the broncliial mucosa. In the earliest stages \;e 
hear usually tine crackling rales. They can often only be heard directly 
after the patient has coughed. 

Bronchial respiration we hear but rarely in early tuberculosis. 
When it appears, we have to deal with a more extensive process. By 
its localization in the apices and together with other signs it is, of 
course, pathognomic of consolidation. The same may also be said as 
regards the other deviation from the normal respiratory murmurs 
which are indicative of profound tissue changes, to discuss which does 
not come within the scope of this report. On the other liand, pleu- 
ritic friction is often lieard at an early period, most frequently in or 
near the axillary line between the sixth and eightli ribs. 

Only passing mention can be made of other diagnostic methods, 
of whicli tuberculin is the most important. Although it is well un- 
derstood that by injection of small doses of tuberculin, and by the 
febrile reaction thus produced in tuberculous individuals, Ave can diag- 
nose early tuberculosis, the method necessitates great care in its ai)pli- 
cation and an apparatus too complicated for general use, so that it 
does not lend itself to a more general introduction. The dangers of 
the preparation in the hands of one w'ell acc^uainted with the method 
are very slight, but by applying carefully the other means of observa- 
tion and examination, a case will rarely be found in which it would 
add considerably to the information gained. 

The fact that certain salts, especially iodine salts, increase ca- 
tarrhal symptoms, and thus make them more perceptible to auscul- 
tation, has led to their administration for diagnostic purposes. For 
similar reasons as the above stated, a general introduction of this 
method cannot be recommended. 

The examination with X-ray has the drawback of a complicated 
apparatus. Besides, its value over the other methods has not yet 
been satisfactorily demonstrated. Various other methods have been 
advocated for the early detection of tuberculosis, — inascopy, sphyg- 
mography, sphygmomanometry, serum test, etc., — all apt to increase 
our knowledge of the disease, but of no practical advantage in the 
every-day diagnosis of so frequent a disease. The careful and pains- 
taking application of the methods well taught and well understood, 
with the simplest apparatus, but applied with a broad conception of 
the pathogenesis of the disease, will bring about nuich earlier diag- 
noses than are usually made. 



"It would tend to uniformity of scientiiic results if all physicians would adopt 
the scheme here proposed." 

The report of the nomenclature committee of the National Asso- 
ciation for the Study and Prevention of Tuberculosis was presented 
at Washington by Dr. Vincent Y. Bowditch, whose associates were 
Drs. Lawrason Brown, G. W. Norris, H. M. King, W. H. Bergtold, and 
J. H. Pryor. The trial for one year of Dr. Turban's scheme here set 
forth was urged, with the prospect of a report at the next annual 
meeting concerning its success or otherwise. The first part — classi- 
fying incipient (favorable), moderately advanced, advanced cases, and 
miliary tuberculosis — is to be used on the admission of a patient to 
an institution. The classification in conformity with Turban's scheme 
proposed by the committee, as here set forth, should be used on 
the patient's discharge. In tlie discussion upon this report the word 
"favorable" was advanced — with general approval, I think — as being 
preferable to " incipient." 


Slight initial lesion in the form of infiltra- 
tion limited to the apex or a small part of one 

No tuberculous complications. Slight or no 
constitutional symptoms (particularly includ- 
ing gastric or intestinal disturbances or rapid 
loss of weight). 

Slight or no elevation of temperature oi 
acceleration of pulse at any time during tlic 
twenty-four hours, especially after rest. 

Expectoration usually small in amount or 

Tubercle bacilli may be present or absent. 

No marked im[)airment of function, either 
local or constitutional. 

Localized consolidation moderate in extent 
with little or no evidence of destruction of 
tissue ; 

Or disseminated fibroid deposits. 

No serious complications. 

Incipient (Favorable) 

Moderately Advanced 


Repo RT . — ( Continued. ) 

Far Advanced 

Marked iiiiiiairincnl of fiiiiotion, local and 

Localized consolidation intense ; 
Or disseminated areas of softening ; 
Or serious complications. 

Acute Miliary Tuberculosis. 

Translation, tvith some 3IodiJications, of Tu7'han''H Scheme for a 
Method of Comparative Statisties for J*ubnonary Tuberculosis. (From 
"Tuberculosis," monthly publication of the Central International 
Bureau for the Prevention of Consumption, September, 1904. Johann 
Ambrosius Barth, Leipzig.) 

Suggested for use in the National Association, with the addition 
of the scheme offered by the Committee. 

1 Extent of disease in the lunss, 

2 How long consumptive? 



3 months 

For exact definition, see below. 

3 General condition of the patient, 

4 General digestion, 

5 General pulse, 

6 General temperature, 




Tubercle bacilli. 

Tuberculous complications, 

Other complications, 
Result of treatment. 

Period to date from the observation 
of the first clinical symptoms, — 
e.g., stubborn coughing, h;pmop- 
tysis, pleurisy, loss of flesh, etc. 
A A = favorable. 

X X =: unfavorable. 

B B ^ unimpaired. 

Y Y = impaired. 

The pulse is to be registered every 
morning and evening, the patient 
F F = maxima for the day over 101° 

f f = maxima for the day from 99° 

F. to 101° F. 
t n tn = normal temperature (mouth). 

+ + =^ tubercle bacilli present. 

^ tubercle bacilli absent. 

Larynx. Name of the organ suffering from 
. . . Name of the disease. 
vide Classification of Results of Treatment 
proposed by Committee on Nomenclature. 

Definition of the extent of disease in lungs, according to Turban : 
I. Slight lesion extending at most to the volume of one lobe or 
two half lobes. 


II. Slight lesion extending further than I, but at most to the 
volume of two lobes; or severe lesion extending at most to the' 
volume of one lobe. 

III. All lesions which in extent of the parts affected exceed II. 
By "slight lesion" we understand disseminated centres of disease 

which manifest themselves physically by slight dulness, by harsh, 
feeble, or broncho-vesicular breathing, and by rales. 

By "severe lesion" we mean cases of consolidation and excava- 
tion such as betray themselves by marked dulness, by tympanitic 
sounds, by very feeble broncho-vesicular, bronchial, or amphoric 
breathing, by rales of various kinds. 

Purely pleuritic dulness, unless marked, is to be left out of 
account ; if it is serious, the pleurisy must be specially mentioned 
under the head of "tuberculous complications.'' 

The volume of a single lobe is always regarded as equivalent to 
the volume of two half lobes, etc. 

By the Committee. 

Proposed Ckissijication of Cases and Results of Treatment in Pul- 
monary Tuberculosis^ to be used in Connection xcith Turban'' s Scheme. 
On discharge : 

Progressive: (Unimproved.) All essential symptoms and signs 
unabated or increased. 

Jiuproved: Constitutional symptoms lessened or entirely absent ; 
physical signs improved or unchanged ; cough and expectoration with 
bacilli usually present. 

Arrested: Absence of all constitutional symptoms; expectoration 
and bacilli may or may not be present ; physical signs stationary or 
retrogressive ; the foregoing conditions to have existed for at lea&t two 

Apparently cured: All constitutional symptoms and expectoration 
with bacilli absent for a period of three months ; the physical signs to 
be those of a healed lesion. 

Cured: All constitutional symptoms and expectoration with ba- 
cilli absent for a period of two years under ordinary conditions of 

An example is here shown (Fig. 109) of how^ a given case might 

' The length of time mentianed is of course somewhat arbitrary, but is intended 
to cover the cases which frequently occur, where the patients leave a sanatorium 
for various reasons, contrary to advice, after a stay of a few weeks, alttiough all 
active symptoms may have ceased completely soon after entrance. 












S' ^ 







B - 





S o 




fD "^ 






1— ( 

2 o 2,0 


3 5^ 

ft o 3 

<-^ 3 








o o 

















I— 1 











f^ . 




T) S) 


£o ^ 



^ ""''S 







5^ T p 










o ' 













3 (B 

cr T 

• O 



















































be labulalod. Siuli tabulaliuii, it will Ix' seen, is rather a description 
than a classifieati*()n. 

This method of liistory-taking, with monthly summary, is in use 
at the Massachusetts State Sanatorium (Figs. 110, 111). There are, 
in addition, cards for recording temperature, pulse, and weight, with 



Fig. 110. 


( First Fxam 
Dates -1 Entrance 
( Exit 



Environment Occupatiou 

Stopped Work Birthplace 



Sent by- 

Ancestry In U. S. 

Habits and Prev. Tr'lm't 

Prev. Diseases 

Family History (Tubennilj-r) M.S. F.B. 

-M.M. M.F.— M.S. M.B.— F.M. F.F.— F.S. F.B.-Children 


Before and at Entr.vnce : 

In Sanatorium: 

At Exit : 



T. B. 



Night Sweats 
















Length of Stay 


diagrams, such as here shown, upon which lesions may be depicted 
(Fig. 112). The physician may have stamps made of these diagrams, 


SO that changes may from time to time be recorded upon repeated 

Fig. 111. 


Monthly Summary. 





N. Sweats 














Ph. Exam, and Remarks 


Chest Expan. 

Chest Capacity- 



Spec. Diet 

Eggs Milk 

A number of systems of symbols and abbreviations have been 
devised by Knopf, Elliot, and others. The physician will probably 
find that simplification will be best effected by selecting and mastering 
only a few signs. 

Fig. 112. 

Every practitioner will modify the suggestions here set forth for 
use in his private work. My own case histories are made upon 



printed cards, containing the salient points here given, four by eight 
inches, whicli fit exactly into one of my desk drawers. In addition 
are blank cards for observations during the progress of the case, 
which can be clipped with the first, upon which the history is taken. 
Every medical man has, or should have, firmly implanted in his 
memory some skeleton upon which to hang his physical diagnosis. 
The following concerning the lungs was taught me in my student days 
by Dr. Abraham Zemansky. 





Auscultation of Breathing. 

Color of skin — 




Shape of chest — 



Local depression. 
Irregularity of chest expansion. 
Frequency of respiration. 

Intensity — 




Expiration prolonged. 
Quality — 







Auscultation of voice and whisper. 

Diminished intensity — 


Weak or feeble, 

Inequality of chest expansion. 
Vocal fremitus — 




Increased intensity — 

Pleural fremitus. 



Bronchial fremitus. 





(Pitch and Quality.) 



Sonorous and sibilant. 


Moist — 

Tympanitic resonance. 

Mucous, crepitant, sub-crepitant, and 

Vesiculo-tympanitic resonance. 


Cracked-pot resonance. 

Pleural (various). 



In non-tuberculous subjects an injection of 0.25 C.c. induces a 
severe reaclion ; 0.01 C.c. i)roduces no reaction. In tlie tuberculous, 
reaction occurs willi 0.00 1 C.c. and declares itself williin four or five 
liours by general symptoms, — rise of temperature to 102°-104° (usu- 
ally after a preliminary chill), pain in ttie lini])s, weariness, cough, 
often nausea and vomiting-, occasionally cerebral symptoms. These 
last about half a day. There are also local reactions — externally, 
redness, swelling, exudation — which subsequently harden into crusts 
and sca])s and fall off; pulmonary foci give rales, increase of dulness, 
of cough and expectoration, and perhaps tubercle bacilli in the 
sputum. Rarely tuberculin injections will iH)t detect tuberculosis. 


The best process of staining the bacilli is the Ziehl-Neelsen 
method, as follows : Spread out the small, yellow, caseous-looking 
points of the sputum by pressure between two cover-glasses. A thin 
film will remain on each wdien the glasses are slipped over each other 
apart. The glasses should then be dried and passed rapidly through 
the flame of a spirit-lamp, care being taken not to scorch the film. 
The cover-glasses should then be floated, film downward, on a solu- 
tion made up as follows : Saturated alcoholic solution of basic fuch- 
sin, 1 part; absolute alcohol or rectified spirits, 10 parts; 5 per 
cent, carbolic acid solution, 10 parts.' This fluid is well mixed and 
a small quantity filtered into a watch-glass, on w^hich the film is 
floated as above described. If time be an object, gently heat the fluid 
over a Bunsen burner or spirit-lamp until steam rises ; then droj) the 
film upon the surface, and at the end of from three to five minutes 
the bacilli will be well stained. Or put a few drops of I lie slain upon 
the cover-glass, hold it by forceps over the flame, heating and reheat- 
ing it, as with the watch-glass. If time be not an oliject, or if sec- 
tions are to be stained, the preparation should be lelt in the fluid 
from twelve to twenty-four liours. The preparalion is then trans- 
ferred to a watery twenty-five per cent, solution of sulphuric acid, 
when the pink rapidly becomes a yellowish-brown tinge. Keep the 
cover-glass in motion to facilitate this change. When the decoloriza- 
tion is complete, there should be no return of the pink on plunging 
the specimen into a bowl of water to which a drop of ammonia has 

^Or this formula: Concentrated alcoholic solution of fuchsin, 10 C.c; five 
per cent, aqueous solution of carhojic acid. 90 C.c. 


been added. It may be necessary to return the specimen once or 
twice to the acid before this end is attained. After thoroughly rinsing 
in this slightly alkaline water the specimen may be counterstained for 
from thirty seconds to a minute in a dilute watery solution of methyl- 
ene-blue. It should then be washed in water, carefully dried, and 
mounted in Canada balsam. The bacilli may now be seen under the 
microscope standing out as bright red rods in a blue background of 
debris, pus-corpuscles, and cells. 



"While ronsnmption is rnaiiily of human propagation, hovine tiihiM-culosis con- 
tribute?; a source of infection to a degree which cannot l)e ignored." 

The means of pasteurization devised by Dr. Rowland (i. Freeman, 
to whose paper the reader may refer for details, should be employed 
wherever the purity of milk is in question. No thermometer is re- 
quired, the apparatus being based on the fact that if two fluids at dif- 
ferent temperatures are placed in contact these two tem})eratures will 
be equalized. • By inversion in a definite amount of boiling water (the 

Fig. ns. — Petri plates ilhistratine the eflRcacy of pasteurization at 68° C. for thirty minute.s in 
destroying the bacteria of milk (Freeman), a. Photograph of a plate twenty-four hours after 
planting with 1-20 C.c. of raw milk,— 7441 colonies are visible, b. Photograph of a plate twenty- 
four hours after planting with 1-20 C.c. of the same milk after pasteurization for thirty minutes at 

68° C. , — no colonies are visible. 

source of heat having- been removed), a properly proportioned amount 
of cold milk is introduced in bottles under such conditions that they 
will not break, with the result that the milk is raised to about 68° C. 
(155° F.). This procedure obviates the injurious chemical changes 
which are said to begin in milk at 80° C. Moreover, milk pasteurized 
as indicated for twenty minutes is fairly sterile ; and this temperature 
is sufficient to destroy the pathogenic germs w^hich are most feared in 
milk, including the bacillus tuberculosis. By pasteurization below 



70° C. the original flavor and taste of the milk is retained, — an im- 
portant practical consideration.^ 

The consumptive mother must be instructed to take great pre- 
cautions concerning the feeding of her infant. Condensed milk, or 
loose milk sold in grocery stores, should not be used. The mother 
should not take into her mouth the rubber nipple : she should not 
taste the food she prepares and then feed the child with the same 
spoon ; she should not blow upon the food to cool it. 

The New York Health Department has prepared for distribution an 
admirable circular in whi(;li details concerning the care and feeding of 
infants and little children among the city's poor, and the arrangements 
made by the Strauss benefaction to these ends, are set forth. 

With regard to the inspection of milk wdiich this department un- 
dertakes it is to be noted that millions of quarts are consumed every 
week in the metropolis, and that some of this vast cjuanlity comes 
from a distance of five hundred miles and is twenty-four hours old 
Avhen it reaches its destination.- The inspectors of the department 
are exceedingly active and careful in the exclusion of imj^ure milk ; 
nevertheless, it is obvious that tlie formation of a corps sufficiently 
large to examine all the sources from which this milk is derived is 
impossible. However, the city's milk receives careful examination. 
An enormous quantity — three thousand cans in a single night — has 
been poured into the sewers by order of the inspectors because its 
temperature, when it reached town, was above 50° F. In one in- 
stance a wdiole train-load was condemned on its arrival. Naturally 
there is some complaint among the milk dealers, wdio declare that the 
quantity seized and condemned is sometimes so great that they are 
unable to supply customers. They declare that the inspectors would 
find the milk all right, so far as the temperature is concerned, if they 
go to the stores from which it is distributed, instead of taking it di- 
rectly from tlie wagon when it enters the city ; and that while it is in 
transit from the car to the distributing point it is difficult to keep it 
cool. The Board's object in declaring milk above 50° F. adulterated. 

^ The thermal death-point of the tubercle bacillus in a moist medium is found 
by Grancherand Lidoux-Libard to be 70° C. for one minute ; by Yersin 70° C. for 
ten minutes ; by Bitter 68.5° C. for twenty minutes ; by Forster 65° C. for fifteen 
minutes ; by Bonhoff 60° C. for twenty minutes ; by Schroeder 60° C. for fifteen 
minutes. These variations are in part due to sputum being the medium : the 
varyincT virulence of the bacilli ; the use of bovine bacilli by some and human bacilli 
by others ; the test of life of the bacillus. 

■■^ Not only New York State, but also Massachusetts, Connecticut, New Jersey, 
Pennsylvania, and Delaware supply New York City. 


and in thus strictly enforcing the regnlation of the health code, wiiich 
orders the condemnation of adnlterated nn\k, is the prevention, as 
far as possible, of the intestinal diseases of children. In warm milk 
(above 50°) bacteria multiply in geometrical progression, and the 
Board considers that the milk should be cared for in such a way from 
cow to home (if we may use the phrase) that such diseases will not 
be engendered in infants. 

The laboratories of the department are open daily for the free ex- 
amination of milk samples ; and details of examinations are furnished 
upon request, as is the case, I believe, with all the department's 
literature. The sanitary code, which it is the business of the Health 
Department to have enforced, recjuires that no such products as un- 
wholesome, skimmed, watered, or adulterated milk, or swill milk, or 
milk from cows or other animals that for the most part have been kept 
in stables, or that have been fed in whole or in part on swill, or milk 
from sick or diseased animals, or any butter or cheese made from any 
such milk, shall be sold. The term " adulterated" here means : milk 
containing more than 88 per cent, water or fluids ; or less than 12 per 
cent, milk solids ; or less than 3 per cent, fats ; or such as is drawn 
from animals within fifteen days before or five days after parturition ; 
or milk drawn from animals fed on distillery waste or any substance 
in a state of fermentation or putrefaction, or on any unhealthy food ; 
milk drawn from cows kept in a crowded or unhealthy condition ; or 
milk from w'hich any part of the cream has been removed ; or such as 
has been adulterated with water or any other fluid or to which has 
been added, or into which has been introduced, any foreign substance 
whatever; or milk the temperature of which is higher than 50° F. 

Xo adulterated condensed milk shall be '• brought into, held, kept, 
or offered for sale in any place in the city of New York." Condensed 
milk is })ure milk from which any part of the water has been removed 
and to which sugars have been added. And such milk is adulterated 
when the amount of fat is less than twenty-five per cent, of the milk 
solids contained therein, or to whicli any foreign substance whatever 
has been added, excepting sugars, as in preserved milk. 

No milk of any sort shall be sold or delivered to the city without 
a written permit from the Health Department, for which application 
must be made. The restrictions noted apply also to cream, which is 
the fatty portion of pure milk rising to the surface when the milk is 
left at rest, or which is separated by other means. Adulterated cream 
is such as has had "-any foreign substance" added to it. 

The department requires that milk must not be stored or sold in 
any rooms used for sleeping or domestic purposes or opening into such 


rooms ; that, except for the purchaser at tlie time of delivery, it must 
be transferred from cans or bottles or other A^essels on streets or on 
ferries or at depots. The reasons for this care is that milk is an ex- 
cellent culture medium for germs, and may thus readily transmit 
tuberculosis and other infections. 

The milk bottles must be washed clean with a hot water solution 
of soap or soda or some other alkali, and then with hot water before 
filling with milk. They must not be filled except at the dairy or 
creamery, and in the city only in rooms so situated as to prevent the 
contamination of the milk by dust or other impurities from the streets 
or elsewhere. Nor may they be washed or filled with milk in rooms 
used for sleeping or domestic purposes. 

The vessels in which milk is kept for sale must be suitably covered 
against dust or other im})urities. Store permits must be publicly 
posted. Wagon permits must be carried whenever engaged in the 
sale or transportation of milk, and of length, width, and color as 
directed. At the end of the day's sale all cans, measures, and other 
utensils used in the sale of milk must be thoroughly cleansed with a 
solution of washing soda in lukewarm water, — a tablespoonful to a 
gallon. The overflow pipe from the ice-box in which the milk is kept 
must discharge, not into a drain pipe or sewer, but into an open water- 
supplied, properly-trapped, sewer-connected sink. The ice-box must 
be thoroughly scrubbed at least twice a week in the same manner as 
the milk bottles. 

In selling milk the contents of the can should be thoroughly 
mixed. This will prevent unintentional skimming and will give with 
the last cjuart a fair amount of cream. 

If in cold weather the milk is delivered to the dealer frozen, tlie 
ice from the sides of the can should be detached and the contents 
gently heated until the ice is all melted. This is essential if there is 
much ice in the can ; otherwise the part dipped out and sold at first 
will contain more of the solids of the milk and cream while the ice 
remaining, and consisting principally of water, will, after a time, melt, 
with the result that the remaining milk may appear to have been 
adulterated with water. For this reason also ice should not be placed 
in milk in order to cool it. 

This Health Department's suggestions for testing milk are as 
follows : 


Fill the cream gauge one-half full with water, at 120° F., to 
which have been added a few drops of a strong solution of washing 
soda. Then, after stirring up the contents of the can of milk thor- 




oughly, fill the gauge to the top mark with the milk. Shake well and 
place in very cold w^ater (say 40° F.). In about thirty minutes the 
cream will have risen and the percentage can be read off, remember- 
ing that the result observed must be multiplied by two, as one-half 
water and one-half milk was used. Example : 8 per cent, of cream 
was observed by this test; multiplying this by two would be 16 
per cent., which would be the true amount of cream contained in 
the milk. Good milk should show 14 to 18 per cent, of cream. 


To test for water the lactometer can be used as follows : Stir the 
milk to be tested so that a fair sample can be taken. Warm or cool 
enough milk to 60° F. to fill the testing cylinder. Insert the lactom- 
eter in the milk in the testing cylinder, being careful not to wet that 
part of the stem above the milk, and observe where it floats. Pure 
milk will not fall below the 100° mark at 60° temperature. It must 
be remembered that skimming the milk will make the lactometer 
float high <?r and the addition of water or cream may make it .sink lower 
than 100° ; but if the appearance of the milk upon the lactometer is 
noted, no one can mistake watered milk for milk to which cream has 
been added, nor pure milk for milk from which the cream has been 
removed, as skim milk. In other words, if the lactometer floats 
below 100° and the milk looks thin, water has been added. If it 
floats above 100° and the milk looks thin, it may be skimmed, or 
skimmed and watered. But if it floats above 100° and looks creamy 
and yellow, and sticks to the glass, you can be reasonably sure that 
it is pure. Good average milk will indicate about 109° on the lac- 
tometer at a temperature of 60° F., and show about 14 per cent, of 
cream by the cream test given above. 

The New York County Medical Society has appointed a commis- 
sion to aid in improving the milk supply of the metropolis. And these 
eminent physicians have formulated requirements affecting the farms 
which they visit as a commission and the handling of the milk 
obtained at these farms. Those who comply with the requirements 
of this body are offered the right to use caps on their milk bottles 
stamped: "Certified" or "Inspected. Milk Commission, Medical 
Society, County of New York." These caps bear the name of the 
dairymen, so that any adulteration may be traced to its source. The 
requirements are in substance as follows : 

Tlie barnyard must contain no manure in summer and rone in con- 
tact with the stable in winter ; it must be well drained and kept rea- 
sonably clean. 



The stables must have adequate ventilation and light ; the floor 
must be of wood or cement ; the ceiling tight, if a loft above is used ; 
basins, hand-brushes, clean water, soap, and clean towels shall be pro- 
vided in the barn or adjacent dairy-room ; the stable shall be white- 
waslied in the fall, and in the spring if deemed necessary ; a sufficient 
number of lanterns shall be provided for proper milking; the ceilings 
and sidings are to be cleaned once a month ; the bedding to be of shav- 
ings, saw-dust and dried leaves, cut straw or other approved material ; 
the soiled bedding to be removed daily ; the manure to be removed 
daily from the stalls and open manure gutter ; covered manure gut- 
ters must be kept sanitary ; the application of land plaster or lime on 
the floor daily is recommended ; the entire floor outside of the stalls 
to be swept daily at least an hour before milking. 

The locder-supply must be pure for all purposes, accessible and 

The Cows. — Milk containing mucus and that from any diseased 
cow must be discarded, as also milk from any animal forty-five days 
before and six days after calving ; the food nmst be suitable both in 
amount and kind and must not give a disagreeable flavor to the milk ; 
the cows must be kept clean on flanks, belly, udder, and tail ; long 
hairs about udders must be clipped, as also the tail sufficiently to 
clear the ground ; the cows must be kept from lying down between 
the cleaning and the milking (this is best done by throat-latching) ; 
the udder must be cleaned thoroughly before milking. 

The Milkers. — No milker or assistant shall have any connection 
with the milk production at any stage if he has any communicable 
disease or if he has been exposed to scarlet fever, diphtheria, typhoid 
fever, or smallpox. After all preliminary preparation the hands must 
be thoroughly washed with soap, water, and brush before milking; 
the hands and teats must be kept dry during milking ; if they become 
moistened with milk they must be wiped with a clean towel ; suit- 
able clean outer garments, such as overalls and jumpers, must be put 
on before milking. 

Utensils. — Strainers — metal, gauze, or cotton — must be absolutely 
clean when used for straining milk ; all dairy utensils must be abso- 
lutely clean and free from dust. 

The milk must not be adulterated in any way ; it must average 4 
percent, of butter fat; cooling must be begun within thirty minutes 
after the milking; the temperature must be reduced to 55° F. within 
two hours after milking and to 50^ within three hours, and kept 
below that temperature until delivered to the consumer. When 
delivered the milk must not average over one hundred thousand 


bacteria per C.c. from May 1 to September 30, and not over sixty 
thousand per C.c. from October 1 to April 30. If the commission's 
requirements are fulfdled, tliere will ])e no excess of the number 

Inspections. — The farms must always be open to insi)e(tion by this 
commission, and samples of milk must be regularly submitted for bac- 
teriological examination. 

In order that the dealers and the commission may be kept in- 
formed of the character of the milk, specimens bouglit at random from 
the day's supply must be sent weekly to the Research Laboratory of 
the Healtli Department, where examination will be made by experts, 
these facilities being freely offered to this end. Latterly the Rocke- 
feller Institute for Medical Research has also co-operated in this work. 

Two certificates are granted by the commission. The first has 
the word '' Certified"' stamped upon it. This certified milk is in- 
spected at the farms every three weeks and tested at the laboratory 
every week. It is supplied only in sealed bottles. All the cows giving 
it must have passed the tuberculin test. It is supposed to be pro- 
duced under conditions as perfect as it is possible to obtain. 

The second certificate carries the word " Inspected." The farms 
M'here this milk is produced are inspected every six to eight weeks and 
the milk examined at the laboratory every three to four weeks. Cer- 
tain requirements of " certified" nfilk, such as metal caps for the 
bottles and sterilized gowns for the milkers, are omitted for tliis 
milk. It is, however, believed by the commission to be a wholesome 
and safe milk. As it will be retailed at the usual prices, it is hoped 
that every one will insist on his dealer supplying it to him. 

"The milk commission has in its employ a trained inspector and 
has the use, free of charge, of the laboratories of the Department of 
Health. It can extend its work to any extent desirable. It remains 
for the public to decide whether or not it wishes to obtain pure milk." 

One must not get the impression here that most dairies are unclean, 
or that the general tendency among dairymen is to be conscienceless. 
Such an impression is contrary to human nature as a whole. Many 
milkmen, moreover, have with wholesome business acumen realized 
tliat this examined product would bring a better price than the ordi- 
nary milk (usually twelve cents a quart), and many dairies have been 
inspected at the request of their owners, who find it profitable to 
•■(inform to the commission's regulations. The dairymen defray the 
cost of the inspections, which is small. 



It is probable that, the treatment and control of consumption will eventually 
come within the jurisdiction of State medicine, as is now the case generally with 
infectious diseases. — Williams. 

A COMMISSION of eminent physicians made in 1898 an agreement 
with the Walker-Gordon Laboratory Company by which the former 
were to serve without compensation, receiving reports from a chemist, 
a veterinarian, a bacteriologist, and a physician concerning the produc- 
tion and transportation of the milk produced and sold by the latter. 
This commission was to select, appoint, and control these experts ; 
should decide at what times and under what circumstances examina- 
tions should be made and reports rendered ; should have power to 
institute investigations by other experts as it should deem fit ; should 
permit such reports to be submitted to the profession at large in a 
strictly professional circular ; but no circular, report, or advertisement 
in relation to " Walker-Gordon Guaranteed Milk" was to be issued to 
the general public without its approval. The compa,ny agreed to pay 
all the expenses of expert control and examination and of the pub- 
lication of the re[)orts. And this compact has since continued without 
modification from year to year. 

Twice each month, at least, the bacteriologist examines the milk, 
the veterinarian makes an examination of the cows and horns, the 
visiting physician visits the farm and examines the employees, and 
the chemist determines the fat in the milk, and makes also full chemi- 
cal analyses whenever the Commission require. 

Concerning bacteriological counts. Dr. Freeman, who is engaged 
for this work, observes : 

"It is well known to bacteriologists that even when milk is well 
agitated one can obtain moderately different results from different 
drops taken from the same bottle, while if counts are made from dif- 
ferent bottles of the same day's supply a still greater variation may 
be obtained, so that counts represent only very roughly the number 
of bacteria ordinarily contained in the milk. 

" It seems to me that while the counts of bacteria are exceed- 
ingly valuable as an exponent of cleanliness and proper handling of 



milk, they should be used only to prevent carelessness at the dairy 
and to stimulate better methods and discipline. 

''The opinion of a milk commission of representative men based 
on an actual knowledge of the management of the dairy is of vastly 
more value to the medical profession and to the public than any state- 
ment regarding the precise number of bacteria in the milk in any 
given day or days. The most important things, after all, are such a 
regime as sliall make contamination by pathogenic organisms imi)rob- 
able, and at the same time insure that the milk is produced under 
such conditions of cleanliness that other bacterial contamination will 
be reduced to the minimum." 

At the request of this commission. Dr. C. J. Marsliall ibrnmlated 
such regulations as seemed best to him to keep a dairy herd free from 
tuberculosis. This accomplished scientist finds tlie disease very preva- 
lent in cattle. From ten to twenty-five per cent, of the dairy cattle in 
large districts in eastern States are thus afflicted, — in some herds the 
percentage being as high as nniety. It prevails most in breeding 
herds where purchases are made without inspection, and the cattle 
are kept from season to season so long as they are profitable and 
their progeny are reared ; also in large herds where the cows are 
purchased without inspection in the open market. Tuberculosis is 
not confined to cows kept in poor premises and belonging to ignorant 
and careless men ; it exists quite as extensively among the best cattle 
kept in good premises and under careful supervision unless recourse 
is had to the protection afforded by systematic use of the tuberculin 

In most dairies the only precaution is to isolate visibly diseased 
anim.als. A cow may have the disease and may even furnish infec- 
tious milk for a long time before manifesting symptoms. Sometimes 
almost all the members of a dairy herd that had been carefully at- 
tended, well fed, and that appear to be healthy, are nevertheless 
in some degree tuberculous. This is shown by the researches con- 
ducted under such auspices as those of the United States Bureau of 
Animal Industry. Tubercle bacilli are often excreted from the udder 
even though this organ presents no clhiical appearance of disease. 

The careful, systematic use of the tuberculin test is essential if 
herds are to be kept entirely free from the disease. It is not sufficient 
to test a herd once and then to add to this herd no animals excepting 
those that fail to respond to the test. Even after such precautions are 

^ I know of a herd, kept under ideal conditions, of which more than half 
were slaughtered by order of its owner after the tuberculin test had been applied. 


taken tubernulosis may enter a herd. All the reasons for this may 
not have been disclosed. A tuberculous cow, or one that has been 
exposed to the disease and is still in the incubative period, may, for 
instance, fail to respond to the test, and may be the means of infect- 
ing the herd if there be not a retesting within reasonable time. All 
the animals in a herd must be retested at intervals of not more than 
a year. 

To maintain a large dairy herd free from tuberculosis is a very 
expensive procedure, and, therefore, one rarely undertaken. It is not 
merely the cost of the tuberculin, for this is a small item. The great 
expense is in discarding cows apparently in good health, often produc- 
ing a large flow of milk, to which most people would take no excep- 
tion. But as long as there is a possibility that the milk of such cows 
maybe injurious, it is felt to be necessary that "guaranteed milk" 
should be above the slightest suspicion, so that people who buy such 
milk shall obtain milk which is beyond question pure and safe. 

The herd maintained by the Walker-Gordon Company, at Plains- 
boro. New Jersey, was collected after the tuberculin test was estab- 
lished. This test has been employed at every step in the enlargement 
and development of the herd. Notwithstanding that all other sani- 
tary conditions are maintained, every animal in the herd and every 
new-comer has been tested and retested in the manner indicated ; and 
no milk of a suspected animal is used. The following are Dr. Mar- 
sliali's regulations : 

1. All cows added to the herd must be free from tuberculosis or 
other disease as shown by physical examination and tuberculin test. 
A test to be valid must be applied Avithin the month before the time 
the cow is brought to the farm. The test may be applied by any 
veterinarian in good professional standing. It is to be made as follows : 
The normal temperature shall be established by at least two prelimi- 
nary measurements made not less than two hours apart, and one shall 
be made before tuberculin is administered. No cow shall be tested that 
has a temperature above ]03° F. The tuberculin shall be adminis- 
tered in the evening. At least three temperature measurements shall 
be made after tuberculin is injected, covering the period from the 
ninth to tlie sixteenth hour after injection. It is required that a full 
re])ort on the inspection and test shall be sent to the superintendent 
of the farm. Tliis report shall include a full and accurate description 
of each cow so that slie may be identified and correlated with the 
report on tier test. 

2. All cattle shall be tagged when brought to the farm so that they 
may be identified, and a careful record shall be kept showing the facts 



in regard to their origin, etc. Animals purchased under tlie condi- 
tions stated in Rule No. 1 shall be kept in a separate stable set apart 

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for this purpose and known as the probation stable. They shall not 
he admitted to the general herd, either in the milking stables or the 


stables where dry slock are kept, until tliey have been retested by the 
veterinarian employed by the Commission. Such retests shall be 
made not later than two months from the time the cows are brought 
to the farm. 

3. Cows that have not been tested with tuberculin may be pur- 
chased, but they must be held entirely apart from the herd in the 
building kept for this purpose until they have passed satisfactory in- 
spection and the tuberculin test. Their milk shall not be used as 
guaranteed milk until this requirement has been fulfilled. After the 
first tuberculin test the cows that pass as satisfactory shall be kept 
under probation as is required under Rule No. 2. 

4. Every aniuial in the herd shall be tested with tuberculin at least 
once each year by the veterinarian employed by the Commission. 
Any animal may be tested at any time when this is considered neces- 
sary by the attendhig veterinarian. The milk from an animal that 
fails to pass a satisfactory tuberculin test shall not be used as guar- 
anteed milk, and the animal must be removed immediately from the 
herd. Cows that react to the tuberculin test shall not be stabled with 
non-reacting cows, either those that are milking or those that are dry. 
No stall or stable tliat has been occupied by a cow that has reacted to 
the test shall be occupied by a non-reacting cow until after it has 
been thoroughly disinfected. 

5. The stalls from which reacting animals have been removed, 
and the immediately adjoining stalls, and the feeding floor in front 
of the whole section from which the reacting cow was removed, 
shall be scrubbed ; and afterwards they sliall be washed with a five 
per cent, solution of carbolic acid or some other equally efficient 

Cornet, of Berlin, considers that the co-operation of the State is 
indispensable with regard to animal tuberculosis and its eradication. 
All infected animals should gradually be removed ; and the recognition 
of the disease in them is ascertainable through the use of tuberculin. 
The margin of error w ith regard to the use of this serum is certainly 
not great — about 2.78 per cent. — and this margin becomes even 
smaller if we allow^ for errors in autopsies and in experimentation. 

The temperatures of the animal under investigation should first 
be accurately determined by daily measurements, best taken toward 
evening, for one or more days before, and then injections of tuberculin 
should be made, ranging in strength according to the size of the 
animal, — for calves, 0.1 ; for cows, 0.5 ; for heavy bulls, 0.6 C.c. 
Animals with fever should not be subjected to the test. The reaction, 
which usually occurs wdtliin twelve to twenty hours, may be measured 


after nine, twelve, fifteen, or eighteen hours. An mcrease of 1.5° C. 
above the normal, or a rise above 40° C. (104° F.), is evidence 
of tuberculosis, while a rise of less than 1.5° C. justifies a suspicion 
of the disease. 

Observation has revealed that a subsequent inoculation, even 
months later, may give a doubtful reaction or even none at all, in 
spite of the fact that the animal has not recovered from the disease. 
Dishonest dealers, knowing this, give an animal which they wish to 
sell an earlier injection of tuberculin, thus rendering it immune to 
the dose which is preliminary to the sale. For this reason Cornet 
advises that the sale of tuberculin should be controlled by the gov- 
ernment; should be made only to veterinarians for the express pur- 
pose of injecting for diagnosis and with a guarantee against fraudulent 

Fig. 115. — Healthy cow. 

use, and that the price of the serum should be made exceedingly low 
so as to facilitate its more general use. The inoculation should always 
be performed by an experienced veterinarian. The animals so tested, 
both those reacting and those tliat do not, should be marked in a 
manner denoting the date and the result of inoculation. 

All animals found to be tuberculous should be separated as far as 
possLJDle from the others, in order to prevent the spread of infection. 
Early slaughter would be the safest means, and would also serve the 
best interests of the owner, since the animal both assimilates less food 
and gives less milk as the disease progresses, and thus continually 
loses in value. Practically, however, it is necessary to restrict 'his 
measure. The disease has become so widely disseminated, involving 
as many as fifty or seventy per cent, or even more of some herds 


of cattle, tliat tlio sudden s\vaini)ing of the market witli meat would 
result in a considerable fall in price and a corresponding loss in 
property to the owner. Chief stress, therefore, should be laid on 
tlie separation of tlie diseased cattle from their offspring. There 
should ho jxartial rcnnineration by means of mutual — perhaps com- 
pulsory — insurance, for the pecuniary loss incident to the possession 
of tuberculous cattle, and there should also be premiums upon the 
possession of healthy Iierds. In order to obviate the dangers from 
tuberculous meat there should be a general inspection of all meat 
offered for sale, and diseased specimens should be rejected. 

All meats should be rejected as dangerous to health and useful 
only for manufacturing purposes, if the meat itself appear diseased, 


li(i. 116.— Diseased cow i nott- ilu- aichvil harki. 

if the bones contain pearly nodules, or if the disease is general and 
severe, involving more than one of tlie body cavities and being asso- 
ciated with much emaciation. Such meat should not be used either 
fresh or cooked, or eaten by either men or animals. 

If the disease involves two of tlie body cavities, but witliout neces- 
sitating the assumption of a dissemination by means of the greater 
circulation, — if, moreover, there is no emaciation and the meat appears 
to be sound, it may be designated as of inferior equality, but not dan- 
gerous to health. Such meat is sold only after having been cooked 
in a steam chamber, cut up into pieces weighing not more than five 
kilogrammes, for half an hour, at 100° C. 

If the tuberculosis is confined to only one of the body cavities, 
or to a single organ, so tliat dissemination by the greater circulation 
may be excluded, the meat is to ])e considered neither detrimental to 


health nor of inferior quahly : and such meat may be freely ofi'ered 
for sale, after elimination of the diseased portions. 

Milk, butter, and whey establishments should also be subject to 
supervision, with reference to the cows from which the milk is ob- 
tained. Here, too, the individual can protect himself from infection, 
either by getting his milk and the milk products entirely from estab- 
lishments under otRcial supervision or by heating the milk sufficiently 
before using it (pasteurization). 

'•Every farmer and cattle-owner can contribute largely to the 
improvement of conditions within the narrow sphere of his own 
possessions, by acting in the spirit of the preceding rules." He should 
isolate his coughing cattle which have infected nasal mucus ; tuber- 
culous men and girls should not tend his cattle or milk them ; and 
consumptives should be rigorously excluded from his stables. 



The sires of future generations must make tliemselves the bondmen of rules 
whicli curb their desires and curtail their personal liberties. — Wright. 

We may note, in a review of ante-natal conditions, that fresh 
parental blood, and all that it connotes, will generally beget healthy 
offspring, having tissues resistant to pathogenic agencies. Impure 
blood and its associations in the parents will too often result in de- 
generated tissues in the olTspring. This is true for other diseases 
in which a vicious nutrition is transmitted, — syphilis, alcohohsm, epi- 
lepsy, asthma, insanity, and cancer, as well as tuberculosis. There is 
then no reason why the influence of heredity in the latter should be 

I think that the terms scrofula and tuberculosis are by no means 
always synonymous. They are not the same disease, simply because 
they often coexist. The latter term is meaningless unless it implies 
the presence of the Koch bacillus ; and this, I believe, is by no means 
invariably the case in scrofula. This latter term may be unfortunate ; 
but there is none other which represents as it does a distinct entity 
upon which the tubercle bacillus is often but not always implanted. 
The scrofulous constitution is sensitive to all irritants and infections, 
not only to tubercular infection. Struma is largely a transmitted con- 
dition. Children are born manifesting it. In some proportion of cases 
there is congenital infection ; but in most cases there is no such in- 
fection. The parents may transmit a baneful influence by toxins ; but 
toxins cannot generate bacilli. Children are born with the scrofulous 
temperament, upon which many otlier factors soon react as complica- 
tions ; these factors we have set forth. Under such conditions the 
tubercle bacillus becomes easily implanted ; then skin lesions, abscesses, 
enlarged joints, and the like, follow. The scrofulous child is seldom 
born with these lesions. 

With regard to the disease tuberculosis itself: The Koch bacillus 
is by no means the only factor to be dealt with, although it is the 
essential one. This bacillus has probably had an existence coeval 
with man. It is much-pervading. The consumptive emits several bill- 
ions during the twenty-four hours; yet most. of us do not evidence 



or suffer from tuberculosis. Most of us, indeed, have been its host, 
but have vanquished the unwelcome guest, — have, in self-preserva- 
tion, successfully overcome it and destroyed its insidious activity. 
The whole of tuberculosis is not comprised in this organism ; for 
the disease is the resultant of many factors. Much has been done 
for the relief of tuberculous patients ; but the discovery of the bacillus 
has 7iot primarily influenced treatment. It were irrational in the last 
degree to deny the usefulness and appropriateness of drugs. In 
this book the rational use of the pharmacopoeia is insisted upon ; nor 
is the evolution of important medicaments from the Materia Medica 
despaired of. Nevertheless it must strike the physician that since 
Koch's discovery, in 1881, there has not been one essential addition 
to our list of drugs which would prove directly efficacious against 
this bacillus or its allied micro-organisms. The anti-microbic remedies 
which have been given internally with a view to destroying these 
germs have almost always been worse than useless, — particularly 
those which have been malodorous and have nauseated ; and meth- 
ods of inhalation, with this end in view, liave been quite unscientific 

However, I do not agree with those who hold that the discovery 
of the Koch bacillus has not fundamentally changed the stat9 of affairs. 
It has, and on the whole beneficially. For this discovery, }ias led to 
adoption (or perhaps to the readoption) of such principles of pro- 
phylaxis and sanitation as have been found effective against infections 
generally. The non-drug procedures, although they may have been 
directed against the bacillus, have nevertheless had their real useful- 
ness in rendering the organism resistant to microbic infection. Our 
improvement in the treatment of tuberculosis has been in our appre- 
ciation and adoption of hygienic measures, not in the use of any 
special bactericide. 

It must, however, be recalled that Bodington and Brehmer and 
Trudeau had made their influence felt long before Koch's discovery ; 
that such measures as these workers relied upon were directed solely 
towards the alteration in the tissues by which they should become 
immune to the operations of the parasite, which had already gained a 

Immunizing and curative sera and methods of vaccination, it is 
gratefully noted, promise much in the way of rendering the tissues 
resistant to tubercular infection. It is heartily and most sincerely to 
be hoped that all expectations entertained for them will be realized. 
However, in the sum of things it were best to rely uj^on such immu- 
nizing agents as fresh air, sunlight, cleanliness, baths, dry-walled, well- 


drained, and well-constructed houses, good food and drink, and a 
general and widely extended comprehension and understanding of the 
laws making for health. 

To revert to heredity, we emphasize that as functional are more 
generally transmitted than anatomical modifications, much may and 
should be done in the way of education and physical training to erad- 
icate vicious metabolism and tissue tendencies. Of course, rapid and 
immediate results will not be expected. It may here be recalled that 
the trend of this book is quite in accord Avith Holmes's suggestion 
that the })roper season for bringing the influence of preventive medi- 
cine to bear on an individual is a century before his birth. I think, 
indeed, that the ])hysician should take a very broad view of tuber- 
culosis, — a view the horizon of which would extend far beyond the 
incidents which are termed life and death. For this disease is, as has 
been noted, an index by inversion of human progress ; in so far as 
the former becomes eliminated will the latter advance. Descartes 
was not altogether right when he declared that if the race is ever 
to attain perfection it must be by means of the medical sciences. 
However, if the fundamental principles of cleanliness and sanitation 
were universally grasped and applied against tuberculosis, the race 
would, perhaps indirectly, but nevertheless surely, be far advanced 
in regard to its civilization, and, what is of still more importance, its 
happiness, its comfort, and its well-being. 

Part XV 


The situation that has not its Duty, its Ideals, has never yet been 

occupied by man. Yes, here, in this poor, miserable, hampered, 

despicable Actual, wherein thou even now standest, here or nowhere 

is thy Ideal : work it out therefrom ; and working, believe, live, be 



When I talked with an ardent missionary and pointed out to him 
that his creed found no support in my experience, he i-eplied : "It 
is not so in your experience, but is so in the other world." I an- 
swer : "Other world ! There is no other world. God is one and 

omnipresent ; here or nowhere is the whole fact." 




Work out your own salvation. — St. Paul. 

Most of these (consumptive) children come from Lille, Soubaix, Turcoinj^. and 
other manuflicturing towns of Northeastern France, where extremes of the most 
abject poverty or great riches are practically the only existing classes. — Britkh Med- 
ical Journal, June 11, 1904. 

"What we need in society is not charity, but fair play ; and he who attempts 
to substitute the one for the other handles a sword which deals fatal blows in two 
directions. " — Tarbell. 

Concerning the sociological aspects of the tuberculosis situation, 
I do in this part, whicli is essentially an expression of personal 
opinion, lay grateful stress upon two facts. 

In the first place, the tendency of civilization is to the good, — more 
than fifty per cent, to the good. If this were not so, existence must 
eons ago have become an impossibility. Obviously the tendency of 
the physical body is in the direction of health and away from disease ; 
otherwise the maintenance of life were inconceivable. And in like 
manner all other aspects of existence — the spiritual, the mental, the 
moral — tend to health. The vnlle zum giiten has, as a potency, cer- 
tainly preponderated over, though of course it has not wholly super- 
seded, the toille zum leben, the mere fundamental will-to-live. And it 
is this will toward the good, this striving after the ideal, upon which 
civilization does and must base all its hopes. 

This fact furnishes the source of the second fact with regard to 
our subject, that tremendous efforts are making to alleviate suffering 
and to prevent death. I have in this book taken but a step into a vast, 
teeming field of endeavor. Most of the work here described — it must 
be evident to the reader who has come to this page — has been under- 
taken from motives in the last degree honorable to human nature and 
tributory to human ideals. 

Having thus given grateful and heartfelt testimony to those two 
facts — I have done so redundantly throughout this book — certain ob- 
servations appear essential. These are based in the main upon con- 
ditions in my own community. Each reader will apply them, as may 
seem just to him, to the conditions with which he is familiar. 

28 i^^ 


I believe that, taking into account not only the present status, but 
also the indefinite future, in which after-coming generations will be 
affected (for such is the philosophy of this book), much that has been 
and is being done in the name of charity is cruelly futile and worse 
than useless, — in essence very baneful. I believe also that the work 
of noble men and women, such as has here been described, is being 
in great measure rendered a veritable Sisyphus-task by reason of an- 
tagonistic social and political factors, overwhelmingly more powerful 
than the forces which these humanitarians can bring into action. 

To him who views the field from a vantage-point sufficiently afar 
to be comprehensive ' those in the midst of the work will say : " Here 
is all this dreadful suffering, this poverty, this anguish of soul, these 
unnecessary deaths from disease, — what are we to do about it ? Don't 
we have to alleviate it?" And to this great-minded questioning the 
rejoinder must be : " Where are all these efforts of yours — all this 
activity — going to end ? Much of your splendid altruism, your self- 
abnegating labor, is useless — pathetically so — for you are not coping 
with fundamentals ; you are but constantly fructifying a deeper and 
more impenetrable jungle. Your efforts have almost entirely the re- 
sult to degrade the individual ; whereas absolutely the only hope in the 
situation lies in his innate nobility." Let us be specific a little. 

This has been called the Golden Age of Charity. There never 
was a time perhaps when so many millions of money have been ex- 
pended to the end that poverty and suffering may be alleviated. 

New York is the most overcrowded city in the world, and each 
week brings it thousands of immigrants to increase its already dread- 
fully surplus population. These immigrants remain because they find 
the metropolis more attractive than our vast and beautiful country be- 
yond. Many, perhaps most, among these new-comers have means 
sufficient to last them but for a brief season ; and when this is spent 
they must perforce resort to charity, which is much too freely dis- 
pensed. Enough should be given them, with railway fare, by which 
they may settle in some other region. There can be no hardship for 
them sufficient to warrant their staying here. This city is not their 
birthplace ; nor are they bound to it by ties of sufficient importance to 
entitle them to sympathy, — such are too recent to be essentially bind- 
ing. If they cannot earn a living here, and will not leave, they should 
be left absolutely to their own devices. It is in the last degree per- 
nicious to be charitable in such cases. 

^I adopt this view-point in this phice though I consider that, having done 
much medical and other w^ork for more than a decade past in this field, I have 
acquired an intimate knowledge of the existing conditions. 



Again, the reflecting visitor to this most congested of all areas on 
earth, the lower East Side of New York City, must (hid it an incon^'-ru- 
ous condition, to which a parallel is hard to conceive, to jjour millions 
of charitable dollars into this region, by which temporary afflictions are 
indeed alleviated, but by means of which the manliness of the indi- 
viduals is subverted. Why, to begin with, has not your magnificent 
donor paid his workman a decent living wage,' with working hours of 
humane limit, instead of going to the labor-market as one goes to 
the meat- or shoe-market? Were this to be done in the beginnin"-, 
there would be no need for charity, and no depreciation of the poor 
man's integrity. Nor could it in all reason make an essential differ- 
ence whether the expenditure be originally by just and equable wages 
or latterly by way of charity. 

As we have seen, settlement work lias made it possible for too 
many families to get bread from one quarter, meat from another, 
clothing from another, comforts from another, — all without price. 
Surely here is an altogether false state of things, so manifest that com- 
ment is superfluous. 

Again, day nurseries are provided in wliich mothers may leave 
their children while they are at work. Here is a touching cliarity 
which certainly appeals to one, and is beyond criticism for a small 
proportion of cases. But they exist now in great profusion, fostering 
a dreadfully false condition of life. They have probably, by removing 
the necessity for parental maintenance, been efficacious more than any 
other one agency in fostering paternal drunkenness and desertion. 
They are subversive of the normal family relation in which the bus- 
iness of the wife is not to work away from her home, but to remain 
within tier home, to make it comfortable and wholesome, and herself 
to rear her children, permitting this privilege to no other arms and 
hearts tlian tier own.^ 

Every conceivable phase of sickness is provided for. There are 
sumptuous lying-in palaces, in which infants begin their charity-eased 
destinies; there are magnificent hospitals and dispensaries in which 
medicine and surgery are to be had cheaper than dirt; there are 
homes and institutions for the convalescent ; and when deatli finally 
supervenes, there are societies which provide free burial, so that 
neither heart-broken survivors need be concerned, nor the honorable 

^ "A fair day's wages for a fair clay's work." — Carlyle, " Past and Present." 

* The report of the New York State Charities Aid Association, issued July, 1905, 

declares that the number of desertions by fathers increases in direct ratio with the 

care provided for deserted children by charitable organizations. Another report 

gives the number of such desertions in New York City alone as 60,000. 


souls of the dead have occasion otherwise than to rest unworried 
and in peace. 

In the indiscriminate charity which vitiates so much hospital and 
dispensary work is to be discerned the trend of things here indicated. 
While the bodies of many of these patients are being attended to, their 
morale and that of their families is being perverted. And instead of 
helping the poor by such means as these, there is much too often 
brought to pass increased wretchedness, increased poverty, increased 
disease, pauperism finally. Is this statement going too far; is it 
unwarranted? Let us see; one may easily trace the steps here as 
elsewhere in charitable enterprise : First, there is the acted lie in 
visiting the dispensary under false pretences. The perfunctory 
question is asked by the clerk, "Can you pay a doctor?" The 
answer is " No," — easy to make by any one bent on getting something 
for nothing, for such are the labyrinthine processes of the human 
mind that one may, if he conclude to cast self-respect to the winds — 
may, if it serve his purpose — satisfy even himself he is poor, no matter 
what is the condition of his affairs. The circumstances of the case 
are not investigated in the manner that charity organization societies 
investigate the cases of the poor referred to them ; not. I believe, in 
any one instance. 

Well, then, the patient having comfortably lied himself into the 
consultation room, gets treated. He secures what he came for, — 
something for nothing ; free advice and medicine. Here, then, is 
fostered and stimulated the habit of getting things without effort. 
Then comes contempt of effort as being unnecessary to procure what 
is desired ; and upon this, lapse into idleness and shiftlessness. There 
is developed the fatal position that the "poor fellow" is entitled to 
be taken care of by the well-to-do. Doesn't the world owe him a 
living? Then must certainly follow, according to natural laws, poverty, 
consequent misery, discontent, hatred of class, social chaos, anarchy. 

Here and there one comes upon instances of obviously untoward 
tendencies. From one excellent sanatorium for consumptives we 
learn that of seventy-two inmates only seven were assisted by their 
families. What have the hearts and hands of these relatives been 
doing all this time? What has become of their cherished ties, their 
endearments, their affections, their memories, encompassing the lives 
of their sick from babyhood up ? Has promiscuous charity reduced 
such sentiments to barren desuetude? 

Here a venerable man, whose very presence is an inspiration of 
nobility, who has seen and striven with much result through many 
vears to curtail such untoward tendencies as these, observes : " Your 



criticism of existing conditions is destructive ; it is not constructive. 
Bad as are our methods of doing charity work, do you know any better 
Avays, and if so, what are they in detail ? We cannot effect reforms 
of present evils without clearly demonstrating the methods by which 
these reforms are to be effected." The answer here, so far as this 
author is concerned, is that this book throughout has been an in- 
sistent appreciation of the present means and methods, which are 
intrinsically beneficent. I would not, if I could, destroy ; but I would 
restrict, curtail, discriminate, regulate, moderate, — I most certainly 
would. And first of all and above all, I should do no harm. I should 
subject these means and methods to eternal scrutiny, as is essential 
for absolutely every human institution. 

To many other phases of modern civilization, more than we can 
even indicate here, is this tuberculosis situation related. Most of 
these rec|uire expert handling by the specialist. There is the relation 
of consumption to the vices and crimes of society — "the diseases of 
society," the "social evil," the occasional brutalities of organized labor, 
by which distress and poverty are visited upon homes ; suffering caused 
by economic and industrial conflicts, rotten tenements, decline in the 
working power of the individual, the difficulty of men to get employ- 
ment, and many others such as we have dwelt upon. 

It is pertinent here to state a situation pointed out by Wykoff in 
his book, "The Workers." Most of the men among whom he lived 
gave little heed to church-going. He set himself to find the reason 
of this. He put on what would be the customary Sunday clothes of 
a workingman — clean, homely, and neat — and in such guise he visited 
at random fine edifices, some of them " fashionable" churches. He 
records that he was in absolutely every instance heartily welcomed 
and most genuinely made to feel at liome both by ushers and pew- 
holders. I think this important to note, for to most human lives 
religion is absolutely indispensable ; and if religion is not to take its 
part in the alleviation of human suffering the case is indeed pitiable. 
Nevertheless, Wykoff found that most of the men with whom he 
worked eschewed religious association. Their general feeling was 
that there was an impassable gulf between their own lives and the 
lives of those who maintained these churches. Some reasons for 
this may perhaps be discerned in the remainder of these pages. 

Other results of indiscriminate charity are set forth by Lecky, 
whose wonderful book, "The Map of Life," is a rare manifestation 
of comprehensive. reflection : 

" It is difficult to overrate the evil effects of injudicious charities 
in discouraging thrift, industry, foresight, and self-respect. They take 


many forms ; some of them extremely obvious, while others can only 
be rii;iitly judged by a careful consideration of remote consequences. 
There are the idle tourists who break down, in a once unsophisticated 
district, that sense of self-respect which is one of the most valuable 
lessons that early education can give, by flinging jience to be scrambled 
for among the children, or who teach the poor the fatal lesson that 
mendicancy, or something hardly distinguishable from mendicancy, 
will bring greater gain than honest and continuous W'ork. There is 
the impulsive, uninquiring charity that makes the trade of the skilful 
begging-letter writer a lucrative profession, and makes men and women 
who are rich, benevolent, and weak, the habitual prey of greedy 
impostors. There is the old-established charity for ministering to 
simple poverty wdiich draws to its centre all the pauperism of the 
neighboring districts, depresses wages, and impoverishes the very 
district or class it was intended to benefit. There are charities which 
not only largely diminish the sufferings that are the natural conse- 
quence and punishment of vice, but even make the lot of the criminal 
and vicious a better one than that of the hard-working poor. There 
are overlapping charities dealing with the same department, but kept 
up with lavish waste through the rivalry of different religious denom- 
inations, or in the interests of the officials connected with them ; be- 
lated or superannuated charities formed to deal with circumstances or 
sufferings that have in a large degree passed away, — useless, or almost 
useless, charities established to carry out some silly fad or to gratify 
some silly vanity ; sectarian charities intended to further ends w^hich, 
in the eyes of all but the members of one sect, are not only useless 
but mischievous ; charities that encourage thriftless marriages, or 
make it easy for men to neglect obvious duties, or keep a semi-pauper 
population stationary in enqiloyments and on a soil where they can 
never prosper, or in other ways handicap, impede, or divert the natural 
and healthy course of industry. Illustrations of all these evils will 
occur to every careful student of the subject. Unintelligent, thought- 
less, purely impulsive charity, and charity which is inspired by some 
other motive than a real desire to relieve suffering, will constantly go 
wTong, but every intelligent man can find without difficulty vast fields 
on which the largest generosity may be expended with abundant 

One anxious to be helpful to others must then reflect that it is 
possible for his well-intended philanthropy to j)rove in the end even 
more disastrous than the condition in which things would have re- 
mained had he not acted. But with regard to our subject there are 
several paths, such as we have set forth, upon which one may tread 


without going very far wrong. One is education, not the sort by 
means of which everybody is to become cultured and diMtnnte, 
with no one left who can wash dishes and make bods, but the 
knowledge of sober, sturdy literature, such as sweetens the soul and 
stimulates to a comprehension of things essential to decent living. 
Especially should be inculcated a knowledge of the sciences which 
have been so nobly instrumental in making existence enjoyable and 
wholesome : which have done so much to eliminate from life cause- 
less, unnecessary suffering. 'j • -iii i.:i !*;.;; t 

Next, the providing of sanitary dwellings, upon small and just 
rentals, in which the poor man and his family may live in dignity and 
in sobriety. And then the poor fellow who is exhausted in body and 
soul ; who has tried hard over and over again ; who, like the pugilist, 
bounding up with strength enough, after the first blow, but who, after 
countless blows have been rained upon him, cannot, however willing 
his spirit, revive through the ten seconds which the game allots him 
sufficiently to meet the next blow, — here surely is one to be helped, 
to have his strength renewed, to be set on his feet, to resume the 
fight of life with a few of the chances, at least, again in his favor. 

There should certainly be some system approximating the German 
method of workmen's insurance against sickness and invalidity. To 
tliis, as we have seen, the workman himself contributes, so that the 
stigma of living upon charity is not his to endure. We have been 
able to discern among our own workmen's associations some efforts 
making to this end. It were well if these associations, declining outside 
contributions, should establish many sanatoria and health farms 
where their stricken members could recover their strength and health. 

I discern with gratification that indiscriminate charity and other 
enervating factors have not altogether dissipated the integrity of the 
individual, — absolutely the one and only force upon which civilization 
can be based. If the human unit be deteriorated, it were vain 
indeed to expect alleviation of untoward conditions. I therefore, 
as one exultant for humanity, quote from an article on "The Help 
that Harms," in which Bishop Potter has detailed his experiences 
several years ago in the Stanton Street Pro-Cathedral. He devoted 
a vacation to work in this lower East Side region, — 

" I gave six hours every day to receiving anybody and everybody 
who came to me. During that time I had visits from dilapidated 
gentlemen from Albany and Jersey City and Philadelphia and the 
like, who supposed that I was a credulous fool whose money and 
himself would soon be parted, and who gave me what they consid- 
ered many excellent reasons for presenting them with five dollars 


apiece. But, during that whole period, not one of the many thou- 
sands who lived in the crowded tenements all around me, and to 
hundreds of whom I preached three times a week, asked me for a 
penny — not one ! They came to me by day and by night, men and 
women, boys and girls, for counsel, courage, sympathy, admonition, 
reproof, guidance, and such light as I could give them, but never, one 
of them, for money. They are my friends to-day, and they know 
that I am theirs ; and, little as that may mean to the weakest and the 
worst of them, I believe that in the case of any man or woman who 
tries to understand and hearten his fellow, it counts for a thousand- 
fold more than doles, or bread, or institutional relief.'' 

Those connected with medical institutions have frequent occasion 
to note the reluctance among poor people to accept relief which is 
offered; there is still to be found a genuine dread of ''going on 
charity."' Mr. Poole has told us how many will not go to dispensaries 
and hospitals until their consumption is far past relief; until, indeed, 
the partaking of charity is all that is left between life and death. 
Surely this is a most pitiable state of things ; yet in it there is saving 
grace, for here is displayed tlie noble dignity of the individual spirit 
upon which the very life of the race depends. 

The corrupt politics of the day — brutally, lawlessly, almost hope- 
lessly corrupt — furnish a gigantic factor making against the humane 
efforts of good men and women. The fundamental reason of this 
corruption lies in the flaccid temperament of the single citizen. The 
government is his, he makes it, he deserves it as it is. The officials 
are in their places, and act as they do either by the citizen's ballot 
or by his disregard of the duty to vote. 

Private enteri^rise has to do a very great deal which our lawmakers 
and our official executives are well paid to do. We get somehow ex- 
cellent tenement house laws passed. Then it is a matter of eternal 
vigilance to guard them against the encroachments of people as mean 
as ever disgraced civilization. Laws against child labor are obtained 
with extreme difficulty, which is merely preliminary to the business of 
getting them enforced. Factory inspectors have constantly to be kept 
to their work. Suitable State institutions, in which consumptives may 
be treated, to the end that the community may be safeguarded from 
infection, can be had established only by stupendous labor, and then 
sometimes this labor is rendered nil by means truly disgraceful to 
the body politic. 

One feature of the federal government must here be emphasized. 
It is the national tariff, unquestionably a very grave falsification of the 
spirit of justice to all men, and of equal political rights, upon which 


our fathers founded this government. Lost this stricture seem fanciful, 
I quote an Englishman, Sir Douglas Powell : 

"The prevention of consumption involves a much wider issue 
than the circumvention of the bacillus. The abolition of the corn 
duties and other Free Trade legislation and improved rates of wages 
have done more to diminish the death-rate from consumption than 
any notification law against the disease would have been likelv to have 

Dr. Bulstrode, of London, corresponded concerning the increase of 
tuberculosis with Mr. T. J. Stafford, Medical Commissioner of the 
Local Government Board for Ireland, who answered : " I am very- 
interested to ascertain approximately to wliat extent tuberculous dis- 
ease depends upon (a) infection; (6) density of population; (e) gen- 
eral unsanitary conditions ; (d) climatic influences ; (e) economic 
causes. Without in any way desiring to cast a doubt upon the im- 
portant influences of infection as a means of distributing the disease, 
I fear we may possibly lose sight of the more responsible factor which 
is at the bottom of the c{uestion. I refer to economic causes. I am 
inclined to look upon all the others I have mentioned merely as the 
agents acting upon a population which from economic causes is unable 
to resist the disease. Whilst I do not for a moment suggest that we 
should not vigorously attack these agents and do great good by so 
doing, if we desire to get down to the bed-rock we must deal with the 
question upon an economic basis. I am at present engaged in some 
researches, somewhat on the lines of Mr. Rountree's York experi- 
ment, with a view to ascertaining how the working classes of Dublin 
live. I do not wish to anticipate the result of these investigations, 
but I believe they will show a general condition of deplorable poverty 
and an unduly large proportion of underfed, badly clothed, and gen- 
erally ill-nourished men, women, and children, endeavoring to live 
under conditions which, to say the least of it, are not conducive to 
longevity. The result in Dul^lin is a very high death-rate and an ex- 
ceptionally high rate of mortality from tuberculosis. Throughout this 
country the steady outflow of the healthiest among the male and fe- 
male population does not tend to improve the physical condition of 
the race, as in addition to drawing away the fittest and depriving the 
country of their labor we have left at home to keep up tlie stock what 
are, comparatively speaking, the weaklings. We have, therefore, in ad- 

' By the simple expedient of Free Trade he (Peel) had given the people bread, 
putting, as Mr. Bright said long afterwards, the Lord's Prayer into an act of Par- 
liament. (Herbert Paul's "History of Modern England.") 


dition to ordiiiai'v public liealtli administrative measures, if we wish 
to deal ofleclivcly witli tuJxTculosis, to face grave economic problems.'" 

This is no place for the consideration of a tariff framed by a party 
of moral ideas for the protection of domestic industries. However, I 
am confident the following statements are impossible of refutation ; 
they are r> propos : 

The idea of a government protecting its industries connotes a 
pleasant, comfortable, paternal state of things. But no government 
can be kindly and paternal except with the money of its people. 

It is the citizen of the country which levies the tariff, and not the 
foreigner, who pays the tariff tax. 

- ■■ The present protective tariff of these United States requires that 
one must oftentimes pay for an article produced in this country as 
much as sixty-five per cent, more than the foreigner has to pay for 
ttiat same article, althougii the producer has paid, in addition to the 
cost of manufacture, the freightage upon it into the foreign country. 

It is impossible to frame a tariff which will be even measurably 
equable and which in its levies shall not unjustly tax many citizens, 
and in reciprocal degree enrich others ; and since practically all the 
necessities of life are on our tariff list, the revenues are finally derived 
from the poor, who are in the vast majority. It is the self-respecting 
poor who have to pay a great deal more for their necessities than they 
would have to pay if there were no tariff.^ 

There is probably in all history or literature no statement more 
meretricious, more preposterous, or (to the American) more humiliat- 
ing than that the industries of these United States need to be pro- 

Together with the tariff there are other politico-sociological factors 
which are inductive of privation, resulting in much unnecessary sick- 
ness and death. The nature of these is demonstrated by means of 
the ordinary channels of information open to every citizen. Neglect 
or condone them as he may, it is impossilDle of belief that he has not 
competent knowledge concerning them. 

There is a dangerous disregard of the country's laws and of equitable 

^ M. Yves Guyot is convinced that not five per cent, of the French people 
reap any advantage from their protective tariff, while all the rest pay tribute under 
it. He points out the "unseen" taxes which this protective system levies. On 
bread and meat alone he estimates this tax in France to be as much as forty 
million dollars a year, — similarly with most of the other necessities of life. "In 
a country whose fiscal policy compels the people to pay a heavy toll on their daily 
bread, it is not strange that there should be reluctance to increase the number of 
mouths to be fed." — New York Evening Post. 


sense such as makes it possible, for instance, for a single individual to 
control more than half tlie meat output of this country; which makes 
it possible for the organization which this one human unit controls to 
slaughter and prepare cattle for market in ways most repulsive and 
unsanitary, and by methods which evidence that practically no consid- 
eration is entertained other than for the money which is to be made.' 

It is very true, and no man can aver the contrary, that in the 
business and finance of this country, he who would act in obedience 
to just and wholesome dictates is like to have his business life crushed 
out and his business career, sucii as should be the am])ilion of good 
men, most ruthlessly destroyed. It has become a dreadfully persua- 
sive opinion, founded upon very connnon experience, that such a 
career, conducted in such a way, has become a practical iiii])()ssi- 
bility, — that honesty cannot be made to pay ; and this stale of 
things is to a calamitous degree becoming subversive of normal trade 

And it is known of all men, and worthy the particular reflection 
of the straight voter — the man true to his party, to whom it never 
occurs to be true rather to his country, the " easy mark," the bulwark 
of rotten politics, the man upon whom the party bosses rely witli 
supremest confidence, born of many safe experiences — that this 
subversion of business morality, so fatal to wholesome ideals aiul so 
degrading to the national character, has been in essential measure 
fostered by the connivance of men voted for and appointed to frame 
and execute our laws. It is true, and all men know it, that a hope- 
lessly large proportion among these politicians are so bounden to 
vast aggregations of wealth that it is impossible for them to serve 
their country in accordance with their oaths of office. 

Wherefore, these and many like considerations make it manifest 
that a condition of things has come to pass which dooms millions 
of our race to grunt and sweat under a weary life, often in dreadful 
suffering and disease, in order tliat a very small and comparatively 
contemptible minority may auiass possessions vastly in excess of their 
capabilities for enjoying them. 

Finally they are true to-day, these words of Jefferson, nor dare 
any man deny them : 

" If once the people become inattentive to the public affairs, you 
and I, and Congress, and Assemblies, Judges and Governors, shall all 
become wolves. It seems to be the law of our general nature, in spite 
of the individual exceptions, and experience declares that man is the 

' "Is Chicago Meat Clean ?" — Collier's Weekly. 


only animal which devours his own kind ; for I can apply no milder 
terms to the governments of Europe, and to the general '^rey of the 
rich on the poor." 

And do what we will, say what we will, continue, reach out 
Avhere we will, we shall always have to conclude that absolutely the 
only hope in the situation with which this book is concerned lies 
in the integrity of the human unit. The health of the human body 
depends upon the stamina of its cellular elements. In like manner 
every aggregation, every community, every nation, every people, must 
be tested by the calibre of its component individuals. 



Gegen Dunimheit kampfen die Gotter vergebens. — Srnii.i.KH. 

The reader must now be impressed with tlie fact that the fear of 
phthisis, which exists to a deplorable degree and is the cause of so 
much undignified conduct and such inhumanity towards the con- 
sumptive, has little reason for existence. We know the methods of 
infection, principally from human sputum, not so often by way of 
ingestion^ and very occasionally by inoculation ; and that, unlike the 
contagious diseases, tlie contact must be frequent, repeated, and 
long continued, if consumption is to be communicated. Terrors of 
all sorts are invariably dissipated immediately knowledge and under- 
standing are arrayed against them ; and with the comprehension of 
these facts concerning consumption, one must lose his fear of the 
disease, and may with equanimity return to reasonable, grown-up 

It is really deplorable to consider the degree of cruelty and self- 
ishness to which this phthisiophobia has driven people. Consump- 
tives must perforce give up light work, such as they are sadly in 
need of. Employers will not engage such men ; they are not going 
to run the risk of catching the chsease, — not they. Here a clerk sus- 
pected of phthisis is discharged ; there a woman loses her place be- 
cause it is whispered "there is consumption in her family." Even 
our powerful government at Washington — powerful enough to be 
merciful — sees to it that its phthisical employees shall be dismissed 
without pension. The work of the postman, so innocuous and so 
suitable for many cases of incipient phthisis, has cruelly been denied 
to such sufferers. The Treasury authorities and the Connnissioner 
of Immigration, despite the protests of eminent physicians, have de- 
cided tuberculosis to be a contagious disease, and have ruled that 
entrance of such alien sufferers into these United States be prohibited. 

A Pennsylvania town makes the imbecile regulation that barbers 
shall not shave consumptives. A Western city is reported to have 
passed an ordinance making it an offence punishable by fine or 
imprisonment for any one to erect a sanatorium within the city limits. 
Disregarding for a moment the inherent inhumanity of this i)rocedure, 



one must note that while this ordinance continues on the statute books 
consumptives are scattered over the entire conmiunity, in hotels, 
boarding- and lodging-houses, private houses, tenements, hovels, prop- 
agating the disease and knowing not how or taking no care whatever 
to act against the si)read of the infection. 

Only the other day injunction was sought, by an individual in 
whose cosmos there was an absurd preponderance of the Ego, against 
the Health Department, which sought to establish a tuberculosis dis- 
pensary for the poor of Brooklyn. Similar examples are come upon 
from time to time in tlie press. An incongruous situation is here 
emphasized in the fact that in Manhattan borougli there is a reception 
hospital for cases of scarlet fever, — a disease much more infectious 
than consumption. It is on Fourteenth Street, adjacent to the most 
crowded region in the whole world, yet no one fears its proximity, 
nor has any one reason to. 

I have merdioned Flick's fight in Philadelphia. Bulstrode writes 
that in an English town where a sanatorium for the relatively poor 
has been inaugurated by the energy and philanthropy of a medical 
lady of eminence, the rector of the parish forbade his curate to visit 
at this institution because, as he declared, the disease is as dangerous 
as smallpox. When passing the sanatorium this precious smircher 
of his uniform crosses to the other side of the road. " It remains for 
the future to decide whether the rector or the patients shall be fur- 
nished with the leper's rattle with which the arrival of one or another 
maybe duly notified." p iio// '!- ';.! ■■''i'A 'n^r 

Some years ago a young woman left New York City for the West. 
She was of splendid intellectual capacity, amiable, gentlewomanly, 
and withal of an exquisitely sensitive nature. She had little means; 
and, in order to travel as cheaply as possible, she took a slow train, 
let us say, on a Monday evening. She reached her destination late 
on Wednesday afternoon, very much exhausted and very ill. Although 
almost six feet tall, she weighed, before going, just ninety-seven pounds. 
She had the lustrous eyes and the pink flush associated with con- 
sumption. Her pale face was suffused with a cold perspiration, and 
she had the cruel cough which wracked her chest and would not let 
her rest. The first thing she did was to go to a home for young 
women, where she asked to remain overnight, so that in the morning 
she could go to the sanatorium where her stay had been arranged for. 
They would not take her in. It was their rule to refuse consump- 
tives, even for a night ; and with the name of the " Poor Nazarene" 
over their door, they turned her away. 
. The reader must now see that there was no occasion for this. We 


might dilate upon the spirit of Christhness to which tliis instil iition 
would ostensibly lay claim, and throuLiii which spirit this very sick 
traveller might surely have been given shelter until tlie morning, at 
least. But, upon a purely practical basis, there is no reason why, 
with elementary knowledge and common sense, such as those con- 
trolling such an institution should have, this sick one could not have 
been provided for without in the least jeopardizing the health of any 
other person. The progress of civilization is never fiu'thered, indeed 
it is most horribly retarded, whenever the stigma of inhumanity is 
fixed upon the fair countenance of religion. 

!lO_,ff Ifi.i^/j'/l 

:iU.:^b\:i'] i'-: 



The gods and goddesses were feasting and loving on Mount Olympus, when 
into their midst there staggered a pale Jew, with a crown of thorns. — Heine. 

It is the spirit of Clirist wliich lias been the supremest influence 
in shaping- civilization dnring twenty centuries past, — a spirit which 
lias on the whole prevailed over all else that has been antagonistic to 
it. It has endured and never has been more potent than to-day, 
despite the amazing obstructions that hove been and are put in its 
way, — the activities of its detractors, the obscurative and preposterous 
reasonings of metaphysicians within the very church founded upon 
this spirit, the manifold wickednesses of its mediaeval priesthood, the 
ghastly hypocrisies among many of its clergy and its professors from 
the beginning through to the present time, and the dissensions among 
the multitudinous sects within this church.' Notwithstanding inquisi- 
tions, tortures, burnings, wars of religion, — more bitter, bloodier, and 
more hellish than those from any other cause, — the benignant Christ- 
spirit has remained vital and dominant, and will continue to be so, let 
us reverently hope, through many centuries hence. 

What reason need one seek why this spirit endures beyond such 
as is revealed in the gospel of this Christ ? Here are set forth, for an 
adequate inspiration. His life, His exposition in parables of natural 
laws and fundamental principles, which are universal in their scope, 
and which, no matter what we will, control us and all other beings 
and things ; His enunciation of the very best ethical guide for the 
conduct of life which the world lias ever known ; His insistence upon 
the renunciation of pleasure and of possessions as a summum bonum; 
His merciful mission ; His intrinsically simple, lofty, lovable character, 
— the idealization of the gentle-man ; His noble altruism ; His tender 
sympathy for men and women who suffer and are in anguish; His 
self-abnegation, even to the death; His supreme sacrifice, and the 
infinite pathos of the hours preceding its consummation. It is none 

^The story is told of an unbeliever who visited Rome in the time of the Borgias. 
He embraced Christianity, declaring that a religion which could endure, despite so 
much wickedness done in its name, was one in which his faith would rest secure. 


other than such influences as these that liave so thoroughly saturated 
the natures and tlie souls of mankind since His advent. And unques- 
tionably, among all these influences, most potent is that ex[)ressed in 
the invitation to the sick and tlie afflicted, whicli \xv\h u\) from Ilis 
great all-enveloping brother-heart : -'Come unto nie, all ye that are 
weary and are heavy laden, and I will give you rest." 

To the good fruit which this spirit has borne every man who lives 
in the world and is of tlie world must give grateful testimony. Such 
testimony is most insufficiently described in this book. However, some 
instances to tlie contrary have been set forth, and to these must be 
added the following : 

Tliere is the " Goodsell-Bedell "' bill, which for years made it im- 
possible to establish a sanatorium for consumptives anywliere within 
New York State.^ 

Here I would wish, for my part, not to be misunderstood. For 
example (and my supposition is purely imaginary, for I know of no 
such case), it would be neither wise nor right to seek to ])]ace a sana- 
torium or a dispensary for consumptives among a block of sumptuous 
dwellings in a city. It would not be right both in behalf of the rich 
resident and of the poor consumptive. For the former is every whit 
as much entitled to have his rights conserved and his sentiments con- 
sidered as is the poor man (and it is, perhaps, superfluous to add 
that he usually has but little trouble in this regard). But especially 
in behalf of the poor patient it were not well to put such a dispensary 
or sanatorium in such a place. An example to this effect, indicating 
a status which I cannot but consider unfortunate, is that of a general 
hospital which has been erected upon perhaps the most fashionable 
thoroughfare in New York City, among residences whose owners are 
said to have fortunes aggregating very many millions of dollars. This 
hospital is magnificent and palatial in its appointments — no other 
terms are adequate. Concerning it the lugubrious plaint has been 
made that here the poor receive treatment and care such as an 
ordinary millionaire cannot afford. Surely the effect of all this u{)on 
many a poor patient's psychism must prove disastrous ; is it not 
likely that much subsequent bitterness and dissatisfaction with life are 

^ " It was one of tlie most disastrous measures wliicli have received legis- 
lative and executive sanction." The effect of this law, continues tlie report (of 
the State Charities Aid Association, for the year ending Nov. 1, 1903), is to malce 
it impossible for any city in the State, or any fraternal order, charitable society, or 
philanthropic individual, to establish a hospital or similar institution for con- 
sumptives outside the city limits, except under practically prohibitive conditions. 

— New York Times. 



thus bred F A sense of proportion is, in fact, absolutely essential in 
this matter; and this, I humbly submit, the Master himself indicated 
in His teachings. ("Give unto Cnesar," etc.) Institutions intended 
for the poor should be placed in the districts where the poor live — 
except there be peculiar and special reasons to the contrary. 

And there are peculiar and special reasons inherent in the san- 
atorium idea, which are, however, distinctly combated and defeated 
by this Goodsell-Bedell bill. The fresh air and the sunshine of the 
country are essential for the consumptive, which have been denied 
him by the terms of this brutal measure. 

As I understand it, the prime instigator of this law was a man of 
colossal wealth — amassed God knows how — who owns a park of some 
twenty thousand acres in New York State. These preserves are so 
vast that one might wander about them from early morning until 
evening without coming upon another creature who could answer 
him in speech. It so happened that tlie health authorities of New 
York City, seeking some means to alleviate the appalling suffering and 
loss of life among its citizens from consumption, found a healthful si)ot 
api)ropriate for a sanatorium, in which a few among these many 
thousand wretchedly sick might find some rest and relief. But it also 
happened that this proposed sanatorium would be erected some miles 
distant from the preserves here mentioned. 

It does not appear that this man has ever manifested a spirit 
other than one essentially ego-centric. Therefore it were useless to 
approach this incident from any other view-point. If, jDerchance, he 
were minded to use his inordinate wealth in this domain in a fashion 
to deserve the congratulations of ;esthetic and cultivated tempera- 
ments, his desire would not in the least have been interfered with by 
the erection of this sanatorium. For, though it would not have been 
magnificent, this structure would have been graceful and in harmony 
with its environment; nor Avould any of its iiunates have been per- 
mitted beyond its gates and fences ; nor is it likely that any one among 
all these sick would ever have otfended even the eye of this precious 
"magnate." Let this be distinctly understood. His " property rights'' 
would not have been encroached upon. 

From the view-point of practical economics and of wholesome 
public policy, such an institution as this in such a position was mani- 
festly essential in order that the infection might not spread among 
many thousands in the civic conununities ; and, as Ave have seen by 
the example of other regions in which sanatoria have been placed, 
both the material prosperity and the actual .sanitary conditions of this 
region wonld have l)een enhanced. Yet, by means of the passage of 


this bill, did a local coterie^ (one of whom was tlie Governor), having 
tlie Legislature of this Empire State " in the hollow of the hand," frus- 
trate the efforts of the Department referred to, thus withholding life 
from many thousands of its people and jeopardizing the health of the 
remainder of its urban populations. I recall no instance analogous to 
this product of American politics. Can the reader find in history one 
exceeding it in prostitution of the law to personal whims, or on(> to 
equal it, indeed, considering the assumptions of political sui)eriority, 
of an uncajolable electorate, and all the rest of it, which are so 
blatantly made by the American citizen ? 

Again. Samuel Hopkins Adams "^ finds that the owners of bad 
tenements in many cities, "both by maintaining evil conditions and 
by opposing or disregarding the tenement laws, are the responsible 
allies of the great white plague." 

"Who are these allies? Let us take up New York City first. 
Going back a few years we find, as the most active and successful 
enemy of tenement reform, a great sectarian body, — the Trinity 
Church corporation. In defence of this corporation it is claimed that 
there has been a change in its })olicy, and that its tenement property 
is now in decent condition and reputably administered. This may be 
true in general ; in certain cases it is not. Whatever the present con- 
ditions may be, within fifteen years the old board was the leader of 
the fight in behalf of "the sacred rights of property" against sanitary 
reform, and the evil that it did lives after it in influence and in 
encouragement to the (non-religious) bodies which are now carrying 
on the war. The Trinity Church corporation (it has always insisted oh 
being regarded as distinct from Trinity Church, of which it is the 
week-day manifestation and " wicked partner") possessed whole rows 
of tenements, mostly in the lower West Side, in which the sanitary 
and moral conditions were about on a par, as is so generally tlie case. 
Not only were the death-rate and tuberculous-rate very high, but 
some of the worst saloons in the district were maintained there, and 
there were conducted also houses of ill-fame which radiated moral 
and physical contagion. In the course of time public; opinion was 
aroused against the corporation — not that its tenements were worse 
than the worst, but because of its church connections — and appeal 
w^as made to the law. With all the force of its great wealth, its 
religious authority, and its tremendous social prestige, the body fought 
and fought so valiantly that to-day the Trinity Church corporation 

^ Harriman, Odell, Goodsell, and Bedell are all residents of Orange County. 
^ McClure's, January, 1905, Tuberculosis ; the Real Race-Suicide. 


suits an,^ stock citations in legal practice. Although finally compelled 
to a more docont standard, the corporation succeeded in obtaining 
decisions which have considerably crippled every subsequent attempt 
at tenement reform." 

Mr. Adams continues to narrate how there are now a number of 
''vulgar persons" owning individual tenements who have banded 
together in the United Real Estate Owners' Association, which is in 
some respects the heir of the old Trinity Cliurch Corporation. This 
association continues the fight against tenement reform and is a most 
virulent factor in legislation at Albany. 

In Chicago there are much the same conditions flourishing upon 
prejudice and greed, in which many among its best citizens and such 
as are of guaranteed saintliness are sharers. Here is an institution 
for the inculcation of morals and learning, maintained the whole world 
knows how, concerning which the grewsome pleasantry is but too 
true, — that this university is in all respects well equipped, providing 
as it does not only the means for the scientific investigation of disease, 
but also the human material upon which to base such study. Con- 
sider again from Mr. Adams : " Well, the University of Chicago doesn't 
need to purchase foul tenements. It owns them now. Early in my 
investigations I came upon them. There are a number of them on 
Blue Island Avenue, Forquer Street, and other slum regions on the 
south side. To the passer-by they are distinguishable by being a little 
more out of repair than their neighbors. A few are so bad that even 
the hardened tenement dwellers shun them, and in those teeming 
thoroughfares they stand silent and unpeopled. The average Chicago 
University tenement may not be the worst in the city, but it is suffi- 
ciently bad to furnish plenty of tuberculosis subjects for the Rockefeller 
fund experiments. Nor is there bright prospect of improvement. 
For the University of Chicago operates its own tenements, and it is 
not what would be called a good agent. Its replies to repeated ap- 
peals for repairs and better sanitation constitute an interesting study 
in the science of evasion and non-commitment. Very possibly Mr. 
Rockefeller knows nothing of the tenement branch of Chicago Uni- 
versity ; but members of the faculty withwdiom I have talked know 
of it and are not proud of it." 

In Boston there is this Gilbertian topsy-turveyism, compelling a 
smile despite every repressive effort, such as one should make in this 
decorous atmosphere : A })hysician prominent in the anti-tubercu- 
losis movement called the attention of the authorities to a row of tene- 
ments in very bad condition, whence had been reported a number of 
cases of consumption. The Board of Health proceeded against the 


owners, and the physician was the principal witness. To his surprise 
he found that the tenements were owned by a syndicate of Back 
Bay people, several of whom were his personal friends, and most of 
whom were socially and religiously prominent, and members of a 
famous reform organization which was even then criticising the city 
authorities for alleged laxity in compelling obedience to the tenement 
laws. Some time ago a number of buildings were called to the atten- 
tion of the Board of Healtli, which sent out notice that certain repairs 
must be made. On looking up the record the board was surprised to 
find them owned by a co-operative building organization made up of 
reform, philanthropic, and settlement people wliich does, for the most 
part, very excellent work in the slum districts. A woman stockholder 
ill the organization came to make an appeal to the officials. 

'• You know we're a charitable organization," was the basis of her 

" Doesn't your stock pay dividends?" asked the official in charge. 

" Oh, yes," was the reply. 

" How much?" 

" Five per cent, last year ; but if it doesn't pay more this year, I 
shall think there's something queer about it." 

To the lady's chagrin the authorities insisted on the repairs being 

The reader will agree, in passing, that in this volume there is entire 
accord with Mr. Adams's observation, — "I do not wish to imply that 
an organization which strives to produce improved tenement condi- 
tions ought not to pay dividends. The Octavia Hill Association does 
this in Philadelphia, — does it well and profitably. But it asks no im- 
munity from anybody ; there is no need of it. Its object lesson, that 
good tenements, with plenty of air and light and decent sanitation, 
can be made to pay four per cent., is perhaps as valuable an educa- 
tional influence as the unhopeful condition there has produced." 

It is worthy of note with regard to these peculiarly sanctified 
business enterprises which Mr. Adams details, that in New York and 
Boston, at least, they were in thriving condition long before those 
dreadful, wicked men, Darwin, Huxley, and tlie rest, knocked from 
under a lot of theological props and destroyed the foundations of 
orthodoxy and right living. 



What if earth be hut the shadow of heaven, and things therein each to other 
lilce more than on earth is thought. — Miltox. 

One of my haunts is a very high cliff overlooking a majestic 
river. There is here an arm-chair which nature has considerately 
cut out of the rock, in the interstices of which some wild flowers 
and blades of grass have managed to manifest their claims to suste- 
nance and moisture and the sun's rays. I have for hours been in 
this seat with no other occupation — is there a better ? — than to ab- 
sorb something of the elemental beauty and grandeur which the 
Onmipotent has here so lavishly dispensed. Several hundred feet 
below, one mellow autumn afternoon, there came up from the shore 
the voices of boys playing at ball — healthy, lusty young fellows — and 
from that distance their shouts made delightful music. Upon the 
river were rowers whose boats looked like toys ; men sailing ; from 
time to time stately white palaces proceeding with epic movement 
upstream; and, pleasantest of all, excursion barges upon which work- 
ing folk upon a holiday were laughing and dancing. Across the river 
was an estuary penetrating a rural panorama until it met another 
splendid body of white-capped, craft-dotted water. Beyond this again 
there were green fields and rolling country. And then, many miles 
away, up to the horizon, was the ocean, upon which well-filled sails 
blended with the cumuli in the blue above. 

The land across the river, up and down, was beautifully undulat- 
ing, — roads winding here and there through fields and wooded lands ; 
pasturing kine ; farm-houses comfortably ensconced among noble trees ; 
and up from the south there came a breeze wonderfully soft, odor- 
ous, caressing, ingratiating to the senses, which moved the foliage 
about me to rustle contentedly. Here was peace, — universal, kindly, 
ineffable ; even to suggest a jarring note were sacrilege. Here one 
might comprehend the poet's meaning, that nature is the garment 
which God puts on in order to manifest Himself to His creatures ; here 
one might reach some comprehension of the Weltgeisf ; here, indeed, 
one might hope to become permeated with the Universal Spirit and 
might come to wonder how that beneficent, heart-resting iniluence 
ever loses its hold upon human kind. 


The afternoon wore away and presently the sunset cast its ever- 
lengthening shadows. And then came the note most affecting in all 
this satisfying atmosphere. Whom has it not touched that has ever 
contemplated it, — the home-lights appearing one by one as the wan- 
ing twilight merges in the evening and the night? Good, kindly folk, 
harming no one ; depriving no one of his own, — for what need amidst 
such superbountiful provision of everything essential for comfort and 
well-being ; resting from their wholesome labors ; soberly contented ; 
happy in their family loves and relations ; thankful in tlieir i)rayers, 
above all, to have been vouchsafed another day of lif(^ — of life so 
sweet, so wholesome, so rich in blessings, so good to enjoy ; of life, 
among all things conceivable, infinitely the most precious. 

And so I walked under the stars aw^ay from this handiwork of the 
Almighty, back to the city built of men. 

This whole world of ours is beautiful, comfortable, and complete 
for the needs of all creatures after the manner here so inadequately 
set forth. To dwell here only upon my own land, wliich is one vast 
and constant reduplication of such scenes : Consider, — our country lies 
between two mighty oceans. Wherefore, so long as it remains united 
the distractions attending armaments, and warfare, and the military 
service should not require consideration. It is within latitudes most 
congenial and favorable to human life. There are within our borders 
natural riches redundantly enough for all to enjoy. The earth teems 
with nutriment far beyond the needs and capacities of her children, — 
the grains, the fruits, the meats to nourish and sustain; the means for 
warmth, for the ornamentation of the person, the decoration of the 
home. Every conceivable thing essential to existence, — nay, every 
luxury that can be desired is superabundantly at hand. How worse 
than wicked, then, how stu}Hd is it, wdiat veritable insanity indeed, 
requiring the attention rather of the alienist than of the judge, 
that moves men to deprive and Avithhold from one another the 
wholesome joys of life, — even the merest essentials to existence ! 
Yet such are the conditions of our civilization that among our ])(^ople 
to-day at least ten millions ^ are in tlie direst poverty and suffering, of 
whom hundreds of thousands must die untimely for want of the 
health, strength, and sunshine, and the air of heaven whicli has been 
provided with such infinite bounty. 

The government of this our country is founded upon i)erhaps the 
noblest political ideals in human history. Here the people, it was 
intended, should govern themselves. Their welfare and their de- 
velopment should be of their own making. Those entrusted with the 

' Robert Hunter. 


macliiiiery of government shonlcl ])e in autliority for stated brief 
periods and should be so i)laeed by the popular appointment. Here 
everv man should be free to work out unmolested his own salvation. 
It is such ideals as these, established by our great-spirited fathers, that 
are the basis of all that is best in our government and our civilization : 
and our present grave danger lies in their neglect and subversion. 

Many millions have emigrated to these shores from the Old World, 
having learned of the generous gifts which nature has here poured 
forth. More than this, they liave believed that here freedom is to be 
attained, with a proper enjoyment of life and the unmolested ordering 
by each man of his own well-being and development. Many among 
them have hoped (the dream was too iridescent for all to liave in- 
dulged in) that here they need no longer fear statecraft, or kingcraft, 
or priestcraft, or the unwilling service of arms, or the repetition of 
such misfortunes as crowd the pages of the Old-World history, — its 
poverties, its pauperisms, its plagues and pestilences, its unnecessary 
deaths, its agonies, despairs, soul-exhaustions, its pitiful hysterias, the 
choking of its ideals, its stagnations, its un-Christlike class gradations, 
the arrogances and greeds among its rich, the cruelties of its powerful 
men. the diableries of its nobility, its bloody and occasionless wars. 
All this was to be left behind. The race was to begin afresh. Why 
not ? Had it not here its destinies in its own hands ? They came, 
and are coming now, these immigrants, many thousands every week, 
and have found, with regard to nature's gifts at least, a realization far 
exceeding their extremest hopes. Nevertheless, in quite the same old 
blind, stupid, fatuous way are the conditions left behind being per- 
mitted redevelopment. It is only names that are being changed. 

There are here statecraft and kingcraft again in fullest measure, 
but under other nomenclature. Many among those elevated to 
authority by the votes of those presumed to be their political equals 
manifest all the vices of the old systems, yet lack in much greater 
degree such fme and noble instincts as have oftentimes cliaracterized 
Old-World potentates, especially the solicitude for the afflicted which 
characterizes the ingrained aristocrat. And liere, quite in the old way, 
many among those sworn to maintain the rights of the people in 
justice and in truth are bound l)y corrupt pledges to the end that an 
unscrupulous and powerful and cynical few may continuously '-support 
and enrich themselves by procuring the degradation and suff'ering" 
of their fellows. 

And then, again, in quite the same Old-World fashion — though not 
nearly to the same extent, thank God ! — do these ruthless and lawless 
elements subsidize to their jiurposes certain among those whose 


ostensible business it is to preach the simple liiith of the Carpenter's 
Son. In the old days it was, — 

Das Eiapoppeia vom Ilimmel, 

Mit welehem man einschlafert, wetiu es Lrreint, 
Das Volk, des grossen Luinniel. 

So here and now — but not so oflen. 1 repeat, for the tliin^' caiiiioL so 
much get itself believed — does the tieverend Mr. Honeyman, iu unc- 
tuous cadence, his finger tips atouch, exhort the poor (Christ's poor), 
the sick, and those with sense of resistance c{uite crushed out, with 
vitality c|uite bludgeoned out : ^ 

True, they are wretched ; they have been wronged ; they must 
Avork until they rot ; for them there are no flowers, nor sweets, nor 
the song of birds : to them even the freest of all benefactions, the air 
of heaven and the comfortable sunbeams, are denied ; to them exist- 
ence is one endless misery. Wait, however; they are evilly entreated 
here. In this life they must be faithful to that station to which tliey 
have been called. But let them think of tliat which is beyond. An- 
other and a beatific environment awaits them, if they but meekly and 
contritely bear the burdens which now for an inscrutable i)urpose are 
laid upon them. (I wonder does the Reverend Mr. Honeyman lor a 
moment believe this which he preaches ; or does either he, or Dives, 
whose pander he is, ever reflect upon its theological alternative? 
Would either the one or the other have courage for introspection upon 
such basis? I think not.) 

And here lies the crux of the whole situation. I shall not in these 
pages — it is not essential — discuss the dogma of the future life. I, 
for my part, humbly and with prayer hope for it; and I have my 
dead, whom I would see again. But my longings and my creed are 
here no more relevant than another's. Our business is to see to it 
that our sick and wretched brethren shall not be cajoled into a dull 
endurance of their present sufferings upon such basis. We have 
here to stand upon but one fact, the truest tact that can be con- 
ceived, the one absolutely unassailable actuality, — the life which I 
and you and he are now living. Nothing sliall subvert the sentient 
being's right to health and strength and happiness here and upon 
this earth. No one knows of any state more precious ; there is none 
more precious than this life, to be developed to the full in all its God- 
besto^ved aspects, — the infant cementing the affection of its parents ; 
the school-child sweetening the home ; the adolescent boy and girl 

1 A type is cliaracterized. Tlie reader will find neitiier here nor anywhere else 
in this book an animadversion upon the priesthood as a calling. 


opposing their inexperienced idealisms to tlie meannesses of life, 
its grotesqueries, and its ghastly compromises ; the youth and the 
maiden joining their liearts in wedlock ; the husband maintaining 
his family ; the wile rearing her offspring ; the mature man prepared 
to accomplish with right doing the world's work ; the venerable coun- 
sellor: '-the justified mother of men," who sits on her porch sur- 
rounded by her children and her children's children, while the rays 
of the setting sun touch warndy her whitened hair. 

Here one shrugs his shoulder: " Yes, all this is true and very 
dreadful which you state. But then we must take conditions as we 
find them," or ''men have got to get along some way," or "business 
is one thing and sentiment another," or " there is no use in trying 
to make the ways of the world conform to abstract theories," or 
many like expressions. "And then," continues the practical man. 
'• what are you going to do about it ? Besides, consider the compen- 
sations for these things in our civilization, consider its achievements." 

Very well, then. Is it really of so great' essence that men shall 
forever with turmoil and wrong-doing, with much anguish, and sweat, 
and dying contrive and build mighty works, tremendous enterprises, 
magnificent structures scraping the skies, giant cities, vast memo- 
rials of material striving, so often miscalled human progress ? Have 
you read Shelley, — 

I met a traveller from an antique land 

Who said : "Two vast and trunkless legs of stone 
Stand in the desert. Near them on the sand, 

Half sunk, a shattered visage lies, whose frown 
And wrinkled lip and sneer of cold command. 
Tell that its sculptor well those passions read 

Which yet survive, stamped on these lifeless things, 
The hand that mocked them and the heart that fed, 
And on the pedestal these words appear. 

My name is Ozymandias, king of kings. 
Look on my works, ye mighty, and despair. 

Nothing beside remains. Round the decay 
Of that colossal wreck, boundless and bare, 

The lone and level sands stretch far away." 

And have you ever thought to put all such '• progress" in the 
balance against Gethsemane ? It is naught, it is all naught, I tell 
you ; it is worse than naught, when set against the single cry of a 
soul anguished for its kind. And is it not Avoful, Christ, is it not 
infinitely woful when, in all this tawdry fabric of civilization, a piece 
of money is so often set against a bitter tear, a shrewd bargain against 
a sick and tired heart; a phariseeism, such as Thou didst hate so 
much, against a life cruslied out before its time ! 




The New York Board of Health has had printed much information con- 
cerning disinfection, etc. I understand that its literature is to be had very 
fjeely ui3on request, and that the Board is prepared to disinfect rooms upon 
application. The Charity Organization Society provides excellent circulars 
concerning preventive measures. There are private enteipi-ises which under- 
take disinfection, among them the Lederle Laboratory, the West Disinfecting 
Company, and the Metropolitan Disinfecting Company, of New Yoi'k City. 
Among manufacturing houses which [)r()vide sputum cups and like parapher- 
nalia, disinfectants, etc., are the Messrs. Seabury & Johnson, Kny, Scheerer 
& Co., and Johnson & Johnson. 

The tubercle bacillus is killed by moist heat (203° F., 95° C.) in one min- 
ute (Bonhoff and Fosher). Solutions of cai'bolic acid and of bichloride of 
merciny cannot be relied upon to disinfect sputum, at least in Iheoiy. Tuber- 
culous sputum dried in air twelve. hours will be completely disinfected by an 
equal amount of a 1 : 10 solution of izal. Chlorinated lime (1:50 solution) 
disinfects sputum. The cocci are destroyed more easily than the bacilli. 

The following solutions and preparations are recommended: 

Soap Suds Solution. — For simple cleansing, or for cleansing before or 
after disinfection by chemicals, one ounce of common washing soda should 
be added to twelve quarts (three gallons) of hot soap (soft soap) and water. 

Strong Soda Solution. — Dissolve one-half pound of conunon washing soda 
in three gallons of hot water. This solution is stronger and more effective 
than the above. It should be applied by scrubbing with a hard brush. 

Weak Soda Solution. — One ounce connnon washing soda to twelve ((uarts 
hot water. 

Heat. — Boiling or steaming in closed vessels for one-half hour, or boil- 
ing in the weak soda solution in open vessels for the same time, will destroy 
ail germs. The soda has the additional advantage of preventing rust in the 

Dri) Chloride of Lime.— This must be fresh and kept in closed vessels or 
packages. It should have the strong, pungent odor of chlorine. 

Chlorinated Lime Solution is made by adding six ounces of fresh chloride 
of lime, having a strong odor of chlorine, to one gallon of water. It must 
be well mixed and should be prepared an hour before using. This solution, 
when fresh, is a reliable disinfectant and deodorizer. 

Formalin is a 50 per cent, watery solution of formaldehyde. It nuist be 
fresh to be reliable. A five per cent, solution of foi-malin is an efficient 
deodorizer and a measurably good disinfectant. Large cloths or sheets hung 
in a room and sprinkled or sprayed with formalin may be used. Ten ounces 
of formalin are requisite for each one thousand cubic feet of air space. For 



seieiitilie disinfection, however, there must be fumigation. For this formal- 
dehyde should be used. 

Many proprietary disinfectants, whose composition is not revealed, are 
relatively expensive and often unreliable. It is essential to remember that 
deodorizers are not necessarily disinfectants; besides, they give an altogether 
fictitious sense of security. 

The Illinois State Board of Health provides these simple, cheap, and 
reliable fonnulas : 

Standard Disinfectant, No. 1. 

Four per cent, solution of chloride of lime. — Dissolve chloride of lime of 
the best qualitj^ in water in ^proportions of six ounces of lime to one gallon 
of water. 

This is one of the strongest disinfectants known. Discharges from the 
bowels of a patient suffenng from a contagious or infectious disease, should 
be received in a vessel containing this solution, and allowed to stand for an 
hour or more before being thrown into the vault or water closet. Discharges 
from the throat or lungs should be received in a vessel containing this solu- 
tion. Chloride of lime in powder maj' be used freely in privy vaults, cesspools, 
drains, sinks, etc. 

Instead of the solution of chloride of lime, carbolic acid may be used for 
the same purposes, in a strength of GA ounces to the gallon of water. This 
makes a 5 per cent, solution of carbolic acid. 

Standard Disinfectant, No. 2. 

Bichloride of mercury, 1 : 500. — Dissolve corrosive sublimate and mttriate 
of ammonia in water, in the proportion of two drachms (120 grains, -\ ounce) 
of each to the gallon of water. Dissolve in a wooden tub. barrel, pail, or 
an earthen crock. 

Use foi' the same purpose and in the same way as No. 1. Equally effective 
but slower in action, so that it is necessary to let the mixture (disinfectant 
and infected material) stand about four hours before disposing of it. This 
solution is odorless, while the chloride of lime solution is often objectionable 
in the sick room on account of its smell. 

Standard Disinfectant, No. 3. 

Bichloride of mercurif, 1: 1000. — Dissolve one drachm (60 grains, J ounce) 
each of con'osive sublimate and muriate of ammonia in one gallon of water. 
Dissolve in a wooden tub, barrel, pail, or earthen crock. 

Use for the disinfection of soiled underclothing, bedlinen, etc. Immerse 
the articles for four hours, then wring them out and boil them. This solu- 
tion is excellent for wetting the floors of ofiSces, stores, workshops, halls, 
and school-i'ooms before sweeping. 

Mixed with an equal quantity of water this solution is useful for wa.shing 
the hands and general surfaces of the bodies of attendants. 

Chloride of lime, carbolic acid, and corrosive sublimate are deadli/ poisons. 


Standard Disinfectant, No. 4. 

.1/(7A- of lime (gM/cAZme).— Slake a quart of freshly burnt lime (in small 
pieces) with three-fourths of a quart of water,— or, to be exact, 60 parts (jf 
water by weii>lit with 100 of lime. A diy powder of slaked lime (hydrate 
of lime) results. Make milk of lime not long- before it is to be used by mix- 
ing one part of this dry hydrate of lime with eight parts (by weight) of 

Air-slaked lime is worthless. The dry hydrate may be pi'eserved some 
time if it is enclosed in an air-tight container. Milk of lime should be freshly 
prepared, but may be kept a few days if it is closely stoppered. 

Quicklime is one of the cheapest of disinfectants. The solution can take 
the place of chloride of lime, if desired. It should be used freely, in quan- 
tity equal in amount to the material to be disinfected. It can be used to 
whitewash exposed surfaces, to disinfect excreta in the sick room (»r on 
the surface of the ground, in sinks, drains, stagnant pools, etc. 

Dust from the walls, pictures, etc., in rooms that have lieen occupied by 
consumptive patients, contains the germs and produces tuberculosis in annuals 
when used for their inoculation. Therefore, rooms should be thoroughly 
disinfected before they are again occupied. Rooms in which ('oiisumi)tives 
live should never be dusted with a dry cloth or brush. Carpets should be 
swept with a broom wrapped with a damp cloth, the latter being disinfected 
after use. Furniture should always be cleaned by wiping with a damp cloth, 
which should afterwards be burned or soaked in chloride of lime solution or 
by boiling for half an hour in a weak soda solution. Cleanliness in the 
house is of the utmost importance. Here impure air is likely to be rebreathed 
again and again. Moreover, fine particles of perhaps contaminated dust 
I- ling tenaciously to various surfaces, and especially to fabrics, even thougli 
there be considerable ventilation, so that thick cai-pets, i^lushes, velvets, rug-s, 
furniture upholstered with roughened fabrics, and heavy hangings should not 
be swept with a dry broom and the deadly feather-duster, which distribute 
all over the room the dust gathered from corners and recesses. Moist tea- 
leaves, or some substitute for them, should be used befoi-e sweeping, and 
moist cloths should be used afterwards. 

The furniture and ornamentation of the house should be as siui|)le as 
possible compatible with a due regard to comfort and the esthetics. Metal 
i)((ls are extraordinarily cheap nowadays. Hardwood floors, if possible, and 
eane-seated chairs are desirable, as is a plain, smooth, unpapered, stained 
wall. For fumigating bedding, blankets, clothing, and other articles, formal- 
dehyde is perhaps the best agency. The manufacturing liouses provide it, 
with instructions upon the packages, stating the amount to be used foi' i-ooras 
of a given size. For thorough disinfection all the articles in a room should 
b< fumigated, except such as are of so little value that they may be de- 
stroyed by burning. It is best to burn, if possible, such articles as have been 
soiled by the bodily discharges of the jjatient. Apparel made of cotton, 
linen, or flannel, and blankets should be thoroughly boiled for at least half 


an hour. Silks, furs, and wrajDS should have the pockets turned inside out 
so that every part of the garment shall be exposed. Mattresses should be so 
placed that both sides may be exposed. Carj^ets should be taken up and 
placed upon chairs before fumigation. All the articles in the room during 
the occupancy of the consumptive should remain to be disinfected, and after 
the disinfection they should, as far as possible, be taken out and thoroughly 
aired. Before fumigating the room, all apertures, speaking tubes, keyholes, 
or fireplaces should be securely stojDped up. The room should be left tightly 
closed for twenty-four hours. 

After the room has been thoroughly aired the floor should be scrubbed 
with soap and water. Tlie furniture and wood-work, walls and ceilings, 
should be brushed over with a moist cloth and then the room should be 
opened and left to air for two or three days before occupancy. If feasible, 
the walls should be repapered. Walls and ceilings, if plastered, should be 
w'ashed with lime solution. 

The test of thorough disinfection, as applied in the work of the New York 
Health Dejoartment by Dr. R. J. Wilson, is to suspend in the room to be 
disinfected the living bacillus pyocyaneus. On the day after disinfection 
the specimen is submitted to culture-test ; if this test demonstrates the de- 
struction of the bacillus, the disinfection is rightly considered to have been 
thorough and complete. 

With regard to advanced and dying consumptives the problem of disin- 
fection and cleanliness is as difficult as it is essential to consider. The pa- 
tient is too sick and helpless to keep himself clean, and he will inevitably 
soil him-self and his surroundings. There is frequent coughing and even 
vomiting, with much emission of infected matter. Eveiything must, thei'e- 
fore, be cleansed repeatedly and constantly. The bedlinen must be changed 
eveiy time it becomes soiled. It must not be agitated, and must be removed 
before the broken-down tissue has had time to dry. 

Latham's precautions with regard to hospital and sanatorium infection 
are : 

The contents of cups and flasks are mixed with sawdust and burnt in 
special small crematoi'ies or incinerators, as should be also the sweeping-s, gar- 
bage, and I'efuse. The flasks are placed in water to which sodium bicarbonate 
Tias been added, and then gradually raised to 102° F., and kept at this tem- 
perature for half an hour. Handkerchiefs may be disinfected in a steam 
disinfection station, but destruction by burning is preferable whenever pos- 
sible. The floors, etc., arc cleaned by means of moist cloths dipped in a ten 
per cent, solution of chlorinated lime. The walls must periodically be well 
sc7-ubbed. Linen, ordinary clothes, nuislin covers, small mats, wicker chairs, 
mattresses, etc., are steam disinfected. Such articles as cannot be steam 
sterilized should be disinfected by formaldehyde. Crockeiy and knives and 


forks ai'e treated in ordinary surjiieal sterilizers. In Latham's plan tlieie 
is a special dust destroyer attached to the engine-room of the sanaloi-iiiin. 

The following- aduiiralile rules have been adopted l)y the State Pxtai'd of 
Health of Kentucky relative to the disinfection of railroad cars in the State, 
and the roads have agreed to abide by them: 

All day coaches engaged in regular traffic shall be thoroughly cleansed 
after each trip at such points as facilities for the same ha\-e been pro- 
vided. In no case shall such cleansing be less frequently performed than 
on every third day of use. In such cleansing, all rugs, matting, and up- 
holstered back rests, when jaracticable, shall be removed from the coach to 
the open air for mechanical cleansing, and be exposed to sunlight when the 
prevailing meteorological conditions will permit. All interior surfaces in 
coaches are to be mopped, sci-ubbed, or cleansed at intervals of not more 
than ten days, with solutions of I)ic]iloi'ide of mercury, carbolic acid, tricresol, 
or other disinfecting preparations preferred by any corpoi'ation and ap- 
proved by this board as to ingredients and strength. Spittoons are to be 
provided in number not less than one for each seat in all smoking cars and 
in toilet rooms. Placards provided by this board shall be displayed at each 
end of all such coaches and in all waiting-rooms, indicating the importance 
of using the spittoons, and it shall be unlawful for any person to spit upon 
the floor or platform of any railway car or other public conveyance, or 
upon the floor of any waiting-room or platfonii in any station or depot. 

All coaches of any kind in -which an acute infectious disease has been 
carried shall remain closed and unoccupied after such person has been 
removed until it has been thoroughly cleansed and disinfected by the use 
of formaldehyde gas in quantities of not less than forty fluidounces of 
formalin to each coach. All day coaches in regular use for through travel 
are to be disinfected after cleansing by some method approved l)y this board 
at intervals of not more than ten days. 

All toilet-rooms, water-closets, ui-inals, sjiittoons, and toilet appliances are 
to be scrubbed with soap and hot water and disinfected with formalin, or 
other approved method, after each trip, and shall be kept as clean as possible 
when on the road, and all similar rooms in stations shall be cleansed daily 
in the same way, and when vault or surface receptacles are used in stations 
these shall be disinfected daily with fresh lime. All preceding regulations 
in regard to cleanliness and disinfection shall apply equally to sleeping, 
dining, buffet, and parlor cars used in the public service. All blankets, 
curtains, and hangings used in sleeping cars shall be exposed to superheated 
steam, or other means of disinfection approved by this board, at intervals 
of not less than ten days, and all mattresses shall be so treated at intervals 
of not more than sixty days. 





The following- were examined for the purpose of ascertaining tlie per- 
centage of alcohol in each. Some of them have been recommended as tem- 
perance drinks (Report of Massachusetts Board of Health, 1902). 

Percentage of 
alcohol (by volume). 

" Best" Tonic 7.6 

Carter's Physical Extract 22.0 

Hooker's Wigwam Tonic 20.7 

Hop Tonic 7.0 

Hoofland's German Tonic 29. .3 

Howe's Arabian Tonic, "not a rum drink" 13.2 

Jackson's Golden Seal Tonic 19.6 

Liebig Company's Coca Beef Tonic 23.2 

Mensman's Peptonized Beef Tonic 16.5 

Parker's Tonic, "purely vegetable," reeonunended for inebriates.. 41.6 

Schenck's Seaweed Tonic, "entirely harndess" 19.5 

Atwood's Quinine Tonic Bitters 29.2 

L. T. Atwood's Jaundice Bitters 22.3 

Moses Atwood's Jaundice Bitters 17.1 

Baxter's Mandrake Bitters 16.5 

Boker's Stomach Bitters 42.6 

Brown's Iron Bitters 19.7 

Burdock's Blood Bitters 25.2 

Carter's Scotch Bitters 17.6 

Cotton's Bitters 27.1 

Copp's White Mountain Bitters, " not an alcoliolic beverage" .... 6.0 

Drake's Phintation Bitters 33.2 

Flint's Quaker Bitters 21.4 

Goodhue's Bitters 16.1 

Greene's Nervura 17.2 

Hartshorn's Bitters 22.2 

Hoofland's German Bitters, "entirely vegetable and free from alco- 
holic stimulant" 25.6 

Hop Bitters 12.0 

■ Hostetter's Stomach Bitters 44.3 

Kaufman's Sulphur Bitters, " contains no alcohol." (As a matter 

of fact it contains 20.5 per cent, of alcohol and no sul])hur. ) . . 20.5 

Kingsley's Iron Tonic 14.9 

Langley's Bitters 18.1 

Liverpool's Mexican Tonic Bitter,^ 22.4 

Paine's Celery Compound 21.0 

Pierce's Indian Restorative Bitters 6.1 

Puritana 22.0 

Z. Porter's Stomach Bitters 27.0 

Pulmonine 16.0 


Pc-rcontapc o! 
nloolxjl (,by volume). 

Rush's Bitters 35.0 

Richardson's Concentrated Sherry \^'ine Bitters 47.5 

Secor's Cinchona Bitters 13.1 

Shonyo's German Bitters 21.5 

Job Sweet's Strengthening Bitters 29.0 

Thurston's Old Continental Bitters 11. 4 

Warner's Vinegar Bitters, " contains no spirit'' (i.l 

Warner's Safe Tonic Bitters 35.7 

Warren's Bilious Bitiers 21.5 

Wheeler's Tonic Sherry Wine Bitters 18.8 

Wheat Bitters 13.G 

Faith Whitconib's Nerve Bitters 20.3 

Dr. Williams's Vegetable Jaundice Bitters 18.5 

Whiskol, '■ a non-intoxicating stimulant, wliiskey without its 

sting" 28.2 

Golden's Liquid Beef Tonic, " recommended for treatment of alco- 
holic habit" 26.5 

Ayer's Sarsaparilla 26.2 

Thayer's Compound Extract of Sarsaparilla 21.5 

Hood's Sarsaparilla IS. 8 

Allen's Sarsaparilla 13. .5 

Dana's Sarsaparilla 13.5 

Brown's Sarsaparilla 13.5 

Corbett's Shaker Sarsaparilla 8.8 

Radway's Resolvent 7.9 

The dose recommended upon the labels of the foregoing preparations 
varied from a teaspoonful to a wineglassful, and tlie frequency also \'aried 
from one to four times a day, " increased as needed." The proportion of 
alcohol in whiskey is ordinarily fifty per cent.^ 



Dr. Simon Baruch, after recognizing the unusual precautions that must 
be taken, on account of the varying conditions of individual phtliisical pa- 
tients against routine practice, advises this treatment: 

After a thorough cleansing with soap and warm water, a day is allowed 
to elapse.' The patient is wrapped snugly in a thin blanket like a muunny 
(unless rectal temperature is above 100°). He is allowed to lie for half an 

1 Because of the agitation against harmful or fraudulent proprietary medicines, 
many alleged remedies have recently changed their formulae ; wherefore, one which 
was correct when the Massachusetts State Board made its analyses might not be 
true of present and altered conditions. 


hour or longer unless he perspires. In afebrile cases it may be necessary to 
cover with additional blankets, the object being to fill the cutaneous arteri- 
oles preparatory to being treated with water. The face is bathed with water 
at 50° Y. Now the blanket is opened over the chest and abdomen, and these 
parts are rapidly and well ruljbed with water at 75° F. After drying, the 
patient is turned on the abdomen and the back is similarly treated. The 
extremities are not treated. Patient is gently dried, dressed, and if afebrile, 
oi'dered into the open air for a gentle walk. Febrile eases are returned to 
bed. This treatment is repeated daily with reduction of two degrees of water 
temperature at each ablution until 60° F. are reached. Now the ablution is 
performed just as the jaatient emerges warm fi'om the bed, as follows: 
Standing in a foot tub, containing sufficient water at 100° F. to cover the 
feet to the malleoli, he receives a rapid friction liath with water at 90°, 
omitting the upper extremities, after which he is dried and sent into the 
open air if his rectal temperature is below 100° F. The water temperature 
is reduced daily two to five degrees until 60° F. ai'e reached. Now^ the ablu- 
tion is replaced by affusion, which consists of pouring four basinfuls of 
water at 90° F., previously held in readiness, over the body. The patient 
standing in a foot tub having the feet covered with water at 100° F., water 
is dipped from a vessel previously in readiness and poured with force over 
each shoulder and the back and chest. Rapid drying while standing on a 
warm towel completes the procedure. Beginning with a water temperature 
at 90°, it is daily reduced a few degrees until 60° or even 50° are reached. 
This refreshing process may be repeated daily. In febrile cases the water 
temperature should not go below 65°. 

Jacobi observes the following : 

Much has been said about hardening. What does it mean? Nothing but 
this: that the resistance of the child to the effect of external influences 
should be strengthened. Is there a uniform method applicable to every 
child, no matter of what age or constitution? Certainly not. But there is 
one object which should be accomplished in every infant and child, — viz.. 
the invigoration of external circulation. The surface of a child from two 
to ten years measures from three to ten square feet. In and under that 
surface there is a lake of blood. In vigorous health this blood is in constant 
and rapid circulation. "Within two minutes it enters and leaves the surface, 
comes from and leaves the centre of circulation, the heart. Slow circulation 
in the surface i-etnrds the flow of blood in the whole body, and impairs the 
nutrition of the heart and every organ, causing congestion and insufficient 
function, and disease. Rapid circulation in and under the skin, causing rapid 
circulation everywhere, propels the totality of the blood in the child's body 
(from two to six pounds according to age — from two to twelve years) into 
and through the lungs, in which the contact with and the absorption of the 
oxygen of the atmosphere take place. Now, the best stimulant of the circu- 
lation in general is, besides muscular exertion (exercise), the stimulation of 
the skin bv cold water and friction. A child of two or three vears should 


liave a daily cold wash, either after a warm bath, or standing in warm water 
which covers the feet, oi- lying on the attendant's lap or on a mattress. A 
brisk rubbing with a wet towel, one or two minutes, and witli a dry towel 
until the surface is dry and warm, is sul'ficient. Older children may have a 
wet sponge squeezed out ovei- them, this procedure being followed by the 
same effective friction; or they may plunge into cold water, — in the winter 
a single moment, in the sunnner several minutes. While in any bath, the 
skin shoi;ld be thoroughly rubbed. This rule must not become a I'outine 
applicable to every individual. Cold water and friction require a healthy 
heart and a certain degree of strength. They only facilitate the reaction 
that should be looked for in every instance. The same healthy child, when 
taken sick or when convalescent from a disease, lacks the necessary vigor, 
and the routine must be interrupted. A child, under size and under weight, 
requires warmer water and friction. That is why a newly born baby or an 
infant of less than one or two years should be spared a low temperature. 
That is why also a child whose feet, after a bath or washing, do not get so 
warm as the rest of the bcxly should be rubbed down not with cold but with 
warm water, or with a mixture of alcohol and warm water, until the consti- 
tution is gi'adually improved and fortified. 

These rules appear simple; indeed, are simple. That is why the discus- 
sions of medical and lay journals met with lately are out of place. There 
are those who, with great earnestness, condenni hardening because they see 
colds, chills, or pneumonia after cold water treatment. If two do the same 
thing, it is not the same. It is with hygiene as it is with diet. The very 
young, the older, the healthy, and the sick, the robust, and the feeble, nuist 
not be treated nor fed according to ironclad rules. It has appeared to me 
that a few good rules, undei'stood and intelligently applied, are a safer 
guidance than the forceful exhibitions of inexperienced medical juvenility 
as lately displayed in the magazines. 

The following is based upon Cornet : 

A sensitive patient, in the winter, begins w4th rubbings morning and 
evening, preferably by an attendant. He is put naked into a large, coarse 
sheet, and then rubbed with long, quick strokes, from head to foot, so that 
a strong glow may be brought to the skin. In a week or moi-e the j^artial 
waist rubbing is begun. The patient lies in bed and his trunk ami members 
are rubbed with a w^ash-rag wrung out of water (66° to 92° F.) until there 
is a ruddy reaction. I'pon this the patient is covered again and i-ests for 
half an hour. Later, when the cutaneous vessels have begun to take on their 
normal functions, the full moist (or wet) rubbings are used with strong 
patients, especially in sunmier. The patient may be taken directly from his 
bed and given the treatment upon an empty stomach; or, weaker individuals 
may have a glass of warm milk or tea half an hour before; or, a shoi't walk 
or a dry rub may precede, in order to induce a good reaction. The patient, 
entirely nude, is wrapped in a cloth wrung out (later wet) in five per cent, 
brine at 90° F., so that it comes in contact with the body all over, and is 


then rubbed by an experienced man, with long, powerful strokes, until there 
is an agreeable feeling of warmth over the entire body. A Avet cloth may be 
laid on the head to guard against headache. The entire rubbing lasts but 
one or two minutes, after which the patient is again laid in a di-y sheet and 
again rubbed. He dresses without delay and goes out into the open air for 
at least half an hour. After his walk he takes breakfast. Weaker patients 
get into bed for another quarter of an hour. The temperature of the brine 
i,s lowered one degree daily down to 70°, 65°, or even 60°. This full rub 
should be done quickly, expertly, and energetically. Relatives and unskilled 
attendants should not undertake this work ; headache, discomfort, and chilli- 
ness may result. The douche can be endured only by the very strong, and 
should be done in the physician's presence. The duration should be gradu- 
ally increased from five to forty seconds; the temperature should be 90° to 
95° F. or warmer. The patient must rub himself during the douche. After 
he is dried, he dresses himself and exercises in the air. The douches are 
absolutely excluded in veiy irritable cases and those with much sputum. 
They induce forced breathing and may lead to the aspiration of sputum. 
The rubs do not serve to cleanse the slcin and are no substitute for baths. 
They seem, however, to harden the body against variations of temperature. 
They are a neuro-vascular stimulant, improving the " peripheral heart," and 
affecting favorably the appetite, the nutrition, and the mental condition. 


Extracts from a typewritten children's journal published under the 
guidance of Mrs. Rosenberg at the Bedford Sanatorium of the Montetiore 
Home, to give an impression of the social atmosphere in these institutions. 

A XiGUTLY Prayer. Her eyes are filled witli a beaming love, 

Now I seek my nightly rest, 'Tu^t like the eyes of the angels above. 

I pray it be both sweet and blest, Flora Mendelsohn. 

And may the day dawn bright and fair, 

And happiness be in the air. 

" Elite Moxday." 

Proverbs. This really hasn't anything to do 

If we wisli liap]iy to be, ^^'ith the color of the day. Usually 

Let us never think of Me. "^^'l^en skies are blue it gives us bright 

Love all, hate none, <"ifl happy thoughts that we are going 

Should be a standard for every one. *" ^'^^'"^ ^ nice day. But Monday is 

If we wish to be forgiven let us for- " blue" in another sense in contrast 

give others, no matter how hard it is. ^\■itll Sunday. Indeed, many a Monday 

:Mamie Peltz. ^^'f' ft"*"! blue in spirits, — yes, some- 

times veiy blue. On Sunday everybody 

Oh. liow we do love our dear nurse; is in highest spirits and full of expee- 

We will always hear her melodious tations. When we arise at morn we 

voice. feel tliat we are going to liave a pleas- 




ant day and that something unusual 
may liappen. We have our breakfast 
and then get dressed, which makes the 
tliought of being here for our health 
disappear. At ten o'clock we are in 
joyous spirits. Almost every one is ex- 
pecting some guest. Even those who 
do not have visitors take pleasure in 
seeing their friends with theirs. We 
spread ourselves all over the grounds 
on Sunday. We feel this is a great 
holiday. The time passes away quickly 
— all too quickly — and when we retire 
to bed we feel that the day has been 
well spent, but we dread the thought 
of Monday morning. We all wish there 
was no such day i s Monday. We feel 
that there is some ugly spirit getting 
control over us; but we struggle hard 
till we gain the mastery over that 
spirit of ill humor and (perhaps) lazi- 
ness, — for Monday is a busy day, and, 
after all, as the day advances, we find 
that we are making the best of things, 
then the blue fades out or changes to 
rose color. Annie Dubenoff. 

Along with the general improvement, 
in ideas and in language, which may 
be observed in the writings of our con- 
tributors, we are rejoiced to announce 
a new poet in Flora Mendelsohn. Try 
again. Flora. 

Sanatorium News. 

The old garden benches have been re- 
paired and painted and are of very 
great convenience to the patients. 

The playground is now in full opera- 
tion. The croquet game has been set 
up, as well as pole-tennis and lawn- 
tennis, and the place is now alive with 
happy, shouting people. In addition, 
a ball nine has scrap games behind the 
coal heap. Some of the younger and 
female inmates have little catching 
boiits of their own. Added to all this 
liveliness is the constant clang of the 
patrol-wagon bell, operated by Little 
Joey, about forty-eight hours in the 

Air. Moss and Mr. Fried were visitors 
last Saturday, and, as usual, were very 
nuieh pleased with conditions here. 
Mr. Moss gave his usual Biblical read- 
ing to the children, and was attentively 
listened to by everybody. 

In honor of Celia Pekelner's birth- 
day last Sunday we had a little enter- 
tainment, which was enjoyed more than 
a big affair. It consisted of .some 
songs, piano solo, and some imitations 
of a phonograph by the latest waiter; 
it would make you break your sides 
with laughter watching him. He was 
the one that made the hit that night. 

The few hot days that we have had 
made a wonderful change in the ap- 
pearance of things in nature. The 
leaves on the trees are coming out, the 
shrubs and bushes are beginning to 
blossom, and all the different wild 
flowers are springing up. Our fine 
lawn looks like a green velvet carpet. 
Wednesday it got a close shave from 
the lawn-mower, pulled by a new hired 
horse. It smelled fine. 

A mad dog had us all badly scared 
on Sunday. He snarled and barked at 
nothing all the time, and Dr. Mendel- 
baum said he had visions. He was 
treated by the Hartfield cold-lead 

Blasting has been heard a good lot 
around here; I think it was the shot 
of the Japanese. 

The children are having a bully time 
picking violets and cowslips. 

In spite of the cold nights last month 
most of the garden seed put in by the 
gardener is showing signs of growing. 
We expect to have a very fine garden 
this vear. 

Answers to Correspondents. 

Dear Editress, — Please be so kind 
and let me know why an owl can't see 
by day. — Heavy Weight. 

Because it is a nocturnal animal not 
planned for day duty. 




Wanted. — Hearts courageous to help 
us tlirough our exercises at school com- 

Wanted. — For the same day, clear 
skies and a punctual train for the vis- 

Wanted. — As many visitors on that 
day as possible to prove their interest 
in us and in our school work. 

Wanted. — More adjectives to express 
our admiration for the budding beau- 
ties about us. 

Wanted. — ^Nlore rambles in the woods 
with Miss Teacher. 

We now get up at half-past six in 
the morning, and the boys take their 
shower-baths before breakfast; they 
like the new arrangement very much. 

A new calf was born at the barn on 
Wednesday, and Mr. Smith thinks it 
will be a prize animal. We now have 
a very fine herd. 

Davis Goldman. 



The simple sanatory tent of Dr. Ulricli has the great merit of cheapness, 
and it may be of any size. Perhaps the best for a single person is ten feet 

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Fio. 117.— The Ulrich sanatory tent. (Dr. Ulrich's tent is mentioned on page 215.} 

by twelve feet. It permits a stove in cold weather, and costs in Minneapolis 

The floor is raised a foot from the ground. A framework of boarding 


one inch by twelve inches is built around the border set one inch to two inches 
away from the edge and at right angles to the floor plane. This frame is 
rigid and extends at least two inches below the under floor surface. This 
arrangement gives the air intake or floor vent. The frame extends below 
the floor in oi'der to make an angular entrance for the air, thereby avoiding 
direct draught. The floor and its framework are built to tit the inside of the 
dependent walls of the tent. In tent making there is always a play of 
several inches owing to the variations in \Addths of canvas and to lechnic. 
It is wise to instruct the maker to measure the base of the tent oi-dered and 
append the results to the delivery slij?. The floor and its frame can then be 
built to fit snugly. The walls are attached to the outside and lov/ down on 
the frame, overlapping liberally at the corners. All four walls can be rolled 
up, and reef loops are attached under the eaves to hold the rolled sides. The 
movable walls permit one to make a canopy or simulate the three, two, or 
one-walled shack. — American Medicine^ May 27, 1905. 

The Fisher tent is raised three feet above the ground. The air enters 
the space beneath the floor through louvre-boards or " luffer-boards" or flaps 
of cloth, which are simply like clapboards hinged at the upper edges and 
hanging one over the other. These flaps are hung at their upper edges by 
cords on the inside of a wire netting surrounding the base of the tent. Thus 
they open inward at the slightest wind pressure, allowing eveiy breeze to 
enter the space beneath the floor, but not allowing it to escape, since the 
pressure from the inside against the flaps closes them. The air is thus forced 
up through the tent. Similarly, the sides of the cupola are provided with 
flaps of the opposite kind ; that is, they are hung on the outside of a wire 
netting and yield to any effort of the air to escape from the tent, but close 
against any wind from the outside. The effect, therefore, is to produce 
" wind pump" ventilation, and to transform the slightest breeze into an 
upward current. 

Free passage of air through the floor is provided by a space three inches 
wide between the tent floor and the walls of the tent, and also by two slits 
two inches wide in the floor, four feet from each end. These slits, as well 
as the openings on the four sides, may be closed by trap-doors, so that the 
tent may be temporarily heated in the morning when the i^atient wishes to 

The length of the tent runs in an east and west direction. The entire 
south wall consists of curtains which roll from the bottom on Hartshorn 
rollers, and may be put down in the daytime to sun out the tent, or on hot, 
close summer nights when the air is absolutely still. In cold weather even 
when the air is still, the cui'tains need not be lowered, as the difference in 
temperature between the breath exhaled and the surrounding atmosphere is 
enough to cause the exhalations to rise and jiass out of the cupola oj^en- 
ings. To provide for this there is a small space above the flaps in the cupola 
always open, and also above the flaps around the base of the tent. 

One other device needs to be explained. This is a regulator under the floor 
of the tent and in the centre. It performs two functions : the first and most 


important is to distribute the air evenly to all four sides of the tent; the 
second is to check the motion of the air when it is excessive, as in a gale. 
A false floor of canvas is constructed a foot below the real floor, and in the 
centre of this false floor is an opening five by seven feet, covered with wii-e 
netting and provided with flaps like those already referred to, but hanging 
down from the wire netting at an angle of less than 45°. Half of them 
— namely, those toward the east — are hung at their east edges; the other 
half, toward the west, are hung at their west edges. Conseciuently the air, 
passing through these flaps, is distributed half toward the east and half 
toward the west, so that each end of the tent is sui^plied with its full share 
of air, whatever the direction from which the wind is blowing. It is found 
that without this distributing apparatus the air is apt to come up on the 
side of the tent most remote from the direction of the wind, and even in 
some cases to produce a revolving motion of the air in the tent, causing a 
down cuiTent on the windward side. With the I'egulator, however, this never 
happens. In case of a gale the flaps in the regulator, which usually hang 
open, are blown shut and keep out an excessive ciuantity of air. The flaps 
at the extreme east and west are lightest and close first. The weights of the 
remaining flaps are graduated, so as to close siiccessively in proportion to 
the severity of the winds. 

The wire netting to which these flaps are attached is surrounded by canvas 
screens projecting seven inches downward from the false door, so as to con- 
stitute a short shaft, as it were, thus compelling the air, before reaching the 
flaps, to already have a general upward direction. The mechanism which 
has been described thus performs four functions: (1) The flaps suiTounding 
the base of the tent act like in-draught fans. (2) Those in the cupola act 
like suction fans. (3) Those in the central opening in the false floor dis- 
tribute the air evenly. (I) The latter also check excessive draughts. The 
result is that the tent automatically provides pure air for its occupants, 
without draughts, and in all conditions of weather, with the single exception 
of weather which is both hot and still, in which case it becomes necessaiy to 
lower the curtains. 

This description is from the report of the Baltimore Exposition. There 
was there also shown a structure, half tent, half shack, to contain five beds 
and costing : for dressed lumber and shingles, $56 ; canvas, $14: ; and labor. 
^18,— $88 in all. 

The Gardiner tent is sixteen feet wide, and in lots of twenty-five costs 
about $90 each. Improvements have been devised since these cuts were made, 
and it now has a wall six feet high, so as to allow proper height for a wooden 
door. Many tents are also made with a vestibule some eight feet or ten feet 
long, which allows space for a trunk, closet to hang clothes, etc.; also, in 
some instances, a wainscoting has been built of wood inside the tent, two or 
three inches from the wall, extending to within three or four feet in height 
from the floor. The air then enters the tent as usual, passes up the wain- 
scoting, and flows over the top of the same, instead of entering at the floor 



The flooiing is made of four-inch tongued and grooved pine boards, suj^- 
ported by joists of two by four-inch timber bolted together, the intermediate 
shorter timbers on the outside being also two by four inches. The uprio'hts 


^'^'^'^''^^ SECTION X-Y -'"^'^Sfe^ 


Fig. 118.— The Gardiner tent. 

are made of two by three-inch joists, the rafters also measuring two by three 
inches, the wood being reinforced by angle irons or plates, as shown. — 
American Medicine, May 27, 1905. 

The Nordrach tent is octagonal in shape, with an oiled floor and strong 
frame of wood and iron, covered with fifteen-ounce double filler army canvas. 
A narrow ventilator, which can be opened or closed, passes around the edge 
of the floor on four sides, and a galvanized iron stationary ventilator, um- 
brella-shaped, fits into the apex and is opened or closed by means of a 
damper. There are doors, and the furnishings are an enamelled iron bed, soft 
warm bedding, a bureau, toilet table, rugs, chairs, a stove, and a wardrobe 
which is built into the tent itself, (See page 476.) 

Details regarding the Ducker tent will be cheerfully furnished by the 
Ducker Comi^any, 277 Broadway, New York City. 



The Tucker tent is thus described in " Some Methods of Housing :" 
A combination roof and fiy ventilator with regulator attachments placed 
in the centre of the top of the tent. 

J," Flour 2 I 4 JoiBts Lpper Vei 

Fig. 119. — The Nordrach tent. (See page 475.) 

Two awning frames making up the front wall of the tent. These may 
be raised at various angles as awnings, or removed entirely so as to admit 
the free entrance of sunlight. 

A side wall ventilation compartment consisting of a hinged width of 
drop-siding opening downward on the outside wall and having in a corre- 
sj^onding jiosition on the inside wall another wider board hinged at the bottom 
and capable of being opened at any desired angle. The method of eon- 
trolling the inlet of fi-esh air is designed to keep the floors of the tent free 
from any draught. 

A fly extending one foot over the edge of the tent and ten inches above 
and parallel to the roof, allowing a free circulation of the air over the entire 
roof of the tent. 

A four-panel, hand-made screen door, wire screen cloth for all open- 
ings, two six-light windows, lumber for frame, floor and sides, all finished, 
cut to measure and ready for assembling, together with twelve-ounce, double- 
filled Monarch army duck cut in proper sizes for roof, fly, and walls of 
tent, complete the outfit, which is sold at Denver, Col., at $75 for size eight 
by ten feet, and at $100 for size twelve by fourteen feet. 

Homer Folks thus describes in " Some Methods of Housing" the pavilion 
tents at the Metropolitan Hospital Infirmary : 

The tent-cottages are an adaptation of a tent-cottage devised by Dr. 
Holmes, of Denver, Col. The frame is made of wood with the outside walls 
boarded half way up. Above this are two frames covered with canvas. 
The inner frame is so arranged that it can be lowered to the floor just inside 



the wall of the lower half of the tent. The outer frame can be raised outward 
so as to form an awning. There is a space of four inches between the inside 
and outside walls. The outer canvas frame extends from the roof to within 
four inches of the wood poi'tion, and the inner canvas frame extends to within 
four inches of the roof of the tent, so that when on account of storm or other 
reasons the upper half of the walls of the tent are closed there is a con- 
tinuous circulation of air entering- just under the roof. The tent-cottage 




Fig. 120.— Details of the Tucker tent. 


combines the maximum of ventilation with the minimum of exposure to the 
weather. It is more comfortable and easily managed than the ordinaiy tent. 
A door is placed at each end, and above the door are two canvas windows 
swung on pivots. The tents measure sixteen by thirty-two feet, the sides 
being eight feet high and the centre of the roof fifteen feet. Each tent con- 
tains twelve beds. The floor of the tent is sixteen inches above the ground, 
with free circulation of air underneath. 

The illustrations and specifications will show the details of the construc- 
tion work. Walls are not plastered; windows and doorways are not elabo- 
rate structures such as are ordinarily put into buildings of a more permanent 
character, and colored ticking and not canvas is used. Ticking gives greater 
freedom of ventilation than does canvas, and, being colored, the glare which 



is so disagi-eeable a feature of many tents is eliminated. Two or more open- 
ings in the inside roof for better ventilation would be a desirable addition to 
these tent-pavilions. 

Twenty stone piers. 
Five 4 X 4 X 32 sills and plates. 
Fourteen 4 x 4 x 14 posts. 

Fig. 121.— The Tucker tent. (See page 476. ) 

Fourteen 2 x 4 x 14 studs. 

Sixteen 4 x 4 x 18 joists, 24-in centres. 

Seventeen 4 x 4 x 20 rafters. 

Eight 11/^ X G X 12 collar ties. 

Total, 1335 ft. 
700 ft. Georgia flooring. 
450 ft. 5-in. lap siding. 
12 sash frames. 
2 door frames. 
110 ft. window sill. 
Two 114 X 4 X 14 ft. corner boards. 
115 yds. ticking. 
Painting, hardware, nails, and six days' labor. 


If roof is used: 

Eight 2 X 5 X 22 rafters 147 ft. 

Twelve 2 x 5 x 10 plates and studs 196 ft. 

Total, 343 ft. 


Details concerning the experimental camp noted in Part VI 11, CMiapter 
I, are thus set forth in The Oiitdoor Life for October, 1904 : 

The dimensions are thirty-nine by fifty-two feet (nmHii)les of thirteen 
feet), the lengtli of an ordinai-y boai-d being taken for economic const ruc- 

V%% Siding 

2 "j 3 Rafter 

Fig. 122.— Pavilion tent at Metropolitan Hospital Jutirmary. 

tion. There are three rooms on eaeli side, thirteen by thirteen feet each, and 
an open space in the centre twenty-six by twenty-six feet. Ordinary matched 
boards, battened, are used for sides and floorings. The roofs are of best 
cedar shingles. Rustic work is used where most effective for trimming, but 
sparingly. The first cabins or sleeping-rooms nearest the camp-fire ai'C en- 
tirely open in front, and Japanese screens are used for privacy, ("urfains 
or rubber sheets could be substituted to keep out the morning liglit, but the 
screens are very satisfactory, the occupant being invisible to those around 
the camp-fire, but having sufficient light to undress by. Of course the venti- 
lation of these rooms is perfect. The rooms furthest away from the camp- 
fii-e were finished with four walls and, a door opening on the platTorm in 
front of the fireplace, out of deference to the women, who objected to the 
Japanese screens as not affording them sufficient privacy. The middle rooms 
were left unfinished for six months while the question of walls and doors, 
which could be bolted, or screens was considered. The men jireferred the 


open fronts with screens; the women the closed fronts with doors. The 
matter was finally compromised with a door and a big window four feet from 
the ground with three sliding sashes, which can be pushed back and leave a 
large air-space at night. Each room has one window opening into the outer 
air. The corner rooms have two windows. The closed fronts and doors have 
this advantage. By covering the outside of the window with mosquito screens 
and having the sashes open inwards, the rooms can be cleared of insects early 
in the evening by a smudge built in a tinsmith's furnace or in a tin pail. 
The door being left open all mosquitoes are driven out. Then close the door, 
remove the smudge and open the window, and the smoke is speedily driven 
out, leaving a room free of smoke and mosquitoes for the night, — quite an 
important consideration in the Adirondack forest in June and July. In the 
open-front sleeping-rooms with Japanese screens this is, of course, impos- 
sible. Bearing in mind that each of the three rooms at the sides is thirteen 
feet square, and that the open space with the raised roof is twenty-six feet 
square, this leaves an open space, on a raised platfonn with three steps, 
thirteen Ijy twenty-six feet in front of the fireplace, which is built of field 
stone and is of ample dimensions to take a stick four feet long. This open 
space, thirteen by twenty-six feet, is used for a dining-room. In the rear 
the chimney is utilized to take the smoke-pipe of a cooking stove, and around 
this is built a kitchen, eight by thirteen feet, one side being left open that 
the cooking may be done absolutely in the open air, with reasonable shelter 
from the rain. This kitchen is found to be not quite large enough, but it 
can be extended for any required lenglh, and can be as readily made twenty 
feet as eight feet long. The open side of the kitchen faces a running brook 
about twenty-five feet from the house. 

Rock foundation for camp-fire, 16 x 10 and 4 feet 

high, ample room, absolutely safe $98 16 

Chimney and fireplace 108 99 

Carpenter work 990 07 

Rustic \\ork 75 00 

Toilet, freight, and incidentals 35 26 

Printing 41 50 

Total $1,348 98 

Being on an island, far up the lake, the carpenters' and masons' bills in- 
cluded boat hire. The building could be put up in most places nearer to 
Saranac Lake for .$1200, and will accommodate six persons, each having a 
room to himself or herself. With extra cots, it will comfortably hold twelve. 

The average cost per head, fully equipped for camping, with stove, kitchen 
utensils, good bed, mattresses, and ample blankets, towels, etc., for eight per- 
sons is less than .$200 per head. 

In such a building, for six oi- seven months of the j'ear. the State could 
house five times the number of persons they could accommodate in any brick 
buildings, with better sanitaiy surroundings, the patients living absolutely 
in the open air and yet sheltered in stormy weather as perfectly as in any 



The lean-to in use at the Loomis Sanatorium is thus deserilied by Dr. H. 
M. King in " Some Methods of Housing:" 

It has a floor space of forty by twelve feet, giving room for eight thirty- 
inch beds. The lumber used for its construction presents a plain surface on 

Windows over Lockers 

I i 

Steamer Obains in Stormy Weather 
1 40- 1 



Fig. 123.— Ground plan of improved lean-to. 

the interior, neither painted nor stained, and the exterior is covered with 
cedar shingles, stained green. The total cost up to this time was a little 
less than three hundred dollars. For obvious reasons, it became necessary to 
hang curtains between the stanchions along the front of the building. For 
this purpose, we procured a curtain made of awning material, weighted with 
a sliding rod with perforations at the ends through which wire guys were 
passed. These curtains were hung on two and one-half-ineh Hartshorn 
rollers, and have proved durable and otherwise satisfactoiy. Seven of these 
were required, costing complete $30. 

This structure was occupied all summer by patients, who were, however, 
comi^elled to use their quarters in the main building of the annex for dress- 
ing, bathing, etc. In order to make the lean-to serviceable for the winter 
without too gTeat exposure and inconvenience to the patients occupying it, it 
was necessary to provide a heated dressing-room. This addition has eight 
clothes-lockers, a shower-bath and toilet, a hot-water boiler and a round stove 
containing water coils which heats the apartment and provides sufhcient hot 
water for bathing purposes. A hand basin with hot and cold water taps is 
included. This addition was placed directly back of the lean-to, the door 
opening to the latter replacing the middle ventilator. The cost of this addi- 
tion, including labor and construction, plumbing, sewer connection, and heat- 
ing apparatus, was $280, making the total of the building, exclusive of the 
curtains, $580, or $72.50 for each patient. It has been occupied more than 
a year with the most satisfactoi-y results. 

The latest modification of this simple structure we are now Iniilding, also 
in connection with the annex of the Loomis Sanatorium. A clear idea of it 
can be gathered from the accompanying illustration and floor plans. It 
really consists of two lean-tos, somewhat larger and more elaborately built 
than' was the first, connected by a commodious sitting-room, which can be 
used in inclement weather, each lean-to opening into this room by a Dutch 



door as shown in the plan. This room, as well as the double-loeker room 
directly back of it, is heated by a larger stove, which, as in the original lean- 
to, also supplies hot water for the baths and hand basins. The interior finish 
of the sitting- room and the locker-room is hard pine, filled and varnished; 
the exterior is covered with cedar shingles and left to weather-stain. Ex- 
posed smooth surfaces, except the floor, are painted. All of the floor which 
is exposed to rain or drip is, at the suggestion of W. H. Scopes, of Sax-anac 
Lake, laid of three-inch material with one-half -inch spacing. The surface of 
each floor plank is slightly rounded, thus avoiding the curling which would 
neeessarilj^ occur in an ordinai-y jjlain floor exposed to the weather. 

The cost of this building, exclusive of curtains, was $1830, and provides 
accommodations for sixteen patients, thus making the cost per patient slightly 
more than one hundred and fourteen dollars. The only essential advantage 
which it possesses over the first building is that it gives ample space for each 
IDatient's rest chair placed at the foot of his bed and protected from the 
weather. Aside from this, it provides several unessential features which con- 
duce to the patient's comfort. 

Unquestionably, buildings of this character providing outdoor sleeping 
accommodations and warmed sitting-room, locker-rooms, bath and toilet, can 
be erected under favorable conditions at $100 per patient, or less. To make 
this plan possible it is, of course, necessary to have a central administration 
building in which are located the various offices, dining-hall, kitchen, in- 
firmar}-, and staff and servant quarters. A sanatorium of this character, 
with a capacity for one hundred and fifty patients, under municipal, county, 
or State control, and designed to reach early ambulant cases of tuberculosis 
among the poor, would cost approximately as follows : 

Main building, three stories and basement, the latter containing the 
kitchen; the first floor the various offices and the dining-hall; the second 
floor the infirmaiy, diet kitchen, etc., and jiossibly the doctors' quarters, 
and the third floor, quarters for the staff and servants, $50,000. 

Various outdoor buildings, such as cold storage plant, stables, etc., from 
$10,000 to $15,000. 

Lean-tos for the accommodation of one hundred and fifty patients, $15,000, 
making a total, exclusive of land, of $80,000, or about $533 per patient. 

Most of the existing sanatoria intended for this purpose have cost from 
$1000 to $5000 per patient, and fulfil the essential requirements for open-air 
cure no better and probably not as well as does the lean-to plan. If we 
expect to give sanatorium training and treatment to those of the poor who 
may be afflicted wath early tuberculosis, it is necessary that we materially 
reduce the cost of constmction, equipment, and maintenance in sanatoria 
intended for this purpose. Otherwise it seems to me that we are entering 
upon an utterly hopeless undertaking. 

Bill of ^Material for Improved Leax-to. 
8 pieces hemlock, 4 in. x S in. x IG feet sills. 
6 pieces hemlock, 4 in. x S in. x 18 feet sills. 

1 piece hemlock, 4 in. x 8 in. x 20 feet sill. 

2 pieces hemlock, 4 in. x S in. x 22 feet sills. 


12 pieces hemlock, 4 in. x 8 in. x 16 feet girders. 

11 pieces hemlock, 4 in. x 8 in. x 10 feet girders. 
56 pieces hemlock, 2 in. x 8 in. x 16 feet floor joists. 
36 pieces hemlock, 2 in. x 8 in. x 20 feet floor joists. 

14 pieces hemlock, 4 in. x 4 in. x 12 feet, surfaced 4 sides, plates. 
54 pieces hemlock, 2 in. x 6 in. x 18 feet, surfaced 4 sides, 

5 pieces hemlock, 2 in. x 6 in. x 16 feet, surfaced 4 sides, 


75 pieces hemlock, 2 in. x 4 in. x 14 feet, surfaced 4 sides, stud- 

50 pieces hemlock, 2 in. x 4 in. x 12 feet, surfaced 4 sides, stud- 

6000 feet No. 2 X. C. shiplap sheathing. 

2500 feet No. 2 N. C. rift gr. flooring, % x 2i/4 inches. 

2200 feet % in. N. C. ceiling. No. 1, interior of living room. 
800 feet % x 4 in. (10 feet length) N. C. pine, slightly rounded 
on top for exposed flooring, to be laid i^ in. apart. 

40.000 red cedar shingles, 16 in. clears 5 to 2 in. 

8 sash 10 X 10 4-light 1% in. glazed S. S. 

6 pr. French windows, 3x4 ft. 6 in. 1% in., 48 lights. 

2 Dutch doors 3 ft. x 6 ft. 6 in., l3/g in., top 1 It., D. S. Bot., 

2 Pan., F. M. 2 sides. No. 1 cypress. 
2 doors 2 ft. 8 in. x 6 ft. 8 in., 1% in. 4-Pan., F. M. 2 S. 
2 doors 2 ft. 8 in. x 6 ft. 8 in., 13/^ in. 4-light 2 Pan., F. M. 2 S., 

No. 1 cypress. 
4 stationary blinds and air boxes for ventilators. 
500 bricks for chimney. 

58 brick piers, cement below surface through frost line. 
Plumbing — 2 toilets, 2 shower baths, 2 wash basins, 1 heater and 

hot water stove combined, 16 lockers 2 ft. square, with 

screen doors. 
Painting — Interior of living room filled and varnished; also 

toilet and locker room. All outside trimmings painted. 
Cupola — According to plan. 
Total cost, including labor and construction, $1830. 

Bill of Material for Original Leax-to. 

10 pieces 4 in. x 6 in. x 14 ft. hemlock, rough, for sills. 

2 pieces 4 in. x 6 in. x 12 ft. hemlock, rough, for sills. 

19 pieces 2 in. x 8 in. x 12 ft. hemlock, rough, for floor timbers. 

6 pieces 2 in. x 8 in. x 14 ft. hemlock, rough, for floor timbers. 
28 pieces 2 in. x 4 in. x 14 ft. hemlock, rough, for studding and 

plates for dressing-room. 

12 pieces 2 in. x 4 in. x 16 ft. hemlock, rough, for rafters and 

collar-bone for dressing-room. 
850 feet hemlock, rough, boards, sheathing and floor lining. 

9 pieces 4 in. x 4 in. x 14 ft. hemlock, planed on four sides for 

4 pieces 4 in. x 4 in. x 16 ft. hemlock, planed on four sides for 
bearing columns. 


20 pieces 2 in. x 4 in. x 16 ft. hemlock, planed on four sides, for 

studding and shed roof rafters. 

21 pieces 2 in. x 6 in. x 14 ft. hemlock, jilaned on four sides, 

for rafters. 

Fe-oo.^ FS 

<5_ t-'L.^r 


Fig. 124.— Plan of proposed shelter, country branch of the Rush Hospital for Consumptives, 


9 pieces 2 in. x (1 in. x 12 ft. hemlock, planed on four sides, for 

600 ft. Xo. 2 rift flooring, X. C. pine. 

1000 ft. X"o. 2 Co'n flooring, X. C. pine, for floor sides. 

Ceiling, lockers, and toilet — 1500 ft. X'o. 2 hemlock flooring, for 
sheathing on sides and roof of lean-to. 

88 ft. % in. ceiling X'. C. pine, for shutters. 

500 ft. soft pine for cornice casings and corner boards. 

14,000 red cedar shingles. 

1 window 11/4 sash, 24 in. x 24 in.. 2 It. 

1 door 2 ft. 6 in. x 6 ft. G in. x IV2 in- i It- 

1 heater and hot water stove combined. 

1 toilet and one shower bath. 

8 lockers