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Transactions 

of the 



Sixth International Congress 
on Tuberculosis. 

WASHINGTON, SEPTEMBER 28 TO OCTOBER 5, 1908. 



WITH AN ACCOUNT AND CATALOGUE OF THE TUBERCULOSIS 

EXHIBITION, 

WASHINGTON. SEPTEMBER 31 TO OCTOBER 13. 1908. 



9n l^tx l^olumeaeL 

VOLUME THREE. 



PROCEEDINGS OF SECTION V, 
Hygienic, Social, Industrial, and Economic Aspects of Tuberculosis. 




Philadelphia: 

WILLIAM F. FELL COMPANY 

1908. 



Contents of Volume III. 



PAOB 

Opening Addrese of the President 1 

Mb. Edwakd T. Dbvinb. 

The Cost of Tuberculosis in the United States and its Reduction 5 

Pbof. Ietinq F18HEB 

The E^Gonomic Loss to N. Y. State in 1907 from Tuberculosis 37 

pBor. Wjo/teb F. Wxllcox. 

The Burdens Entailed by Tuberculosis on Individuals and Families 47 

Mb. Sbbucan C. Kinobley. 

The Monetary Loss in the U. S. due to l^iberculosis, Based on the Returns of the 

Twelfth Census of the U. S 55 

Pbop. Jaues W. Oix>txb. 

The Relation between Tuberculosis and Mental Defect 88 

Db. Maktxn W. Barb. 

The Awakening of a State: An Educational Campaign for the Prevention of 

Tuberculosis 93 

Mb. John A. KiNoeenRT. 

A State Aroused. Effective Control of Tuberculosis in Small Cities and Rural 

Communities 110 

Ms. HoheR' Fovks. 

Standardization of Investigations 120 

pBor. John R. Cohuons. 

The Ransom of a Great City 132 

Mb. Talcott Wiluahs. 

The Influence of Overwork and Nervous Strain in Tuberculosis 135 

Db. Qeobob Dock. 

The " Piece Work " System as a Factor in the Tuberculosis of Wage-Workers 139 

Mzss Janb Addaw and Dr. Aucb Hamilton. 

Tuberculosis as an Industrial Disease 141 

Mb. Fbbdbbick L. HorFUAN. 

Factory Legislation and Tuberculosis 179 

Mb. John Martin. 

The Cosh Value of Factory Ventilation 184 

Pbof. G. E A. Winslow. 

Tuberculosis 191 

Mb. Frank Durrr. 
V 



VI comrsNTS or volume m. 



K«Anoimie A«ip«ete of TnbereakMM in Mflwaak«e 195 

Mm. Thoma* W. B. Ckatzb. 

TnlrMitMry Ttib«teulo«i« among Printen 209 

I>B Jamm AuexANDBS SInxxB. 

Nf>ft«i rm Mortality from Tuberculous Phthims in En^nd and Wales, and on the 

ixjm tft fylfe by this DiMaiie in the variouB Occupations 218 

Dm. JoHH Tatham. 

fie^ltimate Exercise of Police Power for the Protection of Health 222 

r>K. HSfTBT BaIBD FaTIIX. 

The liCglUmate Kxercise of the Police Power in the Protection of Health 230 

HoM. Datxd J. Bbewck. 

A Ctmiprehenslve Program for the Prevention of Tuberculosis 236 

Da. LiTiNosTON FAaaAMD. 

The Ktinntldn of llcUef Agencies and its Variations in the Campaign for Social 

Control 245 

Ma. FaAMCw H. MoLbah. 

PrfVirrvnticm nniiintwrrulouso chex les jeunes filles dans les centres manufacturiers. . 253 

Madams BKaor-BKBOKB. 

Tlin Untenohntiln ('-onsumptlvo 256 

Mow RixBif N. La Hottb. 

InituNi rial ItimtrAnre with Uolatlon to the Conflict with Tuberculosis 263 

l*nor. GHABbRB RlCIIHOND Hbndbbson. 

tlistoint d'un dlNttoitsnlro do Kuulwurg 284 

Ml.LH. L. ('HArTAU 

lid lut(«t nnit(ul>rrtnilrUMt sur \\n nouveau plan k Anvers par I'Oeuvre des dispen- 

salrm aiitltulirrruliHimyH anvorsois , 291 

Da, L. Van Bouarbt, 

llio HnUtlvpYnUin of (Htnmto In the (^imivdgnngtiinst Tuberculosis 296 

Ma. Bhkmhah U. Uommkt. 

Iii> d[ft|N*iMnlrp nntltultomdrtix dc l.yon 300 

My. R. Abuuno bt J. Cdvbhomt. 

IV titslttufUm "llalsan" (Hoalth) and tt« Work 310 

l>a. C NRAMikBa. 

lUlallitn %>t INih^rmiUwts to C>tmo ami the Inoar<<»rated Criminal 320 

t)a. Jvu«^ B. Ranboh. 

•*t«»ly of \\^ IMftUim wt IVwIttulUw to Tub«mikM« 332 

l^. J. WiLUtt-miBT iBVm. 

1W tW i\( a XAVfct^ IW^uwt In th^ KrMikMk of a Sanatorium fvv the Benefit of 
t\^vi^ll^)|ttl\-^ 341 

IV lm)HHiA^,v \^ Kariv Ur^^tnitK^, IVwxi^l HeM. aiKl IVventioii from an 
KVi^^Mfo 8taml|H^lU 349 



OONTBNTS OF TOLUHX m. VU 

PAOB 

The Eariy Recognition of Tuberculosis: Some of the Difficulties^ ProfeosioDal and 

Social, and some Suggestions as to the Remedy 363 

Da. Edwuui O. Otis. 

Institutional Care for Early or for Advanced Consumptives? 361 

Mb. Jacob H. Schxit. 

The Examination of Patients exposed to Tuberculosis and Patients suspected of 

having Tuberculosis 367 

Da. Ijnblt E. Williams. 

Five Years' Inquiry into the Home Conditions of poor Consumptives in the West of 

London 374 

Dk. J. Edwabd SQaiRE, AMD Db. E. B. Hulbbbt. 

How to deal with the Danger to Patients of Return to Unfavorable Conditions 381 

Mb. Waltbb E. Kbubbi. 

The Care of Patients after discharge from Sanatoriums: The Question of Farm 

Colonies and Industrial Settlements 387 

Hbs. Eluabbth W. Nbwoomb. 

A Farm Colony Experiment 392 

Db. Hbnbt Dabton Jacobs. 

A Comprehensive Plan for the Treatment of the Tuberculosis Problem 398 

Mm. Victob Q. Blobdb. 

Training for Professional Nursing in Institutions for Tuberculous Patients 407 

Dm. Cbabubb J. Hattibld. 

Tuberculosis among the Jews 415 

Db. Maubicb Fxbbbbbo. 

The Prevalence of Tuberculosis among the Italians in the United States 429 

Db. ANTOino Stella. 

Is the Prevalence of Tuberculosis among the Negroes due to Race Tendency? 454 

Db. Robxbt Wilson, Jb. 

Pulmonary Tuberculosis among the Scandinavians 463 

Db. Qbobob Douglas Hbai>. 

IHiberculosis in the Irish Race 473 

Db. Lawbbncb F. Fucx. 

Contribution to the Study of Tuberculosis in the Indian 480 

Db. Albb Hbducba. 

Experiences of a Sanitary Inspector with Tuberculosis 490 

Miss Johanna von Waonbb. 

Disinfection in Tenement-Houses: by the Department of Health of N. Y. City; 

with Instructions given by the Visiting Nurses 500 

Mus Elbib Thatbb Fatterson. 

The Disinfection of Houses. What is not Done 502 

HiBB Mabib T. Phxlah. 

Antituberculosis Work in the Pittsburgh Public Schools 505 

Mias Bbbtba L Stabx. 



VUl CONTENTS OP VOLUME III. 

PAaE 

The District Nurse in Providence, R. I., in the Campaign against TuberculoGid 510 

Dr. Jat Pebuns. 

Tuberculmsi:! in Kurul North Carolina 515 

Moa Ltdll Uolma». 

Ainatorium Atmosphere 518 

Uba. Florence R. BrRi:Ea& 

The Nurse and the Tuberculous Patient 5'JO 

Mu» Stella Fewuiith and Mas Locic Croft Dotd. 

The First Open-Air Sanatorium for TuberculoKis in Italy o2o 

Mias Amy Tcrton. 

Report of the Nurses' Work in the Tuberculosis Class of the Presbvterian Hn^ipital. 

Phila.. Pa 528 

Mxas Frances Hostctter. 

The Tubercukwis Work of the Social Service Department at the Massachusetts Gen- 

end Hospital of Boston 531 

Hu8 Ida M. Cannon. 

The Tuberculosis Nurse as a Social Worker 536 

Mias EuzABiiTB p. Upjobx. 

Hume Teaching in "^berculosis da^j 539 

Mxas Edna L. Folet. 

UQHpital Care for the Advanced and Incurable Cases of Consumption 543 

Una S. H. Cabanxm. 

Th« ImportancQ of Nursing and Supervision of Advanced Cases of Tuberculosis . . . 546 

BIiRB Harriet Fuucer. 

The Day Camp 549 

BliRB Scran Fdrrebt Robbins. 

Tte Vahie of a Nune in a Tubezculosia Dispensary 5l>i 

Db. Benjamin Lee. 

TteUM^nigBd Sanatorium F&tient 556 

Haw H. AucB Qaixaohkr. 

IWtttiaqf^pjpiTtaiDUig School for Nunes 5G0 

Has AaniR K. Sctton. 

Vhm Otmuiun In FanuBet of CwHamptivoB and Possible Dangers to the 

IhiUk.r. 504 

Mas Mabrl Jaoqvib. 

"^fcMiuintftdllkftllndmBMkriGt Nnxae tomud Tuberculosis 570 

VasAjOBMNiB R- Smrhwick. 



^'WEjftuAVwittty 573 

Ibm Iio Abab Bam. 



>«tt%^\tt&u 674 



^^f llMVenHiuoiiCABrsR. 
f^^^ ''^^'^'■•^4'klAwWaHrae 576 



CONTENTB OP VOLXTME lU. IX 

Mas 

Elementary Instnxcticm as to IViberculoeis 685 

ICb. A. E. WmsBiF. 

Training Teachers for Educati<xi against Tuberculosis 580 

Mm. Datui S. Smkodbn. 

Educational Propaganda through Ix>cal Lay Agencies; especially in Schools, 

Settlements, ana Charity Oi^ganizations 506 

pEOr. Hknbt B. Wako. 

The Colleges of the United States and the Campaign against Tuberculosis 602 

Ub. Wiixiah Hasmon Nobton. 

The Body or the Bacillus — which shall be emphasised in the Hygienic Education 

of the PubUc? 614 

Db. Howabd S. Amdxbb. 

Hygienic Instruction in Schools 621 

Db. Ubnbt Babton Jacobs. 

A Proposition to Introduce a PubUc Health Week into the Public Schools 628 

Db. Ch. Wabdbll Stiijcs. 

Educational Value and Social Significance of the Trained Nurse in the Tuberculosis 

Omipaign 632 

Mme LcuAH D. Wau>. 

Ia lutte contre la tuberculose k Lyon 641 

Bf . PaUX. CotTBMOMT. 

TViberculosis and Two Thousand Dollars a Year 656 

Db. Hblxn C. Pdtmam. 



The Popular Lecture in the Crusade against Tuberculosis 663 

Db. S. Ajwlphub Kiropr. 

The Blue Star. A Simple and Practical Way to interest People in Tuberculosis 

and to Raise Funds to Combat the Disease 676 

Hiaa C1.ABA E. Dtab. 

Tuberculosis and the Public Schools 682 

Db. LnTBBB H. Quzjck. 

Report on the Teaching of Elementary Hygiene in the Training Colleges and Ele- 
mentary Schools of Great Britain and Ireland 603 

Db. G. a. Hebon. 

Note 8ur le r61e des associations de la propri6t^ batie en France au sujet de la 

tuberculose, et particulidrement de la Chambre Syndicale de Paris 713 

M. A. Habc. 

The Relation between Income and Tuberculosis 717 

Db. Woods HurcBnraoH. 

Le traitement des 6tats pr6-tuberculeux dans les institutions sp^ciales (Preven- 
toriums) 722 

Db, Abthub J. RicHBB. 

Wcnnan's Responsibility in the Prevention of Tuberculosis 725 

Hbs. Isabbl Hampton Robb. 

Some Uses of the Imagination in the Prevention of Tuberculosis 731 

UlBS SaDIB AlUEBXCAN. 



,^ iroNTKN'm OK VOLUME III. 

PAOB 

hlitl lift Mil l'llniiH<nl- in iiii'n*(iHiriK ItiwmUim^, with Hpccial Reference to the Protctn 

ICiitlnti 740 

Uh. J. 11. Kku.000. 

'I'lin |iii|Hiiiiiiicti i»r Onil mill DitiiUil ('H>iuliiionH in Tuljcrculosis 765 

Im. WiM.uu It. WooonuRT. 

Tlin riiiMMilltiii nl Itiiitmnily MiriiUKh IMiyMiriil Kdncation 770 

I'uor. TiioMAN A. H'nmer. 

'Ilin Itoldlloii III liiintlM.iiiiiiiii III tliii rnililom of HcMniring Social Conditions favor- 

hIiIk III (liwiKiiil hiiiiHitiily 774 

Mil. IliiiihKT WATc:tiunN. 

iMiH i(ji|Mwln iii'*(f.ll^<'"t ill* 111 Idilto roiiln' III inlxfrniloHc: Ics tuberculeux pseudo- 

liiiiii |Hiiiiitilft, li<iilMirillil(^n'iiriirliiM'lii|ii4M4;t mitW>ricux 783 

I hi. llAiiiiToiniT. 

Aildiiwi . 789 

Mil. jAI-dll A, ItllH. 

Aildliww ■ 791 

l(»iV. HAUirKL Mf4!||(IHU (^HOTIIRIUI. 
AlMllUW 795 

I hi. T. J. Hi-AvroKii. 

Ailili*wi 797 

t*n. (ItriTiioui Tannwitz. 

AtMtfwf* 798 

MinH llri.KN Toi)i>. 

y^fMriMi 800 

Mum Katn lUuNAiit*. 



A 



/Vlf w» 808 

I'M. ii<l|IKIIT KOOII, 

.^^fnmt (W IhAierl Kixih-HUftiiiiK mir llokAmpfung dor Tuberkulose 810 

f^^ I>ii. UiiiiKiiT Koch. 

4^*1* 813 

/k'^ Mm. liiJiim K. ISiiown. 

MA¥imA»i4 t)ie VnA^kni 814 

^'}f0^ Urn, Xdwahd T, Vwnnu 

815 



^ 



% 

Cube 
rubercu 
The True I 



SECTION V. 

Hygienic, Social, Industrial, and Economic Aspects 

of Tuberculosis. 



FIRST SESSION. 

Tuesday, September 29, 1908. 

ECONOMIC ASPECTS OF TUBERCULOSIS. 

The burdens entailed by tvberctUosis: on individuals and families; on imfu»- 
try; on relief agencies; on the community; on social progress. 

The cost of sectoring effective contrcl of tuberculosis: in large cities; in smaller 
towns; in rural communities. 

Special aspects of the social problem. 



Section Y of the Sixth International Congress on Tuberculosis was called 
to order by the President, Mr. Edward T. Devine, at half past nine o'clock 
on Tuesday morning, September 29th, in the New National Museum. 

Honorary presidents of the Section were nominated and were unani- 
mously elected; as follows: 

The Countess of Aberdeen, Dublin Dr. J, Patten McDougall, Edinburgji 
Dr. Clemente Ferreira, Brazil Dr. Gotthold Pannwitz, Berlin 

Dr. G. A. Heron, London M. Augustin Rey, Paris 

Dr. A. J. Richer, Montreal 



OPENING ADDRESS OF THE PRESIDENT. 

Edward T. Devine, Ph.D., LL.D. 



Tuberculosis is a disease. Its cure is for doctors. Its prevention is for 
sanitarians. Its disappearance from the earth will be their triumph. Its 
continued prevalence and its great mortality are their disgrace. Why then 
VOL. ni — 1 I 



2 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 

should laymen — that is, teachers, business men, nurses, social workers, and 
others who are neither sanitarians nor physicians — come to the International 
Congress, and why should we have this fifth section on industrial, economic, 
and social ns well as hy^enic aspects? 

There are two possible replies. The first, suggested by an eminent phy- 
sician in an address in New York two years ago, is that the doctors have 
been remiss. Social workers, he thinks, have been misled by the enthusiasm 
and vigor of the present public interest in the crusade against tuberculosis, 
and are giving too much attention to matters which are primarily the phy- 
sicians' business. In other words, if doctors and health officers did their 
duty, we would not be here. The other reply would be directly the reverse 
of this. It may be that we have this section on social, economic, and in- 
dustrial aspects precisely because physicians and sanitarians have of late 
begun better to understand their business, better to gage the height and the 
depth and the multifarious aspects of this their ancient enemy. It may be 
that they have come to look beyond the patient, to his family and his neigh- 
bor, beyond the infected lung to the, as yet, uninfected childhood and youth 
of the patient himself, and to the long years of life's prospect, bought it may 
be with a great price of parental devotion, pledged with a sacred bond of ob- 
Ugation to wife and children, a just heritage, precious beyond computation, 
but sacrificed in spite of the price paid, in spite of the sacred bond, in spite 
oi the just clum to an inheritance which would have robbed no other, sac- 
rfioed to our ignorance and our cupidity, and the futility of our im]x>rfect 
eocul arrangements. May it not be that the medical professicm is here 
^rm% evidence, by establishing this section in the International Congress, 
tbal it leaHzes at last that to overeome tuberculosis something more is 
iMftded than the treatment of the individual patient, something more than 
teadonemeiLt of the most enlightened health regulations? — though God 
Vumveittfidbetter health regulations and — ^butno, I shall not further en- 
oQiAL Qpoa the province of the other sections. Let the bacteriologists, 
ttil fidihdboQBlB, axkd clinicians, and surgeons, and veterinarians, and 
VPs£iinm,ud\Ai^dan8 say whether from the scientific and professional 
yJBdL d nn \ltt time has come when we need no longer say concerning the 
teaM&niifta treatment/' God knows and we do not." 

teu^^xmevec, that the last word had been said about all these 

*V)S^.*^)^nntory and climc had }rielded their secrets, and that the 

^"^^V'nsanUbe\»ra of sdenoe had been laid bare, there would be 

^^««i\«e&\Q\ftix^ viae physicians say) a need for public coojx'rar 

'^-^wVxi^naa^raintheBociBl as distinct from the medical vicw- 

y^ '^^AVRTO^n&finehaa those here assembled in this fifth section 

'^'«Vni(ni.^«te^^ipento be doctors of me<liciuc or not, ran 



OPENING ADDBE8S OP TBB PRESIDENT. — ^DETINE. 3 

The keynote of the discussions in this section of the Congress, so far as I 
can forecast it, will be immunity, increase of resisting power. I do not, of 
course, refer to immunization throu^ senuns or vaccination — that is for 
another section; nor to immiuiity throu^ action by government — that, 
although logically a part of our subject, as our subject is stated, is reserved 
for a separate section. 

The keynote of this section is the securing of immunity throu^ such an 
improvement of the general standard of living, such changes for the better 
in wori^ing conditions and in living conditions, as will increase the resiBting 
power of the individual agmnst tuberculosis and against all disease. 

We shall dwell first of all upon the actual burdens imposed upon us 
by this conquerable, but still unconquered, scourge of mankind. We shall 
tiy to translate it into dollars and cents, and shall put by the side of such 
calculations some statement of the cost of actually overcoming the disease; 
though we know well that human life is not to be measured by dollars, and 
that dollars, on the other hand, do not measure in full the heroic efforts — ^the 
inadequate and yet praiseworthy and inspiring efforts — aheady put forth 
in the campaign for the saving of lives and the stamping out of infection. 
We shall not shrink from putting forth in the dearest possible way the 
demonstration that a large part of the explanation of the prevalence of 
tuberculosis lies in adverse industrial conditions, in the nervous strain of the 
speeding process, in long hours of work, and in dangerous features of certun 
trades, which require far more radical and sweeping le^lation than we have 
yet secured, and far more efficient and courageous enforcement of legisla- 
tion than we have known how to demand; and we shall ask high authorities 
in jurisprudence and in medicine to discuss the principles on which the state 
should exercise its police power for the protection of health. We shall not 
blink the fact, on the other hand, that another large part of the explanation 
for the prevalence of tuberculosis lies in the personal habits and in the in- 
sanitary conditions of the homes of the people; and that in this sphere, while 
there b a place for municipal inspection and supervision, it is largely for the 
people themselves to say whether they will reduce, or even entirely elimi- 
nate, the risks which they constantly but needlessly incur. Dark, im venti- 
lated tenements should not be allowed to exist at all. Nothing could be 
more futile than the policy of moving a family, in which there is tuberculosis, 
out of a dark, damp apartment in order that the sick patient may have light 
and air, and leaving the apartment, thus inferentially condemned as unfit 
for habitation, to be immediately occupied by a healthy family, some of 
whose members, because of the darkness and the dampness, now supple- 
mented it may well be by direct infection, will almost certainly find their 
health undermined if they remain long enough. It is for the State to fix 
and enforce a standard of housing higher than that of any of our cities and 



k -awn t N't tai NATIONAL CONGRSSS ON TUBERCCLOSIS. 

>» M,»:iip*i»a; I'ut thw particular evil— insanitary dwellings — to make a 
tivv.i iiiijs*u.ittL iviitnLmtion to the elimination of this disease and of all 
..i>\\4i^\^ riu' xiiiio uiav iiuitml the factory, and to the extent that I have 
\x:u.;;i\i '.ikt\ c\*iitivl I ho houte: but it cannot and need not control our more 

r :v»M'ii.»l ivlatioiishiiw. our jier!«.>nal habits of cleanliness and of diet, 

s . '»4\ *;o iviM*!!^! ju'lioiut which may nevertheless endanger our own 

wn» \ .Iv liMvi i»i' i»(lu»r>t. Into these spheres also the campaign against 

...\.v*..k\«.i iiiii.'^i ix»riu»rsi»K»(^ly extend. The eyes of the people must be 

. V. vx ^' . ho MHiuxv* of dju»K^*r. where they lie. Their perceptions must be 

v. ..^.x. V*M-iv must U^ ilcvclo|HHl among the people everywhere a con- 

V. . V. . •;»>-v4»\il wvW Iviu^, which thoy may carr>- from the kindergarten 

. \ ,w.'*4i> . ukI on lliixui^h all the activities and interests of after-life, 

\ .*;tou.»l. M»mul.comiH*lUng rtvpect.ctmtrolling the actions, sub- 

,^ .i.iuu ix^iwidcration, nnnising enthusiasm: social rather than 

... ....X. \wAsi i>j^»» a n^alization that our personal expectation of 

.^.»i:\ .ksiih nito iw> tlependent largely upon the industrial 
. X ... X ..».:;;* ';w *'* 'ho iH»mmunity in which we live. And so education, 
» ^iivi »h** ix>t|H»iwibiUty of society are the important special 
. UvU »*v' •*^'** iu\iu» vou to discuss. 



\Vt}, 
BtiU . 
tlOIJ, ; 

point, ; 
of the (\ 
he'p to s, 



THE COST OF TUBERCULOSIS IN THE UNITED STATES 
AND ITS REDUCTION. 

By Irving Fisher, 

ProfeoMT of Politie«l Eoooomy at YaIs Uninnity. 



All students of tuberculosis are agreed that it is a costly disease. Sel- 
dom, however, are the costs formulated and expressed in definite figures. 
The object of the present paper is to summarize briefly existing data, to 
classify and estimate the costs, and to point out the extent to which these 
costs are being reduced, as well as the most promising methods of securing 
further reductions. 

We may classify the costs of tuberculosis as follows: 
Cost in lives 
Cost in disability 
Cost in unhappiness 
Cost in money 

These costs are not mutually exclusive, but overlap and are interrelated 
in many ways. It is, in fact, difficult to treat one without treating all. 
The chief and most fundamental cost is the cost of life, with which we shall 
therefore begin. 

I. Cost in Lives. 

The mortality from tuberculosis may be expressed in several wa3^s — in 
terms of (1) the number of deaths; (2) the "crude death-rate"; (3) the "cor- 
rected death-rate";* (4) the death-rates according to age, sex, occupation, 
housing, financial competence, and other pertinent conditions; (5) the per- 
centage of deaths from tuberculosis in relation to deaths from all causes; and 
(6) the curtailment of the "expectation of life." 

The crude death-rate from tuberculosis of the lun^ in the United States 
is g^ven in the census reports, the latest figures being those in the volume 
on "Mortality Statistics, 1906." They relate to the "registration area," 
or States and cities in which accurate records are kept. In this area the 
death-rate from tuberculosis of the lungs amounted to 159 per 100,000 of 
population; the death-rate from tuberculosis in all its forms waa 184. The 

* It IB unfortunate that corrected death-rates are not more generally calculated, 
especially in the United States, where, on account of great variations in the age and 
sex constitution of the population, they would be especially useful. See the writer's 
"Mortality Statistics of the United States Census," Publications of the American 
Koonomic Association, 1899. 



6 SIXTH INTERNATIONAL CONGRESS ON TUBERCttLOSlS, 

re^tration area included about half the population, or 41,0 million out of 
the total population of 83.0 millions. 

The rate for the non-registration area probably exceeds very consider- 
ably the rate for the registration area, because of the fact that the non-re^a- 
tration area contains the major part of the negro population, among whom 
the death-rate is known to be higher than among the whites, and contains, 
also, the great health resorts in which so many consumptives die, and for 
other rcaaons. On the other hand, the non-re^tration area is far more 
rural and less urban than the registration area. Assuming that the urban 
and rural death-rates known for the registration area may be apphed to 
the non-registration area, we obtain for the whole Unit^ States an esti- 
mated death-rate from tuberculosia of the lungs of 142 per 100,000,* or 1 19,- 
000 deaths for our population of 83.9 millions as estimated for 1906. Since 
we lack any exact statistica^ it seems better, in making estimates, to make 
them too small; these figures are probably about three-fourths of the truth, 
and the same ratio of understatement applies to all the calculations later 
in this paper, such as money costs, which depend on these figures. The 
results are so appalling that we cannot be too cautious in stating their 
statistical ba^is. 

Tul>erculosia of the kings causes in the registration area 86.5 per cent, of 
the total deaths from tuberculosis. On the basis of this figure for the entire 
country, the death-rate jrom tvbercidmis in all its fonns is estimated at W4 p*T 
100,000, or 138 /JOO deaths per annum for the population of S3.9 m iUions of 190S. 

It is iJitcresting to compare the American death-rate with the death- 
rates in some other countries. 

NUMBER OF DEATHS FROM TUBERCULOSIS OF THE LUNGS PER 100,000 

OF POPULATlON.t 

AiiAlraltwiu , 76 

Bot^uni ......,.,,,.-, ................................ 109 

Englaiul and Wnlta 1 14 

ItoTy tl8 

NritnorlaiuU , 130 

Uniunl StttUfl 142 

Japan, , , , 145 

JaniAicft ,,..,. , *.........,. V 162 

GfrniAi] Krnpira . . * 183 

Norway , , * , 197 

TrvUnd... .. , , 210 

WtTvia _ . 332 

AustriA 336 

t The figurw for the United States arc for 1906, as above c&lc^ulaied; those for 
AuatnJofiap Kxiglaml and Wale«. Netherlands. Jamaica, Ireland, Italy, and Servia 
an? for 1905; tlitmt* for the Ofnnaii Etiipire, lielgium, and Norw^ay arc lor 1904; and 
tlipse for Aiiatrb and Jnpan. 1003, (See Cenaua, ''Mortality Statistics, 1906/' p. 50.) 

•The delaiU of this calculaiion are aa follows: The death-rate in 1906 for tho 
iT^pslration citic? h gi^-en in th« Census, "Mortality Stati.itics, 1900/' f»age 51, as 181.5 
per 100,000 for 25.8 mUlioiiSi Appljriug this doath-rate to the aon^registration dtios, 



THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 7 

We have estimated the deaths from tuberculosis of all kinds in the United 
States as about 138^000. To realize the magnitude of this figure, we may 
compare it with the deaths from other well-known and much dreaded dis- 
eases. It equals (if we may judge by the registration area) the comlnined 
deaths from typhoid fever, scarlet fever, smallpox, diphtheria, cancer, dia- 
betes, {^pendidtis, and meningitis. 

The extent of the ravages of tuberculosis may be brought home to us 
with great force if we compute how many of those now living are doomed to 
die of it if the present death-rate continues. This can be calculated from 
the deaths at different ages,* as given in the census, assuming that the dis- 
tribution of deaths by age will remain the same. Calculating on this basis, 
it is found that out of 83,900,000, the total number of people living in the 
United States in 1906, almost exactly 5,000,000 are doomed to die of tuber- 
culosis in some form. This number may, let us hope, be materially reduced 
by the preventive causes now being set in motion. 

As compared with the total deaths from all causes, the percentage of 
deaths in the re^tration area of the United States from tuberculosis of all 
kinds in 1906 is not given in the census volume, but may really be calculated. 
It is 11.5 per cent. In other words, one death in nine is due to ttiberculosis. 
The deaths from tuberculosis of the lun^ alone amount to 9.9 per cent, of all 
deaths. For males it is 10.1 per cent, and for females 9.8 per cent. 

The percentage varies greatly at different ages. Calculating from the 
number of deaths given in the Census, "Mortality Statistics, 1906," page 354, 
we find the following as the ratios which the deaths from tuberculosis of 
the lungs bore to the total deaths of that year: 



TUBERCULOSIS OF THE LUNGS AS PERCENTAGE OF ALL DEATHS. 





Age. 




Under 6. 


6 to 9. 


10 to 14. 


[16 to 19. 


20 to 29. 


Hale 


1.1% 
1.1% 


3.0% 

4.2% 


6.4% 
15.4% 


35!8% 


29.9% 
36.9% 


FymRilft I 





which comprise 2.7 millions, we find 4900 deaths. In the same way the rural death- 
rate in the r^;i8trfttion cities is given as 122 per 100,000 for 15.2 millions. If we apply 
this death-rate to the rural non-registration area, which comprises 40.2 millions, we 
calculate the nimiber of deaths as 49,000. Adding 4900 and 49,000, we obtain 53,900 
as the estimated total number of deaths from tuberculosis of the lungs in the non- 
r^istration area. The total population of the non-registration area is 2.7 + 40.2, 
or 42.9 millions. (The death-rate in the non-registration area is, therefore, estimated 
at 53,900 + 42.9 millions, or 126 per 100,000.) Adding the total deaths of the re^- 
tration area, or 65,400, we have the deaths in the country, estimated to be 1 19,500, which 
for a population of 83.9 millions gives as the death-rate for the whole country 119,300 -i- 
83.9 miUions, or 142 per 100,000. 

♦ See Census, "Mortality Statistics," pp. 354-356. 



SIXTH INTERNATIONAL CONGRESS ON TUBERCXTLOSIS. 



TUBERCULOSIS OF THE LUNGS AS PERCENTAGE OF ALL DEATHS.— 

(Continued.) 





AOB. 




30 to 39. 


40 to 49. 


60 to 69. 


70 aoAabtm, 


Male 


27.4% 
26.7% 


18.9% 
14.8% 


Ill 


!:?§ 


Female 





We see that the deaths from tuberculosis reach a maximum, as com- 
pared with other causes of death, at the age of 20 to 29, being then for males 
a little less than one-third of all deaths, and for females a little more than 
one-third. For the entire population, the deaths from ttiberctdoais of the 
lungs at the third decade of life are almost exactly one in three. 

This fact is of great significance in any estimate of the cost of tubercu- 
losis. We cannot estimate the cost of disease by the number of deaths 
merely. A death from cholera infantum or from Briefs disease is not as 
great a loss to a nation as a death from tuberculosis; for the reason that 
infants and the aged are of less value in a population than those living in the 
prime of life. Tuberculosis picks its victims at the very period when the 
value of life is a maximum, after the investment in the education and prep- 
aration for life of the young is finished, and before the period of declining 
vitality sets in, when the productivity of the individual has become ex- 
hausted. 

If we compute the average age at which male 'consumptives die in the 
United States from the deaths at different ages given in the Census, "Mor- 
tality Statistics, 1906," it will be found to be 37.6 years, and the correspond- 
ing average for females is 33.4 years.* At these ages the expectation of 
life is about 30 years, and if there were no such disease as tuberculosis, it 
would bo, acconling to the calculations of T. £. Ha>'wardt in England, about 
a year and a half longer. This figure, 30 years, is approximately the number 
of years of life cut off by tuberculosis, but the method of computing this lost 
life time— by taking the expectation of life at the average age of dying 
consumptives — is not theoretically correct, since it is based on the assump-. 
tion that all consumptives live to the exact age of 37.6 for men and 33.4 
years for women, and then die, instead of d>nng at various ages. 

In order to calculate correctly the aN-erage years of life lost through 

* Or. Price (''Study of the Economic Oouree of Consumption in Wage Earners," 
Journal of the American Mc<iical Asmciation, April, 19C>5) has estimated the average 
AfCO at (loath of con.sumpti>*e workers in Maryland whoeie caaes were especially investi- 
gntotl as ."Wi years, that for males being 36.7 and for females 29.S. 

t The Construction of Life Tables and the Application to a Oompariaon of the 
Mortftlitv fn^m Phthisis in England and Wales during the Decennia 1881-90 and 
lS91-190l). 



THE COST OF TUBERCULOSIS, AND ]TS BEDUCTION. — FISHER. 9 

tuberculosis, we need to consider separately the number dying at each age. 
We then get the following table, in which the expectation of life for each age 
is that calculated by Hayward for England on the supposition that tubercu- 
losis should be completely eliminated. It assumes that if those d3ring of 
tuberculosis had not contracted the disease, they would later die of other 
diseases at the same rates as other members of the community. 



A^B. 


AcmAL Deaths 
ntou 

TCBEBCT.'L.OflM 

or LvNna in 

REOEBTR.l'nO'* 

Aaxa or U. S. 

ml«W. 


AcTTJAiLT 

Lived ar 

TITIM 


YEAMOr 

LiTK Cut 
Orf iiT 
Dkath 


Or 
Waicii 

THE 

Yeabs 
or Liri 
Btroai 

J"* 
Wese: 


An& TV! 

Vtas> 

hmm DO 


LmATtHa 

U THE 
Ykui 

OF Lin 
BfeTVEcrr 


OtQ 4 

5 to 9 . 


f M 1,120 

\ F 934 
/ M 242 
\ F 304 
/ M 292 

\ F 775 
J M 1,980 
I F 3,070 
/ M 8,900 
\ F 9,448 
/ M 9,290 
\ F 6,775 
I M 0,730 
F 3,585 
/ M 6,300 
\ F 3,408 
/ M 1,096 
, F 959 


2^40 

1,863 

1,815 

2,280 

3,650 

9,687 

34,650 

53,725 

222,500 

236,200 

325,150 

237,125 

302,850 

161,325 

378,000 

204,480 

82,200 

71,925 


63,600 
54,732 
13,200 

17,115 

14,6(X> 

40,300 

90,500 

14.^.83.5 

a48,00O 

387,308 

286,000 

220,187 

154,800 

88,550 

82,500 

48,394 

6,795 

6,425 


10,400 

13,739 
2,415 
2,970 
K400 
3,807 


8,580 
8,307 
1,952 
2,854 

2^97 

7,384 
16,467 
29,507 
75.783 
92,840 
S2J00 
09,466 
65,000 
39.703 
82,500 
48,394 
6,795 
6,425 


38,620 

32,686 

8,833 


10 to 14 


11,291 

10.803 


16 to 19 

20 to 29 


29,049 

74,033 

116,318 

272.217 


30 to 39 


294,528 

203,300 


40 to 49 

50 to 69 

70 and over ...... 


150 J21 
89,800 
48.847 


Total 


f M 35,950 
\ F 29;Jfi8 


1,353.056 
978,615 


1,059,995 
1,008,896 


20,215 
20^76 


342,174 
304,380 


697,606 
683,440 


Average; 

ftUl<3 


37.6 
33.4 
35,5 


29,4 
34.5 
32.0 


.6— 
7 
.6 + 


9-5 

10.4 
10,0 


193 


Fenmlea 

Both 


23.4 
21,4 







From these figures we find that for the 35,950 males who died of tubercu- 
losis of the lungs in the regbtration area of the United States in 1906, the 
ages of whom were known, tuberculosis cut off about 1,060,000 years of life, 
which is an average of 20.4 years for each individual. This is, therefore, 
the average expectation of life which male consumptives might have had if 
pulmonary tuberculosis had not cut their lives short. For females the ex- 
pectation of life at the time of dying is 34.5 years. For both sexes combined 
it is 32 years. 

We have calculated these results on the basis of United States figures 



10 



SIXTH USTERNATIONAL CONGBESS ON TUBERCULOSIS, 



for deaths from tuberculosis, combined with Hayward's figures for eac- 
pectation of life in England. We have no good recent life tables in the 
United States, and none at all calculated, like Hayward's, with tubercu- 
losis left out. But the prevailing life tables b the two countries have baen 
BO similar* that it ia practically certain our results are approximately correct. 

The period of I7i to 60 years has, in accordance with some previous 
investigations, IxKjn taken as the average workmg or wage-earning period 
of life in the United States. Of the 29.4 years of life lost by the average 
male consumptive, oner-half a year (0.6 year) occurs, on the average, before 
the age of 17^, and 9.5 years after 60, leaving 19.3 years as the a^^rage loss 
of working life, which falls between the limits of 17^ and 60 years. Of the 
34,5 years of life lost by the average female consumptive, 0.7 year occura 
on the average before the age of 17J and 10.4 after 60^ leaWng 23.4 as the 
average loss of life which falls witliin the working period, 17i to 60 j^eara. 
We see, therefore, that two-thirds of the loss of living years caused by 
tuberculosis of the lungs comes out of the working period of life. 

If we spread the total lose of living years, 29.4 years for males and 34.5 
for females, over the entire number of deaths from all causes, we find that 
the av^erage is 3.0 years for men and 3.4 years for women. In other words, 
had pulmonary tulDcrculoais been entirely al:jsent, the average duration of 
human life of alE men who died in 1906 would have been 3 years longer, and 
that of women 3.4 years longer. Of these lost years, 2.0 and 2,3 respect- 
ively are working years. 

We may compare these results with Jlr. Ila^'Tvanl's figures for England. 
He finds that had phthisis lieen entirely absent in lSDl-1900, the average 
duration of life would have been 2,22 years longer for males; and for females, 
1 .93. Of this loss due to phthisis, the major part is from the working period 
of life, which Ha^^ward takes as from the age of 15 to 65. Of the 2,22 yeaiB 
loet to men, the part which falls between the ages 15 and 65 is 1.67; of the 
.93 years lost to women, the part which falls between 15 and 65 is 1,46. 
'hese figures are not strictly comparable with those we have computed for 
the United Stat^, since the average age of the '*dying^' is not identical with 
the average duration of life. The discrepancy is fully explained in text- 
books on mortality statistics, but it would not probably affect seriously our 
present comparison. 

There is one assumption in the calculations thus far matie which ought 
to be mentioned and amended. This is that had \dctinas of tuberculosis been 
jVpared that disease, their subsequent mortality would correspond with the 
mortality of the rest of mankind. It is likely that their mortality would be 
greater. I do not mean that those who die of tuberculosis are weaker than 

• See the writerV "MortidJiy Statistics of the United States CeoAua," Publicatioiu 
df thfl American Economic AfisocJation, 1^9, p. 159. 




THE COer OP TUBEBCULOSIS, AND ITS B&DUCTION. — ^FISHER. 11 

those who die of other diseases in general, but simply that those who die at 
any time of life are presumably weaker than those who pass that time 
without dying. If the victims of children's diseases were protected from 
them, their lives would, of course, be greatly prolonged, but their subse- 
quent mortality would nevertheless be greater than that of other infants. 
In fact, it is believed by hygienists that the reduction in the deaths of in- 
fants in the last century has been the cause largely of the increased mortal- 
ity in advanced years. As evidence illustrating such a result, we may note 
that in Massachusetts the death-rate in 1895 compared with 1865 showed a 
reduction for all ages up to 40, but an increase for all ages after 50, while 
the intervening deoennium of life, 40 to 49, showed essentially no change.* 

The same principle which applies to the prolongation of lives of infants 
must also apply to the prolongation of lives of consumptives. Consump- 
tives now fall victims to the disease largely in the decennia 20 to 39, and 
presumably represent in general weaker physical organizations than the 
average of those who safely pass this period. Without committing our- 
selves to any theory of specific susceptibility, we may designate their weak- 
ness as "tubercular diathesis." Therefore, if tuberculosis could be com- 
pletely eliminated, the weaker lives now mowed down by it would merely 
be prolonged somewhat, being terminated by a mortality more rapid than 
in the ordinary life table for periods beyond 20 to 39. 

It is, of course, impossible to say exactly what degree of increased mor- 
tality should be ascribed to the present victims of tuberculosis on the hy- 
pothesis that there were no such disease. Yet this would be necessary in 
order to accurately correct the figures which we have computed. Fortu- 
nately some evidence exists in the statistics of post-discharge mortality 
from" sanatoriums for tuberculosis. Dr. Lawrason Brown^ and Mr. E. G, 
Pope, in a very valuable and interesting article, have used the records of 2244 
patients treated at the Adirondack Cottage Sanitarium.f By this means 
they have seppi-ated the mortality for those discharged as "apparently 
cured," those "arrested," and those still with "active tuberculosis," and 
have compared the mortality of each with that of the general population, as 
indicated by Farr's English life table. No. 3. The general conclusions of 
this 8+udy are that the mortality among the "apparently cured" is at first 
about twice, and later about three times, the general population, but is 
coosiderably reduced after 8 or 10 years. The "arrested" patients have 
a death-rate rising in the third year to about ten times the general death- 
rate, and then falling steadily. The patients with "active tuberculosis" 

• See Abbott, "Vital Statistics of Massachusetts," 1856-95, p. 755, in Mass. State 
Board of Health Reports, 1896. 

t"The Ultimate Test of the Sanatorium Treatment of Pulmonary Tuberculosis 
and its application to the results obtained at the Adirondack Cottage Sanitarium,". 
Zeitschrift fUr Tuberkulose, 1908, pp. 206-215. 



12 



BIXTH INTERNATIONAL CONOEESS OK TUBERCULOSIS. 



have a death-rate at first of about forty times that of the general population, 
but decreasing rapidly. For our purposes, the most important figure la 
that expressing the general average death-rate among the "apparently 
cured/* as compared with the mortality of the general population. Their 
experience furnishes the nearest approach to mortality among those with 
tubercular diathesis but free from tul^erculosis. Unfortunately, they are 
not really free, however, as most of them later die of the disease* On the 
basis of the diagram on page 211 of the article above referred to, the "ap- 
parently oured'^ die on the average 2,3 times as fast as the genera! popula- 
tion during the fiist 10 years. After 10 years the imperfectly cured seem 
to be weeded out and the death-rate decreases materiallyj but the data after 
10 years axe too meager to enable us to make exact estimatea. We may 
be sure, however, from the form of the mortality curves from the three classes 
of discharged patients — each of which falls after a weeding-out process — and 
from other indications that the average mortality of the " apparently cured," 
if statistics were long enough extended, would be found less than double 
that of the general population, and that the average duration of life after 
discharge is greater than half the average duration of life (32 years for both 
sexes combined) among the general population of corresponding age. In fact, 
taking the survivorship curve for the " apparently cured/'* which extends 19 
years, we fijid that even if the further end were bent downward for the last 
9 years of the 19, so as to correspond to a hea\'ier mortality than the meager 
data for these 9 yearn indicate, the average duration of life could not, under 
any reasonable formula for continuing the cun^e, be less than 16 years, 
and might be aa much as 20 or even 25 years. At the worst, therefore, the 
mortality among ''apparently cured" consumptives is such as to make their 
lives 16 instead of 32 years, or, on the average, 16 years shorter than those 
of the rest of the population. It b not to be inferred, however, that these 
persons would have had so excessive a mortality if they had never con- 
tracted tuberculosis. Their curtailment of life is not pi'iocipally due to 
inherent weakness of constitution, but to tubercular relrs^es. Three- 
fourths of the deaths among the "apparently cured'' are froi5Lreturmng 
tuberculosis. We feel, therefore, safe in saying that the curtailcueat of 
life due to weakness of constitution, "tubercular diathesis,'* caimoL L^^ore 
than half of the total curtailment of 16 years* In other words, if tub 
losis were non-existent, the expectation of life of those who fall its vieti^ 
would be at least 24 years, as compared with the ordinary expectation of ;] 
yeaiB among persons who never have tuberculosis. The eradication o? 
tuberculosis would, therefore, save on an average at least 24 years for each 
person who now falls victim. This is making what appears to be a very 
generous allowance for the fact that the lives saved are weak. We conclude 

* Ibid., p. 209. 



THK COST or TUBEBCULOBIS, AND ITS REDUCTION. — FISHER. 13 

that the annual life cost from tubercplosis in the United States is, therefore, 
about 138,000 lives shortened, on the average, at least 24 years each. 

We may now apply our correction for constitutional weakness or tuber- 
cular diathesis to the calculation of the loss of working years. We found 
that, without such correction, the 32 years of life supposed to be cut off for 
each consumptive were made up of 0.6 year before the age of 17}, 10 years 
after the age of 60, and 21.4 years between these ages. Carrying out the 
previous calculations corrected on the new basis, we find that of the mini- 
mum of 24 years cut off, the parts constituent are } a year before the age of 
17}, 6} years after the age of 60, and 17 years between 17} and 60. The 
woricing period lost by death is, therefore, at least 17 years for each dying 
consumptive. 

II, Cost in Disabilitt. 

Turning from the cost in lives to the cost in invalidism or disability, we 
find the best figures in the intendve "Study of the Economic Course of Con- 
sumption in Wage-earners,"* by Dr. Marshall L. Price, of Baltimore, now 
eecretaiy of the Maryland State Board of Health. This paper shows that 
deaths among several hundred workmen in Maryland were preceded by an 
average period of 1 year and 6 months of total disability, following a pre- 
vious period of 1 year and 7 months of partial disability, during which the 
workman was able to earn about half wages. 

Mr. Christopher Eastonf constructed statistics to cover 100 cases in New 
Yoric city from the tuberculosis infirmary on Blackwell's Island, in which 
he found the "average duration of the disease before a patient's admission 
was 7 months and 21 days; the average period of unsteady employment 
3} 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 dissipa- 
tion or some other cause than consumption. The duration of the disease 
above g^ven, 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 patients admitt^ to the State 
Sanatorium, Rutland, Mass., is stated as 12} months, although they receive 
a more incipient class of patients than the Blackwell's Island Infirmary." 

We shall take as the period of total or partial disability for the workmen 
the figures of Dr. Price,t viz., three years and one month. But for consump- 
tives in general this average should be considerably increased. 

The period of disability for the well-to-do is undoubtedly in general 

greater than for workingmen, chiefly for the reason that the workman is 

• Journal of the American Medical Association. April, 1905. 

t "Consumption and Civilization," by Dr. John B. Huber, Philadelphia (J. B. 



lippincott Co.)i ld06, p. 121 
J "Study of the Econo 
If a nihall L. Price, Journal of the American Medical Association, April, 1905. 



t "Study of the Economic Course of Consumption in Wage-earners/' by Dr. 






14 



SIXTH INTERN ATIONAIi CONGRESS ON TUBEECULOSIS. 



forced to exert all the working capacity he has up to the lateat possible 
moment, after which the course of his disease is apt to be more rapid than 
that of hb well-to-do brother, who is more likely to stop from work in time 
to secure recovery. 

So far as I know, however, there are no exact figures to show the period of 
total or partial disability for the well-to-<io. It is probable that death ia 
usually preceded by a period of from 3 to 5 years during which little or no 
work is done. 

It seems safe to say that 4 years — certainly 31^ — is not an excessive esti- 
mate for the infectious period preceding the death of consumptives. If 
we multiply this figure by the number of deaths per annum from tuber- 
culosis in the United States (138,000), we shall have a figure, 4S0,CKK) to 
552,000, which expresses approximately the average number of persons con- 
stantly suffering from active tuberculosis in the United States and infecting 
others. In other words, there are always about half a million consumptives 
in our country, without counting ''latent" cnses. 

Since, as Dr> Price has shown^ for the working class the period of partial 
disability is about equal to the period of total disability, and since the 
working class constitutes the great bulk of consumptives^ we may conclude 
that of the 500,000 consumptives always existing about half are totally and 
the other half partially disabled. The estimate of 500,<>DO conaumptivea 
is believed to be a very safe one. Osier estimated that there are at least 
a million and a quarter of cases in the United States all the time, and even, 
this figure is regarded by Dr. Huber as very conservative. It seems, how- 
ever, much too high, for it would require an average period of tubercular 
activity of nine years. 

Dr. Price estimates that *'in the State of fliaryland at the present time 
there are 10,000 consumptives,* 8000 of whom have ceased to be economic 
factors in their communities. The State may have to provide for the sup- 
port ultimately of these SOOO people who are not economic factors and the 
majority of whom have no likelihood of ever becoming such, a number 
larger and more expensive in proportion than the German army, and who, 
far from procuring anil guaranteeing the safety and integrity of the State, 
are a source of danger or an actual menace to those about them/' 

In treating the subject of disability it must not be forgotten that, In 
addition to those who are conscious of having tuberculosis, there is a larger 
number who, without knowing it, suffer some disability from latent tuber- 
culoda. 

Nagell has found that 07 per cent, of adults who die of other diseases 
than tuberculosis are somewhat tubercular. Other investigators have con- 

• On this baais, acooniing to population, Ibe number In the United Stotee Mrould, 
bf About 750,000. 



THE COST OF TUBEECUL0SI8, AND ITS HEDUCTION. — FISHEB. iS 

firmed the concIuBion that over 90 per cent, are affected. In other words, 
most people who grow up have mild tuberculosis without knowing it. They 
may have suffered from what they believed to be prolonged "colds," "bron- 
chitis," or " malaria," and recovered without ever having suspected that they 
had tuberculosis. Any such periods of disability are really costs of tubercu- 
losis. An interesting case has recently come to the attention of the writer. 
A lady over 75 years of age was suffering from a "severe cold " and was 
advised by a friend to have her sputum examined. Much to her astonish- 
ment, the germs of tuberculosis were found. Shortly thereafter, however, 
her cou^ cleared up and her sputum disappeared. Many of her relatives 
had died of tuberculosis. She had been associated with them since child- 
hood. Some 50 years ago she is said to have spit blood. It is probable 
that this woman had unconsciously been fighting tuberculosis for half a 
century, during which time she was usually feeling very well. 

Of course, there are no means of estimating accurately the disabilities 
thus suffered from latent tuberculous. In the aggregate, owing to the great 
number of such cases which we know must exist and the number of years 
they live, it seems not unlikely that the total disability from this cause will 
equal the disabilities known to be suffered by those subject to active tuber- 
culous. That thb should be the case would require only an average disabil- 
ity among latent cases of 3 to 4 days a year. 

Dr. Barnes in an interesting paper has shown that there are a great 
many cases in which delay in diagnosis occurs.* The experience of all who 
have visited Saranac Lake, Colorado Springs, or Santa Barbara and similar 
resorts will corroborate these results. 

Nothing has yet been said in regard to the disability, or indeed, mortal- 
ity, of cured cases of tuberculosis. It must be admitted that the number 
of such cases is as yet insignificant compared with the total number of deaths. 
It is only the lucky few in whom tuberculosis is discovered early enough in 
the incipient stage. 

Among the really incipient and "curable" cases, about one-third die 
after a more or less prolonged period of disability; one-third have the disease 
arrested during a period of partial disability lasting a number of years. 

♦ Of 165 cases there were 89 cases, or 54 per cent., correctly diagnosed; 76 cases, 
or 46 per cent., incorrectly diagnosed. Of the 76 cases, the resulting delay in correct 
diagnosis was: 

Two to aiz months in 41 cases 

Six to twelve months in 15 cases 

Over twelve months in 20 cases 

The longest delay was 120 months 

The shortest delay was 2 months 

The average delay was 11.3 months 

(From "Mistakes in the Diagnosis of Pulmonary Tuberculosis," by Harry Lee Barnes, 
H.D., The Journal of the American Medical Association, Feb. 16, 1907, vol. xlviii, 
pp. 601-«)5.) 



16 sntra IKTERVAWONAt Congress 0^"TTrBElicin^Bi8, 

Of the remaining third which is '^appairntly cured/' a large namber relapse 
later, and few have their original working capacity restored for a normal 
period of after life. 

Taking the statistics of Brown and Pope already referred to, we find that 
they indicate an average life after discharge for those who still had *' active 
tuberculosis " of about 4 years; for those with the disease "^ arrested/' about 
10 yeare; and for those who were ** apparently cured/^ about 16 to 20 years. 
The last-named figure is the least certain, owing to the fact that, when the 
BtaliBtics were compiled, the number of ffersonB who had been discharged 
ifrom the sanatorium over 10 years was too small to ^furnish a very adequate 
basis on which to compute the after-age. 

For these three classes there are no exact figures for working capacity. 
It is a reasonable hypothesis that those with ** active tuberculosis"^ have a 
working capacity which is almost negligible, and the ''arrested" and "ap- 
parently cured" have recovered respectively about one-half and three- 
quarters of their normal capacity. 

III. Cost m Unhappiness. 
In addition to the costs thus fur considered, there is the cost which cannot 
be calculated, in tils appointment and unhappincsa on the part, not only 
of the consumptive himself, but of bis family and friends. It would be idle 
to attempt to estimate this "misery cost" of tuberculosis, and still more 
idle to attempt to express it in money. Suffice it to say that, on the average, 
each consumptive places upon three or four other members of the com- 
munity the burdens of his prolonged illness and death. There must always 
be between one and two million people in the United States upon w^hom the 
dark shadow of this scourge rests, and doable this number, if we include 
those who mourn the loss of their loved ones. 



IV* Cost in Money. 

Wc come, finally, to the cost of tul^erculosis in money. This cost con- 

'aUts of actual money expenditures and of loss of earnings. The actual 

monc*y cost occasioned to the patient and his family by tuberculosis con- 

aistft of expenditures for physicians, medicines, nursings traveling, and 

UBually— -alas I— burial The loss of money earnings are those occasioned 

by the [jcriod of disability, and the capitali^d value of the future earning 

jMiwor rut ofT by death. The loss of earnings during disability is merely 

the money measure of the disability already considered; and the capitalized 

Vftlue of the unlived years of work is merely a partial money measure of the 

fan of life. In a sense, therefore, the computation of the total money lo^, 

Ifc^fcur^i^f^ loB3 of earnings and capitalized labor power, covers most of the 

•Hta ilnady considered. 



THE COST OF TUBEECULOSIS, AND ITS REDUCTION. — FISHED. 17 

In speaking of the great cost of tuberculosis among worldngmen in pro- 
ducing relative inability to work. Dr. Price says: 

"Of 177 wage-earning males tabulated in this paper among whom care- 
ful inquiry was made concerning the original and ultimate economic condi- 
tion, 72, or 40 per cent., became dependent on charitable aid during the course 
of their disease; 26, or 14 per cent., died in charitable institutions; and we 
have good reason to suppose that the majority of others received at some 
time charitable aid. . . . 

''Histories of such families show that the result of such long-continued 
illness is not onl^ a complete exhaustion of the family treasury, but an 
ultimate destruction of a considerable portion of the family from the disease. 
There seems to be no other disease of such malign influence in its tendency 
to bring the family unit down to the lower levels of social and material wel- 
fare." 

The figures of Dr. Price include loss of wages during the period of partial 
disability and during the perod of complete disability; also the expendi- 
tures falling on the patient, those falling on the family, the cost of mainte- 
nance, and expenditures incident to death. Dr. Price estimates the income 
for unskilled labor at $300 per annum. 

Among cases of great loss. Dr. Price finds one, the case of a man aged 66, 
who was totally disabled during three years, and suffered an actual loss 
during that time of $8800, and a " potential loss," that is, the cutting short 
of earning power by death, of $28,600. 

The Maryland Conunisaon on Tuberculosis, using Dr. Price's figures, 
finds: 

"The average individual loss entailed by the disease for each wage- 
earning male dying from tuberculosis in Maryland is $741.64." 

" The average potential loss to the community 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 tuber- 
culosis each year cannot, at the very lowest estimate, be less than ten milUon 
dollars." 

Dr. Huber quotes Dr. W. H. Thomas, of Chicago, who estimates that the 
cost of tuberculosis in the State of Illinois amounts to thirty-seven million 
dollars annually; and the Ohio State Commission estimates the loss in Ohio 
at seven million dollars annually. 

Concerning New York city, Dr. Biggs writes: 

" It may be conservatively estimated that each human life at the average 
age at which the tubercular deaths occur is worth to the municipality 
$1500. The cost of each life at this age is usually more than this. This 

* This estimate is high, owing to the fact that the earnings are not discounted and 
the oonfiumptive is supposed to have naturally as high an expectation of life as others 
of his age. 



SIXTH mTERNATIONAL CONGRESS ON TUBEHGULOSIS, 



jpYtM A total value to the lives lost annualiy of $15,000,000. [For New 
York city.] 

" We may further assume that for an average period of at least nine 
CDODtba these persons are unable to work and must be cared for. The iosa 
of their services during this period may be estimated at $1 per day, and the 
cost of foodj nursing, medicines^ attendance, etc., at S1.50 more per day, 
making a further loss of 12,50 a day for each person dying for a period of 
270 days. This gives us a further loss to the munictpfllity of $8,000,000, 
making a total annual loss to the city from tubercular diseases of at least 
$23,000,000* It has been estimated that in the United States annually 
not less than 150,000 deaths are caused by the tubercular diseases, and 
estimating the value of theae on the basis just given, we have an annual Iosa 
to the country of more than $330,000,000."* 

Dr. Huber, assuming that there were 1} millions of tuberculosis cases in 
the United States, and that one fourth of them cannot work, and that the 
wages lost are Si, 50 a day, has estimated t that theTO is an annual loss in 
wages of $140,000,000. In a paper on "Economics of Tuberculosis/'t Dr. 
Huber quotes Cornet for Prussia, stating that for 300 working days of the 
year, the German consumptive, for whom he allows one year of disability 
before dying, loses 2 marks daily, or 600 marks in all. To this he adds 2.2 
marks per day for physicians, medicines, fooii, and care. As 72,000 die 
from tuberculosis, this makes a loss of over SQ million marks annually, or 
3.1 marks per capita in Prussia. 

Among the few curable cases who are treated and partially recover their 
working power, the subsequent lossof efllciency shows itself in reduced money 
earnings. Dr. Bardswell § gives the following figures as loss of wages in 
typical cases of workmen in whom tuberculosis had been arrested; 4s*, 6s., 
12s. 6d., 2g., 6b. 6d., I6s, 6d,, per week. In one case there was no change, 
and in three other cases there was a gain of 4s., 43.^ and 5s. respectively, or 
in all an average loss of 3s, 2d., which amounted to about 13 per cent, of 
the wages. 

These figures which have been given are for the poorer classes, and there- 
fore should be taken to represent rather the minimum than the average cost 
of consumption during the life of the patient. For the well-to-do, the 
money expenses are enormously greater because of a longer period of refrain- 
ing from work, and because of the higher rate of earnings forfeited during 
that period, and because of the more lavish expenditure of money for medi- 
cal care and change of climate. 

In order to obtain a few typical cases of expenses occasioned by tuber- 
culosis among the well-to-do, I have made inquiries among physicians and 

♦ Handbook of the New York City Charity Organizatioii Society. 
t "Consumption and Civilizfttion/* by I>r, John B. liuber, pp. 89-92. 
; New York Mk<UpiiI Jounml. Oct, 8. 1904, 

i **Tho CoDflumptive Working Man/* by Noel D. Bardswell, Scientific Presa, 
[.oadon, 1906, p, &5. 



raz coer of tuberculosis, and rrs beduction. — fishsr. 10 

patients in Colorado. These show that the cost of tuberculosis among the 
well-to-do is surprisingly great. One New York merchant, by no means 
reckoned wealthy according to modem standards, estimates that during 
the period of his illness there had been an annual lessening of his income, 
as compared with what it would otherwise have been, of over $21,000, as 
follows: 

ANNUAL COST OF ILLNESS. 

L(M8 of buainesB for six months preoeding illness $5,000 

One year cost at Saranac $4,500 

Lees regular expenses 1,500 3,000 

IxMB occasioned by absence from business in New York 8,000 

Cost of seeking new location in West 3,000 

Loss in income during change 2,000 

$21,000 

This patient had the good fortime to have his disease arrested. He has 
decided to remain in Colorado, although this continues to entail upon him 
an annual loss which he estimates at $22,500, and which has thus far been 
incurred for seven successive years, as follows: 

ANNUAL COSTS NOW. 
Loss each year, at present, because of unusual absences irom busi- 
ness because of voluntary and enforced vacations, say $8,000 

Decreased physical efficiency, say 7,000 

Additional domestic expenses 2,500 

Additional personal expenses 1,000 

Extra traveling and vacation costs 2,500 

Doctors, mediSnee, niuses, etc., of family and self 1,500 

$22,500 

It is fair to add, however, that as this man states in his letter to me, " these 
figures do not take into account any of the gain which I believe to be my 
portion. I would not go back to the old life that I left, with its engrossing 
cares, for all the financial cost. My life out here in the West has been so 
much more pleasant in many ways, and in addition to this my very illness 
gave me a love for the out-of-doors which would never have come to me in a 
big city like New York." Most consumptives are not so philosophical, even 
among the fortunate few in whom the disease is cured or arrested. 

In another case, which also was cured, there was a period of complete 
disability for 3 years, followed by a period of partial disability for 2 years, 
after which the patient resumed full work. The financial loss during these 
5 years is estimated at $18,000, or an average of $3600 a year. 

Dr. Gildea, of Colorado Springs, after looking over a long list of patients 
and estimating as carefully as he could the financial loss which he knew them 
to suffer, concludes: " I have patients who have been spending from $10,000 
to $20,000 a year from 5 to 15 years, with very little prospect of any end to 



20 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



the expense-s. Even people in moderate circumstances spend SIOOO a year 
from 1 to 5 years before they resume even partial work*" 

We shall now attempt to make a very rough e^nmte of the average cost 
of tuberculosis in all classes. Unfortunately there are no exact figures for 
earnings in the United States* For rough purposes we may use the law 
of distribution of earnings which Vilfredo Pareto* has found uniformly 
applying in numerous tjtates of Euro[>e and at different periods of history* 
To apply this law we need only know the usual minimum wage for unskilled 
labor* Fortunately there arc enough trustworthy estimates and observa- 
tions of the wages of unskilled lalx)r to make us reasonably certain that %l 
a day for 300 days in a year, or S300 a year, is no exjiggeration for the usual 
minimum. The result of the computation from Pareto *s law of distribution 
is that the average income earned by workers of all classes in the United 
Btatos is aljout $800, including the entire range of incomes from $300 to 
$30,00(J or more a year. This result is not to be relied upon as a statistical 
fact, nor is it quite to be classed among statistical guesses. Although it is 
only a rough calculation, there can be little doubtj on the basis of the great 
uniformity which Professor Pareto finds in (.Ufferent countries and at different 
times in the distribution of incomes, that it is roughly true. In order to 
give a wide latitude of possible error we may say that the average probably 
cxccxjda $700 a year, and cannot be much over $1000. Hon, Carroll D. 
Wright, whose opinion is probably worth more than that of any other man 
in the United Stales^ says in a letter to the writer, that he would not regard 
IKKXJ aw exc^&ive. Inasmuch as we are here more Interested in a safe 
minimum tlian in an exact average, we shall, in the fallowing estimates, 
!JM«» I7(K) as a basis of calculation. That this figure is safe is evident from 
WTverjd corroborative source— for instance, the report of the Bureau of 
I/iiUjrf ohowM that the average income from 2116 male heads of families 
ninttuK thn wnrktngmen investigated with reference to the cost of living was 
f^l^. OtlicrH of the working classes, such as women and unmarried young 
IUHM, iiiirn lesH than this figure, but^ on the other hand, the average must be 
fhl*ril t'ffniidorftbly by the far larger incomes of the higher industrial and 
iNoritttnloiiAi olwueo. 

Wn fiMNUmo that for workingmen in general the periods of partial or total 

i\ b;fi( ., aiti tlm Name as those found in Marj'land by Dr, Price, As we 

h" I , lb*' average for the whole community will be somewhat larger, but 

Im ordnr t*i Im on llie nafe side— that is, to be sure that our estimate of costs 
\u bhliiw thn tjtiHi—we nhall take 14 years as the duration of the period of 
jmrHul imd id»*i» of the jwriod of total disability* We may now compute 
(hi^i \\m »vv<u'Mtfci loKiK of earnings from tuberculosis for the entire country 

• dnim iriOrtniotnie Politique, 1S97, voL ii 
t iCigUtooutb AiluuaJ Report, 1903^ p. 97. 



THE COST OF TUBERCULOBIB, AND ITS REDUCTION. — FISHES. 21 

must be at least $525 dining the period of partial disability, and $1050 
during the period of total disability, or $1575 in all. 

The above figures do not take into account the cost of medical atten- 
dance, medicines, special food, nursing, etc. It is impossible to give any 
but minimum figures for the expenses, but we are probably safe in taking 
$1.50 per day (the figure which Dr. Biggs has taken in New York city for 
workmen alone) or $800 for the period of total disability, without making 
any allowance for the period of partial disability. This will bring up the 
total cost preceding death to about $2400. 

In the same way we may estimate roughly the capital cost through the 
cutting o£F of useful life. First, reckoning that the average American con- 
sumptive loses 21 years of working life, and discounting at 5 per cent, the 
earning capacity according to the above tentative figures at $700 per year, 
we find the capitalized earning power thus cut off amounts to about $9100 
for each death. The method of calculation is like that used by Fan* and 
other writers on the valuation of labor power.* The figures are " gross" in 
the sense that they make no deduction for cost of support. Adding the 
$2400 of cost preceding each death to the $9100 cut off by death, we reach 
$11,500 as the total average cost. 

The above figures have been worked out on the hypothesis that the vic- 
tim of tuberculosis, had it not been for this disease, would have been subject 
to the ordinary mortality. But, making full and more than full correction 
for constitutional weakness, which has already been discussed, and substi- 
tuting for the 21 years above ascribed to the working period of life the cor- 
rected figure of 17 years, we get $7000 as the discounted value of the earn- 
ing power cut off by each death from tuberculosis. This, added to the $2400 
of cost preceding death, gives $10,300 as our minimum estimate of the 
total money cost. 

We must reduce this estimate, however, still further, owing to the fact 
that not all persons of working age are actually bread-winners. The census 
figures show that over 90 per cent, of men over 16 years of age and 20 per 
cent, of women are employed in gainful occupations. Two-thirds of the 
women are single. The estimate for women does not include married women 
who do their own [housework as among those engaged in " gainful occupa- 
tions." However, although not earning money, housewives perform work 
which is worth money, and their death causes an actual money loss to the 
family. When the housewife dies, a hired housekeeper or servant must be 
employed, or else the family must go to the expense of boarding out; in any 
case, it is fair to regard the death of an active housewife as a money loss. 

^ * For an interesting general application of the method to include the calculation 
of indemnitv for lost earning power throu^ maiming, disability, or death, see ' ' Physical 
CoonomicB," by E. E. Holt, Journal of the American Medical Association, July 21, 1906. 



22 



aiXTH INTERNATIONAL CONQEfiaS ON TUBERCULOaia. 



If WO tako thU fact into consideration, it will be found that two-thirds or 
mcjitJ ^*f wcjTiion ut working age are actually at work. This ratio, taken in 
coiiDcction with the corrosponding ratio for tnen^ shows that over three- 
fourUin of 111! ^srMoaM of both sexes of working age are either actually earning 
mumy or waving expense by housekeeping. Using this ratio of three- 
fiiUHhn, v/h\d\ \n a wafe niiiiimum, aa expressing the ratio of actual workers 
Uj thoMe of working agCj and spreading the cost of $10,300 for the actual 
Wf^rkofN ovtir all thoHO of working age, including those who do not work, we 
lind ifjat the average death from tuberculosis means an actual money loss 
of l77*Jfi; and, rrtrnemlxjring that the cost of medicine, nursingj medical 
iilUmAtiiH'A% etc, hi just an great in the cases of non-workers as in the case of 
wrM'kiirN, w« riia-y wiy that the average cost is at least $8000, of which $2400 
initiHf^ in ilhioKM preceding death and $5600 from death itself* 

'I'liih IWKK) rriWHt, however, be still further reduced if we wish to compute 
(,Ihi htm Hiiflcrui by the comniujuty as distinct from the loss suffered by the 
luiiinuiiiptiv'h ItiruHi^lf. The earnings are, to a large extent, merely a loss to 
Mio dyiiift f'ojwMinptive himself. These evidently stiuid on a differcEt foot- 
iii^ ffiiJii ilio ex(jei»ies which have to be borne by others. These latter 
runU w« wImIi now to Bcgregate. Including housewives^ we find that the 
WiU'Knrw ooriatiluto about 45 per cent, of the whole population. The other 
ftft pdi" imril,. ar» drjjendent upon them. The ratio, however, in which the 
tlt^oiniut of the 4fi per cent, are coasumed by themselves and the remaining 
lA pt*l' iHHiL of Uie population will be more th^m 45 to 55, owing to the fact 
Ihwt Hii* f'A im' vAitii, include children. If we take the rough estimates of 
I'ikiuiuiittutf pownr *if the Bureau of Labor* and apply these to the age dis- 
Uibutiuu nf |Mp|iulation a« given by the census, we shall find that those who 
^^^... I. (.,!,, (,|„| 4/^ ji„r (Uiiitt of population which works consume about three- 
I*' '"ii U'ttd pniduct, leaving two-fifths to be consumed by the remain- 

i^ \ iviit. \Vii iiuiy, therefore, conclude that approximately two- 

' ''- Mniu**y lf«« entailed by the death of consumptives falls on 

i' tii upiiu them. Applying thb figure, we find the cost of 
I b,v uui\li (U'lUh from consumption, S4S0O is loss to the con- 
.o)l uiul fillJiHj to others, as, for instance, his wife and the 
1 *w* huH and would have had- This sum, $3200^ may becon- 
> thi* in)itir4il»le interest which the faniily or friends of the 
"^ hi-* hl« a Hum such that his life should have been 
t Uk oixlor to indenmify others for the economic loss 
,. >iiiwvi we have found that there are annually over 
, v,..,.i.i.wirt in the United States, the annual loss 
>tHiHfitiv<is themselves exceeds $440,000^000, 
luplivcrt themselves exceeds S660,000,000, 

w^ .,.. Vuuuid Uejwrt, 1903, p. 19. 



THE COST OF TUBERCUUMIS, AND ITS REDUCTION, — FIBHER. 23 

making a total annual loss of about $1,100,000,000. If this annual loss 
should continue indefinitely, it would represent capitalized an offset against 
or deduction from our national resources of $22,000,000,000. These figures 
are the minimum measure of that part of the cost of tuberculosis which can 
be expressed in money. 

If we apply these figures to the deaths which may be expected from the 
total population now living, which has already been calculated at 5,000,000 
persons, we find that, at $8000 per head, the total cost occasioned by the 
illness and death of people now living will eventually be over $4,000,000,000. 

Another method of dividing the money cost for each death is to distin- 
guish between gross and net cost. Dr. Farr has computed the gross and net 
value of a laboring man from birth up to old age. The gross value is the 
capitalized value of future earning?,- the net value is the gross value less the 
capitalized value of the cost of maintenance. The following figures for 
representative agw illustrate Dr. Farr's calculations:* 

148 143 6 

30 474 233 241 

60 238 141 97 

If we take the ratio of capitalized cost to gross value, we find that it is 
remarkably constant during the ages at which consumptives die. This 
ratio at the ages 20, 30, 40, and 50 is respectively 51, 49, 50, and 51 per cent. 
Assuming, for want of better data, that these ratios apply for American 
workers of all grades, we find that the weighted average ratio of net to gross 
value, on the basis of the deaths from tuberculosis at different ages, is ap- 
proximately 50 per cent, for each worker who dies from tuberculosis. Since 
we have already shown that the gross value for each worker d3^g from 
tuberculosis is at least $7900, we may assume that the net value is 50 per 
cent, of this, or about $4000, and that the difference, $4000 also, is the capi- 
talized cost of maintenance. Since we have estimated that only about 
three-fourths of those who die from tuberculosis are actual workers, we must 
spread the $7900 capitalized earnings per capita for workers over all deaths, 
making $6000 per capita and subtract from this the $4000 capitalized cost 
of maintenance, which applies to all the deaths, whether of workers or non- 
workers. This leaves $2000 as the net capitalized cost of earning power cut 
off by death. This is the cost of death. As to the cost of illness preceding 
death, the lost earnings are all net. That is, before death tuberculosis costs 
the victim lost earnings and does not save him or any one else the cost of 
support. These lost earnings, we have seen, amount to about $1600 per 
worker, which means $1200 per death, which, added to the $800 expenses of 
* "Vital Statistics," London, 1855, p. 536. 




SIXTH INTERNATIONAL CONGRESS OK TUBERCITL0SI8. 



Btcknefis, makfis 12000 of total costs precediog death. Adding this 12000 to 
the preceding S20(K)» we find S4000 a& the mininiuni estimate for the total 
net cost per death from tuberf^uiosis. Multiplying this figure by the mini- 
mum estimate^ 138,000 deatbj annually in the United States, we obtain 
1550,000 Bs the annual net cost of tuberculoaiB in the United States, or half 
the gross cost of $1,100,000,000, 

In computations in which the data are so meager, especial pains have been 
taken to understate the cost of tuberculosis* The figures, where they cannot 
be exactly ascertained, are all niiniinum figures. The truth must, there- 
fore, be greater than the estimates given, probably by 25 per cent., possibly 
by 100 per cent. Moreover, it must be remembered that the computations 
have not included the unknown losses from latent tuberculosis. As has 
already been remarked, it may well be that in the aggregate these losses equal 
or exceed those from the disabilities in ** active tuberculosis" which precede 
death. Nor have we attempted to evaluate the loss in happiness, or ''men- 
tal anguish,'* 

While it is impoesible to eompnto in dollars and cents "mental anguish" 
and other "sentimental " values of life, it must not be forgotten that these 
values exist, and are even more precious than cold earning power, an csti- 
matCj or rather a minimum estimate of which, can be made. In reckoning 
the ^'net" value of lives lost from tuberculosis, we assumed that the non- 
worker is worse than worthless, for he costs money in support and con- 
tributes no earnings. His capitalized value, therefore, entered our calcula- 
tions as negative or subtractive terms. In other wortls, the calcidation of 
net value treats the whole leisure class as though they were economic para- 
sites, an<l counts a man^s wife and children, bo long as they are not engaged 
in "gaijiful occupations,'' as merely it^Bma of cost, but yielding nothing in 
return. If this were true, it would profit each w^orker to get rid of all his 
dependents, and he should feel economically benefited when tuberculosis 
destroys his wife or children. Obviously such a \iew ta not only partial but 
absurd. It is true that the death of a dependent saves money to the sup- 
porter, but a full economic view should include how much sentimental value 
the head of the family puts on his dependents. It w'ould be only where little 
or no such sentimental value exists, as, for instance, in the case of the 
paupers, criminals, and defective classes, ia penal iustitutiona, reforma- 
tories, poor-houses, etc., wiiere it w^ould be even approximately correct to 
say that deaths from tuberculosis conistitut« an economic sa^■ing to society. 
The number of deaths among such classes which are chiefly a burden is 
extremely small. The man who spends a great deal on his family does so 
because they are so precious to him, and this expenditure, while a cost, is 
mostly significant as indicating that he couceives a sentimental value wlaich 
is high, though impossible to express in figures. In practically estimating 



THE CX)ST OF TUBSRCULOSIS, AND ITS REDUCTION. — VIBHER. 25 

the actual economic losses from tuberculosis it would be therefore probably 
more correct to adhere to the so-called "gross" cost; in other words, to 
assume that each person, even a non- worker, is "worth ius salt" to some- 
body. 

IV. Reducing the Cost. 

If only one-fourth, or 1,250,000, of the 5,000,000 lives to be lost from 
among the present generation alone can be saved, the effort of saving them 
will be worth a billion dollars. That this result can be achieved, and at 
much less cost, no one who has studied the subject can be in doubt. 

Or again, let us consider, as a practical business enterprise, what it would 
be worth to a nation to permanently reduce by one-fourth the annual cost 
of tuberculosis. This would mean an annual saving of over $275,000,000, 
the capitalized value of which would be $5,500,000,000. If it should require 
the investment of tliis amount to secure the saving of one-fourth of the 
annual deaths from tuberculosis to present and successive generations, the 
investment, from a purely monetary point of view, would be paying 5 per 
cent. If , as is unquestionably the case, the result be secured with a much 
smaller expenditure, the returns would be proportionately greater. 

At present the sum annually invested in the attempt to cure tuberculosb, 
in spite of its large absolute amount, sinks into insignificance when consid- 
ered in comparison with the waste of life which it is intended to combat. 
Dr, Biggs estimates that the total expenditure in the city of New York in 
its public institutions for the cure and treatment of tuberculous patients 
is not over $500,000 a year, which is about .5 per cent, of the economic 
waste from tuberculosis in New York city alone. 

The question is sometimes asked whether or not it pays to try to save the 
lives of consumptives. Dr. Bardswell, in his book on the "Consumptive 
Working Man," answers this question with an emphatic "yes." Even a 
cursory examination of the facts will make it clear that he is right. Taking 
one of the typical American sanatoriums in which excellent treatment is given 
at a greater expense than in some of the smaller institutions, it is found that 
the average cost of treating a patient during the average stay (three months) 
is $175. This takes into consideration the interest on the capital invested 
and depreciation. The prolongation of life by the sanatorium treatment 
has been already shown. About one-third of the patients are discharged 
with active tuberculosis, and their lives continue on the average about four 
years. Another one-third have the disease arrested, and live on the average 
ten years after leaving the sanatorium. The remaining one-third -are ap- 
parently cured, and their average prolongation of life is not certain, but 
is more than 16 years. The average prolongation of life, for all classes, is, 
therefore, more than 10 years, which must certainly effect a saving of several 
thousand dollars, both to the patients and to those dependent upon them. 



26 



SIXTH INTEHNATIONAL CONGRESS ON TUBERCULOSIS > 



Tbe major part of this saving can properly be credited to the sanatorium 
treatment, and repays manifold the investment of S175* 

These calculations do Eot take into account the indirect benefits from 
the sanatorium treatment. All students of sanatoriums are agreed that the 
principal benefit is indire-etj through the influence which tlischarged patients 
have on the habita of Uving in their family and neighborhood- It is im- 
possible, however, to express these benefits in figures* 

The object of our niovement ih, however^ not so much the cure of those 
who fall into the grasp of our microscopical foes as to prevent the disease 
from spreading. Only in this way can it ever become eradicated. Our 
hope and belief in the practical erodicability of tuberculosis is based not on 
theory only, but on facts. These facts are of two kinds: one is the wide 
variations in tuberculosis in d^erent conditions; the other, tbe great re- 
ductions which have already been made in the death-rat^ from tuberculosis. 
The figures for death-rates which we have already given ."^how a remarkable 
variation. The new countries, like Australia, lead in freedom from the 
disease. In New Zealand the death-rat« is especially low, being 57 per 
100,000 in 1905, in spit« of an age distribution favorable to the disease. 
The death-rates in Austria and Servia are nearly six times as great. There 
is also great variation in the death-rates in the various States of the United 
States. Thus, Michigan has a death-rate as low as 90 per 100,000, while 
Maiyland has 181 per 100,000** 

Individual cities show great differences in death-rates. In Scranton, 
Pa,, the death-rate is 72, and in St, Joseph, Mo,, the death-rat^ is 86, These 
are extremely low. At the other end of the scale we find the death-rate in 
the city of Washington,! 264; San Francisco, 276, and in the Bronx Borough, 
5031 

There is no way of explaining these great differences in the life^ost of 
tuberculosis in various countries except by differences in environment. 
Other differences, such as those of race, sex, or age, distribution of the 
various jwpulations, or differences in the accuracy of statistics, are quite 
insufficient to account for the facts. The influence of these factors ami otliers 
has been investigated sufficiently to make it practically certain that en- 
vironment 13 the supremely important caused 



* If we take States which are rasftrts for conHumptivea, we find the death-rate 
much higher, that for Colorado being 253 per 100,000. 

t The city of Washington hm v, death-rate from the vrhitea of 159 and from the 
colored of 463 (Ceiwud, *'M<irtalitv Statktics, 190li/' p. 52), 

{ Aaide from environment, the only important cause to which the v$.riattona in 
tubercular mortality might be ascribed are age and racial gu.HcepttbiUty, Age has 
already been diseu^i^ed and aepnuiited for. Part, if not most, of the fio-oalled racial 
diffpreticcs in rejipcct to tubcrculosifi are at bottom not racial at all, but environmoiitaL 
The Negroes and Iritih* fur instance, have hi^h tuberculosis death-ratea, in part becau*i© 
of bad housing and bad G<;oDoniic conditions. Aa to the high death-rate among 



THE COST OF TUBEBCULOBIS, AND ITS BEDUCTION. — FISHER. 27 

The chief environmentai factors afifecting the death-rate from tubercu- 
lo&ds are of two kinds: (1) Exposure to tubercular infection, (2) and un- 
hygienic conditions of living which lower the ph3rsiological resistance to 
infection. We need not, in this paper, enter into particulars, except to 
point out that poverty is one of the causes of tuberculosis, as well as one of 
its effects. What is often mistaken for the influence of race is the influence 
of occupation or economic condition. That poverty, which always means 
bad housing, is associated with tuberculosis is well known. Bulstrode has 
^ven the death-rate from pulmonary tuberculosis in Hamburg according 
to income tax classes. That for incomes of 900 to 1200 marks is 55.4; 
that for incomes of 25,000 to 50,000 marks is 7.5, or one-eighth as much. 
Similar statistics have been given by other writers, such as Reincke, Biggs, 
Hoffman, Brandt. Korosi, and others. 

As Cammir-Perier* has said : " The struggle with tuberculosis is intimately 
bound up with 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, oflBcial and voluntary." 
Not only will the reduction of tuberculosis lessen poverty, but the reduction 
of poverty will lessen tuberculosis. 

In this connection it should not be forgotten that the poor, among whom 
most of the infection occurs, change dwellings frequently, and thus rapidly 
spread infection, great in any case. 

We cannot here repeat or elaborate statistics showing the reduction in the 
death-rate from tuberculosis already achieved. A few illustrations may, how- 
ever, be given as an introduction to the economic aspect of this subject. 

Dr. Biggs estimates that for the boroughs of Manhattan and the Bronx 
in twenty years there has been an actual decrease in the total number of 
deaths, notwithstanding an increase in population of nearly 70 per cent. 

The late Dr. S. W. Abbott, formerly secretary of the Massachusetts State 
Board of Health, f shows that the death-rates in Massachusetts from con- 
sumption of the lungs per 100,000 have declined as follows: 

the Irish, see Dr. Newsholme, on "Phthifiis Death-rate," Jour. Hygiene, July 1906, 
p. 375. 

The death-rate from tuberculosis amone the Negroes and Indians is also raised by 
the mevalence of syphilis and alcoholism, wnich create a predisposition to tuberculosis. 

The Jews have a low death-rate, but in an article on "Tuoerculosis in the Jewish 
District of Chicago" (Journal of the American Medical Association, Aug. 6, 1904) Dr. 



Theodore B. Sachs proves that tuberculosis among the Jews is really greater than the 
figiues show, because when the Jews fall sick, they almost invariably seek a different 
ctimate, so that their deaths are not counted in tne locedity of their residence. The 
low death-rate among Italians may possibly be set down in part to their use of oil in 
rface of butter (see "Tubercle Bacilli m Butter," by E. C. Schroeder and W. E. Cotton, 
Washington Government Printing Office, 1908), as well as to their out-of-door habits. 

* "Consumption and Civilization," by Dr. John B. Huber, p. 326. 

t Quarterly Publication of the American Statistical Association, March, 1904, 
"The Decrease of Consumption in New England." 



28 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



Dr-ATHH Pill 

Ykapw. 100.000, 

1S5I to 1860 3ftd 

1S6I to 1870.... 349 

1871 to 1880 327 

1S81 to 1890 292 

1891 to 1900...... .... ..< 214 

1&96 156* 

Dr. Abbott shows, ia the report on eonaumplion in New England pre- 
vioualy referred to, that the annual decrease of tuberculosis in pereentagea 
in various States of New England waa, at the time of writing, as followa: 

Maine..., 3^ 

New Hampshire , .....,,,,..,, 2.3 

Vermont .-.,.»,... *,.....,.,..,,.,.,,...,.. ..^ 3.1 

Massachuselte , , . , .2^ 

Rhode Inland ,...............,<........... , 1.7 

Connecticut « 4 ...,.....,,,...*, , , * 1.9 

In the United States as a whole^ judging from the census figures, the 
death-rate from tuberculosis is now probably about three-fourths of what it 
was twenty years ago. 

In Prussia the death-rate from tuberculoaia between 187S and 1S87 
oscillated between 310 and 325 per 100;(XX)j and then descended! with great 
regularity to about ISO to-day, 

England has the distinction of having the lowest death-rate from con- 
sumption of any large country in Europe, and the decrease in the death- 
rate from tuberculosis, since the sto-tigtics of the disease have been kept, 
have been very marked. In England in three-fourths of a century the death- 
rate from tuberculosis ha^ fallen to one-third of what it was. 

Mr. Haywardi the medical officer of health for Haydock, Lancashire, 
England, who has already been quoted, shows the extent to which^ on the 
baais of the decennium 1891-1900^ life had been lengthened through the 
reduction of deaths from phthisis, as compared with the decennium 1881^ 
1S90- He compares the mortality in 1891-1900 with what that mortahty 
v>oidd have been if the death-rates from phthisis had been the same as they 
were in the pi-eviotia decennium^ lSSl-1890, and if phthisis liad prevailed as 
a cause of mortality with the same proportionate intensity. In this way he 
measures the proportionate number of lives actually saved during 1891-1900 
by the reduction in moi-tality from phthisb, as compared with 1S81-1890, 
He finds that through the reduction in tuberculosis alone within ten years 
the male expectation of life of the general population had lengthened by 
0.45 year, and the females, 0,68 year*} 

"^ Thia figure is taken from CetiHUt* Report, ''Mortality Stall-^tica, UM>6/' p. SU 

tSee al!»o '*The Mortality from Phthisis and from other 'l\tljerrular Diseasca/' 
by the same author, in thoTranflactionfl of the British Congresaon TubcrculoaiBf London 
{Wm*aowM)» 1903. 




THE COST OK TUBEBCUL08I8, AND ITS BEDUCHON. — PI8HEB. 29 

Bulstrode* has emphasized the almost universal tendency of tubercu- 
losis to decline. Many quoting his figure have concluded that the tendency 
is due to some mysterious reduction in the virulence of the disease. One 
can scarcely doubt, after reading what Newsholme has written, and in view 
of the imiversal improvement in sanitation, that the reduction in the disease 
is no mystery, but is a natural and necessary consequence of the efforts being 
made to combat tuberculosis and disease in general, f 

The means by which the devastation of life and property caused by 
tuberculosis may be further reduced are well known: a more prompt diagno- 
sis of tuberculosis; the exactments and enforcement of laws securing the 
reporting of tuberculosis cases; the prohibition of indiscriminate expectora- 
tion; the difflnfection of premises occupied by infectious cases; free examina- 
tion of sputum; the prevention of overcrowding; the destruction and pro- 
hibition of windowless sleeping-rooms; the better sanitation of places for 
work, schools, public buildings, and private dwellings; cleanliness in streets; 
purer foods, especially meat, milk, and butter; the establishment of san»- 
toriums, isolation hospitals, dispensaries, the education of the physician, 
and — last but not least — the education of the general public through tuber- 
culous classes and the dissemination of information as to how to live 
hygienically — ^the establishment, in fact, of higher health ideals. Besides 
other agencies for the achievement of these results, there should be a national 
health organization, formed by combining into one department the existing 
scattered health agencies of our Federal Grovemment, and adding new 
bureaus, especially one of information on matters of health. 

In the opinion of the writer, the best immediate results are to be obtained 
by the isolation of the incurable consumptive — a field of investment even 
more fruitful than sanatoriums. It is true that no immediate economic 
benefit to the patient or his family accrues from such hospitals, and this fact 
has hitherto led to the more generous endowment of sanatoriums for curable 
cases; but a broad view must recognize the fact that isolation hospitals, by 
preventing the spread of infection and gradually reducing the mortality 
from tuberculosis, indirectly repay to society a very handsome profit on the 
investment. 

Dr. Newsholme t has explained more satisfactorily than any one else the 
decrease in the death-rate from tuberculosis which has been going on even 

• Thirty-fifth Annual Report of the Local Government Board, 1905-06, Sanatoria 
for Consumption, London (Darling), 1908. 

t To some extent the reduction in tuberculosis is apparent rather than real, due 
to the fact that formerly any wasting disease was sometimes set down as consumption, 
wid the fact that to-day, on the other hand, some deaths actually due to tuberculosis 
are concealed, being set down to pneumonia, bronchitis, etc. — in order, especially, to 
secure insurance, which otherwise would be invalidated. The extent of this vitiation 
of comparative statistics can only be guessed at, but is not usually believed to be great. 

t ''Phthisic Death-rate," Journal of Hygiene, July, 1906, pp. 304-384. 



ao 



flIXTH DTTEBKATIONAL COXGRESS OX TUBEBCDLOBIS. 



prior to the discovery of Koch, and piior to the attempt to establish special 
or ■AoatonumB for its treatment. He points out that this steady 

tucUon hao occurred in almost exact proportion to the use of public hospi- 
taU, which have taken the consumptive away from his home and thereby 
.leduoed the amount of infection which he communicates to his family and 
'aeighbon. 

Wo all know or l)e!ieve we know that to a great extent the foci of infection 
perpetuate themselves, especially in tenement districta. It is, therefore, 
Boiiiewhiit suqirifting that the explanation of Newsholme has not been em- 
pha«iKcd earlier. Newsholme has shown that the reduction of tuberculosis 
in lOnKland han not been due to the erection of special hospitals for con- 
tfuiiiption, 8uch Bj^ecial hcspitals have been altogether too few and too 
recent to have caufied so great and prolonged an improvement. He has also 
iown that the death-rate from tuberculosis has decreased iji different 
^flountriPH in pmporUon to the extent to which "in relief" in public institu- 
tionM haii replaced ''out relief" in the homes of the sick, and that the 
ftppnrf^rifly anomoloufl increa«e of consumption in Ireland Is explainable 
tlirouj^h tlie ivlative inci-ea^ in the ratio of "out relief" as compared with 
"in relief '* in that country** 

Witlioufc rclaxirig any of our other efforts to conquer tuberculosis, we 
ought to tnake^ on a large scale and immediately, provision for isolating in- 
oiiriiblcn. Tliia wUl^ of oourae, cost money, but the fight against tubercu- 
liOBlH iH l)ouiid i<i l)e coHtly* and consists in fact of substituting money cost 
ivc«tcd in hoapitala, attendants, and education for the far greater cost now 
incurred from death and invalidism. 

\Vc luivc alni^iuly seen that money invested in the effort to eradicate 
tuboi*oulo*da would be money well invested. It has been claimed thai a 
practiced demonstration of this has already been made in Germany; that^ in 
fact, the money invested in sanatoriums for workingmen, in connection 
with the govonunenlat system of workingnien's insurance, has been repaid 

the insurance companies. It has therefoi^ been suggested that it would 
pay insurance companies to establish sanatoriums for the treatment of 
tul>erculosis. While it richly repays the conimuiiity to establish such sana- 
toriumH, it is Pxtn*moly tloubtfiil if it is true that insurance companies would 
bo finnnoially Ix^ltoretl by embarking on such an enterprise, Mr. Hoffman 
htm shown that ihv coiilniry wimld UKire likely be the c&de.f Mr Hoffman 

t: " As a financial proposition, I am confident that the Gennan system 
muitoria for cousumjitive \vorkn\en can nc\*cr be made to rest upon sound 



..^ * ^ »W lToUntl'« "Cniwuir .\Kiun»t Tubftrouloaw*' (2 vpK), Dublui (Mauiud). 
IvOK. vt*J I, p, 71. 

t ''IniliiKthAl Iiwtimiifr nml 1\ibprculo«k/' by Fredwidc L. Uoffman» Mnlicsl 
luiamtnrr wia rnu-liHauor. l>oc,. 1001. 



THK COST OF TUBEBCULOSIS, AND ITS REDUCTION. — FISHEB. 31 

actuarial principles and be made a paying proposition."* He points out 
that the cost per patient of the industrial population, treated in a sanatorium, 
could scarcely be less than 1100 or $120, which would be several times as 
much as any possable returns, so small is the premium in industrial com- 
panies. Neverthleless, he shows that there has been a great loss to the Pru- 
dential Life Insurance Company from consumption, the annual cost to that 
company being about $800,000. Selecting the figures for the consumptives, 
he finds that, on the average, they have paid $24 and have cost the company 
$134. Among the early ages, the loss is still more striking. For ages 25 
to 29, the company receives $18 per capita in premiums and pays out $150 
in losses. 

The reason for the great losses suffered from tuberculosis among insurance^ 
companies is due to the fact, as Mr. Hoffman points out, quoting the words 
of Dr. Green, author of the most recent treatise on medical examination in 
life insurance, as follows: 

"Curiously enough, despite the well-known infectivity of tuberculosis, 
insurance companies have, until quite recently, failed to inquire as to the 
applicant's association with consumptives. As a' result of this omission, 
companies have insured thousands of men exposed daily in their own house- 
holds to infection through their wivesf or children." 

German insurance has, however, entirely justified itself on the ground of 
general public policy. It may be said with considerable confidence that the 
benefits already received by society exceed many times the efforts which 
have been put forward to achieve them. 

Dr. Arnold C. Klebs thinks th^t the system of insurance for workingmen 
in Germany has become " the most powerful factor in the tuberculosis pre- 
vention in that country,"^ and adds, "The tremendous expenditure neces- 
sary for this has been amply justified by the results."} 

Dr. UIrich,|| in "Tuberkulose und Arbeitsversicherung," quotes from 
Bielefeldt (Ztschr. f. Tuberk. u. Hlsttw., Bd. vi, Hft. 3, S, 201): 

" Over 29,000,000 marks have been spent up to 1903 for sanatoria, and 
27,000,000 marks for the care of consumptives in these institutions; 78,329 

* Transactions of the Second Annual Meeting of the National Association for the 
Study and Prevention of Tuberculosis, p. 155. 

t The most complete study of marital infection is that of the late E. G. Pope, of 
Saranac Lake, edited by Karl Pearson, Drapers Co. Research Memoirs, London, Oulan, 
1908. 

t Transactions of the Second Annual Meeting of the National Association for the 
Study and Prevention of Tuberculosis, p. 144. 

f Ibid., 145. Also, Dr. S. A. Knopf, "What shall we do with the Consumptive 
Poor?;' Medical Record, July 5, 1902. 

" ''A Preliminary Discussion of Workingmen's Insurance Against Tuberculosis," 
Henry L. Ulricb. St. Paul Medical Journal, 1905. 



J"- 
by Dr.] 



32 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



consumptives liave had care for a period of seventy-two to eighty-seven days. 
lleHitlea this, all large centers are provided wiih. daily excursion Bpots sit- 
ntiicd somewhere in the neighlK>ring country, and some of the societies own 
convalescent homes. From the report, of twenty of the states of Germany, 
the decline of the mortality from tuberculosis in 1900-01 was 4.4 per cent.; 
in 1901-€2 was 1 per cent." 

Whiles therefore, it may be difficult to contrive a scheme by which in- 
Hurance compMnics can make money by curing tuberculosis^ it might pay 
them handsomely to expend money in educating their *'risks." Moi-eover, 
there can be little doubt that, in a broader view, the community can " make 
money" even by curing tuberculosis. If tl)e facts were possible of tabula- 
tion, it would be found that the money already invested by society in this 
fight had been returned many times over. 

Dr. H. B, Raker, in the '* Teachers' Sanitary Bulletin of Michigan" for 
April, 1905, issued by the State Board of Health, shows a saving of 583 
lives per annum from tuljerculoais during I89S-1903, as compared with a 
previous period of 1869-9L Computing each life as worth $1000, he reekona 
that this makes an annual saving of double the cost to the State. 

We most note, finally, that the problem of tulwrculosis is only one small 
part of the whole problem of public health. There are other diseases equally 
preventable and almost as costly, particularly insanity. Fortunately to a 
large extent the same efforta put forth to reduce tuberculosis will, at the 
same time, reduce largely other diseases, for the method of preventing and 
curing tuberculosis is at the bottom merely the promotion of hygienic habits 
and conditions of life. Pasteur has said that it h within the power of man 
to rid himself of every parasitic disease. It is, however^ no part of the 
present paper to study the more general aspect of the economies of disease* 
Many interesting articles have already been written on the subject.* 

VL Summary. 

Tho chief resulta of this paj>er may be briefly summarized as follows: 
The oofit of tuberculosis is fourfold — cost in lives, cost in disability, cost 

In hnppinoHSj and coat in money. 

Thn dfMfcth-rates from tuberculosis per 100,000 of population in the 

Untl^'d HUiim in 1006 were as follows: 



• ^inntitf lhe» ntn>nirent statementa of the econoraio waste from diaeBfl*> ar© the 
(ifin Ity Prtjr^NHWjr J. P. Norton, on "Tlio Economic Advisability of In 



iIm 



Department of Health'^ (Journal of the American Merfical 
-•■ ''HMi); ftnother by Professor Noitnan E. Ditman, on "Ediicalion 
■ in llie FifUi of Preventive Meriirfne" (Columbia Univensity 
J,,,, ,,, [1(1(1 n tbirci by Dr. Gt-orge M. Kober. on "The Conservation 



ftf 1 iUy IIU.I Ih'iilth Ijv Imimjvt'd Water Supply ''(Publicatioafl of the Conference on 
NalDittI Kmourci-B, he)J ul it'O Whi(« House, May, 1908J. 



THE COST OF TUBERCULOBIS, AND TIB BEDUCTION. — FISHER. 83 

RsGiaTmATioN OoHTursirTAx. U. S. 

AmKA. (Eruiated). 

Tuberculoflis of the lunn 159 142 

Tuberculosis of all kiD<& 184 164 

The number of deaths in 1906 in the United States from tuberculous 

RaaiSTKATIOH OOMTENKNTAI. V. 8. 

Abba. (EnuiATBD). 

Tuberculosis of the lungs 65^1 119,000 

Tuberculosis of aU kin£ 75,512 138,000 

The total number of deaths from tuberculosis is equivalent to the total 
number of deaths from smallpox, typhoid fever, scarlet fever, diphtheria, 
cancer, diabetes, appendicitis, and menin^tis. The total number of persons 
constantly suffering from active tuberculosis in the United States is about 
500,000. 

There are alwa}^ one to two million people in the United States being 
rendered miserable through illness from tuberculosis in the family circle, 
and as many more mourning the loss of friends. 

Of those now living in the United States, the number who will die of 
tuberculosis, if the present rate of mortality continues, is about 5,000,000. 

Tuberculosis of all kinds causes one in every nine deaths; tuberculosis of 
the lungs, one in ten. 

The percentage of deaths from tuberculosis of the lungs is greatest in the 
working periods of life, the maximum percentage being between the ages 
of 20 and 30, when one-third of all deaths are from this cause. 

The inddence of tuberculosis of the iimgs is earlier for females than for 
males. 

The average age at death is for males 37.6 years; for females, 33.4 years. 

If we assume tuberculosis absent and that those who now die of it would 
conform to the ordinary mortality, we find that each death from tuberculosis 
cuts life short on the average 29.4 years for males and 34.5 for females, or 
32 years for all persons. 

Of this loss, the major part occurs in the working period of life, which b 
conservatively assumed to be the period between the ages of 17J and 60. 
Males lose of this working period an average of 19.3 years; females, 23.4 
years; and both sexes combined, 21.4 years. 

But, in order to be sure of understating the costs, it is assumed that con- 
sumptives are usually weaker than most persons of equal age, and making a 
liberal allowance for this weakness, based on the mortality among those dis- 
charged from the Adirondack Cottage Sanitarium, we find that death from 
tuberculosis cuts off at least 24 years, of which at least 17 are in the working 
period above mentioned. 

On the average, each death from tuberculosis is preceded by a period of 
total disability, which (in turn) is preceded by a period of partial disability. 
VOL. ni— 2. 



> 



SIXTH INTKRNATIONAl, CONQRESa ON TUBERCULOSIS, 

ror workingmen the period of total disability is, according to PrioCj 1 year 
und 6 months, and of partial disability 1 year and 7 months. For other 
claasea the perioils are probably greater. 

Latent tuberculosis b responsible for many protracted ^^oolda/' "bron- 
chitis/' etc., aggregating a total disability of large dimension. 

The losaea of money due to tuberculosis are of two kinds; (1 those preced- 
ing and including time of death, and consisting of loss of earnings, cost of 
medical attendance^ medicines, nursing, special food, traveling, and funeral 
expenses; and (2) conBiating of the CRpitalized value of the eammgs cut off 
by death. The average of the former cost, up to the time of death, exceeds 
<8400 per death j the latter exceeds $9100, if we aesume that full expecta- 
tion of life applies to the consumptive; or, if wc nuike liberal allowance for 
constitutional weakness, it still exceeds S7900. On the latter hypothesis, 
the total ejepense corresponding to each death from a consumptive worker is 
over $10,300. Since only about threo-fourths of those li\ing in the working 
period are actual workers, this minimum is reduced to about $SO(H). Eight 
thousand dollars is, therefore, the very least at which we can reckon the 
average cost in actual money of a death from tuberculosis in the United 
States. Consequently, the total loss in the United States from the 138,000 
deatlis exceeds 3^1,100/100,000 per annum. Should this annual cost con- 
tinue indefinitely* it means a total capitali;!ed loss of 1^2*2,000,000,000. The 
saving of one-fourth of a!l deaths from tuhercidosis in perpetuity its worth a 
capital expenditure of over S5,500jO<XijOOO. Of this cost about two-fifths, 
or ove-r $3200 for each death, is Imrne by others than the consumptive, 
and an^ounta to over $440^000,000 per annum. 

I The 5,000,000 people, who will some time die of tuberculosis, will ulti- 

mately cost the work! $4,000,000,000. If one-fourth of these lives can be 
saved, the effort is worth over SI ^tKKl/JOO/XK). 

[ The figure $1,100,000,000 for total coat is ^'groas" cost. We may com- 

pute the "nct'^ cost by subtracting the capitalized cost of support. This 
l^nfires any sentimental worth of life^ and counts the leisure class and all 
tli'|}eiident«, such aa non-working wives and children, bs expensive drones 
ln«t^iiul of precious to their supporters. On this ba%is tuberculosis^ whenever 
It klllh a drpcndentj saves money for the community. Even on this narrow 
rt^nknning the cost of tuberculosis exceeds an average of $4000 per death 
iWJiU) for the iUneea and 12000 for the death itseJO, or $550,000,000 for the 

Tluit tulH*rcuUrf(is may be practically eradicated is evidenced by the fact 

IlifU Mm iiHirtrdity varies so greatly in difTerent communities, and is declin- 

iua in Hliii<ir<t all. 

' Thtt wwf of treating patients at consumptive sanatoriuraa for incipient 

^H||H«ii U Tt*pM miuiy times over, both Uy the consumptive himself and to 



THE COST OF TUBERCULOSIS, AND ITS REDUCTION. — FISHER. 35 

those dependent upon him, to say nothing of the indirect benefits in lessening 
the disease through the education of the public. 

From an economic point of view, the investment in isolation hospitals 
for incurables is at present probably the most profitable method of spending 
money for reducing the costs of tuberculosis. 



Lop Gastos de la Tuberculosis en los Estados Unidos. — (Fisher.) 
La mortalidad consecuente d la tuberculosis, en bus diferentes mani- 
festaciones, en los Estados Unidos se calcula ser de 164 por cada 100,000 
de poblaci6n y el numero de defuciones en 1906 es 138,000. A este paso 
5,000,000 estan llamados a fallecer de tuberculosis en los Estados Unidos. 
El t^rmino medio de la edad en el cual las defuciones ocurren en los hombres 
es de 37.6 anos y en las mujeres es de 33.4 afios. "Lac espectaci6n de la 
muerte" (aunque calculada en una tasa alta de mortalidad) es a lo m^nos 
a los 24 anos, delos cuales 17 a lo m6nos sucumben en el perfodo mas activo 
de la vida. El t^rmino medio del tiempo de deshabilidad precedente a la 
muerte excede tres afioe, delos cuales la mitad es im periodo de ima deshabili- 
dad total. Ferdidas pecuniarias consecuentes a la tuberculosis, incluyendo 
las ganancias probables perdidas por la muerte, excede $8,000 por cada de- 
fucion. La p^rdida total en los Estados Unidos es mas de $1,100,000,000 al 
afio. De esto cerca de dos quintas partes, 6 sean un poco mas de $440,000,- 
000 al alio, es debido a otras causas. Un esfuerzo en reducir la mortalidad 
d ailo quinta parte pudiera valuarse, por decirlo asi, a una ganancia de 
$5,500,000,000. Los gastos de el tratamiento en los sanatorios es sobre 
remunerado en la prolongacion de las vidas. 



Ce que coiite la Tuberculose auz Etats-Unis. — (Fisher.) 
La mortality de la tuberculose dans toutes ses formes aux Etats-Unis 
est estim6e A 164 par 100,000 de population et le nombre des morts en 1906 
k 138,000. Suivant ce calcul, des gens qui vivent maintenant aux Etats- 
Unis 5,000,000 mourront de la tuberculose. L'dge moyen de la mort des 
tuberculeux est 37.6 ans pour les hommes et 33.4 ans pour les femmes. 
Cette moyenne constitue une perte d'au moins 24 ans de vie, dont 17 au 
moins se trouvent dans la p^riode productive de I'existence humaine (et 
pourtant ces chiffres sont bas^s sur une moyenne de mortality plut6t 61e- 
vde). La p6riode moyenne d'incapacit6 de travail qui pr6cMe la mort par 
tuberculose d^passe trois ann^es, dont la demiSre moiti^ est ime p^riode 
d'incapacit^ totale. 

Le coAt de la tuberculose, y compris la capacity de travail capitalis^e 



*-» 



BIXTH INTERNATIONAL CONGRESS ON TtTBEBCtTL081S. 



perdue par suite de mort, d^passe 8,000 dollars par mort, Le coCit total aux 
Etatfi-Unia d^passe $1^00,000^000 par an. De ee coClt, deux cinqui^mea 
environ, c^est-inlire plus de $440,000,000 par an^ retombent eur des per- 
eonnes autres que les tuberculeux* Un effort pour rt^duire la mortalit6 
d*un quart vaudrait bien, si n^eessaire, une d^pense ou plut6t un placement 
de $5,000,000,000. Le coilt du traitement des malades dans les sanatoria 
est repayfi blen des fob par les vies des travailleura que Ton prolonge ainsl. 



Die Kosten der Tuberkulose in den Vereicigten Staaten*— (Fisk^er.) 

Man schatzt die Totiesrate iui Tuberkulose in alien ihren Formen in den 
Vereicigten Staaten auf $64 per 100,000 der Bevolkenmg, und die Zah! der 
Tode-sfalle im Jahre 1906 auf 138^000. Nach dieser Rate werden von den 
jetzt in den Vereinigten Staaten lebenden 5 Millionen an Tuberkulose sterben. 
Das durchBchnittUche Todesalter ist fiir mannliche Individuen 37.5 Jahre; 
fur weibliche, 33,4 Jahre, Die "Expectation of life" die verloren geht 
(obwoh] sie auf Grund einer besonders hohen Todesrate angenommen T^ird) 
ifit zum Mindesten 24 Jahre, von welchen zum Mindegten 17 in die Zeit der 
Arbeit fallen. Die Durchschnittsperiode dxirch Arbeitsunfahigkeit hervor- 
gemfenen Todesfallen an Tuberkulose iibersehreitet drei Jahre, von welchen 
die zeite Halfte eine Periode totaler Arbeitsunfahigkeit ist. 

Die Geldkosten der Tuberkulose euischliessend die kapitalisierte Arbeits- 
kraft, die durch den Tod verloren geht, iibersteigen $8,000 per To<tesfall. 
Die Totalflumme in den Vereinigten Staaten iibersteigt $1,100,000,000 per 
annum. Von dieser Summe sind ungefahr ^weifunftel,oderuber vierhundert- 
vierzig Millionen DoUara per Jahr anderen Ursachen als der Schwindsucht 
BuauBchreiben. Es wiirde wert sein, einen Verauch zu machen, die Sterl>- 
lichkeit auf ein Viertel herabzudriicken, wenn man, wenn es notwendig 
ware, $5,500,000,000 investieren wiirde. Die Kosten der Behaudiung von 
Patienten in Sanatorien machen sich vielfach bazahlt durch die Verlang- 
erung des arbeitsfiihigen I^ebena. 



• 



THE ECONOMIC LOSS TO NEW YORK STATE IN 1907 
FROM TUBERCULOSIS. 

By Wai/ter F. Willcox, M.D., 

GoDwlCini StatiatkiftB for tite New York State De|Mrtinwit of HoalUu 



Attempts made to estimate the loss to a community caused by a single 
epidemic of disease like cholera, yellow fever, or typhoid fever, or by the 
steady drain upon the community's energy and resources resulting from a 
^despread and fatal disease like tuberculosis, usually take one or the other 
of two forms — a statement of the efifect of the disease upon the average life 
time of the individual, or a statement of its effect upon the earning power of 
the community. Of these two methods, the former seems to me the more 
signiScant. A statement that elimination of human tuberculosis would in- 
crease each person's expectation of life at birth by a specified number of 
months seems to me a truer measure of the wei^t of that incubus on society 
than a statement that its removal would increase the earnings of the com- 
munity by a specified number of dollars. We do not live in order to earn: 
we earn in order to live or to live well. But the two methods are by no means 
mutually exclusive, and when it is a question of the community's duty to 
cooperate in the struggle against tuberculosis and to make suitable appro- 
priations for that purpose, the second method may prove the better. 

Neither method can yet be applied effectively to any disease in New 
Yoric State. Still some preliminary considerations on the data that are 
needed may serve to elucidate the problem. 

For the first method, a life table of the population of New York State is 
indispensable, and this we cannot have until the registration of deaths that 
is just beginning to be adequate has been continued effectively for several 
years. At the present time, Massachusetts is the only State in the Union, 
I believe, for the total population of which a life table has been prepared, 
and even that life table has not been applied to the present problem.* 
There is no better method available under this head than to apply to New 
York State the figures for England and Wales for 1881-90. The death-rate 
for England and Wales from phthisis in 1881-90 was 172 per 100,000; that of 
New York State in 1907 for the same disease was 171 per 100,000, showing 
an agreement so close as to make it admissible to apply the results for Eng- 
land to this State. 

* Mass. State Board of Health, Thirtieth Annual Report (1898). 

37 



38 SIXTH INTERNATIONAL CONGER ON TUBERCUIOSIS. 

At the meeting of th^ British Congress on Tuberculosis held in 1901 Dr. 
T, E. Haj'Martl showevl from his life tables that '* if there had been no phthi- 
sis, the average length of life for each indindual bom would have been in- 
cr&ftsed by two and a half years.*' With tubereuloeds eliminated and all 
other conditions unchanged^ a male child at birth would have an expectation 
of living 45,9 years instead of 43.3 years; a female child at birth would have 
an exi>cctation of living 49.2 years instead of 46.7 yeara. Owing to the spec* 
iai ineidence of tubercidosia upon the years of working life, this gain would 
benefit mmnly the adult iiopulation. A youth fifteen years of age would 
have an increase of more than three years in the total expectation of life 
were tuberculosis t<j diaii.pj>eAr. 

A child of either sex at birth would have its expectation of productive 
years — that b, the yearn Iwtwwn fifteen and sixty-five — increased by nearly 
two years were tulxircutiwin to disappear. The number of years of produc- 
tive life that might l>o exj^ectotl by the average male infant under the condi- 
tions provailing in Kngland in 1881-90 was 28.6; if tuberculosis had been 
absent and all oth**r c^mrJiiiouH had remained the same, that expectation of 
working life would have been 30.6 yeam, an increase of 6.8 per cent. Per- 
hap* ihifl warranto the concluBion that the earning capacity of the popula- 
tion of tivw York State would im increased about 6.8 per cent., or one- 
fiftorsnlh, fjy the elimination of tuberculosis. 

We may now turn to the wcond method that has been tried for estimate 
Ing thii loNM from tul»crcuIottis, namL>ly, a computation of the effect of the 
diMTitKt o|Kit) the earning jK)wer of the community* Under this head there 
ftro tlireo c*tn«»f)tionH that should be kept distinct — the cost of production, 
the loHH from sickness, and the loss of prospective earnings. 

1. If n youth dies at or before reaching the self-supporting age, those 
who have paid for his nurture would lose their outlay. The fact that they 
never expectx^il to be reimbursed for it is Irrelevant to the present problem* 
This outlay may be called the cost of production. If earnings have begun 
but have not equaled the outlay, the difference between the two may be 
called the net coat of production, 

2. If each person dying from tubereulosis had died when he did, but 
without previoiLs impairment of his health or ability, his economic value to 
fiuiiily and community would clearly have been greater. The difference be- 
tween that economic value and his value under the actual conditions may 
be called the loss from sickness* 

3. If a person dies of disease prematurely, the present or discounted 
value of that jwrson's earnings between the date of death and the end of his 
|irohablo life, diminished by the present value of hU cost of future roainte- 
llftniM?p constitutes what may be called the provspective earnings. 

Of these three notions, the first, the cost of production^ is important only 



COST OF TUBERCUL08I8 IN NBW YORK IN 1907. — WILCOX. 39 

because and in so far as it throws tight upon the last — the prospective earn- 
ings. The economic loss consists of the second and the third combined, 
thai is, the immediate or individual loss due to the sickness, and the remote 
or social loss due to the destruction of prospective earnings. 

In order to estimate the prospective earnings it is necessary to know 
the probable annual earnings for each future year, the probable cost of main- 
tenance for that year, and the rate of interest at which these future sums 
should be discotmted in order to compute their present value. 

I am not aware that any serious effort has been made to obtain the in- 
formation required for such a computation. The starting-point is in the 
average annual earnings for a productive laborer in New York State. On 
this, the widest basis available for recent years, is the return of wages for 
persons engaged in manufacturing in 1905. These include 603,519 male 
wage-earners at least 16 years of age, and 98,012 clerks, salaried officials, and 
firm members, a total of 701,531. Assuming that all the latter class were 
males between sixteen and sixty-four years of age, the two together include 
27 per cent, of the male population of productive age. The average annual 
earnings of the 604,000 wage-earners was $579; that of the clerks, salaried 
officials, and firm members was $1 134, and that of the two groups combined, 
$657. The corresponding figures for 1890 and 1900 do not differ widely. 
No doubt the 364,000 adult males engaged in agriculture and the 408,000 
engaged in domestic and personal service in 1900 earned less money on the 
average than those working in manufactures. Probably the 657,000 en- 
gaged in trade and transportation received not far from the same average 
amoimt, and the 108,000 in the professions received more. On the whole, 
and pending fuller information, it seems fair to assume that the average 
man of productive age (sixteen to sixty-four) in New York State earns about 
as much as an adult male wage-earner in a factory, or, say, $580 a year. 
This may be compared with returns from 4270 New York State families of 
wage-workers and persons on salaries not exceeding $1200, in which the 
husband earned an average income of $633. It may be further assumed 
that fully half of a man's earnings are used for the support of other mem- 
bers of the family. It is reasonable to assume, then, that the average man 
in New York State between sixteen and sixty-four years of age earns not less 
than $1 a day more than is required for his own maintenance. 

For the life table figures which are needed we may return to the Massa- 
chusetts life table already referred to, the only American table for a large 
unselected and typical population. The method of William Farr, illustrated 
in his "Vital Statistics," pp. 531-537, and his article In the "Journal of the 
Statistical Society," vol. xvi, has been followed with some modifications. 
The present value of net prospective earnings has been obtained by dis- 
counting at 3^ per cent, per annum. As the eamin^^ of a woman in any one 



^ 



mXTa INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



i 



Vl ^ dMmufiicturmg industries of New York State in 1890, 1900. and 1905, 
^M!*b«lw«ea£0 and 56 per cent, of the earning of a man, the net prospective 
WMUgi of a woman have been assumed to be one-half those of a man of 

In ilrntin^ with the mathematical problems arising at tUs point in the 
lircxuaoiit, ] would rvfer the reader to the Supplement to thia paper^ prepared 
hy Ur. Jamcis MfMuhon, 

Ui^Rnnliii^ (ho deaths from tuberculosis in New York State in 1^7, the 
l\*>M»rt iif tho Stutft Department of Health Bhows only the total Dumber, 
lO.^Tii, b'or IlKKS we have more detailed information from the Federal 
|||t|Hirt, ** MorUiliiii Siatislics, 1906," which distributes the deatlvs from tu- 
ItrrtMiliiHiK in Nt^w York over fifteen age periods. I have assumed that the 
|i*^rtvtiUKi^ hi 11H>7 were the same. These fifteen groups were then subdi- 
> idin! into 24, and each of those into male and female^ in accordance with 
thi» pmjwirtious prevailing in the entire registration area in 1906. The 
lYvmllA aro t^hown below: 



lOiTlMATED PROSPECmVE EARNINGS LOST BY DEATHS FROM TUBERCU- 
LOSIS IN NEW YORK STATE, 1907, 





DBilTiU. 


Pbubht 


Valdi or Net PRotPiMTrrTE Eakhiho*. 


Ana. 


Fer Capita. 


Tolal. 




Male. 


Faoule. 


MiOe. 


FeraiOQ. 


M*lc. 


FBDule. 


Oto 4 


666 


554 


11,850.00 


1930.00 


$1,220,000 


$515,100 


Mo U 


128 


138 


3.190.00 


1,595.00 


392,400 


220,100 


ItMii H.. 


94 


186 


4,694.00 


2,347.00 


441,S00 


436,400 


[hUi lU. 


412 


620 


5,ti%,00 


2,348>00 


2,347,000 


1,766,000 


U»liiU4 


OIQ 


1044 


5,809,00 


2,lJ04i)0 


5,321,000 


3,032.000 


SI Ml H ■>■■■■• . 


1020 


1010 


5,497.00 


2J4S,00 


5,007,000 


2J55.000 


nil. 


121U 


071 


5,071,00 


2,536,00 


6.17G.OO0 


2.642,000 


■Sw 


no6 


803 


4,656.00 


2,328.00 


5,56:1.000 


l,S69,OO0 




024 


&4B 


4,164.00 


2,082,00 


3,847,000 


1,135,000 


21^411. 


K18 


407 


3,580,00 


1,790.00 


2,928.000 


728,400 




an 


*i8e 


2,007.00 


1,454.00 


l,77ft,000 


415,000 




4:ti 


211 


2,117.00 


1,059.00 


912,400 


25.S,400 


tItHMlll 


:UK) 


1H7 


1,140.00 


570,00 


342,000 


106,600 


\\y In \W 


?':u 


ir^n 


121.70 


G0.S5 


27 ,.500 


0,431 


Ml . ' 1 


VVJ 


112 


—725.00 


— 3G2.,'jO 


—95,700 


—40,600 


1 , \\ 


7U 


tw 


—1,289.00 


—044.00 


-101,800 


— 42,.sno 


u^u 


'J\> 


AJ 


— l.;U3.00 


-657,00 


— 3S,0S0 


-^21,030 


IL 


U 


—1,009.00 


—505.00 


—11,100 


—5,555 


»tft i« ^wi 


\ 


1 


—746-30 


^^73.20 


—746 


—373 


\ 


' 


— iOD.20 


—230.10 


—460 


—230 


ImIiiI 


UiUT 


T373 






$36 652,714 


115,5^,043 



COST OF TUBERCULOSIS IN NEW YORK IN 1907. — WILCOX. 41 

The best estimate we have been able to make of the present or discounted 
value of the prospective earnings lost in New York State in 1907 by pre- 
mature deaths resulting from tuberculosis is $36,625,030 plus $15,608,437, or 
$52,233,467. To this figure something should be added for the loss from 
sickness. In order to estimate that loss, it is necessary to know the average 
number ill from the disease at any moment, the average length of time during 
which the disease impairs or destroys earning power, the average length of 
time during which the invahd requires nursmg and medical attendance, the 
average earning power of a healthy person. There are no American statisti- 
cal data with which I am acquainted on any one of these points. Hence no 
other method than that of expert guessing seems available under any of 
these heads. 

I am ready to accept assumptions made by Dr. Hermann Biggs in an 
estimate made in 1903. He wrote: "We may further assume that, for an 
average period of at least nine months, these persons (t. e., those who died of 
tuberculosis) 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 
foodf nursing, medicines, attendance, etc., at $1.50 more a day, making a 
further loss of $2.50 a day for each person dying for a period of two hundred 
and seventy days." This estimate indicates an economic loss of $675 from 
each case of tuberculosis resulting in death. If this is thought a large sum 
for an average, it should be remembered, as at least a partial counterweight, 
that no allowance has been made for those many cases of tuberculosis that 
impair the earning power and involve some cost of attendance, but do not 
cause death. If the conjectures of Dr. Biggs are accepted, the loss from 
sickness resulting from the 16,570 deaths from tuberculosis in New York 
State in 1907 would amount to $11,184,750. The final result of this study 
is indicated by the following statement of the economic loss to the popula- 
tion of New York State in 1907 from tuberculosis: 

Loss of future earmng power $52,233,467 

Loss from sickness 11,184,750 

Total loss $63,418,217 

The probable error in the foregoing figures no doubt must be measured 
by millions of dollars. The method is believed to be fundamentally sound, 
but the numerical assumptions still call for critical analysis, and in some 
cases, at least, may be very wide of the truth. 

Thus far we have been concerned only with human tuberculosis. The 
bases for an estimate regarding the loss from bovine tuberculosis are even 
more slippery. The neat cattle in the State in 1900 were valued at $62,735,- 
174. I have obtained an expert opinion that at least one-tenth of these 
animaJB are tuberculous, and that an animal suffering with the disease loses 



42 



SIXTH INTERNATIONAL CONQHESS ON TUBEBCUL03IS. 



at least one-fourth of its value. The minimum reduction in the value of 
neat cattle in New York State then from bovine tuberculosis is 11,500,000, 
In the light of all the evidence it seems admissable to conclude that the 
disease of tuberculosis In New York State at the present tinie reduces the 
expectation of life of each child at birth by two and a half years, and causes 
the population of the State an annual loss of about $65,000,000. 



SUPPLEMENT. 

Method of Estimating the Present Value of the Net Prospective Earnings 
Lost by Deaths from Tuberculosis in New York State in One Year. — 

(Professor Jamks McMahon, Cornell University.) 
To leatl up to the solution of this important problem, a few preliminary 
sections are devoted to the general question of the present value of future 
wages. The mathematical principles employed are similar to those used 
in Dr. Farr'a article, previously referred to. It is thought^best t^ ^vc fuller 
details concerning the derivation of the formulae, and the method of using 
them in numerical computation. 

1, Formula for present value of a given sum due in a given number oj years: 

Let the int-erest on one dollar for one year be i, expressed as a fraction of 

a dollar; let a sum of P dollars be put out at interoet, and let it amount in 

one year to A^ dollars, in two years to Aj, and m n years to Aj,^ the interest 

being compounded annually; then — 



A, = P (1 + i), 
A, = A, (I ^ i) = P(1 + i)* 
A, = A, (1 + i) - P U + ]/, 
An-- An_i(l + = P(i + i)" 



(1) 



Solving the laat equation for P gives— 



(1 + \)n 

Let V be the present value of one dollar due in one year; 

and P ^ An v" . 



(2) 



(3) 



This is the formula for the present value of A^ dollars due in n years. 
2. Present value of wages earned continuously throughotd a year: 
Let the 3'early wages be w dollars. If this were all paid in advance, it 
would amoimt, at the end of the year, to w{l H- i). If, on the other hand, 
it w^ere all paid at the end of the year, ite value would then be w. If^ how- 



COST OF TUBEBCULOBIB IN NSW TORK IN 1907. — ^WILCOX. 43 

ever, the wages were earned continuously, and also paid continuously as 
earned, then the value (wO of the wages at the end of the year would be 
just the average of these two sums, that is, 

w' = w (1 + ii). (6) 

and the present value of this at the be^nning of the 3^ar is 

p = w (1 + ii) w, (6) 

by formula 4. 

3. Present value of wages received by all persons above a certain age: 
Let Fx be the average number of men who live through the year from 

age X to age x + 1, as given by life tables; and let w, be the average wages 
received by a man duiing that year of age; then the total sum received by 
the Px men is PrW,; and hence, by formula 6, the present value (px) of 
this at age x Ls — 

I>x=(l + iOPxWxv. (7) 

Again the Px + 1 men who live from age x + 1 to age x +2 earn during that 
year the sum Px + iWx -i- 1; and the true value of this at the end of the year 
is (1 +ii) Px + iWx + 1 by formula 5; hence its present value (p'x) at the age 
X is, by formula 4 — 

P'x = (1 + iO Px + , wx + , v». (8) 

Similarly, the present value at the age x of the wages earned from age x+2 
to age x+3 is — 

P'x = (1 + ii) Px+3 Wx+a v», (9) 

and so on. Hence the present value (Wx) of the wages earned by all men 
above the age x is 

Wx= (1 + ii) (PxWxV + Px+x Wx+i V» + Px+a Wx+aV»). (10) 

4. Present value of excess of future wages above the cost of maintenance: 
Let the average cost of maintenance of a man from age x to age x -f- 1 be 

mx dollars; and let the excess of his wages over cost of maintenance be ex; 
then — 

ex — Wx— mx; (11) 

and it is evident that the present value (Vx) of the net income of all men 
above the age x can be found by merely replacing each w in formula 10 by 
the corresponding e. Thus: 

Vx= (1 + iO (PxexV + Px+i ex+i V» + Px+a Cx+aV* + . . .) (12) 

5. Average present value of net prospective earnings of a man at age x: 
This average value (vx) is found by dividing the total V^ by Ix, the 

number of persons alive at age x, as given by the life tables; hence — 



44 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



Vi = 



Ix 



(13) 



6. Mode of computing F, and Vj. from Hie formvla: 

When the duta are arranged in five-year groups, it is convenient to d&- 
note by G, the present value at age x of the net income earned by the whole 
group frona age x to age x+5; then — 

(H) 

and from this can be computed Gq, Gj, Giq, . . . G^^. (It will be ob- 
served that in our data the five e coefficients are constant throughout each 
group.) The successive numliers V^, V^j, V.^ . , » . are computed in 
this reverse order from the relation, 



V,,-G,^^v* V 



I+S, 



(16) 



the truth of which is evident from the fact that Vx -^ s is the value at age 
x + 5 of all the net earnings above that age, and that the factor v^ carries 
on this value to the age k* In applying this relation the term V^^ is first 
found from the data for the last group (ages 100 to 103) by means of the 

formula* 



V,M = (1 + iO PlooClwV + Plot eio, T* + PlMeiwV*), 



(16) 



which is a special cose of formula 12; and V^ is then found by putting x^ 95 
in formula 15, giving 



Similarly, V„, V^, 



. are found from the relations. 

Vpo = Goo + V» Vgs, 

Vss = Ggj + V* Vflo 

V, =G5 Vv» V„, 



are found by dividing V^, V^, V,^ 
respectively, in accordance with 



finally, v,, v^, v,o, - . , 

by 1„, I, J Ijof 
formula 13. 

7. Mean prospective earnings for each group: 

The mean prospective earnings (v',) for a man in the group from age 
X to age x + S ifl given by the approximate formula, 

v'i= Jtvi + vi + 5) 

♦ For thwe fonnul« Ihe MassftchuMtU life table (referred to bjr 
been Aflflum&d to run out at age 103j and we have taken Piot *«7, Pko» 
10, li«-4, 1,6,-0. "f-' 





COOT OF TUBERCULOSIS IN NEW TOBE IN 1907. — WILCOX. 45 

thus, for instance, the net pro^>ective earnings for each man in the group 
between the ages twenty and twenty-five is taken as — 

▼'» — f (Vjo + Vj5). 

8. Formvla for the economic loss to the State of New York from the deaths 
due to tubercidoeis in one year: 

Let Dx be the annual number of males dying from tuberculosis in the 
group between the ages x and x +5; then the economic loss (Lx) to the State 
due to these deaths is — 

Lx = DxVx, (18) 

and the total annual loss (L) is 

L = Do v'o + Ds v'j + D,o v'w + (19) 

9. Numerical data and restdts: 

In applying these general formulsB to the particular problem before us, 
the rate of interest is assumed to be 3^ per cent., hence l+i>= 1.035, and 
v» 0.966 18. The value of P^ and Ix are obtained from the life tables for 
the State of Massachusetts, which are presumed to indicate fairly the death- 
rate in the State of New York at the various years of age, for the general 
population. The average annual wages for males (Wx) and the average 
cost of maintenance (m^) that have been used in the calculations are shown 
in the following table, and are thought to conform fairly to modem American 
conditions: 

Agb Psriod. Wx mx Ox 

Oto 4 100 -100 

6to 9 150 -150 

10 to 14 50 200 -160 

16 to 19 400 260 150 

20 to 24 600 300 300 

25 to 29 600 300 300 

60to64 "....!.../....".../... 600 " 300 300 

65 to 69 500 300 200 

70to74 375 300 75 

76to79 200 300 -100 

80 to 84 300 -300 

85 to 89 300 -300 



From the above data the values v^, v„ v,o, .... have been 
computed as in Section 6, and then v'o, v',, v'^, ... as in Section 7. 
The values of the latter series of averages are shown in the third column of 
Dr. WiUcox's table. The values of Dx are given in the first column of that 
table; and those of Lx (found by formula 18) in the fifth column. The total 
yearly loss for males (L) is shown at the foot of the fifth column. 



46 



SIXTH INTERXATIONAL CONGRESS ON TUBERCULOSIS. 



Las Perdldas Economicas del Estado de New York a Consecuencia de la 
Tuberculosis* — (Wilcox*) 

Las perdidas economical do una comuoiUad a consecuencia de la tuber- 
culosis, se compone de varios elementos, tres de estos pueden ser calculadoa 
con alguna exactitud con la ayuda de los inforraes existentca. Estos tres 
son: Primero, las perdidas a consecuencia de la disminiicion en !a capaci- 
dad de los salaries y el aumenlo de los gastoa desi-le cl pnncipio de la en- 
fermedad y la muerte del paciente; sogundo las penlidas en las gananciaa h 
consecuencia de la muerte prematura, esto os durante el tiempo entre la 
muerte por tubci'culosfis y la muerte de otra enfermedad dado el caso que 
el paciente no hubiera sido victima de la tuberculosis; tercero, las perdidaa 
pecuniarias de los agriculteres y lecheros cada ano a consecuencia do la tuber- 
culosis bovina. El elemento primero ha aido determinado ser aproximada- 
mente de 111,184,750 en el Estado de New York. El eegundo es mucho 
mayor, es probable que las ganancias prospectivas de las 16,750 personas 
que muHeron de tuberculosis en el Estado de New York en 1907 fue de 
552,251,757, 

Las perdidas anuales de los duenos de ganado del>e ser k lo menos de 
1,500,000 y las perdidas totales de los diffcrentea fueutes no puede ser menos 
de 65^000,000 al afio. La perdida de la vida espectativa es igualmente con- 
ciderable. Vn niilo tendria la perspectiva fie la vida al tiempo de nacer, 
aumentada en dos anos y medio si la tuberculosis desapareciera y las otras 
con(^ciones fuesen como al pre^Gnte. 




THE BURDENS ENTAILED BY TUBERCULOSIS ON 
INDIVIDUALS AND FAMILIES. 

Bt Sherman C. Kingslet, 

Buperintendent, Chieaco Relief and Aid Sodety. 



This paper will deal only with workingmen's families — men whose normal 
wages range anywhere from nine to eighteen dollars a week. When all goes 
well, these families manage to get along without the intervention of charity. 
When, however, any considerable misfortune or disaster overtakes them, 
they are compelled to seek assistance from charitable agencies. 

The Family without a Margin, — From necessity the budgets of these 
families are scaled down to the lowest possible amount. According to the 
man's skill, industry, and physical ability he seeks out the best neighborhood 
and the best tenement he can a£Ford. The food and clothing of the family 
are seldom all that could be desired, and when there is dckness, financial 
depression, or idleness, there is retrenchment verging on privation. In cases 
of casual illness, minor accidents, or death, union or lodge benefits frequently 
help out. 

These people are accustomed to hard, exhausting, laborious work. 
They make light of physical pain. Both men and women often force them- 
selves to their tasks when their physical condition \a not fit to assume the 
burden. Since one visit from the physician means a day's wages or more, 
a physician is called only in cases of absolute necessity. This outlay cuts 
into the sum set aside for rent or into what is it hoped will buy shoes or 
clothes. Colds and coughs are of little account. This neglect is responsible 
for serious infractions on health, on the part both of the children and of the 
parents. It is not that the parents are thoughtless or careless, but that the 
stem necessities of the situation are so exacting that they shrink from any 
avoidable expenditure. These are only a few of the hardships and con- 
sequences of living on an income that is exhausted by the barest necessities. 

Tvberadosis Far Advanced when Discovered Among Ihese People, — ^The 
early diagnosis of tuberculosis depends not alone upon the skill, the devotion, 
and the public spirit of the physician. In some way or other the patient 
must be brought to his attention. All the considerations offered above 
serve as deterents. These people often find it difficult merely to take the time 

47 



18 



SIXTH IKTEBNATIONAL CONGRESS ON TUBERCULOSIS, 



from their employoient to visit a dispensary or ta go to a ph3^sician*s office. 
They miist report regularly^ or their job is tnenat^L They are not able to 
do many kinds of work, and the only resource for maintainiiig the family 
eeems to be to hold on to this particular work. The infertetl man goes to 
his employment day after day, cherishing a delusion of mingled hope and 
feftr» He believes it will wear off, and vaguely hopes that he will be better 
Boon. Not infrequently he fears the worst, but having no means of relief in 
Bight, he wit! not seek advicSt but prefers to go on as long as he can hold out, 
rather than to face the conse<]uences. This means that the disease runs on, 
and he is doomed before he faces his possible helpers. The only chance thia 
man has of ha^dng the disease treated with any success is that it should be 
discovered in its incipiency. 

Financial Standing of the Family as Affected 6y Tuberculosis on the Part 
of Uie /?rea//-!rmTier.— Perhiips as often as otherwise a man has gone through 
the ijitermittent stage of employment, and does not come to the attention 
of the tubrrculof^ls committee or the physician until he is already forced from 
work. Immodiately the financial needg of the family have advanced tre- 
mendously, while the income has been perhaps absolutely cut off. The aver- 
age nunil^cr of rooms occupied by surh families in our large cities is alxjut 
three and a half. These rooms are in tenements, in congested districts, 
where the milk supply and other food-atufTs are not of the best They are 
in factory regions, where both smoke and dust are more prevalent. Imme- 
diately there is a need for more roomg^ in order that too many members of 
the family may not be forced to occupy the same room with the tuberculous 
pationt More and better food is perhaps ordered; the patient needs a 
porch, or at least a window facing the air and light. Perhaps the ^ife has 
already begun waaliing and scrubbing or waiting on tables. It is more than 
a chikrs task to take care of the patient, and the mother is require<l to de- 
vote much of her time and energy night and day to the sufferer. This, with 
the loKH of Bleep and care of the children, renders the situation particularly 
dangerouH to her* During the late stages, two adults are practically kept 
from remunerative employment* Thus the situation drags on through the 
long, exhausting course of the disease. 

Crmcrrtfi HnMetiA hnpa&ttL — ^The chapter of consequences is a long and 
gkKJiuy i>nc. The accompanying chart was compiled from families receiving 
MdMtiuice from tlic Chinngo llelief and Aid Society. The average income of 
thoK} twelve men liefore the disease compelled them to quit work was f 12,66. 
The duratii>Ti t»f non-om ploy men t when tlus chart was made was eleven and 
on6-hatf months. It hapfieneil that the 37 children in these families were 
all imdiir working ago. In all Imt one or two instances the wife had found 
employtiicnt at wasliingt Hcnibbiug, or waiting on tables, and their earniiiga 
miule an average weekly income for the twelve families of S4J6. In 50 con- 



L 



J5^ 

I 



1 hug 

-12 i 



aa 







1^6 



1^ 



III ir.^ 



J 


i 


: 


8 

to 


8 

00 


1 


8 

fa 


8 


HBOOa J*> Oji 


' 


* 


■* 


* 


■* 


n 


■* 


^i 


3 


s 


: 


s 


8 


s 


1 



I* 






IP 



I 



lo&Tj p OM I « 



^ 



c '^"H 



s s 



4 

IS 



Q l£r 



r-fl » 



££S 






Or? S 

ill ^ 






1^' 



1 H - i^ 

B " ? £• ■ 

illll 



^/ i 






lOV 



3^ 



id 



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33 



s«s 



a 



n 



.4 

So- 



a-' 









48 




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pins 




i 


^ 


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s 


§ 




1 


■fftlKWa jp oiij 


- 


•* 


^ 


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■* 


1— 1 Q 




P3 




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§ 

c 



fl I 






its >t 



!f3 



1 I 1 I 



I I I 



amoo^ ja'aj4^| 



'OmMQM 









^ S: o M 



■9E 






50 



T0BEECULOSIS AS A FAMILY BXTHDEN. — ^KINOSLBY. 51 

secutave tuberculoiis cases taken from our files, the afflicted member in some 
instances was a child, in others, the woman; the average income was $4.50 
a week. The children will be forced to leave school at the earliest possible 
mom^it allowed by the law, and some of the women are already breaking 
under the strain. No one knows how many of the children will become in- 
fected before their struggles are over. In a paper read before the last meeling 
of the National Tuberculosis Congress, Dr. Theodore B. Sachs, head of the 
Sanatorium Department of the Chicago Tuberculosis Institute, gave the 
results of an examination of the children in 150 such families. From 25 to 
30 per cent, of the children of these families had positive signs of tuberculous 
infection. Dr. Ethan A. Gray, head of the dispensary department of the 
Chicago Tuberculosis Institute, finds a sdmilar situation among the children 
of those families examined thus far under his department. The following 
extracts are from letters written by Dr. Sachs r^arding two applicants for 
admission to the Edward Sanatorium. They suggest some of the concrete 
burdens. 

"Mrs. F. is the mother of five children. She is compelled to earn a living 
for her family. Washing is her occupation. The extent of her disease is 
not such as to preclude 'arrest,' but it can hardly be expected that if 
'arrest' takes place, she could continue to work and still maintain her 
condition. I mention this economic side of the case because of its close re- 
lati(Hi to the medical aspect. If Mrs. F. should enter the sanatorium, her 
case must be investigated with a view to lifting from her shoulders the 
burden of supporting this large family by the arduous occupation of washing. 
If this can be done, her admission to the sanatorium will be the proper thing; 
otherwise I believe there would be no permanent improvement." This 
woman's husband died of tuberculosis. 

Another ^milar case: 

"The present home surroundings of the family are unhealthful. Would 
it not be advisable to move the entire family into a healthier portion of the 
city, where outdoor treatment can be carried out? If the Relief and Aid 
assists tMs family by paying the increased rent, the solution will be much 
cheaper than an indefinite stay at the sanatorium. However, if the ad- 
mission of the patient on trial is requested, it will be granted, provided that 
immediate steps be taken to move this family to proper quarters, thus 
making ready a place for the patient to return to as soon as discharged." 

These are some of the economic burdens inflicted by tuberculosis upon 
the families of the poor. It is a pitiful struggle, waged in three rooms and 
a half, on an income of less than five dollars a week. 

Some Obvious Needs, — Among the great needs made apparent by these 
conditions are hospitals for advanced cases. These hospitals must more and 
more gwn the confidence of the people. They must be an answer for the 
ffltuation that will satisfy not only the families of tEie afflicted persons, but 



52 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS, 



the conscience of the community. In many localities the community itself 
will not stand for inforced removal of cases to the tuberculosis hospital as 
it is now conducted. The conditions in these homes are exceedingly favor^ 
able for fostering and spreading the disease. There is the gradual weaken- 
ing of the physical resistance of the family through privation and care^ and 
the inforeed congestion fimshes the work- 
Secondly, there should be a large increase in the possibilities of care in 
sanatoriums. Every day discovers fathers and mothers who could be saved 
if there were $50, S200, or $500 to expend iji their l^half. Without inter- 
vention they must be lost to their children and to their community. Left 
to themselves, death is certain. We are as much mtcrested in the present 
generation as in any equal number of persons to be bom at any time in the 
future. From $10 to $20 a week, usually more than the entire income of the 
family, is now required in most sanaUiriums, and in many places there is no 
such resource at all. The success in home treatment, under the direction of 
the increasing arniy of skilled physicians, the church class, and day camps, 
13 encouraging enough to foster and increase such agencies. 

Thirdlyj the crusade against this disease is creating a new conscience. 
Bad tenements, unsanitary buildings, ill-ventilated places of employment, and 
heiilth-meuacing occupations are now seen and known in their true hght 
by an increasing army of sMlSed and public-spirited physicians, by the grow- 
ing host of social workers, by the press, and more and more by the general 
public. More and more this body of people is watching the patient as he 
returns from the sanatorium, the disease ai'rested, the body strongs courage 
restored They are following these people from the healthful surroundinga 
that have led to tliis restoration to these alleys, basement homes, alcove 
rooms; to the ill- ventilated places of employment; and they are finding that 
here is the secret of the disappointment following sanatorium treatment. 
These conditions help to produce tuberculoais in normal people* The sana- 
torium, the day camp, and the church class cannot expect to render these 
people proof againat impossible conditions. This body of people is becoming 
thoroughly conscious of the deadly effects of bad conditions. These w^eakest 
members of society are at last finding a hast of helpers. The burden of 
these conditions has become a matter of conscience with this host^ and it is 
their busing to see to it thut the whole body of people shares that con- 
sciousness and that conscience. The result of this should be fit living con- 
ditions and a chance for a normal life for every man, woman, and child. 



Cargas que Impone la Tuberculosis sobre Individuos y Familias.— 

(IvlNGSLEY.) 

Este escrito se limita i considerar las famlhas 6 individuos de modesta 
lenta, gente de trabajo que gana de nueve A diez y ocho dollars por semana. 




TUBERCrTLOSia AB A FAMILY BUKDE^. — ^KINOSLST. 



€a 



neceddadea de !a vida acaban con la renta de esta gente, la eual no d^ 
mai|;en para emergencias. Por estas y muchaa razonea scmejantes la tuber- 
culosis estA muy avanzada cuando se def^cubre entre esta geiitc. La sola 

transa de recohnxr depende de un pi-onto diagnostico, 

Estds faniiljas en nuestras grandes ciudades viven en un tdrmino medio 
de cerca de tres y raetlio cuart^s. Acompana d este escdto un cuadro que 
deniue^tra la^ contUcionea, primitiva y poHterior^ de doce familias cnyo padre 
tenia tuljterculosis, y muestra el decrecimiento de una renta niAs 6 menos de 
$12.66 por semana, antes de la enfennedad, hasta S4.66 por semana tlespuea 
que el hombre se vi6 obligado a abandonar el tmbajo, Esto era gana^lo por 
I& mujer. En cincuenta familias con^cutivas que recibfan auxilio de la 
misma Sociedad, en algunos casos la enfermedad era en la mujer 6 el uifio, el 
t^rmino me<lio de renta era $4,50 por semana. 

En un examen reciente de 150 familias^ por el Dr. Teodoro B. Sachs, de 
25 ^ 30 por ciento de todoa los ninos en estas familias mostraban signos de 
infeeci6n. Estd enfermeiiad saca los ninos de tas escuelas en la mas tem- 
prana edad posible, agota la vitalidad y los recursos de la familta y se apodem 
de los miembros mds di^blles de ella. 

Algunas claras nece^idades sugeridas son mda hoBpitales para loa caaos 
Avansadcm; mds sanatorios para los casos Lnciptent^s; md3 foudo» para salvar 
IKulres y madnes todavfa en eatado incipient^; amplio aumento de clfnica 
lul>ercubsa; dias de eampo, elases de iglesia como adjuntas al cuidado de los 
pacientes en el bogar. 



Les charges imposles par la tuberctdoGe atix indmdus et aux families.— 

(Kjngslev.) 

Ce mdmoire est limits h la conald^ration des families et des individus 
de moyens mod^r^a, d'ouvriers qui gagnent de neuf k dix-huit dollars par 
Betnaine. Les n^cessit^s de la vie 6piusent les gages de ces gens et ne lassieut 
rien pour les accidents. Pour cette raison, et pour beaueoup d'autrea, la 
tuberculose est d^jA fort avanc6e quand elle est di5couverte parmi oea gens. 
L'unique espoir de gu6rison depend d'une diagnose pr6cace. 

Ces families dans nos grandes villes logent en moyenne dans trois cham- 
bres et demie. Une cart« ddmnntrant lea conditions *'avant et apr^s" 
de douie families dont le p^re 4tait tuberculeux accompagne le m^moire et 
comftate une diminution dans les gages moyens de $12,66 par semaine, avant 
la maladie, 4 $4,16 par semaine quand Thomme cesse de tmvatller, Cette 
demidrc eomme est gagn^ par la femme. Parmi cinquante families prises 
de miite et qui recevaient du secours de la mfime Soci^l^, les gages moyeus 
^laient $4.50 par semaine, lors nifirae que dans certains cas e'^tait la femme 
ou un enfant qui ^tait malade. 




M SIXTH INTERNATIONAL CONGHEBa ON TUBERCULOSIS. 

Dana un examen lucent de cent cinquante families par M, le docteur 
Theodore B. Sachs, vingt-cinq k trente pour cent de tous les enfaQts de cea 
fatnille^ ont pr^sent^ des signes d'infection. Cette maladie chasse lea en- 
fanfs hors de I'^cole au plus tendre &ge, ^puise lea reasources et la vitality 
de !a famille, et s'empare des membera affaiblis. 

On sugg^re comme besoms ^vidents un plus grand nombre d'h6pitaus 
pour les cas avancfe; un plus grand nombre de sanatonum.s pour lea cas 
commengants; plus d'argent pour sauver les p^rea et lea m^res qui se trouvent 
encore dans la premi&re p^riode; augmentation dii nombre de cliniques tuber- 
culeu^eii^ des camps de jour; et des classes dans les ^gliaes comme accessoirea 
au soin domiciliaire des malades. 



Die Individuen uiid Familien auferlegten Biirden der Tuberkulose.— 

(KlNGSLEY,) 

Dieser Vortrag war begrenzt durch die Erwagimg von Familien und In- 
dividuen von massigem Euikommen^ von arbeitenden Menschen, die von 
neun bis achtzelin Dollars per Woche verdieneii. Die Erfordernisse dea 
Lebens brauchen tien Veniienst dieser Leute auf und lassen nichts fiir un- 
vorhergesehene Notwendigkeiten ubrig, Aus diesen und vielen ahnlichen 
Ursachen ist die Tul>erkij lo.se selxr vorgeschritten, wenn sie unter diescn 
Lenten entdeckt wird. Die einzige Hoffnung aid Wiedergenesimg hangt 
von einer friihaeitigen Diagnose ab. 

Diese Familien leben in unseren grossen Stadten durchschnittlicli in drei 
und einem halben 2immer* Eine Tabelle, welche die Verhaltniase von 
Ewdlf Familien zetgt, bevor und nachdem der Vater Tid:>erkulose hatte, 
begleitet den Voi-trag und zeigt eine Verniindenmg einea Durchschnittaein- 
kommena von 12 Dollars 66 C^nts per Woche vor der Kranfcheit zu 4 Dollars 
16 Ccntji nachdem der Mann gezwungen war, »eLne Arbeit aufaugeben. Dies 
war von der Frau verdient worden. In fiinfzig aufeinander folgenden Fami- 
lien, die von dei'selben Geeellschaft Hilfe erhielten, war in cinigen Fallen 
die Krankheit auf Seite der Mutter oder eines Kindes; das Durchsehnitts- 
einkommen war 4J Dollars per Woche. 

Bei einer kiirzlich durch Dr. Theodor B. Sachs voi^enommenen Unter- 
surhung von 150 Familien zeigt«n 25 bis 30 Prozent aller der Kinder in 
diesen Familien Zeichen von Infektion. Diese Krankheit zwingt die Kinder 
iin nioglichst friihen Alter aus der Schule, erschopft die Mittel der Faniilio 
und die Lebenskraft, und haftet sich an die schwachen Mitglie<ler. 

Einige augenfa!lige Erfordemisse sind mchr Hospitaler fiir vorgeachrit* 
tene Fftlle; mehr 8anatorien fur im Anfangsstadium befindliche Falle; mehr 
Gelder, um Vater und Mutter im Anfangsstadium zu retten. Kin weiterer 
2uwachs von Tuberkulose-KUniken, Tagesiuhestatten, Kirchenklassen aU 
Unteratiitzung fiir die Ileirafursorgo fiir die Patienten ist VOn Noten. 




THE MONETARY LOSS IN THE UNITED STATES DUE TO 

TUBERCULOSIS, BASED ON THE RETURNS OF THE 

TWELFTH CENSUS OF THE UNITED STATES. 

By James W. Glover, 

ProfeMor of Hftthenuttica and Insuraooe, Univenity of Mifthi ga g. 



Thia paper is the outcome of a method which the author has had in mind 
for aome years, but owing to the pressure of other work, and the excessive 
amount of calculation called for in the reduction of the statistics, it has not 
been found feasible to carry it out until now. I think it is generally accepted 
by students of vital statistics that the best way to accurately measure and 
detect changes in the effect of any disease or set of diseases is to construct 
mortality or life tables from time to time based on the population and vital 
statistics of the community. These tables will, of course, reflect all the 
errors contained in such statistics, and it is therefore primarily essential 
that all possible care should be taken in the collection of this material. The 
primary object of this paper is to determine from the data furnished by the 
twelfth census of the United States the effect of tuberculosis of the lungs on 
the population, from both the vital and social point of view. In order to 
do this the life tables were first deduced taking into account deaths from all 
causes. Then a second set of life tables was prepared taking into account 
deaths from all causes except tuberculosis of the lungs. The latter tables 
represent the vital conditions which would exist in an ideal community in 
which there are no deaths from tuberculosis. The effect of morbidity 
from this disease still remains, mortality alone having been excluded. The 
full effect of the disease could be measured only when both mortality and 
morbidity are taken into account. The method adopted in this paper will 
apply equally well to morbidity when accurate statistics of the same are 
available. At present, however, this is not possible, at least with the same 
d^ree of precision as in mortality. The results obtained on this conserva- 
tive hypothesis are startling enough, and should be all the more impressive 
when it can be so easily shown that they might be considerably increased, 
and legitimately so, by one enthuaastically inclined to include every item 
of loss in the endeavor to convince the public mind of the magnitude of the 
scourge with which we are dealing. 

65 



56 



SIXTH INTERNATIONAL CONGBESS ON TUBEKCTTLOSIS. 



TABLE I.— POPULATION A^rD VITAL STATTSTICS FOR xMALES, DRAWN 
FROM THE TU'ELFTH CENSUS OF THE UNITED STATES. 



AoB Gftatrr. 


HUJ» POPDWTION* 


All Caubi». 


Deai^a FRnv 

or TX i; LUNCM. 


DSATSfl PBOH 

Au* Cavbes £x- 

CSPT Tcibkiu:ti- 

unia. 


20-24 


3,634,373 

3,369,077 
2,931,037 
2,636,434 

2,2flS,n2 

1,H45.235 
1.569,273 
1,147,810 

919,645 
668,749 
4-W,160 
261,St>3 

122,454 
40,709 

9,3SS 
2,432 


25,252 
24,173 

22,349 
23,296 

22,42g 
22,529 
23,915 
24,024 

20,269 
2S,.'>53 
28,761 
24,627 

17,525 
8,457 
2,616 
1.045 


6,839 
7,154 
6.285 
5,6H6 

4,547 
3,736 
3,216 
2,608 

2,066 
1,753 

L2ei 

755 

30tJ 
99 
25 
11 


18,413 

17,019 
16,064 
17,610 

173SI 
18,793 
20,609 
21,416 

24,203 
26,810 


26-29..,...-,.,-... 
30-34 


35^9 


40-44 


45-49 


fiO-64 

55-60 


60-64 

65-69 


70-74...* 


27,470 


75-79 


23,872 

17,217 
8,358 

2,591 
1,034 


80^4 

S6-S9 

90-94 

95-W 



The first table presented, Table I^ is drawn from the population and 
vital Btatmtics of the Twelfth CenBua of the United States, and all the results 
which follow are based upon these figures* It will be obsen-'eil that the in* 
vestigation refers to males aged twenty and over. The ages are taken in 
five-year groups. The group 20 to 24 refers to mates who have passed the 
twentieth birthday and have not reached the twenty-fifth birthday, the 
age inter\'al thus including five yeara. The table shows that on June 1, 
1900, the date of the census enumeration, there were in the United States 
3,684,373 young men over twenty and under twenty-five years of age; that 
in the census year beginning June J, 1S99, and ending May 31, 1900, there 
were in the Unitetl States 25,252 deaths from all causes among young men 
over twenty and under twenty-five years of age, and that 6S39 of these 
deatlis were due to tuberculosis of the lungs, and the balance, 18,413, to 
other causes* 

The totjil deaths from all causes are undoubtedly understated and the 
-"p^tlis from tuberculosis are probably understated to a still greater degree. 
5 Honorable S. N. D. North, Director of the Bureau of the Census, says in 
report on tuberculosis in the United States, prepared for the International 
igress on Tuberculosis, that ''there is a large margbi of possible error and 
)bably of underatat«ment in the recorded deaths from tuberculosb even 

the registration area Add to this the protean forms of 

'ibereuloais, the difficulty of its diagnosis in some cases, the unwillingness 



THE COST OF TUBERCULOSIS IN THE UNITED STATES, — GLOVER. 



57 



of the attending physician to sign the certificate of death of a patient whose 
illoess from this disease he may have failed to report as required by law, 
and perhaps the fact that the occurrence of the death from this cause may 
be thought undesirable as a matter of record by the friends or relatives, or 
may^ perchance, conflict with representations made in applications for poli- 
dea of insurance — -there are reasons enough why many deaths from tubercu- 
loeas should not be reported and henc^ not be compiled under thb cause. 
It in pro!3!i}*le that the present tcntlenry is to uncleratate- 
ment, rather than to overstatement, in the returns of death from the various 
forma of tuberculosis, " 

The effect of understatement in deaths from all causes is to a large 
extpnt elim!nate<l from the final conclusions reached in tlijs paper, for the 
reason that they are based on the tMerence Ijetween two tables both of 
which contain the errors of undorstntement under discussion, and the 
process of taking the difference practically eliminates these errors. An 
understatement of deaths from tuberculosis alone woodd have the effect 
of decreasing and minimizing the final results, which again only serves to 
empliasize their conservative nature. 

There Ls one feature respecting the ^dtal statistics which I deem of suffi- 
cient importance to mention here. The population is given for each age, 
but unfortunately the same divLsion is not given in the vital statistics of the 
United States census, the custom here being to give the number of deatlia in 
quinquennial or five-year groups, as shown in the above table. Tliis is, 
in my judgment, a serious mistake, and I hope it may not continue much 
longer. The accurate reduction of census and vital returns by strict math- 
ematical processes requires that the deaths for any calendar year not only 
be ^ven for each age, but also that the deaths in each age be divide<l in two 
groups according to the calendar year of birth. One of the chief purposes of 
the eatabliahment of the Bureau of the Census and the collection of vital 
fitati^tics is to obtain data which shall serve to accurately measure changes' 
which are going on in the mortality rate of the United States and its various | 
subdivisions, and in particular with reference tfl certain causes^ such as 
tuberculosisj typhoid fever, pneumonia, etc. This cannot be done with 
Bcientific precision unless the alx»ve-mentioned records are forthcoming. 
I would therefore suggest that, if it is not thought advisable to give the gen- 
eral \'ital statistics in this detail, a special volume for scientific uses be pre-^ 
pared by the Bureau of the Census. Such a volume woidd in many respects 
be more valual>le and serviceable than some of the reports now issued* 

With the data of Table I a function, F (x, t), was assumed to represent 
the aggregate of males in the United States bom before the time t and sur- 
viving to the age x. With this function, in accordance with the genera! 



66 



SIXTH INTERKATIOSAL CONGRESS ON TUBERCm^OSia. 



theory of reduction of population statistics, we have the following formula 
to express the probability of living one year at age x: 

Px = CVx + 1 -Sr Vx) - (Vr + 1 — M') + (Vr + 1 + M') (1) 

On oecount of the deaths being given only in five-year age groups, it was 
necosaary to make soveral approximations. After some study of the nia^ 
terial, it was decided to apply formula (1) to these groups, assuming x to be 
the first age below the mean agp of the group. This gave the series of fleath- 
rates for every fifth year l^eginning with age seventeen, and the tleath-rates 
for the remaining ages 1^'e^D obtained by interpolation. With a radix of 
100,000 at age twenty, the number of survivors at earh higlier age was ob- 
tained. This may Ijc defined as the normal mortality table; it exhibits the 
decrease in sur\'ivor3 when tuberculosis is present in the community. By 
the phrase "tuberculosis present'' is not meant that everybody in the 
community has it^ but that the disease is present in the community and 
every memhor runs the risk of being exposetl to it. This is the condition, of 
course, everj^vhere at the present time. The thiril column ui Table 11 ex- 
hibits the life table under discussion. It shows that the group of 100,000 
at age twenty is reduced through death from all causes, including tubercu- 
losis, to 93,311 at age thirty, to 85,907 at age forty, to 44^419 at age seventy, 
to 84 at age one hundred. 

The next step was to use the data nf Table I, with deaths from tubercu- 
losis excluded, and in like manner construct a mortality table. The result 
is shown in the second column of Table II, By ** tuberculosis not present" 
is here meant that there are no deaths from this disease. The effect of 
morbidity due U) the presence of the disease in a form not fatal, and the 
increased ravages of other diseases under this favorable condition, are still 
contained in the tabJe just described. The decided improvement in sur\ival 
shown is due solely to the elimination of cases of tuberculosis with fatal ter- 
minatiou. An initial group of lUJ^OOO at age twenty under these conditions 
would contain 95,132 survivors at age thirty; 89;479 at age forty, etc. The 
fourth column is the dilTerence between the second and third, and shows 
the loss in survivors due to the presence of tuberculosis. For example, if 
there were no deaths from tuberculosis, there would h>e 1821 more survivors 
at age thirty than at present, 3572 more at age forty^ etc. The table shows 
that the maximum increase in sur\ivors is 5517 at age sixty-two. The 
higher ages of the table show that the eUmination of tuberculosis would have 
a decided effect on the longevity of the race. For example, at age eighty the 
number of survivors is increased from 19,839 to 22,717, that is, 2878, This 
is an increase of more than 14 per cent. At age ninety the increase is over 
17 per cent. If the data were at hand to construct the table at the higher 
ages with greater precision, I doubt not the figures would show the end of 



tabu: n.— mortal ity t able for males when tuberculosis is 

NOT PRESENT, WHEN TUBERCULOSIS IS PRESENT, AND THE 
DIFITERENCE in survivors AT EACH AGE. 



AoB. 



20. 
21. 
22. 
23. 
24. 

25 
26 
27 
28 
29 

30 
31 
32 
33 
34 

36 
36 
37 
38 
30 

40 
41 
42 
43 
44 

46 
46 

47 
48 
49 

50 
51 
62 
63 
54 

56 

56 
67 
58 
69 

60 
61 
62 
63 
64 



NUMBKB LonMo, 

TUBEBCUZX)ai» — 



Not 
Praeent 



100,000 
99,541 
99,065 
98,671 
98,079 

97,588 
97,098 
96,610 
96,123 
95,630 

95,132 
94,628 
94,119 
93,605 
93,071 

92,518 
91.946 
91,356 
90,748 
90,122 

89,479 
88319 
88,143 
87,461 
86,725 

85,965 
85,172 
84,348 
83,493 
82,597 

81,662 
80,689 
79,680 
78,636 
77,521 

76,338 
76,091 
73,784 
72,420 
70,973 

69,448 
67^62 
66,191 
64,472 
62,626 



Prasent. 



100.000 
99,396 
98,756 
98,081 
97,405 

96,727 
96,048 
95,367 
94,686 
94,000 

93,311 
92,619 
91,924 
91,226 
90,611 

89,780 
89,033 
88,271 
87,494 
86,706 

85,907 
85,098 
84,279 
83,450 
82,591 

81,703 
80,787 
79,844 
78,875 
77,871 

76,833 
75,763 
74,662 
73,533 
72,339 

71,083 
69,770 
68,403 
66,986 
65,499 

63,947 
62,337 
60,674 
58,965 
67,143 



Sdrvi. 

vow A1 

Each 

AOE. 




145 
309 
490 
674 

861 
1,050 
1,243 
1,438 
1,630 

1,821 
2,009 
2,195 
2,379 
2,560 

2,738 
2,913 
3,085 
3,254 
3,416 

3,572 
3,721 
3,864 
4,001 
4,134 

4,262 
4,385 
4,504 
4,618 
4,726 

4,829 
4,926 
5,018 
5,103 
5,182 

5,255 
5,321 
5,381 
6,434 
6,474 

5,501 
5,515 
5,517 
5,507 
6.483 



AOB. 



65. 
66. 
67. 
68. 
69. 

70 
71 
72, 
73 

74 

75 
76 
77 
78 
79 

80 
81 
82 
83 
84 

85 
86 
87 
88 
89 

90 
91 
92 
93 
94 

95 
96 
97 
98 
99 

100 
101 
102 
103 
104 



NUMBSK LXVTNO, 
TuBEHCDLOfilB 



Not 
Present. 



60,665 
58,604 
56,457 
54,238 
51,890 

49,437 
46,903 
44,312 

41,688 
38,986 

36,241 
33,487 

30.755 
28,074 
25,378 

22,717 
20,134 
17,667 
16,346 
13,163 

11,147 
9,318 
7,688 
6,259 
5,039 

4,010 
3,155 
2,453 
1385 
1,403 

1,011 
705 
475 
308 
186 

101 

47 

17 

5 

1 



Present. 



55,222 
53,214 
51,134 
48,996 
46,750 

44.419 
42,026 
39,593 
37,142 
34,635 

32,104 
29,679 
27,087 
24,654 
22,224 

19,839 
17,536 
15,347 
13,297 
11,377 

9,611 
8,014 
6,596 
5,357 
4302 

3,415 
2,680 

2.078 
1,592 
1,182 

849 
589 
395 
255 
154 

84 

39 

14 

4 

1 



LoBB nr 

SUBTI- 
VOBSAT 

Each 

AOB. 



5,443 
5,390 
5,323 
5,242 
5,140 

5.018 
4,877 
4,719 
4,546 
4,351 

4,137 
3,908 
3.668 
3,420 
3,154 

2,878 
2,598 
2,320 
2,049 

1,786 

1,536 

1,304 

1,092 

902 

737 

595 
475 

375 

293 
221 

162 

116 
80 
53 
32 

17 
8 
3 
1 




59 



m 



SIXTH INTEHKATIONAL CONGRESS ON TtTBERCULOSlS, 



the cohimn of survivors at bji age much higher than 104, It would not be 

surprising if an exhaustive mathematical analysis of the eombined effect of 
tuberculosis and other preventable diseases showed that under more favor- 
able circumstances, with these diseases eliminated, the age of man could be 
extended to 150 years and even higher. In other words, it is pos^ble that 



TABLE in. 

CowPARATivE Tablei SHowi>rca Tata DEAfH-rLATH Per Annum Pur 1000 Persons for 

All. Ages Between 20 and 80; (n) by the American Experience 

Table (M- MoBTALixiTf (h) bt thb United States Twelfth 

Census Returns for Males, When Titbercflosis 

13 PftESEST, When Not Present, a>;d thh 

Difference, 



Auk. 



20 

21 

22 

S3 

24..... 

25 

26 

27 

28 

29 

30. 

31 

32 

33 

34 

36 

SS 

37...... 

38 

39 

40 

41 

42 

43...... 

44 

45 

46 

47...,-. 
Vi t < ■ *• • 
49 



DxATa-BATn Feb Annum Fttn lOQQ. 



Atnericiu) 

Experi- 
ence 
Tablo. 



7.80S 
7.S55 
7.900 
7.958 
8,011 

8.065 
8.130 
8.197 
8.264 
8.345 

8.427 
8.610 
8.607 
8.718 
8.831 

8.946 
9,089 
9.234 
9.40S 
9.586 

9.794 
10.008 
10.252 
10.517 
10.829 

11,163 
11.562 
12.000 
12.509 
13.106 



Whflti Tubercu- 

1 



Pfeaeut. 



6.040 
6,439 
6.S35 
6.892 
6.961 

7.020 

7.090 
7.151 
7.235 
7.330 

7.416 
7.504 
7.593 
7.a38 
8.076 

8.320 
8.559 
8.802 
9.000 
9.215 

9.417 

9.624 

0.836 

10.294 

10.752 

11.211 
ll.ft73 
12,136 
12.729 
13,330 



LB N«lt 



4.590 

4.7&2 
4.987 
4.991 

5.006 

6.021 
5.020 
5.041 
5.129 

5.208 

5.298 
5.379 
5.461 
5.705 
5.942 

6.1S3 
6.417 
6.655 

6.808 
7.135 

7.376 

7.611 
7.851 

8.302 
8.763 

9.225 

9.675 

10,137 

10,731 

11,320 



Differ- 
ence. 



L450 
1.657 
1.848 
1.901 
1.955 

1.999 

2.064 
2.110 
2.106 
2.122 

2,118 
2.125 
2.132 
2.133 
2.134 

2,137 
2.142 
2.147 
2.108 
2.080 

2.0-11 

2.013 
1.985 
1.992 
1.989 

1.986 
1.998 
1.999 
1.998 
2,010 



DsjikTB-nATc Per Akhttk Pick 1000. 



AUE. 



55.,. 
50.,, 
57 . . . 
58... 
59... 



70... 
71„. 
72.,. 
73... 
74... 



75... 
76... 
77... 
78... 
79.., 
80... 



AmorioaQ 

eQcij 
TftbL«. 



13.781 

14.541 
15.389 
16.333 

17.396 

18.571 
19.885 
21.335 
22.936 
24.720 

26.693 

31.292 
33.943 
36.S73 

40.129 
43.707 
47.647 
52.002 
56.762 

61.993 
67.665 
73.733 
80.178 
87.028 

94.371 
102.311 
1U.064 
120.827 
131.734 
144.466 



Wh*n TubercUr 



Pr»Bne. 



13.925 

14.532 
15.121 
16.2.^S 
17.363 

18.471 
19.593 

20.715 
22.199 
23.695 

25.177 
20.678 
28.167 
30.900 
33,617 

36.362 
39.087 
41.812 
45.840 
49.361 

53.873 
67.893 
61.905 
67.408 
73.076 

78.651 
84.249 
89.822 
98,564 
107.316 
116.084 



it Not 

Prwetit. 



11.915 

12.505 
13.102 
14.179 
15.260 

16.335 

17.406 
18.4SG 
19,981 
21.487 

22.981 
24,480 
25.970 
2S.633 
31,313 

33.973 
36,636 
39.304 
43.291 
47,273 

51.257 
55.242 
59.216 

64.815 
70.410 

75.991 
81.584 
87.173 

96.032 
104,855 
113.703 



DifTer. 



2.011 
2.027 
2.019 

2.059 
2.103 

2.136 

2.187 
2.229 
2.218 
2,208 

2.196 
2,198 
2.197 
2,267 
2,304 



2,451 
2.508 
2.549 
2,588 

2,616 
2.651 
2.889 
2.683 
2.666 

2.660 
2.665 
2.649 
2.532 

2.461 
2.381 



THE COST OF TUBERCULOSIS IN THE UNITED STATES. — GLOVER. 61 

the normal age of man lies somewhere near one hundred and fifty, and that 
he is now prevented from attsiining this age by the presence of a multitude 
of factors which are coming to be recognized as preventable. By this 
increase in the period of longevity, it must be understood, of course, that 
the decline in the vital forces does not be^ until a much later time in life 
than imder present conditions, that both mental and physical vigor may 
normally continue long after age one hundred has been passed, and that the 
period which now corresponds to the weakness of senility and old age should 
not arrive, \mder ideal conditions, until after age one himdred and twenty- 
five. 

Table III deals with the important matter of death-rates. The death- 
rate is ^ven for each age from twenty to one hundred and four. It is 
obtained by finding the ratio between dx, the number dying between ages 
xand x+l, and 1„ the number surviving to age x. It is expressed in terms 
of the death-rate per 1000. That is, Qx=g is multiplied by 1000, and 
the value of 1000 q, is given when tuberculosis is present, when not present, 
and the difference. For the sake of comparison, there is also given the 
corresponding death-rate by the American Experience Mortality Table, 
the table now used by practically all insurance companies. 

The normal death-rate per 1000 per annum, at age twenty, is 6.040; 
this would be reduced to 4.590 if tuberculosis were not present. It thus 
appears that 1.450 deaths per thousand of population at this age arc due to 
this disease. At age twenty-five there are 7.020 deaths per 1000 living, of 
which 1,999 are due to tuberculosis. At age sixty the death-rate advances 
to 25.177 per 1000, of which 2.196 are due to tuberculosis. The difference 
column increases slightly, but does not vary much from two per thousand. 
This shows that advanced age is no protection against tuberculosis. In- 
deed, the danger from exposure to it is greater at age sixty than at age 
twenty. Many statisticians have fallen into the error of comparing the 
deaths from tuberculosis with deaths from all causes, and, because this ratio 
decreases at the higher ages, have inferred that tuberculosis is not so much 
to be dreaded, say, after age forty. The fact is that we are more likely to 
notice the ravages of the disease at age twenty-five, since it is the cause of 
two out of every seven deaths, whereas at age sixty it is the cause of two out 
of every twenty-five deaths. Other diseases which are not active at age 
twenty-five are decimating the population at age sixty at the rate of twenty- 
three per thousand. Moreover, as the population at twenty-five is much 
larger than that at sixty, the number of deaths in the former group is very 
much larger than in the latter. But we cannot compare the effect of the 
disease at different ages unless we observe groups at these ages containing 
precisely the same number of people. According to the table under dis- 
cussion, in a population of 1,000,000, age twenty-five, 1199 deaths would 



m 



BIXTH INTBRNATIOXAL CONGRESS ON TUBEBCUIX)Sia. 



occur within the year from tuberculosis* In a population of 1,000,000, age 
ajrty, 2196 deaths would occur from the same cause, or 197 more fatal 
terniioatioas under like conditioDS would occur at age sixty th^n at age 
twenty-five. It seems essential, then, that this fallacy should be corrected 
and the public warned that age is do protection from this disease^ and ex- 
posure to it is attended with more and more danger with increasing age. 

The next table presented is a comparative one, ehowing at certain ages 
the total number of years of future lifetime wliich will be lived by the sur- 
vivors of 100,000 males at age twenty, and the complete expectation of life 
and the loss in same due to the presence of tuberculosis. By summing the 
column in Table II headed '^Number Living" from the bottom upward, it 
is evident that we shall obtain the total number of future years of lifetime 
which will be lived by the group of survivors corresponding to the age to 
which the summation extends. An examination of Table IV shows that 
the survivors at age sixty would have 1^062,496 years of future lifetime 
before them il tuberculosis were not present. Under normal conditions 
mth tuberculosis present the survivors at age sixty have 952,505 years of 
future lifetime to live, a loss of 109,991 years of future lifetime due to the 
presence of tuberculosis. In like manner it is seen that at age twenty 
the total loss in years of future lifetime sustained by a group of 100,000 
young men is 243^412 years. A consideration of tlus column headed " Loss 
in Years" will make clear how it happens that the presence of tuberculosis 
can bring financial loss on the community. We have at this age a loss of 
243,412 yearSj most of which is lost Ijefore the young men who are now 
twenty attain the age of seventy. If it is assumed in round numbers, for 
purposes of illustration, that 200,000 of these years of future lifetime are 
lost by the original group of 100,000 survivors at age twenty befoj^ they 
attain age seventy, it is clear that these years have been lost during the 
earning or wealth-producing period of life. If each year repi'esented a loss 
of SlOO in wealth to the nation, we should have a loss on this group of 
$20,000,000, the interest factor being neglected. There were in 1900 over 
700,000 young men in this country twenty years of age, and accordingly the 
loss which the country must expect to sustain on this group, the interest 
factor being neglected^ is, in round numbersi S140,000,000, In a later part 
of this paper we shall see that the capitahBcd or present value, \vith interest 
aasumetl at 5 per cent, on this particular group of young men on a wealth- 
producing basis of SlOO per annum, is exactly $35,332,569, These facts ai« 
pointed out at this time in order to emphasize how and where the loss due to 
tut)erculosis or any other disease occurs. The presence of a dise;ise in any 
group of persons or in any community inevitably decreases the total future 
lifetime of that group, and a direct measure of the loss due to any disease must 
be found in the number of years taken out of the life of the group* 



TABLE IV.— CtMCPAiunva Tabub Snownfa at Ages 20 to 104 thb Total Nuubbr or 
YxABfl or Futubs LiFXTim which will be Lived bt the Surviyors of 100,000 

AT AOX 20, AND TBS LO88 IN SaUB DdS TO THE PRESENCE OF TUBERCULOSIS. 



AOB. 



20 
21 
22 
23 
24, 

25 
26 
27. 
28. 
29. 

30. 
31. 
32. 
33. 
34. 

35. 

36. 

37 

38. 

39. 

40. 
41. 
42. 
43. 
44. 

45. 
46. 
47. 
48. 
49. 

50. 
51, 
52. 
53. 

54. 



55 
56 
57. 

58. 
59. 

60. 
61. 
62. 
63. 
64. 



Total Fvtubb I^fb- 

mcB IN Ybabs When 

TuaaacDLOUB — 



bNot 
Pnnot. 



Yevs. 
4,566,480 
4,466,939 
4,367,874 
4,260,303 
4,171,224 

4.073,636 

3,976,538 
3379,928 
3,783305 
3,688,175 

3,593,043 
3,498,415 
3,404,296 
3310,691 
3,217,620 

3,125,102 
3,033,156 
2,941300 
2351,052 
2,760,930 

2.671,451 
2,582.632 
2,494.489 
2,407,038 
2320313 

2.234.348 
2.149.176 
2,064328 
1,981335 
1398,738 

1317.076 
1,736,387 
1,656,707 
1,578.071 
1,500.550 

1,424.212 

1,349,121 
1.275,337 
1302.917 
1,131,944 

1,062,496 
994.644 
928.453 
863.981 
8OI355 



bPrewot. 



Ymn. 

4323,068 
4323,672 
4,124,916 
4,026335 
3,929,430 

3332.703 
3,736,655 
3,641,288 
3.546.003 
3.452,603 

3359392 
3,266.673 
3,174,749 
3.083.523 
2,993,012 

2,903332 
2314,199 
2,725.928 
2.638,434 
2,551,728 

2,465321 
2380,723 
2,296,444 
2312,994 
2,130.403 

2,048.700 
1,967.913 
1388.069 
1309.194 
1,731323 

1,654.490 
1.578,727 
1.504.065 
1,430,532 
1358,193 

1.287.110 
1317,340 
1,148,937 
1.081.951 
1,016,452 

952,505 
890,168 
829,494 
770,529 
713.386 



Loss IN 
YuBft. 



Yean. 

243.412 
243367 
242,958 
242,468 
241,794 

240.933 
239.883 
238,640 

237,202 
236.672 

233,761 
231.742 
229,647 
227,168 
224,608 

221370 
218,967 
215372 
212.618 
209.202 

205.630 
201,909 
198,045 
194,044 
189310 

185,648 
181363 
176,769 
172,141 
167,415 

162,586 
157.660 
152.642 
147,539 
142,367 

137,102 
131,781 
126,400 
120.966 
115,492 

109,991 
104.476 
98359 
93.452 
87.969 



AoB 



66, 
66. 
67. 

68. 



70. 
71. 
72. 
73. 
74. 

75. 
76. 
77. 
78. 
79. 

80. 
81. 
82. 
83. 

84. 

85. 
86. 

87. 
88. 
89. 

90. 
91. 
92. 
93. 
94. 

95. 
96. 

97. 
98. 
99. 

100. 
101. 
102. 
103. 
104. 



Total Futcb* Lifb- 
TiHK IN YsABfl When 

TUBSBCCLOUB 



Ifl Not 
Present. 



Yean. 
740,690 
682,086 
625,629 
571,391 
519,601 

470,064 
423,161 
378,849 
337.161 
298.176 

261,934 
228,447 
197,692 
169318 
144340 

121.523 

101389 

83,722 

68.376 

55313 

44.066 
34.748 
27,060 
20301 
15,762 

11,752 
8,597 
6,144 
4359 

2,856 

1,845 

1,140 

666 

357 

171 

70 

23 

6 

1 





la Present. 



Yean. 
658,164 
604,950 
5533I6 
604,820 
468,070 

413,651 
371,625 
332,032 
294,890 
260355 

228.161 
198,672 
171,485 
146.831 

124,607 

104,768 

87,232 
71.885 
58,588 
47311 

37,600 
29,586 
22,990 
17,633 
13331 

93I6 
7.236 
5,168 
3,566 
2,384 

1,535 
946 
551 
296 
142 

58 

19 

5 

1 





I<OB0 IN 

Ybabs. 



Yean. 
82,626 
77.136 
71313 
66,571 
61,431 

56,413 
51,536 
46317 
42,271 
37,920 

33,783 
29,875 
26,207 
22.787 
19.633 

16,765 
14.157 

11.837 
9,788 
8,002 

6,466 
5,162 
4,070 
3.168 
2,431 

1,836 

1.361 

986 

693 

472 

310 

194 

114 

61 

29 

12 
4 
1 





63 



6i 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSia. 



Table V exhibita the expectation of life of two groups, the firet with 
tuberculosis not present, the second with tulierculosis present. The table 
showa that the expectation of life at age twenty is 46.165 years if tubercU' 
losis is not present, but that under prevailing conditions a young man of age 
twenty hag tliis expectation of life reduced two years and one hundred and 
fifty-eight days, owing to the presence of tuberculosis in the community. 
These figures are derived from the figures of the prececUng table. For the 
expectation of life is merely tlie average future lifetime^ so that we have only 
to divide the total future lifetime at a given age by the numl>er of sui*vivor3 
at that age, taken froni Table 11, to obtain the average future lifetime* 
To this quotient is addml one-half year, to provide for the fact that deaths 
on the average occur uniformly throughout the year, so that in the long run 
the average length of life in the year of death is six months, or one-half year. 
The two columns giving the expectation of life were obtained in this manner. 
Our chief interest lies, however, not so much in the columns themselves, as 
in their difiference, showing the individual effect of tuberculosis on the future 
lifetime. Although there may be more or less error in the statistics from 
which the two main columns were drawn, these errors, being of like nature, 
will most likely diaapi>ear in taking the difference of the columns. Con- 
siderable reliance, therefore, may be placed upon the two columns giving 
the loss in years of total future lifetime and the loss in years and days of 
individual expectation of life. That the expectation of life of every person 
in the community aged twenty is reduceri two years and one hundi*ed and 
fifty-eight days Is a very significant fact, and it hardly seems possible that a 
stronger argument could be put forward for the support of a nation-wide 
antituberculosis campaign. Even at age thirtj-'-five its effect on the ex- 
pectation of life is one year, one hundred and sixtynane days, and the figures 
are not materially reduced, when the age is considered in connection there- 
with, at the higher wages. 

Few people are aware of the enormous loss in wealth which this country 
suffers on account of tuberculosis. The amount of this loss has a special 
Bignificance when considered in connection vnth the cost of an organized 
campaign having for its object the practical elimination of tuberculosis. 
To accomplish this result it is essential that extensive and continuous finan- 
cial assistance l)e forthcoming for a considerable period of years, and the 
question arises as to bow much the nation or State would be justified in 
spending to check the disease within its boundaries. I have considered this 
subject in some detail, and derived tallies from the population and vital 
Etivlisties of the twelfth census of the United States, by means of which the 
monetary loss sustained by a community of given population can easily be 
computed. These tables were deriveii by the application of well-known 
actuarial processes, the object being to determine the monetary loaa-rate at 
each age based upon some unit of net wealth-producing capacity. 



THE COflT OF TCBERCULOSIS IN THE UNITED STATES. — GLOVER. 



65 



TABLE V. 

OOKPARATITB TaBUB SHOWIKa AT AOES 20 TO 80 THE COMPLETB EXPECTATION Of 

liinB When Tubbbculosxs is Not Present, When Present, and the 
LoflB IN Years and Days Dub to the Presence of Tuberculosis. 



20 
21 
22 
23 
24 

25 
26 
27 
28 

20 

30 
31 
32 
33 
34 

35 
36 
37 
38 
30 

40 
41 
42 
43 
44 

45 
46 
47 
48 
49 





EZPECTATIOH 


or lawmWmtti 


Tmrnacuhtmrn jb— 


Not 

PlWMlt. 


Pnmkt. 


Yam. 


Years. 


46.165 


43.731 


45.376 


42.903 


44.501 


42.260 


43.812 


41.556 


43.029 


40.841 


42.243 


40.124 


41.454 


39.404 


40.661 


38.682 


39.864 


37.057 


39.067 


37.230 


38.260 


36.501 


37.470 


35.770 


36.670 


36.037 


35.869 


34.301 


35.072 


33.568 


34.278 


32.837 


33.488 


32.108 


32.701 


31.381 


31.017 


30.656 


31.135 


29.030 


30.356 


20.203 


20.677 


28.476 


28.800 


27.748 


28.024 


27.010 


27.256 


26.295 


26.401 


25.575 


25.733 


24.850 


24.980 


24.147 


24.231 


23.437 


23.488 


22.733 



Locia 

XN YCAKS 
AJTD DaT8. 



Yarn. 

2 

2 
2 
2 
2 

2 
2 
1 
1 
1 

1 
1 

1 
1 
1 

1 
1 
1 
1 
1 

1 
1 
1 
1 




Days. 
158 
130 
118 
93 



43 

18 

357 

331 

306 

280 
256 
231 
207 

184 

161 

130 

117 

95 

75 

56 

37 

19 

2 

350 

334 
310 

304 
200 
276 



AOB. 



50 
51 
52 
53 
54 

55 
56 
57 
58 
50 

60 
61 
62 
63 
64 

65 
66 
67 
68 
60 

70 
71 
72 
73 
74 

75 

76 
77 
78 
79 
80 



GoifPLBTB 

Expectation 

OF LiPB Whkn 

Tdbkrcuumu n- 



Not 
PreMnt. 



Yean. 
22.751 
22.020 
21.202 
20.568 
10.857 

10.157 
18.466 
17.785 
17.110 
16.440 

16.709 
15.159 
14.527 
13.001 
13.206 

12.710 
12.130 
11.582 
11.035 
10.512 

10.008 
9.522 
9.050 
8.588 
8.148 

7.728 
7.322 
6.928 
6.542 
6.184 
5.840 



Present. 



Yean. 
22.034 
21.338 
20.645 
19.954 
10.276 

18.607 
17.048 
17.207 
16.652 
16.010 

15.305 
14.780 
14.171 
13.568 
12.084 

12.410 
11.868 
11.331 
10.803 
10.298 

0.812 
0.343 
8.886 
8.440 
8.014 

7.607 
7.213 
6.831 
6.456 
6.107 
5.781 



Loea 
XN Ykabs 
AND Days. 



Yean. 




Days. 
262 
240 
236 
224 
213 

201 

180 
178 
167 
157 

147 
138 
130 
122 
114 

106 
09 
92 
85 
78 

72 
65 
60 
54 
49 

44 
40 

35 
31 
28 
25 



Before entering into det&Us the method may be briefly outlined. It is 
assumed that on the average each male member of the community can add 
a net sum of one himdred dollars each year to the wealth of the community. 
This ability to produce wealth is assumed to continue until age seventy, and 
then cease. The total gain which is thus contributed is found for each age, 
and the equivalent capitalized sum is computed, taking into account the 
VOL. in — 3 



66 



BIXTH IN'IKBHA.llOHAL CX>NGRES3 OX TUBERCITLOSIB. 



interest factor, 5 per cent*, and the mortality factor, determining the prob- 
able length of life. The gain in wealth is first computed on the assumption 
that there are no deaths torn tuberculosis, and then again on the assump- 
tion that the conditions as regards tuberculosis are those which now prevail* 
The gain in the former case will, of course, be greater than in the latt-eJ, 
because, witli deaths from tuberculosis eliminat-efl, people would live longer, 
and hence contribute for a longer period of years to the wealth of the com- 
munity. This excess, wliich would be realized if there were no deaths from 
tuborculosis, is the monetary loss which the community must suiTer owing 
to the presence of the disease. Technically si>eaking, the difference l:>etween 
the capitalized value of the future net wealth-producing capacity of an in- 
dividual in a community at a ^ven age, first on the assumption that tuber- 
culosis is not present, and tlien on the assumption that it is present, is the 
loss which the community must inevitalily sustain on that individual so 
long as the disease remains unchecked in the community. 

Returning now to detjiila, the first step was to deduce matliematically 
the mortality table on tlie assumption, that tuljerculosis is present in the 
community* that is, a normal table, and then a second mortality table on 
the assumption that there are no deaths from tuberculosis of the lungs. 
Both of these tables were carefully derived from the statiBtica of the twelfth 
census by well recognized, strict mathematical processes, there being but 
little approximation necessary, and these approximations of a minor char- 
acter. Such errors aa exist, arc due to errors in the statistics given, and not 
to the processes of re<luction employed. The nature of the errors which 
appear in the statistics and are necessarily contained in the mortality tables 
set forth in Table II have already been considered in a previous part of this 
paper* After having derived the respective mortality tables, tlie next step 
taken was to find the present value, or, as it is more frequently called, the 
capitalized value, computed at 5 per cent., of an annuity of SlOO per annum 
payable at the end of each year. Such annuity values were computetl for 
every age from twenty upward for each table. Two seta of annuity tables 
were computed, the first being for a life annuity and the second for an an- 
nuity continuing until age seventy. The values of the life atmuities are set 
forth in Table VL An examination of the first column of this table, which 
exhibits the present or capitalized value of an annuity of $100, when tuber- 
culosis is not present* shows that such value is equal to $1671.66 at age 
twenty, decreasing to $1504.61 at age tliirty^five, to $1222.30 at age fifty, 
and to $t)65.5l at age sixty. These are the figures for an anniuty payable 
throughout Ufe^ The next column gives the value of a similar amiuity 
based on the mortality table derived when tulierculosis is present. A glance 
at this column sliows that there is a loss in the value of the annuity at each 
age when compared with the value at the corresponding age m the preceding 




68 StXTH INTERNATIOPfAI^ CONGRESS ON TUBERCULOSIS. 

will not serve our purpose in measuring the monetary loss if we assume that 
wealth-producing capacity ceases at age seventy. In order to determino 
the loss under the latter hypothesis, it will be necessary to find the present 
or capitalized value at each age from twenty to seventy, computed with 
5 per cent, interest, of an annuity of SlOO per annum. These values are 
given in Table VIL As might be expected, they are smaller than the cor- 



TABLE V^I. 

pRBfiCNT OB CAFrrALIZED VAiUIfi AT EaCM AoE FHOM 20 TO 70 COMPUTIID wim 5 

Pkr Cent. lirrEREBT or a Wealth Inchement or Savtng or $100 Per 
Annum at the End or Each Year until Aoe Seventy. 





WBftH TUDUlCt7L06ia 1»— 


Lou IH 




WSBH TflBKnCDl.OBia u — 


Look m 








Valiju 
AT Each 


AOB. 






Valub 


AOB. 




\ 






AT %KCm 




Not Pren&t. 


PfCBuat. 


Agk. 




Not Pre«]iii. 


Pmoot. 


AflB. 


20 


Ilp642.29 


«1.694,7S 


$47.51 


45. ... . 


•1,214.80 


«1, 190,59 


•24,21 


21........ 


1,632.36 


1,584.69 


47.67 


46. , . . . 


1JS7.42 


1,164.29 


23.13 


K2 


1,622.20 


1,574.71 


47.49 


47 


1,158.97 


1,136.95 


22.02 


23...,,... 


1,611,86 


1,664-82 


47.04 


48 


1,129.38 


1,108.46 


20,92 


24........ 


1,600.94 


1.554.47 


46.47 


49. ... . 


1,098.72 


1,078.88 


19.84 


25 


1,589.44 


1,543.63 


45.SI 


50 


1,066.86 


1,048.14 


18.72 


26 


1,577.34 


1,532.27 


45.07 


51..... 


1,033.71 


1,016.09 


17.62 


27 


1,564.57 


1,520.38 


44.19 


52 


999.15 


982.63 


10.52 


2B 


1,551.12 


1,507.90 


43.22 


53 


963.02 


947.55 


15.47 


2ft 


1,537.08 


lj494.S3 


42.25 


64 


926.73 


911.39 


14.34 


30 


1,522.37 


1,481.16 


41.21 


55 


887.08 


873.88 


13.20 


31 


1,507,01 


1,460.84 


40.17 


66 


846.90 


834.84 


I2.0G 


32 


1,490.92 


1,451.83 


39.09 


57 


804.99 


794.10 


10.89 


33 


1,474,06 


1 ,436.0$ 


37.98 


6S 


761.16 


751-44 


9.72 


34... 


1,456.64 


1,419.79 


36.85 


69 


715.52 


70G.93 


8.59 


as 


,.1»43S.62 


1,402.92 


35.70 


60 


667.79 


660.28 


7,51 


36 


1,41994 


],.1S.S.43 


34.51 


6J . . , . 


617.68 


611.21 


6,47 


37 


1,400.56 


1,367.25 


33.31 


62 


564.84 


5.W.36 


5.48 


38 


1,380.46 


1,348.37 


32.09 


03 


508.89 


504.36 


4.54 


39.....^ 


i;J59.54 


1328,65 


30.89 


64..... 


450.09 


446.45 


3.64 


40,.... ,. 


1,337.7S 


1,308.06 


29.72 


65 


387,87 


385.09 


2.78 


41..,..^ 


1,315.11 


1,286.51 


28.60 


66 


321.58 


319.59 


1.99 


42 


1^1.45 


1,263.97 


27.4S 


67 


250.50 


249.22 


1.2a 


43 


1,266.76 


1,240.36 


26.40 


68 


173.79 


173.10 


.69 


44 


1.241.21 


i;215.92 


25.29 


69 


90.74 


90.49 


.25 






.... 


.... 


70 


0.00 


O.OO 


.00 



4 



responding values for an annuity payable throughout life. At age twenty 
when tuberculosis is not present the value of the annuity is $1042.29, at 
age thirty-five 11438,62, at age sixty $667.79. The next column shows 
the corresponding values when tuberculosis is present; they are, of course, 
smaller, the value at age twenty being $1594.78, at s^e thirty-five $1402.92, 
and at age sixty $660.28. The next column, which is the diiference between 



^THE CO0T OF TUBERCULOSIS IN THE UNITED STATES. — GLOVER. 60 

the two columns just considered, taken for each age, shows the loss in value 
of the annuity at each age due to the presence of tuberculosis in the com- 
munity. It is the fundamental table arrived at in this investigation, and 
^h its use we shall be able to compute the monetary loss sustained by any 
community with a coneiderable d^ree of precision, bearing in mind, of 
course, that we are here dealing only with male lives between ages twenty 
and sixty, both inclusive, on the assumption that they can produce wealth 
at the unit rate of $100 per annum until age seventy. Knowing the loss 
sustuned in a community, on this annual wealth-producing basis, it be- 
comes merely a problem of mulliplication to determine the loss sustained 
by the community on the same group when the actual annual wealth-pro- 
ducing capacity per individual has been exactly determined. 

It may be possible that the conditions within a community are such that 
the wealth-producing capacity from ages twenty to seventy b not uniform, 
or that it does not cease at age seventy, but at some earlier or later age. 
As soon as such conditions have been set forth definitely, the fundamental 
mortality tables deduced in this paper, together with the commutation 
eolunms given in a later table, make it possible to compute, with all the 
precision which the original statistics afford, the exact loss which will be 
sustained under the stated conditions. In other words, there is no occasion 
with these tables at hand for any estimate to be made other than the eco- 
nomic estimate as to wealth-produdng capacity, and even these figures can 
now be obtained with a fair degree of accuracy for many classes of occupa- 
tions. The last colunm, giving the loss in value at each age, it must be 
remembered, is the present or capitalized value of future losses. It repre- 
sents the average loss at the given age sustained by the community on every 
male individual in the community of that age. I wish particularly to em- 
phasize that this is not the loss sustained on each individual who dies of 
tuberculosis, but on each and every male individual in the community. 

To illustrate this point, I next proceed to show how it happens that 
$13.20 is lost by the community on every male within that community aged 
fifty-five on the assumption that tuberculosis is present in the community 
and that all males aged fifty-five can produce, on the average, an addition 
of $100 per annum to the wealth of the community until age seventy. 
Table VIII is constructed with this end in view. I have assumed a com- 
munity in which there are 76.338 males aged fifty-five, this number having 
been selected because it happens to be the number of survivors fihf)wn m 
Table II at this age when tuberculosis is not present. Table VII tiUowtA 
that when tuberculosis is not present the capitalized value of %Ui^^ \>^F 
annum is $887.07 at age fifty-five for each peraon. Multiplying by 7^,-^^, 
we find the present value for this number of persons to be $tt7,7M/w4 
We now wish to show how this sum improved, at interest at 6 por wfiw- 1^ 



70 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



annum, will provide SlOO at the end of each year for each survivor of the 
oripnal group of 76^338 persons and not be exhausted until agp seventy^ 
In other wordSj \vc wish to show that 567,717,854 is the present value of the 
$100 which will be produced at the end of each year by all the survivors of 

TABLE VnL 

Table SaowijiTG how at Aqe 55 a Bvm op $100, PtiontjcED at the End of Eacb Yelah 

TNTiL. Ace 70, has when CcjmpocSded at 5 Per Cent, a Cai^itauzed 

OR Phesbnt VA[,rE OF 1887.08 when Tubercui-obis is Not Phes- 

EXT AKD J-'il73.S8 WHEN TOBERCULOStS Ifl PRESET^ (MaLES). 





CAptTALiBEQ dk FaEBE?iT VALt7iB ro« 76,338 pEiuONfl. Eacq Aoed 55- 


- 


Wbea Tubentilmm u NiA Vn^^bL, 


WWa TubarDU^ous it Fiv»etii. 






Fund 






Fund 






Fynd ivt the 


ImpTOTGd ftt 


LenVtOO 


Fuoft at f-he 


Improved at 


Lca«100 


Abb. 


Besinbtna of 


6% flt End 


for Each 


Boginmng of 


A% nt Knd 


for Each 




Eiwh YfiK. 


of Eftcli 
Yew. 


Survivor. 


Each Year, 


of Eusta 
Year. 


Survivor. 


65 


67,717,^54 


71.10a,747 


7,509,100 


66.710,002 


70.045,503 


7,492.800 


66....... 


63,594,a47 


66,774,379 


7,378.400 


62,552,703 


65.680,338 


7,346,000 


57 


59.305,979 


62,365.778 


7,242,000 


58.334,338 


61.25 1,0.55 


7,193.800 


58 


5S,123J7S 


67,879,968 


7,097,300 


54,(}57.2ii5 


56,760.U8 


7,034.100 


59 


50,782,567 


53,321,807 


6,044,800 


49,726,018 


52.212,310 


6.867,400 


60..,,,.. 


46,-377,000 


48,695,850 


6,785,200 


45,344,919 


47,612,165 


6,694.500 


61 


41,910,15..^ 


44,00*1,183 


6,619,100 


4(1,917.665 


42,963,548 


6,516.000 


62 


37.387 083 


39;2.5fi,437 


6,447,200 


36.447,548 


38.269,926 


6,332.400 


63.. 


32,809,237 


34,449,69fl 


6,2R2,600 


31,937,526 


33,534,402 


6,136,800 


64 


28487»099 


29,596,463 


6,056,-500 


27.397,602 


28,767,482 


5,930.500 


65...,,.. 


23,520,963 


24,706,451 


6,860,400 


22,836,982 


23,978,832 


6.714,800 


66 


18,846,051 


19,788,354 


5,645,700 


18,264,032 


19,177,234 


5.491,400 J 


67 


14,142,654 


14,849,7fi6 


5,423.800 


13,685,834 


14,370,126 


5,261,8001 


68....... 


9,425,^86 


9397;286 


6,189.000 


9| 108,326 


9,563,743 


5.020,600 1 


SB 


4,708,286 


4,&43,700 


4,943,700 


4,543,143 


4,770,300 


4,770,300 



CapttaUzed Value, Tuberculosis Not Present, 76.338 Males 

A^cd 55 , ■. «67 ,717,854.00 

Capitalized Value, Tuberculosis Prefsent, 76,338 Male* 

Aged 65 , 66,710.002.00 

LosB in CapitaUzed Value. Due to Tuberculoeis, on 76,338 

Males Aged 55 11,007,852.00 

Loss in Capitalized Value. Due to Tuberculosis, on One 
Male Agc<i55 $13.20 

67,717^54 = 76,338 X 887.07 (92.266) 66,710,002 - 76,338 X 873.87 

(67,324). 

this origiaal group, money being assumed to be worth 5 per cent. Referring 
now to Table VIII, the fund at the beginning of the year, $67,717,854, im- 
proved at 5 per cent,, becomea $71,103,747 at the end of the year; the number 
of survivon? by Table II is 75,091, which, miiltipUed by SlOO, the amount 
produced by each individual during the year, gives $7,509,100; this, do- 




THE COBT OF TT7BERCUI*0SIS IN THE 



'ATES .^-GLOVER , 



71 



ducted from S71,10a,747, leaves a bdance of $63,594,647, the fund at the 
beginning of the next j^ear, when the survivors are fifty-sis years of age. 
This fimd^ again improved at 5 per cent-, amounts to $66J74j379. Deduct- 
ing from this $7,378,400, the wealth produced by the 73,784 anrvivore 
ehown in Table II at age fifty-seven, we have a fund of $59,395,979 to begjn 
with at this age. Proceeding in this manner we find that when the survivors 
have reached age sixty-nine there b a fund of S4,70S,286 romaining. Tliis 
impro%'ed at 5 per cent, amountg to $4,943,700 at the end of the year. But 
at this time Table II showg that there are exactly 49^437 survivors at ago 
seventy, who have produced $4,943,700 in wealth during that year, thus 
GEftcUy exhausting the fund. It is thus seen how the original $67,717,854 
is the present equivalent of the earning during the succeeding fifteen years 
of the oripnal group of 76,338 males aged fifty-five under the stated con- 
ditions. 

In a siDiilar manner the second half of the table exhibits the progress of 
a fund of $66,710,002. This fund represents the present value of the future 
wealth produced by the same group of 76,338 persons at agp fifty-five on 
the basis of a producing capacity of $100 per annum working until age 
aeventy, on the aagumption that tuberculosb is present. This represents 
ibe DDrnial condition under which people are working at the present time 
with respect to tuberculosb* The table shows that this fund when improved 
at 5 per cent, will supply $100 at tlie end of each year for each sur\'ivor, the 
number of sur\ivora in the group, of course, Ijeing determined in accord- 
ance with the death-ratea shown in Table III when tuberculosis is present. 

We may now regard the community or nation as the recipient of the 
aimual wealth-producing capacity of each male within it between, aay, 
tigpB twenty and sixty. If the unit of wealth-producing capacity per annum 
B token as $100, the eonimunity may be regarded as in receipt of a wealth 
increment or annuity of $100 per annum, such aiuiuity being based upon the 
life of the inriividual within the community ami continuing until age seventy. 
Having found the capitalized or present value of the future wealth-produc- 
ing capacity of 76,338 individuals in the community at age fifty-five, first 
on the assumption that tuberculosis is not present, and then on the as- 
sumption that tuberculosis is present, it is evident that the difference between 
these two values is tlte present or capitalized value of the loss which the 
oonununity must inevitably sustain on this group of 76,333 persons bo long 
as the disease remains unchecked in the community. This difference is 
$1,007,852. Dividing it by 76,338, we find that $13.20 is the loss per in- 
dividual at this age, Thb b the figure g^ven opjxysite age fifty-five in the 
cctlumn he^ed "Loss in Value at Each Age " in Table VIL 

Turning now to a further consideration of the fundamental column of 
rTable VII, we note that the loss is given at each age from twenty to seventy, 



72 



8IXTH INTEBKATIONAL CONGRESS ON TUBERCULOSIS. 



both inclusive; the loss begins fit $47.51 and gradually decreases to nothing 
at age seventy. The decrease is not imiform, and the greatest loss, as might 
be expected, ia sustained in the earlier ages. Before passing on to an 
application of the results contaiaed herein, it ought to be pointed out that 
the method indicated is far more genera] than the particular applications 
made in a later part of this paper. It has there been assumed that the 
earning capacity would cease at age seventy; also that the earning or wealth- 
producing capacity throughout this interval is uniform. Neither one of 
these assumptions is peculiar or essential to the method of valuation set 
forth in this j:»aper. The loss which would be sustiuned under any other 
conditions could equally well be obtained as soon as those conditions were 
^ven. The mortality tables having once been derived, the fulfilment of 
any set of conditions involving nnnuities of any description or under any 
status could be obtained by well-known actuarial processes, 

I next pass to the first application of Table VII, namely, to find the pres- 
ent value of the total loss sustmned in the United States, 

Table IX, sho'wing the capitalized or present value, compounded an- 
nually at 5 per cent., of the loss due to tuberculosis on the male population 
of the United States for each age, and certain age groups between the ages 
twenty and sixty^ on the basis of a wealth-producing capacity of $100 per 
annum until age seventy, is computed in accordance with the Ios&-ratioa 
previously determined* The column headed popidation is taken from the 
twelfth census of the United States. It appears that there were 743,687 
young men liWng at age twenty; the loss-rate at tliis age is $47.51, hence the 
total loss is $35,332j569. The number living at age twenty-one was 739,047, 
the loss-rate S47.67, the capitalized loss $35,230,370. Proceeding in this 
manner with ages twenty-two, twenty-three, and twenty-four, we find that 
the loss wliich this country mil sustain on the age group 20 to 24 is $174,- 
084,182- Since this group is assume*] to produce annually until age seventy, 
the loss which has the present value just found wilf be spreati over the first 
half of this century* Glancing ilown the loss column, a decrease in the 
figures is noted; the greatest loss, over thirty-five million dollars, at age 
twenty, decreasing to less than twenty millions for the group at age forty and 
to about two millions for the group at age sixty. This decrease is not due 
alone, of course, to the decreasing loss-rate, but also in part to the smaller 
population at the higher ages. The table shows that most of the loss will 
he sustained on that portion of the population between ages twenty and 
forty, the loss on the 20 to 39 group being $525,873,205, while the loss on 
the 20 to 60 group increase the total to $671,018^025. The reason for this 
b easy to explain; the younger generation living between ages twenty and 
forty working under the assumptions until age seventy ^vill have a longer 
interval to produce wealth than the group of persons living between ages 




THE COST OF TUBERCULOSIS IN THE UNITED STATES. — GLOVER. 73 

TABLE IX. 

Tavlb flaownfo ths Capttalizbd ob Present Yaxajt, Compounded Annually at 

5 Feb Cent, of the Loss Dub to Tuberculosis on the Male Fopu- 

ULTioH or the United States fob Each Aqb and Certain Aob 

Gboxtps Between Aoes 20 and 60 on the Basis of a Pro- 

DUciNG Capacitt OF $100 Per Annuh until Age 70. 



AOK, 



20 
21 
22 
23 
24 

ao-24 

25 
26 
27 
28 
29 

20-29 

30 
31 
32 
33 
34 

20-34 

35 
36 
37 
38 



20-39 



PoruLA- 
noM, 1900. 



743,687 
739/)47 
745,491 
721347 
734301 

3,684373 

745,136 
673,629 
666,166 
684,941 
599305 

6,963,450 

777386 
502398 
579386 
643,950 
628337 

9394,487 

608,152 
492,186 
476387 
661,768 
509341 



12,530,921 



$47.51 
47.67 
47.49 
47.04 
46.47 



45.81 
46.07 
44.19 
43.22 
42.25 



41.21 

40.17 
39.09 
37.98 
36.85 



35.70 
34.51 
33.31 
32.09 
30.89 



Total Loss. 


AOE. 


$35,332,569 
35330,370 
35,403,368 
33,955,683 
34,122,967 


40.. 
41.. 
42.. 
43.. 
44.. 


174,084,182 


20-44.. 


34,134,680 
30,355352 
29,437,876 
29,603,150 
25,320,636 


45.. 
46.. 
47.. 
48.. 
49.. 


322336,476 


20-49.. 


32,031,132 
20,181,328 
22,648,199 
20,659,221 
19,458.163 


60.. 
51.. 
52.. 
53.. 
54.. 


437314,519 


20-54.. 


21,711,026 
16,985,339 
15,831310 
17,706,235 
15,724,276 


55.. 
56.. 
57.. 
58.. 
59.. 
60.. 


525,873305 


20-60.. 



POFULA- 


Lou- 


TIOM, 1900. 


BATK. 


643,551 


$29.72 


393,935 


28.60 


451,803 


27.48 


390357 


26.40 


389326 


25.29 


14,799,693 





476,468 


24.21 


349,745 


23.13 


337,687 


22.02 


349,707 


20.92 


331,628 


19.84 


16,644,928 





454,433 


18.72 


276,208 


17.62 


310,129 


16.52 


264,837 


15.47 


263,666 


14.34 


18314,201 





297,606 


13.20 


244,362 


12.06 


207,971 


10.89 


202,677 


9.72 


195,194 


8.59 


275,887 


7.51 


19,637398 





Total Lobs. 



$19,126,336 

11,266,541 

12,415,546 

10,302,785 

9343,526 

588327,939 

11,535390 
8,089,602 
7,435,868 
7315,870 
6,579,500 

629,784,069 

8,506,986 
4,866,785 
5,123,331 
4,097,028 
3,780,970 

656,159,169 

3,928.399 
2,947,006 
2,264,804 
1,970,020 
1,676,716 
2,071311 

671318,025 



forty and sixty. While these figures are startling in magnitude, I wish 
again to emphasize that they are more than conservative and may with 
certainty be set down as minimum figures. The chief circumstances which 
tend to make the results minimum are the following: 

(a) They are based upon reported deaths from pulmonary tuberculosis. 
Reasons have already been given why these reported cases are considerably 
below the actual number. 

(&) The figures given are based on cases of pulmonary tuberculosis with 
fatal termination, hence the effect in the decrease in length but not in 
breadth of life is considered. It is suffident to call attention to the fact that 
the presence of tuberculosis in the community involves a tremendous in- 
creaae in morbidity; that cases without fatal termination are far more 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS, 

numerous than those with fatal terminaiioti; thai tuberculous morbidity 
subjects the community to the attack of other diseases, with the result that 
many such cases, owing to lowered vitality , terminate fatally; that the 
earning or weaUh-producing period in both fatal and non-fatal cases of 
tuberculosis or other diseases wliich have invaded tlie community owing to 
tuberculous morbidity must ncceaaarlly be considerably <Uinbished, The 
loss-rates obtained in the preceding computations are based upon the as- 
sumption that the individual can produce wealth or a net economic gain at 
the average nnit rate of SlOO per annum until the age of seventy, but it is 
clear that the tuberculous individual must be incapacitated, whether the 
case terminates fatally or not, for a number of years within the wealth- 
producing period. During these years, instead of adding he is actually 
Bubtracting wealth from the community. The individual with lowered 
vitality produces a smaller wealth increment and the individual who cannot 
work becomes a financial burden upon the community. 

(c) The present figures relate only to males between ages twenty and 
Bixty working until age seventy. The loss due to the burden of tubercula^is 
on the male population under twenty and over sixty is not counted. As it 
happens that mRmbers of these groups are largply dependent upon the pro- 
ductive capacity of the main group between twenty and sixty, it follows 
that tuberculosis in these dependent groups would serve to produce a greater 
drain upon the supporting group. 

(d) The loiss-results refer to a fixecl time and t<i a particular group^ namely, 
the present value of the future loss which will be sustaine<i on the group 
living at that fixed time between ages twenty and sbtty. It is evident that 
as tliis group moves on in time, other groups of the li%ing will come in, and 
upon these new groujjs axJditional losses will be sustained. For example, 
the group now living between ages fifteen and nineteen in five yeara will be 
a group between ages twenty and twenty-four, a group upon which, we have 
seen, the loss is very great. The atlditional loss which will be sustained 
u|X)n these emerging groups within a fixed interval of time wiil l>e con- 
wtlered in another paper. 

(e) The monetary loss due to tuberculosis among females has not been 
considered at all. 

When the appropriate statistical material is available, the methods set 

forth in this paper may be employed to determine the loss on all these 

mitted faetore, but for the purpose of clearness of presentation it was 

ided to confine the attention to the definite group of wage-earners be- 

>Gn ftges twenty and sixty. The results obtained on this group are com- 

•atively free from the criticism of personal estimate. Moreover, with all 

' element© above mentioned omitted, the magnitude of these minimum 

^f^s should be sufficiently great to sharply call the attention of our 



THB COSrr OP TITBEHCDLOSIS IN THE UNITBD STATES, — GLOVER. 



75 



.le^alative bodies and others in authority to the fact that they have a great 
problem confronting them. In adtlition to the suffering, misery, and un- 
timely deaths due to tuberculosis, the ooimtry is constantly subjected to 
a tremendous fmancial drain. No clearer duty lies before the people of 
this country to-day than the conservation of these vital forces which are now 
BO imneccasarily and cruelly being wasted. If the minimum value of the 
mooetary loss involved in this waste of vital forces can be determined, are 
we not justified in expending a large fraction of this minimum amount, if 
it can reasonably be shown that such expentliture will result in the elimination 
of a corresponfling proportion of the fatal terminations from tuberculosis? 
The practical question arises as to what the annual loss may be, I give 
in Table X both the annual and total losses for certain areas. The detailed 
total losses for New York State, New York city, Illinois, and Chicago, based 
on their estimated population in 1908, and computetl in accordance with the 
preceding methods, are given in Tables XII, XIII, XIV, and XV, appearing 
at the end of this paper. All these areas have an average tuberculosis death- 

TABLE X.— MINIMUM AJJNUAL AND TOTAL LOSSES ON TUBERCULOSIS, 



United States 
United Sts(«B 



New York State 
New York City. 






POHJLATIOM. 


Ykas. 


AHHtrjil. LOH. 


Torju, IjOta. 


*76,212,16S 
186,970.173 


1900 
1908 


*36,756,22S 
41,044J37 


«671,OI8,025 
7G5,73S,924 


ta ,546.355 
t-1,338,324 


1908 
1908 


4.364,517 
2,322,9H 


79,678.192 
4:2,406,884 


t6,617,7l0 
t2,-l97,472 


IQOS 
IQ08 


2,834,198 
1,367,511 


51.740,833 
24,965,1-13 



« Genaua^ 1900, t E^imated- t f^timate of Chioa^ Bureau oi Statibtifs. 



rate in excess of the average for the United States on which the losa-rates 
Are determined; for this reason, in addition to those before considered^ the 
computed losses may be regarded as very conservative. 

The annual loss is obtained by merely spreading the total loss over a 
period of fifty years, and is the annual payment on a fifty-year annuity 
whose present value computed at 5 per cent, b equal to the total loss. Fifty 
years was selected as the maximum length of time within which the loss 
would be sustained, because those who are now twenty and over will have 
attained or passed the age of seventy after the lapse of fifty years. It is 
evident that the actual annual loss is not uniform, but wCl be heavier in the 
earlier than in the lat^r part of this fifty-year period. The table shows that 
ftt the present time the minimum annual loss in the United States is about 
forty-two million dollars, in the State of New York almost four and one- 
half miUion dollars, and in the city of New York almost two and one-hall 



7« 



SIXTH INTEORNATIONAL CONGRESS ON TUBERCULOSIS. 



million dollars. Applying these figures directly, we may say without fear 
of exaggeration, and indeed with greatest conservatism, that the State of 
New York can weli afford to expend $4^364,517 each year in a campaiga 
against this diaei^e, so planned as to bring about its practical extermination 
by the end of half a century. The ehare of the city of New York in this ex- 
penditure would be $2,322,914. The State and city are certainly going to 
lose these amotinta each year, and more, if tuberculosia remains unchecked, 
so that to remain inactive is only to court financial loss. Referring to total 
losses, it appears that the capitalized value in 190S of the losses which will 
be sustained within the next fifty years are» for the United States, $765,538^ 
024; for the State of New York, $79,678,192; and for the city of New York, 
$42,406,884. Tlik means that the State of New York is certain to be 
poorer by an amount whose value to-day is in the neighborhood of eighty 
million dollars unless the disease h checked. Can the State afford to remain 
idle and submit to tlus drain? The city of New York bears more than half 
this burden, and ita weight with a growing population ia bound to increase 
unless unusual measures are taken to greatly reduce the tuberculosis death- 
rate- Similar remarks apply to the State of Illinois and the city of Chicago. 

In passing I wish to state two simple rules which may be employed to 
roughly estimate the annual and total losses due to the presence of tubercu- 
lous within a given area. 

To deteTTniTie the annual loss in dollars divide the total population by two. 

For example, this rule ^ves the annual loss for Illinois as $2,808,855, 
which differs but little from the computed loss, $2jS34,198, given in Table X. 

To dett^rmine the total capiixdized loss in dollars miUiiply the total poptda^ 
tion by ten. 

The total loss for Chicago by this rule would be S24,974,720; the com- 
puted lo^, as given in Tables X and XIV, is $24,965,143. These rules, it 
must be remembered, relate to the loss which will be sustained on the group 
of males living between ages twenty and sixty at the given time, on the 
assumption of an individual net wealth-producing capacity of one hundred 
{lollars per annum until age seventy^ money being considered to have an 
interest-earning power of 5 per cent. The rules may be safely relied upon to 
give mlmmum losses for any area whose tuberculosis death-rate b in excess 
of 140 per 100^000 of population* Another way of stating these rules is that 
the annual tax of tuberculosis is fifty centa, and the capitalized value of 
tlicfio annual levies amounts to ten dollars for every man, woman, and child 
in the community. The logical conclusion b that any State or community 
with an average tuberculosis death-rate in excess of 140 per 100,000 of pop- 
ulation can profitably expend at least ten dollars per capita of the total 
population U the disease can thereby be practically eradicated. 

It seems to me that it ia well worth while for our legLslativc und municipal 



THE COST OV TUBEHCULOSIS IN THE UNITED STATES-^GLOVEH. 



77 



muthorities to give this matter their serious consideration, and deal with it 
in a omimer whoee scope is appropriate to the magnitude of the questions 
inTolved. There are few, if any, problems before our National Conser\'a- 
tion Commiaaion of equal importance. While this paper deals specifically 
with the one disease, tuberculosis, it b clear that the aame principles apply 
lo the whole list of preventable diseases which are now sapping the vital 
^Dec^peB oi the nation. A reasonable minimum death-rate should be 
iBBigned for each preventable clLsease and every means within our power 
fsmployed to reduce the higher rates now prevailing to these figures. With 
respect to tuberculosis, the Federal Government^ each State, and every large 
municipality should construct tuberculosis sanatoriunis to be conducted 
upon a liberiU and adequate scale, should build, equip, and endow them not 
for five but for fifty years, and aU advanced and open cases of this disease 
^ould be segregated therein and cared for at public expense. This step 
would have a decided effect in diminishing the spread of the disease, for it 
would mean the effective isolation of many dangerous centers of tuberculous 
infection. A wide^spread and effective campaign of education should be 
undertaken. These^ of course, are only suggestions of a genera! nature* 
The point which the writer particularly desires to emphasize is that the 
figures contained in this article justify the early organization and financing 
of a national campaign against the great white plague under the authority 
and support of the Federal Government, the several States, and their muni- 
dpaljties^ WhUe much good can be and has been accomplished by individ- 
ual initiative, by public Buhscription, and by the tuberculoaia stamp move- 
ment, they are all hopelessly inadequate to successfully cope with this big 
problem without the aid of the State. The financial support for this tTie- 
mendous battle must not be subject to the variations and uncertainty of 
private gift and unorganized public subscription. It must have the financial 
backing and support of the public represented through its legislative rmd 
governing bodies. 

Another phase of this subject, and one which appeals directly to every 
life insurance policy-holder, is the effect which tu!>ercuIosis has upon the 
ooet of insurance. Tuberculosis death-claims head the list of payments of 
practically all old line companies at the present time. And this in spite of 
the fact that they reject applicants who, after careful medical examination, 
are found to have tubercuJodis or a bad family history with respect to this 
t^aease. The fraternal companies are likewise burdened with a heavy mor- 
tality from tuberculosis. The official reports of the Mofiem Woodmen of 
America show that more than 14 per cent, of their total mortality from 1S91 
to 1907 was due to tuberculosis, and that 5156 deaths during that p>enod 
tost the order $9,066,000* This drain has induced the society to attempt 
to reduce the tax by establishing an open-air colony in Colorado for the 



ts 



SIXTH INTERNATIOKAL CONGRESS ON TUBERCULOSIS. 



cure of Woodmen who are afflicted. It is not uncommon in Europe to find 
sanatoriums maintained by insurance companies for the benefit of their 
policy-holders, but I am not aware of any similar undertaking by any of the 
large legal reserve companies in tbia country. Certainly there would seem 
to be sufficient justification, from a business point of view^ for large expen- 
ditures in this direction on the pfirt of cur giant life companies. Table XI 
exhibits the amiual and single premiums for ages twenty to sixty-five, com- 
puted at 5 per cent.j when tuberculosis is present, when not present, and the 
difFerence^ showing the saving which would l>e effected in premium payments 
on an ordinary whole life i>oIicy for one thousand dollars if tuberculosis 
were eliminated. The reduction which would be effected in annual pre- 
miums, shown in the first difference column, averages about $1.75 per 
thousand of insurance. Accordingly, every policy-holder carrying a ten- 
thousand dollar oi-dinary whole life insurance policy is annually contributing 
from fifteen to twenty dollars of liis premium on account of thLs disease. 

During each of the last five years the amount of insurance in force held 
by American old line companies has been in excess of ten billion dollars. 
If all this were ordinary whole life insurance, the saving in annual premium 
collections which would be effected if tuberculosis were not present would 
be $17^500,000. Assuming roughly the proportion of whole life insurance 
to be two-lliirds of the total insurance in force, it appears that premium 
collections would be reduced about S12,000,OOD per annum at the present 
time if there were no deaths from tuberculosis. On the same basis it is not 
unlikely tliat more than one hundred and thirty million dollars in annual 
premiums have been paid out during the last tliirty j'ears in this country on 
account of this plague. 

These losses are computed on a 5 per cent, basis^ while most companies 
now operate on a 3 per cent, basis. The difference is offset, however, by the 
fact that the number of deaths in the company must be somewhat lessened 
by the selection in risks due to the medical examination when the policy is 
issued. But it is interesting to note that in spite of this selection the 
body of policy-holders eventually lieeome exposed to the infection^ and a 
large number of them contract and die from the disease after entering the 
company- 

In conclusion, I submit Tables X\l cind XVIT, which contain the com- 
mutation columns for Dj, N,, and M^, based on the mortality tables set 
forth in Table II and computed witii 5 per cent, interest. It is hoped they 
will tje found useful to students, actuaries, aad others who may desire to 
pursue these investigations further. 




THE COer OF TDBEBCUIiOSIS IN THE UNITED STATES. — GLOVER. 



79 



TABLE XI.— SAVING IN INSURANCE PREMIUMS.— Annual and Sinolb Prr- 
muMB roR Ages 20 to 65, Compdted at 5 Per Cent., When Tuberculosis is 
I^UBSENT, When not Present, and the Difference, Showing the Saving Which 
Would Be Effected in PREiauM Payments on an Ordinary Whole Lifb 
Policy foe $1000 if Tuberculosis Were Eliminated. 



AOB. 


AxiruAL PsEiamf 
Wbxm TtiBi»cuM»ia 

m — 


■NCB 
OB 

Savimo. 


Ao». 


SisotE PBEunnf 
When Tuberculobib 

18 — 


DlFFEB- 

EMCE 


• 


PrMent. 


Not 
Praeent. 


Preoent. 


Not 
Preaent, 


Sating. 


20 


$10.50 
10.79 
11.08 
11.36 
11.66 

11.98 
12.32 
12.67 
13.06 
13.46 

13.87 
14.31 
14.78 
15.29 
15.81 

16.36 
16.94 
17.64 
18.18 

18.86 

19.68 
20.34 
21.16 
22.03 
22.94 

23.91 
24.93 
26.01 
27.16 
28.37 

29.66 
31.03 
32.50 
34.08 
35.73 

37.48 
39.33 
41.30 

43.40 
45.63 

48.00 
50.54 
53.28 
56.25 
59.36 
62.63 


$8.83 
9.09 
9.36 
9.64 
9.94 

10.26 
10.59 
10.95 
11.33 
11.74 

12.17 
12.62 
13.10 
13.61 
14.14 

14.70 
15.29 
15.90 
16.55 
17.24 

17.96 
18.73 
19.54 
20.41 
21.33 

22.29 
23.30 
24.38 
25.52 
26.73 

28.01 
29.37 
30.83 
32.39 
34.03 

35.76 
37.60 
39.56 
41.66 

43.88 

46.23 

48.75 

51.47 

54.41 • 

57.49 

60.74 


$1.67 
1.70 
1.72 
1.72 
1.72 

1.72 
1.73 
1.72 
1.72 
1.71 

1.70 
1.69 
1.68 
1.68 
1.67 

1.66 
1.65 
1.64 
1.63 
1.62 

1.62 
1.61 
1.62 
1.62 
1.61 

1.62 
1.63 
1.63 
1.64 
1.64 

1.65 
1.66 
1.67 

1.69 
1.70 

1.72 
1.73 
1.74 
1.74 
1.75 

1.77 
1.79 
1.81 
1.84 
1.87 
1.89 


20... 

21 


.$180.61 
184.72 
188.73 
192.65 
196.75 

201.02 
205.60 
210.17 
215.07 
220.18 

225,51 
231.09 
236.91 
243.01 
249.28 

255.73 
262.38 
269.24 
276.34 
283.70 

291.36 
299.33 
307.63 
316.29 
325.16 

334.25 
343.60 
353.24 
363.17 
373.35 

383.80 
394.56 
405.66 
417.12 
428.70 

440.42 
452.32 
464.45 
476.83 
489.34 

502.00 
614.90 
628.05 
541.54 
664.86 
568.09 


$156.^5 
160.32 
164.34 
168.41 
172.70 

177.21 
181.97 
186.98 
192.26 
197.75 

203.49 
209.48 
215.74 
222.28 
228.99 

235.90 
243.01 
250.36 
257.93 
265.77 

273.87 
282.27 
290.99 
300.05 
309.31 

318.81 
328.56 
338.58 
348.91 
359.49 

370.33 
381.48 
392.96 
404.81 
416.78 

428.91 
441.23 
453.78 
466.61 
479.64 

492.61 
505.89 
519.42 
533.27 
646.96 
660.65 


$24.26 


21 


24.40 


22 


22 


24.39 


23 


23 


24.24 


24 


24 


24.06 


25 


25 . 


23.81 


26 


26. . 


23.53 


27 


27 


23.19 


28 


28 


22.81 


29 


29 


22.43 


30 


30 


22.02 


31 


31 


21.61 


32 


32 


21.17 


33 


33 


20.73 


34 


34... 


20.29 


36 


35 


19.83 


36 


36 


19.37 


37 


37 


18.88 


38 


38 


18.41 


39 


39 


17.93 


40 


40 


17.49 


41 


41 


17.06 


42 


42 


16.64 


43 


43 


16.24 


44 


44 


15.84 


45 


45 


15.44 


46 


46 


15.04 


47 


47 


14.66 


48 


48 


14.26 


49 


49 


13.86 


50 


50 


13.47 


61 


51 


13.08 


52 


62 


12.70 


53 


53 


12.31 


64 


64 


11.92 


65 


55 


11.51 


56 


56 


11.09 


57 


57 


10.67 


58 


58 


10.22 


59 


59 


9.80 


60 


60 


9.39 


61 


61 


9.01 


62 


62 


8.63 


63 


63 


8.27 


64 


64 


7.90 


65 


65 


7.64 



80 



SIXTH INTERNATIONAL C0N0BES3 ON TUBERCULOSIS. 



TABLE Xn,— TUBERCTLOSIS LOSSES IN THE STATE OF NEW YORK. 

TaBI-B SaOWTNO TBK CAPrTALlEEU CR t^HKSENT VALmC, COMPOUNDED ANNf ALLY AT 

5 Pkk Cent., of the Lo&s Due to Tuberculosis on th» Malk Popu- 
lation OF THE State or New York for Each Age and CcEtTAiN 
Ags GttotTPB Between Ages 20 and 60 on the Babis of a 
Producino Capacity of ilOO Per An'nuu lentil Aoe 70. 



20.. 

21 .. 

22 .. 

23 ., 

24 .. 

20-24 .. 

25.. 

26 .. 

27 .. 

28 .. 

29 .. 

30-29 .. 



30 
31 
32 
33 
34 



20-34 

35 
36 
37 
38 
39 



noM, 1908.* 



20-39 1,501,682 



74,185 
75,031 
77,781 
79.363 
82,217 

389,477 

85,353 
7&,G02 
79,727 
83,960 
74,602 

791,781 

99,297 
61V234 
74,405 
67,150 
68,962 

1,162,829 

81,939 

54,307 

.. 60,179 

69,376 

63,052 



ttATK. 



$47.51 
47.67 
47.49 
47.04 
40.47 



45.8! 
45.07 
44.19 
43.22 
42.25 



41-21 
40.17 
39.09 
37.98 
36.85 



35.70 

34.51 
33.31 

32.09 
30.89 



Total Lou. 



t3.524,S29 

3,019,031 
3,693320 
3,733,236 
3,820,624 

13,391340 

3,910,021 

3,542,592 
3,523*130 
3,628,751 
3,154,470 

36,150310 

4,092,029 
2,459,770 
2.908,491 
2,550,357 
2,541,250 

50,702,707 

2,925,222 

2,219,235 
2.004.562 
2,226,276 
1,947,676 



62,025,678 20-60 



AOB. 



40. 
41. 
42. 
43. 
44. 

20-^4. 

45. 
46. 
47. 
48. 
49. 

2CM9. 

SO. 
51. 
52. 

53- 
54. 

20-54. 

55. 
56, 
57. 
58. 
59. 
60. 



Popula- 
tion, ieo8. 



84,120 
46,103 
57,407 

48,035 
47,400 

1,784,752 

57,553 
40,249 
39,199 
42,134 

40,257 

2,004,144 

56,230 
30.444 
35,981 
30,710 
31,784 

.189,293 



36,039 
29,035 
24,660 
24,977 
24,162 
34.976 



Lofw^ 

BATX. 



129.72 
28.60 
27.48 
26.40 
25.29 



24.21 
23.13 
22.02 
20.92 
19.84 



18.72 
17.62 
16.52 
16.47 
14.54 



13.20 

12.06 

10.89 

9.72 

8.59 

7.51 



2,363,142 .... 79,678,192 



Total 



$2,500,046 
1,318,689 

1,577,544 
1,268,124 
1,193,746 

69388327 

1393,358 
930,959 
863,162 
881,443 
798,699 

74,756,448 

1,062,626 
536,423 
594,406 
475,084 
455,783 

77,870,770 

475,715 
350,162 

268,M7 
242,776 

207,552 
262,670 



* Population estimatedi 




THE CO&r or TUBERCDLOSIS IN THE UNTTBD STATES. — GLOVER. 



81 



TABLE Xm.— TUBERCULOSIS LOSSES IN THE CITY OF NEW YORK. 

Tabla Showino the Capitauzed or Present Value, Compounded Annually 

AT 5 Per Cent., of the Loss Due to Tuberculosis on the Male 

Population or New York City for Each Age and Certain Aoe 

Groups Between Aoes 20 and 60 on the Basis op a Pro- 

DuciNO Capacitt OF $100 Per Annuu until Aoe 70. 



AOK. 


POPUX-A- 
TIOH. 1006.* 


L08»- 
SATB. 


Total Low. 


AOB. 


Popula- 
tion. 1908. 


Loss- 

KATE. 


ToTAi. Loss. 


20 

21 

22 

23 

24 


37,739 
39,190 
40,957 
42,914 
44,302 


$47.51 
47.67 
47.49 
47.04 
46.47 


$1,792,979 
1,868,187 
1,945,048 
2,018,675 
2,058,714 


40.... 
41.... 
42. . . . 
43. - . . 

44.... 


32,438 
30,797 
29,181 
27,263 
26,117 


$29.72 
28.60 
27.48 
26.40 
26.29 


$964,057 
880.794 
801304 
719,743 
635,209 


20-24 


205,102 





9,683,603 


20-44.... 


070,202 


.... 


38,011,733 


25 

26 

27 

28 

20 


45,489 

45,589 
45,090 
44,996 
44,100 


45.81 
45.07 
44.19 
43.22 
42.25 


2,083,851 
2,064,696 
2,019,041 
1,944,727 
1363,225 


45.... 
46.... 
47.... 
48.... 
49.... 


23,690 
22,138 
20,939 
19,803 
18,718 


24.21 
23.13 
22.02 
20.92 
19.84 


571,114 
512,052 
461,077 
414,279 
371,365 


20-20 


430,966 





19,649,143 


20^9....^ 


1,075,390 





40,341,620 


30 

$1 

S2 

38 

34 


43,305 
42,472 
41,702 
40,957 
40,213 


41.21 
40.17 
39.09 
37.98 
36.85 


1,784,599 
1,706,100 
1,630,131 
1,555,647 
1,481,849 


50.... 
51.... 
62.... 
53.... 
54.... 


17,847 
16,964 
16,067 
15,159 
14,262 


18.72 
17.62 
16.52 
15.47 
14.34 


334,096 
298,906 
265,427 
234,510 
204,517 


90-34 


630,615 





27,807,369 


20-54.... 


1,155,689 





41,679,076 


85 

36 

87 

38 

30 


30,455 
38,559 
37,613 
35,997 
84,167 


35.70 
34.51 
33.31 
32.09 
80.89 


1.408,544 
1,330,671 
1,252389 
1,155,144 
1,056,419 


55.... 
56.... 
67. . . . 
58.... 
69.... 
60.... 


13,606 
12,697 
11,864 
11,031 
10,173 
9,491 


13.20 

12.06 

10.89 

9.72 

8.69 

7.61 


179.509 
153,126 
129,199 
107.221 
87386 
71,277 


20-30 


825,406 





34,010,036 


20-60.... 


1,224,661 





42,406.884 



* Population at each age, based on figures given in paper by John F. Roche, in 
"An InTeatigation into the Mortality Rates of the City of New York," Transactiona 
ci tbo Aotuanai Society of America, vol. vii, p. 426. 



b 



gi 



SIXTH INTERNATIONAL CONGBESS ON TtTBERCULOSIS. 



TABLE XIV.— TIIBERCUU)SIS LOSSES IN THE STATE OF ILLINOIS. 

Table SnowiTfa tub Capitalizew or Pbksent Value, Compoundep Awwuallt 

AT 5 Per Cent,, of the Loew* Due to Tubercui-osis ox the ALllb 

Population of Illinois for Each Age and Certain Aqe Gnoupa 

Between Aoes 20 and 60 on the Basis op a Probucinq 

Catacit^ of ilOO Per Annum until Age 70. 



AOB. 


TION. 1B0S.» 


Low. 

HATE. 


Total Lou. 


AOK. 


Ponn.A- 

TtOH. IftOS. 


LoM- 


Total. Lou. 


20 

21 ...... 

22 

23 

24 ...... 


51.637 

52,300 
53,139 
52,163 
54,348 


$47.51 
47.67 
47.49 
47.04 
46.47 


12,453.274 
2,493,141 
2,523,571 
2.453,748 

2,525,552 


40.... 
41,,.. 
42... 
43... 

44.,,, 


51,364 
32,772 
37,406 
31.390 
30,413 


$29.72 
28,&0 
27.48 
26.40 
25.29 


$1,526,538 

037.279 

1,029,566 

828.&96 
769,145 


20-24 


263,587 




12,440,286 


20-44,.,. 


1,169.040 





45.849,470 


25 

26 

27 

28 

29 


54,549 

50,976 
50,802 
54,463 
48,653 


46.81 
45.07 
44,19 
43.22 
42.25 


2,49.«t,S90 
2,207. 4S8 
2,244,940 
2,363,891 
2,055,.5S9 


45.... 
46,... 
47.... 
48.... 
49. . . . 


33,997 

25,497 
24,721 
25,266 
24,573 


24.21 
23.13 

22.02 
20.92 
19.84 


823.067 
58fl,746 
544,356 
52S.565 

487,528 


30-20 


523,030 




23,900.084 


20-49. . , , 


1,303,094 





48,822,732 


30...... 

31 ...-,. 

33 

33 

S4 


62,464 
42,424 

48,796 
45,346 

44,217 


41.21 
40.17 
39.09 
37.98 

36.85 


2,574,141 
1,704,172 
U907,436 
1J22,241 
1,629,396 


50,,.. 
51,... 
62. . - - 
53.,., 
54... 


31,225 
20,089 
22,152 
18,991 
18,601 


18,72 
17.62 
16.52 
15,47 
14.34 


584,532 
353,968 
365,951 
293,791 
266,738 


20-34.,, .. 


766,277 


, , . , 


33,437,470 


20-54.... 


1,414,152 


.... 


50.687.712 


35 

36 

37 

38 

39 


50.124 
41,913 
40,259 
45,466 
41,590 


35.70 
34,51 
33.31 
32.09 
30,89 


1.789,427 
1,440,413 
1,341,027 
1,4.59,004 
1,284,900 


55.... 
56... 
57.... 

58.... 
59.... 
60.... 


20,320 
17,591 
15,404 
15,035 
14,383 
18,018 


13.20 

12.06 

10.89 

9.72 

7.51 


268,224 
212,147 
167,750 
146.140 
123.550 
135,315 


ao-3» 


985,635 





40,768,246 


20-60..., 


1,514,903 




51,740.838 



4 
4 



* Populiittpn ^tim&ted. 



4 



M 



THX COST OF TX7BERCULOSIS IN THE UNITSD 8TATKS. — GLOVES, 



83 



TABLE XV.—TUBEROULOSIS LOSSES IN THE CITY OF CHICAQO. 

Tabls SBownra thx Capitalized or Prxsemt Valttk, Compounded Annuai^lt at 
6 Pkr Cknt., or the Lobs Due to TusERcuLoeis on the Male Popu- 
lation OP Chicago por Each Aoe and Certain Aqb Groups 
Between Ages 20 and 60 on the Babis op a Producino 
Gapacttt op 9100 Per Annum until Age 70. 



Adi. 



20. 

22. 
23. 

24. 

20-24. 

25. 
26. 

27. 
28. 
29. 

20-29. 

30. 
31. 
32. 
33. 
34. 

20-34. 

35. 
36. 
37. 
3B. 

39. 

20-39, 



TION, 
1W8,* 



21.361 
22,350 
23,223 
23,979 
24,620 

115,533 

25,143 
25351 
25,842 
26,016 
26,075 

244,160 

26.120 
25,838 
25,500 
25,049 
24,658 

371,331 

23,^99 
23,475 
22399 
22,200 
21,411 



485,315 



Ixwa- 



$47,51 
47.67 
47.49 

47.04 
46.47 



45.81 
45.07 
44,19 
43.22 
42.25 



41.21 

40.17 
39.09 
37.98 
36.85 



35.70 
34.51 
33.31 
32.09 
30.89 



Total Loh. 



91,014^1 
1,065.425 
1,102,860 
1,127,972 
1,144,091 

5,455,209 

i.iai^i 

1,151,584 
1,141,958 
1.124,412 

1.101.669 



,.., 11,126,633 



1.076,405 

1,037.9)2 

997,030 

951,361 

908,647 

11,097,988 

856,764 

810,122 
762,766 
712,398 
661,386 



19,901,424 



Aa*. 



40. 
41. 
42, 
43. 
44. 

20-44, 

45. 
46. 
47. 
48. 
49, 

20-49. 

50. 
51. 
52. 
53. 
54. 

20-54. 

55. 

56, 
57. 
5S. 
59. 
60. 

20-60. 



TION, 


■JLTB, 


20,543 

19,609 
18,620 
17,587 
16,622 


»29.72 

28.60 
27.48 
26.40 
25.29 


578,196 





15,437 
14,343 
13,253 
12,177 
11,127 


24.21 
23.13 
22.02 
20.92 
19^ 


644,533 


.... 


10,115 
9,153 
8,253 
7,425 
6,682 


18.72 
17.62 
16.52 
15.47 
14.34 


686,161 


.... 


6,135 
5,507 
5,177 

4,889 
4.744 
4,653 


13.20 

12.06 

10.89 

9.72 

S.59 

7.51 


717,356 






ToTU^Lotft. 



$610,538 

560,817 
511.678 
464/297 
417341 

22,466.595 

373,730 
331,754 
291331 
254,743 
220,760 

23,939,413 

189353 
161,276 
136340 

114.865 
95320) 

24 637,067 

80,9^ 
67.500 
66378 
47,521 
40.751 
34,944 

24,965,143 



* PopulAtion by ages based on totals furnished by the Bureau of Statistics of the 
City of Chicago. 



K^ 84 


SIXTH INTERNATIONAL CX»NGBFi^ ON TUBERCULOSIS. ^^^| 




TABLE XVI. 


*■ 


^^^ Commutation Colitmns, Tubercclosia Excluded, 


5 Per OEirr. ^| 


^^m 


Di. 


Ni, 


^M 


H 20 


37688.^8 


667710.636 


.'i892.77.S0 ^M 


^ 21 


35729.4SI 


630030,688 


5728.0204 ^1 


■ 22 


338G5.357 


694301.207 


5565.2999 ^1 


■ 23 


32091.800 


560435-850 


5404.4676 ^ 


■ 24........ 


30411.151 


528343.960 


5251.9142 ^1 


K 25 


28818,006 


497932.809 


5106.9206 H 


^ 26.. 


27307.913 


469114.803 


4(4B9.1125 ^M 


^m 27 


25876.826 


441806.890 


4838.4026 ^M 


■ 28 


24520.3G6 


415930.064 


4714.1720 H 


B 29 


23232,966 


391409.698 


4504.3995 ^^^ 


H 30 


22011.400 


368176.742 


4479.1735 ^^^| 


1^ 31 


20852.176 


346165,342 


43fi8.ll24 ^^^ 


■ 32 


19752.394 


325313.166 


4261.2905 ■ 


■ 33 


1870^,069 


305560.772 


4158.5560 _^^H 


^ a4... 


17716.312 


2S68SL703 


4056.9065 ^^^ 


■ 35 


16772.615 


269135.191 


qorvf. fi^in ^^^1 


■ 36........ 


15875.158 


252362.576 


.1857.Rft:^l1 ^^^M 


■ m 


15022.181 


236487,418 


3760.8759 ^^H 


■ 38 


14211.624 


221465.237 


3005.6599 ^^^1 


B S&..,,,,.. 


1344L5I3 


207253.613 


3572.2032 ^^^ 


H 40 


12710.105 


193812.100 


3480.9579 ^^H 


■ 


12015.577 


181101.996 


3391.6720 ^^H 


■ 43 


11356.310 


169086.418 


3304.5764 ^^H 


■ 43 


10730.623 


157730.108 


3219.6650 ^^^1 


B 44 


10134,799 


140909.485 


3134.8237 ^^^ 


H 


9567.6047 


136864.686 


3050.2383 ^^H 


H 46 


9027.9492 


127297.0823 


2966.1829 ^^H 


■ 47 


8514.8640 


118209.1331 


2SS3.0008 ^^H 


■ 4S 


S027.I932 


109754.2691 


2800.7993 ^^^M 


B ^^ 


7562.9043 


101727.0759 


2718.7580 ^^B 


H fiO.., 


7121.2310 


94164.1716 


2^-17.2225 ^^^1 


■ 


6701. 3 15S 


87042.9406 


2556.4138 ^^H 


■ 52 


6302.3972 


80341.6248 


2476.6055 ^^H 


■ fiS 


5923.6388 


74039.227G 


2397.9612 ^^H 


B ^ 


5561.5674 


68115.5838 


2317.9680 ^^B 


H 55... 


5215,9008 


62554.0214 


2237.1379 ^^^B 


■ 56.. 


4886.3786 


57338.1206 


2155.9922 H 


■ 57........ 


4572,6940 


52451.7420 


2074.9921 W 


■ 56 


4274.4392 


47879.0180 


1994.4848 " 


■ 5d 


3989,5555 


43604.6088 


1913.U56 


H 60........ 


3717.9348 


39615.0533 


1831.5040 


■ 61 


3459.5164 


35897. U85 


1750.1300 


■ 62 


3214.1224 


32437.6021 


1669.4746 


■ 63........ 


2981,5721 


29223.4797 


1580.9778 


B ^ 


27^,2876 


20241.9076 


I50B.6729 


H 65. 


2544.6833 


23483.6200 


1426.4158 


■ 66 


2341.1720 


20938.9367 


1344.0809 a 


k d 



THB C08T OF TUBEBCULOSIS IN THE UNITED STATES. — GLOVER. 



85 



TABLE XVI.~Continued, 
CoxmrTATiON CoLuiafB, TxmmicvhOBia Excludkd, 6 Pxb Gxnt. 



z. 


Dx. 


Nx. 


Hz. 


67 


2148X1026 


18697.7638 


1262.3946 


68 


1966.3112 


16449.7612 


1181.9893 


60 


1790.6069 


14484.4600 


1100.9610 


70 


1624.8048 


12693.7631 


1020.3403 


71 


I468.U60 


11068.9483 


941.02328 


72 


1320.9664 


9600.8323 


863.78406 


73 


1183.5652 


8279.8669 


789.28600 


74 


1064.1456 


7096.3007 


716.22641 


76 


933.26020 


6042.1561 


645.63864 


76 


821.27670 


5108.8949 


677.99603 


77 


718.35590 


4287.6182 


514.18369 


78 


624.50960 


3569.2623 


454.54453 


79 


537.66370 


2944.7527 


397.42756 


80 


468.36050 


2407.0990 


343.73661 


81 


386.80840 


1948.7385 


294.10125 


82 


323.32670 


1561.8401 


248.95241 


83 


267.47506 


1238.5144 


208.49824 


84 


218.50119 


971.03934 


172.26120 


86 


176.22504 


752.63816 


140.38987 


86 


140.29526 


676.31311 


112.85177 


87 


110.24131 


436.01785 


89.478561 


88 


85.476470 


325.77654 


69.963312 


89 


65.538540 


240.30007 


64.096675 


90 


49.671500 


174.76153 


41.349645 


91 


37.219727 


126.09003 


31.263059 


92 


27.560191 


87.870303 


23.375878 


93 


20.170028 


60.310112 


17.298119 


94 


14.297608 


40.140084 


12.386182 


95 


9.8122300 


25.842476 


8.5816380 


96 


6.5166332 


16.030246 


5.7531851 


97 


4.1814963 


9.5137128 


3.7284606 


98 


2.6822566 


5.3322165 


2.3283410 


99 


1.4851561 


2.7409699 


1.3642064 


100 


.76805348 


1.26480380 


.70782470 


101 


.34039139 


.49676032 


.31673672 


102 


.11725750 


.16636893 


.10981172 


103 


.03284520 


.03910143 


.03098324 


104 


.00625623 


.00625623 


.00695832 



86 



SIXTH INTERNATIONAL CONQEiBB OK TUBERCDIiOalB. 



TABLE XVII. 

COMMTTTATIOK C0LUMN3, TUBERCULOSIS INCLUDED, 5 PeH CENT. 



20. 

21. 

22, 

23 

24 

25. 

26. 
27. 
28, 
29, 

30. 
31 

33, 
34 

35 

38 
37, 
38 
39 

40 
41. 
42 
43 
44 



45, 
46 

47, 
48, 
49, 

SO, 
51, 
52, 
&3, 
54, 

55, 
60, 
57 

5S, 
59 

60, 
61. 
62, 
63, 
64. 

66. 



Dt 



37688.9 

35677.4 
33759.7 
31932.3 
30202,2 

^503.8 
27012.6 
25543,9 
24153,6 
22S36.9 

21590.0 
20409,4 

19291J 
18233.0 

17229.2 

ie27e,2 

15372.2 
14514.9 
13702.0 
12932.0 

122027 
11512.2 
10S58.5 
10230.6 
9651.67 

9093.30 

8563.18 
8060J7 
7583.20 

7130.18 

6700.14 
6292.19 
5905.47 
5639.24 

51S9.S2 

4856^ 
4540.14 
4239.21 
3953.71 
36S1.S3 

3423.47 

317S.31 
2946.21 

2726.90 
2516.81 

2316^ 



N: 



648517.8 

610S2S.9 
575151.5 
641391.8 
509459.4 

479257.3 
450693.5 
423680.9 
398137.0 
373983.4 

351146.5 

329556.6 
309147,0 
289S55.3 
271621.7 

254392,5 
23S 116.3 
222744.1 
208229.2 
194527.2 

181595.1 
169392.4 
157880.3 
147021.7 
136782.0 

127130.3 
118037.0 
109473.9 
101413.7 
93830.50 

86700.32 

80000.17 
73707.98 
67802.51 
62263.27 

57073.46 
52215.64 
47676.50 
43437.29 
39483.57 

35801.74 
32378.28 
29199.96 

26253.75 
23526.86 

21010.05 



Mx. 



6807.1418 
6590.3406 
6371.5567 
6151J960 
5942.1901 

5741.9749 

55,^1.0124 
5368.6077 
5194,6338 
5028.2156 

486S.7965 
4716.3078 
4570.4509 
4430.9398 
4294 .836 1 

4162.3129 
4033.3378 
3908.0378 
3786.3555 
3668.8269 

3555.3324 

3445.8896 
3340.3699 
3238.64.S0 
3138.2641 

3039.43^ 
2942.3398 
2847,1447 
2753.9830 
2662,0529 

2571,5354 
24S2.6706 
239-5,5856 
2310.5381 
2224,8773 

2139.0594 
2053.6188 
1968.9003 
1885.2648 
1801.0771 

1718.5900 
1^36-5022 
1555J498 
1476.7154 
1396.4675 

1315,8863 



THE COST OF TUBERCUTX)SI8 IN THE UNITED STATES. — GLOVER. 



87 



TABLE XVU,—CorUinu€d, 

OOMMXTTATION COLUUNS, TuBEBCULOeiS InCLUDBD, 5 PeR CeNT. 



66 
67 
68 
60 

70 
71 
72 
73 

74 

76 
76 
77 

78 
79 

80 
81 
82 
83 
84 

85 

86 
87 
88 
80 

00 
01 
92 
93 
94 

05 
96 
97 
98 
99 

100 
101 
102 
103 
104 



Dx. 



2125^ 
1945^ 
1776^ 
1613.30 

1459.87 
1315.46 
1180.31 
1054.50 
936.496 

826.742 
725.425 
632.671 

548.428 
470.838 

400.292 
336.972 
280.865 
231.767 
188.858 

151.940 

120.650 
94.5800 
73.1606 
55.9518 

42.3010 
31.6160 
23.3463 
17.0344 
12.0458 

8.23955 
5.44413 
3.47719 
2.13792 
1.22969 

.638736 
.282438 
.096572 
.026276 
.006256 



Nx. 



18693.71 
16567.87 
14622.37 
12847.00 

11233.70 

9773.829 
8458.373 
7278.066 
6223.568 

6287.072 
4460.330 
3734.906 
3102.234 
2653.806 

2082.968 
1682.676 
1345.705 
1064.839 
833.0725 

644.2143 

492.2740 
371.6152 
277.0352 
203.8746 

147.9228 
105.6212 
74.00624 
50.66891 
33.62451 

21.57875 
13.33920 
7.895073 
4.417888 
2.279968 

1.050278 
.411542 
.129104 
.032632 
.006256 



Hx. 



1236.6707 
1156.6336 
1079.0632 
1001.5549 

924.94390 
850.04034 
777.51120 
707.92479 
640.13781 

574.96076 
613.03463 

454.82797 
400.70559 
349.22405 

301.10195 
266.84711 
216.78598 
181.05524 
149.18391 

121.26488 
97.219860 
76.886591 
59.966100 
46.244496 

36.257307 
26.686468 
19.822817 
14.622481 
10.444278 

7.2123563 
4.8090957 
3.1012846 
1.9275316 
1.1210759 

.58876156 
.26285491 
.09041741 
.02472701 
.00595832 



THE RELATION BETWEEN TUBERCULOSIS AND 
MENTAL DEFECT. 

Bv MABTtN W, Barr^ M.D., 

CMef PhysLolan to the Feniuylwuii Trniniag School for Feeble-minded Children, Elwyn, P». 



The exceedingly close and intimate relation existing between tulierculods 
and mental defect is proved in statistics gathered in diverse places by earnest 
seekers after cause and effect in the study of both maladies. 

Before entering upon the much contested question of heretUtary trans- 
mieaion, let us first note and carry forward with us a point, that experience 
and investigation have demonstrated, of a peculiarity common to lx>th, and 
raore frequently encount-ered in these two than in any other maladies, viz., 
an interpenetrating power, fitly denominated poisonous, that attacks the 
whole being, causing a cert-aln tearing down and disintegration of the entire 
Bjrstem, and superinducing a weakness and inertia utteriy subversive of all 
resisting power. This once accepted^ it becomes easily recognizable that a 
prolonged association of such conditions — ^be the agent contagion, infection, 
or a continuous generati^'e transmi^ion— must inevitably result in an 
increase of degeneration or in a final surrender of the lesser t-o the greater ill, 
in accord with the disproportioned influences of heredity and environment.. 

It is not surprising, therefore, that statistics reveal numbers in advanced 
stages of mental degeneration developing tuberculosis under attack, or for 
eause that would be of little moment in a normal condition; and in like 
manner that those entering life with the enfeebled constitution of a tuber- 
culous progenitor should, on the slightest provocation, lapse into imbecility, 
or, on the other hand, that a similarly enfeebled condition encountering 
some other vicious strain should unit« in utero to produce a starved condition 
of the being favorable t^ the development of a degenerate, mental or physical, 
OT both. This h not mere argument, but a principle demonstrated by 
experience and fouiitled upon well-authenticated data. 

In the etiological investigations pursued in the Royal Albert and Darenth 
Asylums, covering some 2380 caseSj Drg, Beech and Shuttleworth find 
28*31 per cent, due to a tuberculous family history. Second on their list as 
a direct factor in the production of idiocy, it is exceeded only by that of the 
abnormal condition of mothers during gestation. Grabham, in a study of 

88 



TaBSBCULOBIS AND MENTAL DXFSCT. — BARR. 89 

240 cases, ascribes 22 per cent, to the same cause; whereas Dr. Caldecott, 
of the Eariswood Asylum, e&ys he finds a history of tuberculosis, associated 
sometimes, however, with other causes, in 25 per cent, of his cases. 

In a personal study of 4400 cases I find 7) per cent, due to tuberculous 
heredity, the family history otherwise being exceptionally good, no other 
causes, even the most remote, being apparent. 

Some examples of such heredity are as follows: 

Mother and paternal grandfather died of pulmonary tuberculosis. 
Child an idiot. 

Father and two relatives died of pulmonary tuberculosis. Child an idiot. 

Paternal grandfather died of pulmonary tuberculosis. The child an 
epileptic imbecile. 

Paternal grandfather died of pulmonary tuberculosis. Four children 
feeble-minded. 

Both parents died of pulmonary tuberculous; number of other cases in 
family. Child an idiot. 

Maternal grandmother and grandfather both died of pulmonary tubercu- 
losis. Child an imbecile. 

I would reiterate that these are not isolated cases, but a few of many 
from which have been eliminated all cases of associated neuroses. 

Now of associated cause I would cite : 

Paternal grandfather died of cancer. Mother had goiter, was weak and 
nervous, and died of pulmonary tuberculosis. Three sons also died of the 
same disease; and the patient, the eleventh child bom, an idiot. 

Paternal grandfather a dipsomaniac; maternal grandparents both died 
of pulmonary tuberculosis. Mother an epileptic, and the child an imbecile. 

Both grandfathers drunkards; both maternal grandparents died of 
pulmonary tuberculosis. Mother extremely nervous, the child an idiot. 

Maternal grandfather died of pulmonary tuberculosis. Mother a con- 
firmed drunkard, the child an idiot. 

Paternal grandfather and father both drunkards; mother also a drunk- 
ard; she and her three brothers and her husband's two sisters died of pul- 
monary tuberculosis. The child an idiot. 

Maternal grandparents were first cousins — one died of apoplexy and the 
other of paralysis. Paternal grandfather died of cancer of stomach, and 
paternal grandmother of tuberculosis. Father nervous and asthmatic, 
with insane heredity, contracted syphilis and infected mother. The only 
child an imbecile. 

Here is evidence that should at least arrest attention, if it does not 
convince. Granted that tul:)ercles are not actually transmitted, there is not 
the shadow of a doubt that their effect upon even the strongest constitution 
is such lowering of tone and lessening of all its physical forces as to render it 



90 



SIXTH INTERNATIONAL CONGHESB ON TUBERCULOSIS. 



susceptible to any sudden attack, or to coojjcrate with any neurosis, patent 
or latent, in the work of tlisiiitegration, inducing an enfeebled condition 
utterly unequal to the work of successful procreation. The child who 
comes of such stock enters life poorly equipped for the struggle. Environ- 
ment, toning up^ and training may and do accomplish much for it, but 
there must be no intermission in tliis continual uplifting. Once the sus- 
tmning power is relaxed, the protecting hand withdrawn, he sinks. 

To aU engaged in the care of mental defectives tuberculosia is a senous 
problem, and the methods for combathig it form a most important branch 
of the work, to which end camps and hospitals are necessary adjuncts. As 
the imbecile, careless bej^ond description, will not fail to disseminate or to 
perpetuate the ill, not only Is isolation the bast means of safeguarding, but 
in the permanent sequestration of the tuberculosk imbecile rests the only 
aafety for society. 

In England^ in the public and semipublic institutions for defectives, the 
existence of tuberculosis disqualifies for admission. 

Baroness Rappe, of Stockholm, Sweden, while not avowedly admitting 
tuberculous cases to her school, finds that it frequently develops daring 
convalescence from other diseases, when such patients are at once sent to 
huspitftls. 

Tuberculosis is a prolific cause of death among defectives. In Denmark, 
the Keller Institutions show in eleven years a mortality of 224, of which 51, 
or 22,8 per cent*, were ascribed to this cause. In France, tuberculosis is 
cominon among mental defectives, the hospital of Bic^tre reporting 57 out 
of 207 deaths, or 27.54 per cent., due to thLs cause. Dr. F. E. Rainsford, of 
the Stewart Institution at Dublin, states that there has been a marked 
increase in the number of tuberculosis cases, and deaths from the same, 
notwithstanding that every precaution has been observed. Tuberculosis 
with epilepsy accounts for at least 75 per cent, of the deaths among Ida 
patients, Caldecott, in a study of 1000 deatlis, finds 392, a fraction less 
than 39.2 per cent, due to tuberculosis, and many of his necropsies reveal 
from 85 to 90 per cent, of old tuberculous scars. 

In the United States reports vary %vith location. Thus in the Massa- 
ehusetts institution at Waverly, having 1222 inmates, there is not a single 
active case. The Iowa Institution, with a population of 1066, reports only 
4 tuberculous cases; whereas Wisconsin, with an equally favorable climate, 
reports only 2 active eases among 770 inmates. Indiana, on the other 
hand, with a population of 1080 inmates^ reports 20 cases, with a percentage 
of the 2*58 deaths occurring in ten years as high as 43.2, The Illinois institu- 
tion finds no less than 35 per cent, of its 1153 inmates with tuberculoua 
history, to which 30 per cent, of deaths are due; and the New York Institu- 
tion also ascribes 35 per cent, of deaths to the same cause. New Jersey, 



1 



TUBERCULOSIS AND MENTAL BEFECTT. — BARIL 



di 



reporting but 2 avowed cases among: 370 children j has yet averaged one 
death a year for ten years, giving 15,9 per cent, of the 63 deaths reported. 
In Pennsj'lvania the Western Institution at Polk reports of 352 d^iths, 100, 
OT 28.5 per cent., due to tuberculosis. At the Eastern Institution at El^vyn 
there are at present 1085 children. Of these, 50, or 43 per cent., are tuber- 
culous. In a study of 755 deaths I find 168, or 22J per cent,, due to tuber- 
culosiB, by far the larger proportion occurring among males — 118, against 
50 females, or 70.24 per cent, against 29.S per cent. Among th^e the most 
proiihc death period appears between the fifteenth and twentieth years — • 
31 per cent., — the smallest number, not over 12 per cent*, occurring after 
the fortieth year. 

The natural concliision and opinion founded upon data so universal is 
that two such correlated sources of t^n evils, — tuberculosis and mental 
defect, — ^the direst in both cause and effect that can afflict humanity, 
demand the strictest quarantine and the most unremitting protection; to 
this end, therefore, the strong arm of the law should be invoked. 

In America, Connecticut leads the way in legislation, forbidding the 
mArriage of epileptics; Indiana follows, forbidding the marriage of those 
afBicted with any hereditary flisease. 

May such examples be emulated in all lands and, furthermore, be ?o 
extended that the penalty of the law may l>e enforced^ not only upon such 
marriages, but upon the illegal cohabitation of all so affected, until, by means 
of isolation, sequestration, and asexualization the increase of degenerates^ 
mental, moral, and phyMcal— shall be checked, and the elevation of the 
race thereby insured. 



Relations entre la Tuberculose et le D^faut de Mentalit^.^ — (BakhO 

L'a^jsertion que la tuberculose est un facteur puissant dans la production 
de la d^gen<5re8(^nce mentale de m&me que de la d^g^n^rescence physique 
m confirme quand on compare deux tables 6tioto^quea, fondto sur deg 
Etudes faites de plus de six mille cas, I'une en Angleterre et I'autre en Am^ 
rique, Selon la premiere la tuberculose est la aeconde, et aelon la table 
amMc^ne la troisi&me dans T^num^ration des causes de la fofie. 

L'opinion ainsi formfe se v^rifie encore davantage par les statistiques 
des divers asiles oil I'histoire de famlile des maladea r6v61c la tuberculose 
comme cause, soit seule, soit associ^e avec d'autres hdr6dlt4^3 ficheuses. 

De mfime les statistiques de mort obtenues en Am^rique, dans les Isles 
Britanniques et sur le continent montrent un rapport, vaaiant suivant la 
location et T^soctation, entre 15 et 75 pour cent. 

Cea r4sultats servent k d4montrer encore la prudence des motifs qui 
causent T isolation des tuber culeux dans lea iustitutionsj et aussi la n^cessit^ 



B2 



SIXTH INTERNATIONAL CONGRESS OS TUBERCULOSIS. 



de s^uestrer et garder pour to u jours les idiots de tout degr<5. II est ausd 
Evident m§me pour un observateur superfidel que la tendance de ces deux 
formes de d^g^n^rescence est de r^ulre au minimuin le pouvoir de rfeistance, 
Naturelleraent I'iissociation intime de telles conditions doit assurer k la 
victime la certitude de I'une ou de Tautre des mfirmitds, ou, ce qui arrive 
tr§a souvent, un melange des deux; dc sorte que le malade tuberculeux peut 
tomber dans ridiotle, ou Tidiot peut mourir de la tuberculose. 



Tiber die Beziehung der Tuberkulose zu geistigenDefecten.— (Bajui.) 

Die Behauptung, d ass die Tuberkulose ein roachtiger Factor im Hen^or- 
bringpn sowohl geistiger als korperlicher Entartungen ist, findet ihre Besta- 
tigung, wenn man die zwei atiologiscben Tabellen vergleicht, iiber das Stu- 
dtum von mehr als 6000 Fallen. Die eine Tabeile ruhrt von England her und 
nennt den erwahnten ursachlichen Zusammenbang in zweiter Stelle; die 
andere iet in Araerika zusammengpsetzt und nennt denselben an dritter Stelie. 

Die auf diese Weise gewonnene Ansicbt findet nocb ihre weitere Be- 
kraftigung in den Statistiken verschiedener Heilanstalten in denen die Tuber- 
kulose als Ursac'he der Geisteskrankheiten, entweder allein oder in Verbindung 
mit anderen erbUchen fatalen Ursacben, aufgezabltwird. 

Ebenso zeigen die in Anierika, in den Britischen Inseln und auf dem Konti- 
nent gesammelten Statistiken^ entsprechend der Lokalitat und andereti Ver- 
h&Hnissen, ein Schwanken in der gpnannten Beziebung von 15 bis 75 Proaent. 

Die Leitmotive, welche bei der Isollrung von Tuberkulosen in Anstalten 
dienen, und ebenfalls bei Absondem und fortgesetztem Sicherbalten von 
alien Graden Schwachsinniger, sprechen dafiir, 

Ea ist fiir jcdcn sorgfalligen Beobachter klar, dass bclde Degenerations- 
formeQi die Widerstandsfahigkeit hcrabgesetzt werden. 

Es ist deshalb natiirlicb, dass durch eine nahere Beriihrung und ein 
Ineinandergreifen der Verhaltnisse das eine Ubel in das andere sich fort- 
setzen kann, oder beide glcifhaeitig In Verbindung bestehcn konnen. So 
beobachten wir auch FsUe, wo tuberkul^e Kranke einer Idiotic verfallen, 
oder wo bei Schwachsinnigen der Tod durch Tuberkiilose verursacht wird. 



THE AWAKENING OF A STATE: AN EDUCATIONAL 

CAMPAIGN FOR THE PREVENTION OF 

TUBERCULOSIS. 

By John A. Kingsbury, 

Aarirtut SKretarr. State Cfaaritin Aid AawoUtion, N«w YoA City. 



Those of us who are planning the awakening of a State to the complete 
realisation of the tremendous need of concerted action in the combat against 
tuberculosis must recognize the fundamental fact that, as in all great move- 
ments, so in the movement for the prevention of tuberculosis, popular 
education is an indispensable factor toward its ultimate success. The 
masses must be enlightened and aroused. Such education must deal with — 
(1) what the conditions are, and (2) with what they should be. little eflfort 
in the latter direction can be expended to any great effect until the necessity 
for an improvement has been fully demonstrated. There is but slight 
excuse, therefore, for showing that a faulty condition exists unless one is 
prepared to point the way out of the untoward mtuation. 

An educational camptugn for the prevention of tuberculosis will follow 
two more or less distinct lines, the first being intensive, and the second 
extensive. The intensive will, of necessity, center in certain cities or 
definite localities, where, by sound and sane sociological methods, we will 
proceed to ascertain what the conditions in that vicinity are, and then to 
make the facts unearthed generally known in order to awaken the community 
to the existing situation, and to point out a course of definite procedure 
that will result in improvement. The extensive education is not so much 
concerned with determining the actual conditions that exist, but, on the 
basis of what is generally known, — ^the facts already revealed through 
printed reports of municipal and State departments of health, — we must 
assume that everyone realizes that the conditions are in sore need of im- 
provement, and we must at once begin a general propaganda of publicity, 
with a view to popularizing and disseminating all the facts known about 
the disease — ^how it spreads, and how it may be prevented and cured. 

The Intensive Campaign. 
The intensive dde of such an educational campaign, as I shall discuss it, 
falls under three distinct heads: (1) Preparation, involving investigation; 



M 



SIXTH INTERNATIONAL CONORESa ON TUBERCULOSIS. 



(2) a discussion of methods and means of arousing the public and disseni- 
Lnating both the knowledge gained through the investigation and the facts 
conceniing the comnmnicability of the disease, its cure and its prevention; 
and (3) the application, which requires thorough organization with a view to 
putting into operation definite constructive measures of private an<l muni- 
cipal control of tuberculosis. I shall confine myself to the first two pKa.se5 
of the question, leaving the last for a supplemental paper that will deal 
solely with that side of the subject. 

Preparation. — On the intensive sidej the first step to be taken in an 
educational campaign that has for its purpose the awakening of a State 
is to select some city in which to conduct a careful scientific investigation 
that will reveal the following facts: 

I. Concerning the care of consumptives. 

A. The extent of the disease. 

1. What has been the death-rate of pulmonary tuberculosis 
during the entire period for which data are available? 

2. How does the death-rate from tuberculosis in this city com- 
pare with the death-rates from the same cause in other 
cities of the State of about the same size? 

3. How does the change in the death-rate from this cause in 
this particular city during the period for which the statistics 
are available compared with the change in the cities of 
similar size in this State? 

4. How are the death-rates from tuberculosis distributed 
for the previous year — by wards or other political or geo- 
graphical subdivisions? 

5. How are the deaths from tuberculosis distributed, for the 
previous ten years, by street numbers? 

6* Do particular houses seem to l>e centers of infection? 

7. How are deaths from this cause distributed for the previous 

year — {a) by age periods; {b) by occupation; (c) by civil 

condition? 

B. What is now done for consumptives in the city studied? 

1. How many incipient cases have been sent to State or private 
sanatoriuma during each year for the past ten years? 

2. What provision is available for the local care of advanced 
cases either at a municipal or county hospital? 

3. What provimon has been made for the home treatment of 
tubercidosb? This inquiry may be made in the following 
subdivisions : 

a. Are physicians required to report to the Health De* 
partment all cases of tuberculoak coming to their 
knowledge? 

h. To what extent is this requirement, if made, actually 
carried into effect? 

c. What is the present number of registered cases? 



1 



THE AWAKENING OF A STATE. — KINGSBURY. 05 

d. Of the deaths from tuberculonis during the post year, 
how many had been previously rejMrted um hnving 
tuberculosb? 

e. What is the attitude of the health officiuld and physi- 
cians generally toward the reporting uf tul>ercukn»i8 
cases to the Health Department? 

/. Does the Health Department make provision for free 

sputum analysis? 
g. How many such analyses were Me('uro<l during the 

previous year? 

C. What is done for cases of tul>erculosis reported to the Health 
Department? 

1. Is the physician making the re|K)rt calUnl u])on to make 
further reports at inter\'als? 

2. Are cases visited by physicians from the Health Depart- 
ment? 

3. In case the consumptive has insufficient means to secure 
proper medical care and nursing, are such medical care and 
nursing provided by the Health Department or by other 
agencies? 

4. Is there a local tuberculasis dispensary, or does any existing 
dispensary or hospital make special provisi(»n for the home 
treatment of cases of tuberculosis? 

5. Is there any provision for distributing eggs, milk, or other 
articles of food to needy consumptives, either by public 
authorities or private agencies? 

6. In case of the death or removal of a person having tul)ercu- 
losis, what is done by the Health Departnicut to insure 
adequate disinfection of the preniises before the rooms are 
occupied as sleeping quarters by other i)ersons? 

D. To what extent does the athninistration of relief to needy 
families in their homes by public authorities and private agencies 
take into account the special needs and circumstances of families 
in which there is tuberculosis? 

1. In how many families now receiving relief from the public 
authorities Is there a case of tulwrculosLs? 

2. What amount and forms of relief are given to these families? 
Is it sufficient to insure — 

a. Suitable living quarters, so that other meml^ers of the 
family are not required to sleep in the same room with 
the consumptive? 

b. Abstention from hard physical or imsuitable lal)or on 
the part of the consumptive? 

c. Special food for the consumptive in sufficient amounts 
and of proper kinds, and 

d. Sufficient food and clothing for the other non-wage- 
eaming members of the household, in so far as the same 
cannot be provided otherwise? 




^>I»M^ 



BDCTll INTERKATION^AL CONGBE80 ON TUBERCULOSm 



e^ Compliance^ on the part of the children of the bouse' 
hold, with child labor and compulsory school attendance 
lawa? 
/. Proper medical oversight of the patient for the purpose 
of securing adequate protection for other membera of 
the household? 
g. What means, if any, exist for providing employment of 
suitable character for consumptives who have returned? 
3* How far are the aJxjve special standards of relief of consump- 
tives' families accepted and carried into effect by private 
relief -giving agencies? 

n. What measures have been taken to acquaint the wage^amers of 
the city with our present knowledge of the treatment of pulmonary 
tuberculosis? To what extent has any work been undertaken, either 
ay^tematically or occasionally, along the following lines? 

1. The preparation of preas articles for publication. 

2. The holding of public meetings for the purpose of interesting 
special groups of people; c. g^, the medical profession, clergynien, 
school-teachers, labor organizations, 

;i. Open-air stereopticon exhibitions. 

4. The distribution of suitable leaflets by the aid of — 

a, Industrial establishments. 

b, I^bor unions. 

c, l^iblic achoolSf etc. 
fi^ TIh> jHwting of suitable bulletins In street-ears, public buildings, 

llUlip-pt)(ita. 
6» Th* adoption and inforcement of anti-spitting ordinances. 

UL VVhai H»8 l*oen done toward the promotion of general hy^^enic 
UWamrTw havhip special value in the prevention of tuberculosis? 

Iv Mm til* Pity a suitalile building code, such as will gradually 
K^vwm naucnstion in quarters at present congested, and effectually 
w«v«tit new oonters of congestion? 

^ ^^UMTtUon of milk: What regulations have been established, 
tf **yi ^'^ W«*'^ ^* *'^^ protection of the niilk-supply by inspec* 
^Mirw ^hi* dairies? By regulation and inspection of places at 
ZQitk ndlk iH (-*^ld? To what extent is the tuberculin t^t applied 
%|«i««* ^vh^M' tiiilk is gold in the city? 

^ ■mHnU MHw^rvisiioii of lodging-houses; What regulations, if 

^kCw t*''^'^* (*H(rd>li.shed concerning lodging-houses of the 
xtg\ \^ ^ tiHiuirei-1 to open a lodging-house? How 

JJLv «^^4t Uinis*\s are there, and what ia the average 

^jT V^ »\f |tvl|Ei*rslf 1^*' *li'^ reflations insure conditions as 
iilSib^MM(t«r%' M »**y ^» ^*^'^ special reference to the probable 
SSm rf 4 toiiWittibto number of tuberculous lodgers? 

1\i UkdJk4^ ^Xi^iMMMI Wc outlined in a city of, say, from 60,000 to 
^(^ ^^ liliout 1100, and will take from one to two 
%m «KMii«uce of the mvesUgators and the natune 



THE AWAKENING OF A STATE. — KlNaSBURY, 



97 



of the sources, Wlien the facta revealed by this investigation are carefully 
incorporated in a written or printed report, illuminated by clear aad com- 
preben^ve tables, chartSp and diagrams, one is preparer! for active and 
vigorous campaigning. The popularization of that material through press, 
lectures, pulpits, and numerous meetings held in connection with a tuber- 
culosis exhibition, where the means of prevention and cure and the infor- 
K mation concerning conimunicabiUty of the disease are graphically shown, 
y constitutes the task of educational propaganda. 

But tliere is another tine of preparation almost as important as the 
investigation, which, of course, cannot and should not be wholly separated 
from it. Indeed, they will necessarily proceed more or leas Bimultaneously. 
I refer to the effort to secure the sj'mpathy and cooperation of tlie community 
in tbe movement. Fortunately, the easiest way to secure tliia united action 
is the most effective way, viz,, to get the heterogeneous community separated 
into its most homogeneous groups^ — the groups showing the greatest con- 
sciousness of kind. Such groups are accustomed to act together, and one 
is certain, by securing the active interest of their leaders, to have the hearty 
support of the rank and file. It is necessary tf:> secure only the most im- 
part&nt groups in any city, as these will be imitated by the lesser ones. 
These groups, however, are not always identical in the different communities. 
In one place the strong groups are the women's clubs^ the fraternal orders, 
and religious societies; in another it is the college, with its associations and 
groups intereated in education; again it is tbe volunteer firemen, tlie 
V.M,C*A.,thelocal mill tary companies; elsewhere the laborunionsare especially 
strong, the doctors are well organized, a splendid public school spirit pre- 
vmbi, and an active city superintendent is ready to assist in any meritorious 
educational work. Certain of these almost always exist in every com- 
munity, and^ whether larige or small, they should be interested. 

In setting out to interest, these groups, an important matter to be guarded 
against is that of permitting the movement to become monopolized, or to 
appear to become monopolized, by any one group or set of groups. From 
the outaet it must be taken for grantecl that this great crusade against 
tuberculosis recogoizes no race or color, no party or creed, nor is it to be 
controlled by cliques. It is with this assumption that we appear before the 
le-aHers of the groups that have been found to be dominant in the community 
where we are working* 

For our purpose the most important of these groups that we find in 
eveiy community is the physicians. If our city is of any considerable 
gi^ we will soon find ourselves stepping carefully over distinct tines of 
deavage withiii the medical profession. These lines do not separate only 
the old and new schools. They are more likely to radiate from the different 
hoGuiiAls- It is most important, however, to secure the interest and 

VOL. Ut^4 




9S 



SIXTH mTERNATIONAIi CONGRESS OX TUBERCULOSIS. 



cooperation of the leading physicians in each of the several meclical cliques. 
This matter must be reckoned with seriously if complete success is to be 
secured, for the professioTial differences that exist militate somewhat against 
any movement of tliis character. 

It is itsually far better, therefore, to niake the campaign a general move- 
niert, having both lay and medical representation, and, having gained the 
hearty sympathy, support, and approval of the physicians, it is probably 
advisable, as a rule, to place it under the control of laymen. 

Another group that must be carefully reckoned with, since it represents a 
powerful macliine that may be wielded for good, is the labor unions. In most 
cities the labor unions are affiliated into a central body, composed of dele- 
gates from unions of each of the organized trades. If these leaders can be 
rejiched through the central body and convinced that this movement is one 
that has for its aim the general interests of the laboring class j that it is a 
movement that is not a mere charity, — which word they usually despise, — 
but one that will go far toward relieving the conditions that are claiming so 
great an annual tribute from their ranks. This^ however, is no mean task, 
but one well worth while accomplishing. For is it not worth every effort to 
enlist so powerful a force in this "holy war'*? It will be a veritable army 
within the walls of the enemy, for it is here that this treacherous little foe 
levies hia most awful tribute of death. Occupational statistics show us 
that it is the stone-mason, cigar-maker^ and printer, not the lawyer, the 
doctor, or the merchant, who most frequently falls a prey to this insidious 
foe. This is what the laborer must know, and must be taught if he does 
not know. He wi!l not be long in learning, nor will he be slow in throwing 
himself into the breach, if he is convinced that the movement that solicits 
his support is one that strikes at the root of the evil, 

A labor leader recently said: "Labor will not be slow to see the impor- 
tance of joining forces in combating this disease, which claims for its victims 
hundreds of the wage-earning class as against small numbers of the income- 
receiving classes. Labor is keenly alive to the economic phases of tuber- 
culosis; to the fact that unsanitary workshops and unhygienic home condi- 
tions, unceasing and grinding toil at a wage tliat is insufficient to provide 
proper and wholesome food; to the indisputable fact that unjust social and 
economic conditions constitute the principal predispoang cause of tubercu- 
losis," 

This same labor leader, when convinced of the soundness of this move- 
ment, was responsible for bringing together the labor forces at Albany, and 
enlistingtheirinterest and support in the New York State campaign. From 
the cooperation of labor in that city, one of the most important 
results of the campaign has already been accomplished. If co6peration of 
this group is desired^ it must be shown that the oigamzed labor movement 



^ 



THE AWAKENING OF A STATE. — KINGSBURY. 



w 



18 ft powerful force in this countryj and an important factor in the well- 
being of our land. Moreover, it must be presented with a complete pro- 
gnuu of education — a program that not only emphasizes the importance of 
fresh air, recreation, temperance, and sunshine, but one that insists upon the 
oondition^ that will make thcae thinga possible, a program that demands 
proper ventilation of factories, with complete and adequat-e sanitary regu- 
lations; wholesome housing conditions; reasonable hours of labor, and a 
real linng wage — a wage that, besides enabling the laborer properly to feed 
and clothe himaelf and family, and to give his children an education, will 
permit of some recreation. 

To sum up, the gospel of the tuberculosis crusade must be spread to the 
entire community by means of its social groups. 

Methods of Educatiov. — The methods to be employed la conveying the 
information gained through the investigation to all the people of the com- 
munity, and in spreading the gospel of prevention and cure, include the 
following; (1) exiiibitlons; {2} advertising; (3) lectures; (4) group' meetings; 
(5) press notices; (6) literature; (7) sermons, and (8) mass-meetings. 

1, Exhibiiimis, — ^Tbe value of tuberculosis exhibitions as a means of 
popular education is now t-oo well known to warrant discusaon here. A 
word might be said, however, on the question of the organization of an 
exhibition for general educational purposes. Too often these exhibitions 
seem to have been organized on the basis of institutions and localities, with 
a view to showing wlutt each has accomplished. Tliis involves much 
repetition of details, unimportant to the masses, and is likely to leave the 
mind without a very definite impression having been made. While such a 
general exhibition may be of great interest to phyaicianB who desire to 
study temperature-charts, dif^ams, and methods of adnunigtration, they 
tend to confuse the mind of the general public and are not striking enough 
to be Interesting to the average layman. An exhibition that is to appeal to 
the common man should be more than a vast collection of illustrative 
material. It should contain as little as possible — only the essential facts 
about the disease, given in terse texts, graphic charts and striking pictures, 
all falling into an effective organisation that should predominate i& definite 
po^tive direction, rather than in "don'ts" and in negation. It should be 
so simple and so interesting that he who runs not only can, but must, read. 
The following outline is offered as a suggestion for the accomplishment of 
this d^deratum : 



A General Outune of a Tubehcttlosis Exhibition, 
The exhibition should comprise seven sections, namely: 

1. The extent of the disease. 

2. The nature of the disease* 



100 SIXTH nsTiaiNATlONAL CONGKB&S ON TUBEKCfULOSlS- 

3. Where the germ grows. 

4. How the disease spreads. 

6. How it is cured, 
d. How it is prevented. 

7. Tuberculosis in animals. 

Section 1. The Extent of the Disease. — Under thia heading include 
charts showing the number of deatha in the State in a year; the proportion 
of all deaths due to tuberculosis; the numlo^r of deaths in the locality in 
which the exhibit is heidj the proportion of deaths in that locality between 
the ages of twenty and fifty due to tuberculosis; one or more pin maps, 
showing the exact location of each death that has occurred during the past 
ten years in one or more cities investigated; charts showing the economic 
cost of tuberculosis, tuberculosis as a cause of dependence, etc. 

Section B. The Nature of the Disease,— -^\\ovf a colored plate of the tuber- 
cle bacillue^r niagniiied many thousand times; brief statements as to the first 
symptoraa of the disease, its duration^ its effect upon the lunp;B^ etc. 

Section 3. Where the Germ GraiDS^ — Show bad housing and good housing 
conditions; bad and good factory conditions; suggest the relation of in- 
ebriety and other evils to tuberculosis; show overcrowded and unventilated 
schools, theaters, and churches. 

Section 4- ^^^^ ^ Disease Spreads. — ^By plates, photographs, etc^ 
suggest the various ways in which the disease is communicated from one 
person to another: sleeping in the same room; children plajdng on the 
floor of room where patient is sick with tuberculosis, etc. 

Section 6. How it is Cured. — Model or cut of outdoor sleeping porch; 
aanatorium and hospital exhibits; steamer chair, Bleeping bag, etc. 

Section 6. Hon} it is Prevent^, — Illustrate the dif!erent precautions for 
receiving and destroying sputum; the literature for di.'^tribution; the care 
of the individual patient in such manner as to protect the other members of 
the household, etc. 

Section 7. Tuherculosis in Animals, — Show pictures of tuberculous 
cattle; state what animals are largely subject to tul>erculosis; quote figures 
as to the percentage of reaction to the tuberculin test, etc. 



Such an exhibition, held in any community where a campaign is l>eiag 
waged, should center all the active educational effort. It should, therefore, 
Lie hekl In a hall where crowds will assemble and where they can be properly 
accommodated. 

2. ^d^rrfmn^.— Advertising the educational work of the campaign is 
itself one of the most important means of educating the public. Through 
judicious advertising of the exiiibition and the meetings many of the essen- 
tial facts about the disease can be brought to the attention of all who read. 
For work of this character, the more effective methods of advertising consist 
in the use of large billboard posters, window cards, posters placed in street- 
car windows, hand-biUsj tickets to special labor meetings and to the exhibit, 
theee to be placed in the pay envelop of the employees of all large industrial 



THE AWAKENING OF A STATE. — laNGSBURT. 101 

establishments, letters sent to special groups inviting them to attend meet- 
ingiay and outdoor stereopticon shows. These advertisements can give some 
definite information about the disease we are trying to combat. The 
street-car companies usually ask no other compensation for covering a 
window on dther side of the car with a poster announcing the exhibition and 
lectures than a prominent notice at the bottom of the poster stating that 
tuberculosis is spread by careless spitting, and that people, therefore, should 
not spit on the car-floors. Practically every store will place a hand-bill in 
each ddivery made dtiring the campaign, and every factory will put a ticket 
into each pay envelope of its employees admitting them to the special meet- 
ing that is to be held for them in connection with the exhibition. On the 
backs of these bills and tickets should be printed some important informa- 
tion, as, for example : 

Don't Give Ck)NSUB«»TioN to Others! 
The spit and small particles coughed up and 
sneezed out by consumptives, and by many others 
who don't know they have consumption, are full of 
tiny living germs. 

These Germs Are the Cause of Consumption I 
Don't spit on the sidewalks I It spreads disease. 
Don't spit on the floors of your room I 
Don't spit <m the floor of your workshop I 

Don't Let Others Give Consumption to You! 

On the back of the stationery used in inviting members of various groups 
to the special meetings that have been arranged for them, a veritable tuber- 
culosis catechism can be printed. On the screen opposite a busy comer, 
where the outdoor stereopticon exhibition is being given, can be thrown 
annoimcements of the meetings and of the exhibition, interspersed with any 
number of bulletins conveying information about the disease. By this form 
of advertising many who do not attend either the lectures or the exhibition 
are given some important information about the disease, and in this way 
the advertisement fulfils in part the function of the lecture. Moreover, the 
information often suffices to make one curious enough to attend the meet- 
ings, in order to get a more definite idea regarding this disease, which he fears. 
In New York State we have found that there is nothing quite so effective 
in getting out the crowds as the street-car window-posters. Personal 
letters to the members of the various groups are scarcely less valuable, 
but this method is much more expensive. Still, when one considers that a 
page of important information, printed on the back of the stationery, has 



102 



SIXTH INTEENATIONAIi COXGRESS ON TUBERCULOSIS. 



been placed in the hands of the recipient of the letter, possibly this method 
is, aft€r all, most worth while. 

3* Lectures. — Every afternoon and evening stereopticon lectures by local 
phj'Bicians should be given in connection with the exhibition. In order to 
make these lectures successful each doctor who is to talk should be furnished 
in advance with a book of views corresponding to the set of slides on wliich 
he is to speak. These pictures should be arranged in some logical order, 
and accompanying each there should be a brief description that can easily 
be woven into a simple talk. The pages containing the pictures should be 
numbered to corresptmd with the slides, so that the lecturer can furnish 
the lantern operator with the list of the sUdes, arranged in the order in 
which he wishes to present them. Some such device as this is necessary 
not only to secure good simple talks^ but in order to get physicians to talk 
at all. Furthermore, this device does more thau simply induce physicians 
to talk: it gets a large number of them directly interested in the work. 

4. Group Me€ii?igs, — In connection with the exhibition, wherever this 
is possible, special meetings should be arranged for all the more important 
groups in tlie city. The methods of interesting these groups have been 
sufficiently discussed, and we need here indicate only briefly a typical plan 
of organization. Assuming that we have secured the interest and support 
of the leaders of, for instance, the various women's clubs of a city, an excellent 
scheme is to ask the president of the strongest club in the city, if she appears 
to be popular with most of the others, to preside at the meeting, and to call 
together the officers of the other clubs to act as a committee on arrange- 
ments. If this hi done a sufhcient length of time before the beginning of 
the active campaign, announcements through the regxdar meetings of the 
various clubs can be made, and invitations extended to the members to 
come to the meeting in a body. If time does not permit of this, a good 
plan is to send out a brief letter announcing the special meeting that has 
been arranged for the members of women's clubs and other women's organ- 
iJEations, urging the members to make a special effort to be present. These 
letters should be signetl by the president and the secretary" of the organization 
to whose members they are sent, if this is possible; if not, they should be 
sent in the form of an inWtation from the club whose leader is to preside* 
These lettens should be written on stationery on the back of which is printed 
information about tuberculous^ as this will be read by nearly every one 
receiving them, even though they do not come to the meetings* The 
speaker announced in the letter should be a physician who is quite popular 
with the women, preferably one who is especially inter^ted in tliia subject. 
A large proportion of the meml>ers of every group that it is deemed desirable 
to reach can in this way be brought to the meetings. Ten or fifteen such 
group meetings may be held during the campaign. 



THE AWAKENING OF A STATE.— KINGSBURY, 



103 



6. Press Notices. — Great care should be taken in giving out notices of 
the plan of campaign or of the facta revealed by the investigation, not to 
permit any of the papers to get "scoopa/' The materiai should be justly 
di\'ided between the evening and the moming papers. In this way the 
papers will be not only wUling, but anxious, to sec;u*e the material, especially 
if it is prepared for them. If they are properly approached^ there is prac- 
tically no limit to the space they are willing to give to &uch a movement. 
In New York State, during the progr^s of the campaign, some papers have 
gone to tlie extent of getting out s|5ecial etlitioiis on the prevention of tui>er- 
culosis. *'The Auburn Daily Citizen" got out auch an edition, and thousr- 
ands of copies were sent throughout the State of New York, attracting a 
great deal of attention to the work. The paj^er contained a complete account 
of the plan and scope of the campaign, and the most valuable lectures that 
had b^n given were reproduced in full. The editorial page was entirely 
devoted to reprinting the strongest editorials on the Ciimpaign that had 
appeared in the leaiiing papers of the State during the year: The Yoiikers 
movement was described; the Knopf Prize Essay was reviewed; and many 
cuts of the State's exhibit were reproduced. This has bean one of the most 
successful features that has developed In any of the cities in which we have 
conducted our campmgn. 

At the proper time the entire program of the campaign should be printed 
in all the papers, with a number of the most striking facts wliich the inves- 
tigation has revealed. Thereafter, during the progress of the campaign, 
tha program each day should appear in the press^ with a complete account 
of the meetings of the previous day. 

6, LUerature. — One of the chief purposes of such a campaign as I am 
descnbtng is to get desirable and readable literature into the hands of as 
many people as possible. At every exliihition, and in connection with all 
meetiDgs, some simple statement about tuberculosis, printed on cardboard 
[* of & axe convenient to be placed in the pocket, should be distributed. The 
BO-called "Don't" card, now so familiarj answers thb purpose admirably. 
But there should be a more complete statement of the tuberculosis situation 
than this- There should be a small pamphlet, of 8 to 12 pages, which sets 
forth in simple language all the facts about the disease. This pamphlet 
should treat of the eoctent and nature of the disease, tell how the germ 
grows, how the d^ase is spread, cured, and prevented, iind give a short 
statement about tuberculosis in animals. This should be in such form as 
to serve at once as a brief text on tuberculosis, and as a catalogue of the 
exhibition. Such a pamplilet is publication No, 104 of the State Charities 
^d Association, of whit^^h nearly 300^000 copies have been distributed during 
the paatt month at the county fairs in New York State. Other literature 



I 



104 



SIXTH INTERNATIONAL CONaBBSS ON TUBEKCULOSlS. 



ahould be provided, such aa the well-known "Sweeping and Dusting Cards," 
the "Knopf Prize Essay/' "The Rogers Working Progra-m for a Small 
City," "Information for those Having Diseases of the Lungs and those 
Living with Them/' etc. The last three being somewhat expensivej we 
find it necessary to distribute them more sparingly, and generally they need 
be placed only in the hands of those especially interested in the movement. 
(The Knopf Essay is frequently sold at a very nominal pnce, Dr. Knopf 
having Idndl)^ provided us with them at actual cost to himself.) 

7* Sermons, — Whenever it is poaaible, arrangements should be made 
with the imiiisters of the city to preach a sermon on tuberculosis on the 
Sunday preceding the opening of the active campaign. In order to get the 
ministers interested, we have found it a good plan to send them a cordial 
letter and a free copy of the Knopf Esaay. This will enable them to fam- 
iliarize themselves with the subject, and, aa a rule, there will be little trouble 
in securing their cooperation, at least to the extent of getting a strong 
indorsement from the pulpit. Another plan that has been found very 
Buccessful is to induce the ministers to permit the physicians of the cities 
to occupy their pulpits on the Sunday evening prior to the opening of the 
campaign; the former scheme, however^ is generally better^ for ministers 
are usually more effective speakers, 

8, Mass-meetings,— The active campaign in any city should always be 
concluded by a large and enthusiastic mass-meeting. Tliia should be 
advertised and emphasized throughout the entire campaign, and the people 
who attend the various lectures and group meetings should be impressed 
with the fact that they will hear something quite diflferent at the mass- 
meeting, and that they will be told very definitely what should be done by 
the community as a whole to prevent the spread of tuberculosis. The 
mayor of the city or some other prominent public official should be asked 
to preside at this meeting. The speJikera should include some leading 
political lights — the Governor, the lieutenant Governor, the speaker of the 
house, or the mayor of one of the largest cities; one of the leading physicians 
of the State or of some other State; a representative of the State Depart^ 
ment of Health; some layman who is prominently identified Mith the 
movement; the head of the largest and most prosperous business concern 
in the city; and one or more of the most prominent Protestant and Catholio 
clerg}^men should be asked to participate. Such a meeting as this can be 
made the climax of the campaign, but if it Is not carefully planned, it may 
easily become an anticlimax. 

In addition to securing the right speakers and the preparation of a 
strong program, another method that will do much toward packing the 
haU is the issuing of special invitationa "to be presented at the door/' 




THE AWAKENING OF A STATE. — KINQSBCTET. 



105 



This invitatiOE must be sent to the select of the city^ and a certain number 
must *^adnut to platform." It must be given out in the press that admission 
until, say 8 o'clock, is by card, which may be obtained by applying at 
such and such a place. • 

If it seenia advisable to make tliis meeting more of a feature, a hundred 
or more of the leading citizens and their wives can be asked to serve on a 
committee on arrangements or as honorary vice-presidents. Thia idea, 
if properly developed, will inevitably create wide interest. The plan can 
be made still more effective by reserving all seats in the house and having 
ftdmissdon by ticket, but this entails no small amount of work. If tickets 
are to be issued, an attractive invitation with a return card request for 
seats should be sent to a sufficient number of j?eople to insure replies enough 
to more than fill the house. Seats for applicants must be selected with 
great care, and all arrangements must 1>e quite fomiab It is well to prepare 
a very artbitic program and to print on it the names of the committee on 
arrangements or vice-presidents. It becomes really a social occasion^ 
and must be carried out as such. Such a meeting will cost at the rate of 
from fifty cents to a dollar an admission. In other words, to fill a hall that 
seata 2000 persona will cost from one to two thousand dollars. If sufficient 
funds are available for carrying out this p!an properly, it makee a fitting 
eloae to a campaign. 

The total c^st of an active campaign such as the one just described la a 
wty of, say, 75,000 inhabitants will he from five to six hundred dollars, 
ezclu^ve of the investigation and the mass-meeting* This cost will, of 
courae^ vary greatly in different cities of the same State. 



^ 



The Extensive Campaign. 
Thus far I have given some of the 'more important means'and methods 
of awakening a community to the necessity of stamping out tuberculosis 
and arousing it to active participation in the fight against the disease. 
This intensive method alone, however^ is quite inadequate. In the first 
place, it is too slow. To conduct a campaign according to such methods 
requires from four to five weeks in each city^. e.j from three to four weei<3 
should be given to the preliminary preparation and a week to vigorous 
campaigning. Such a campaign cannot be carried on to advantage during 
the summer, hence one cannot expect to reach more than eight or ten cities 
in a year, At this rate it would take at least five years to cover the cities 
of a State like New York, not to mention the many villages that exceed in 
populadoo a considerable number of the cities. In the second place, the 
effects of such a method as we have described would be likely to be quite 
fleeting. Lastly, such a system overlooks a very large portion of the pop- 



106 



SIXTH mn^NATIOMAL CONGEESS ON TUBERCULOSIS. 



ulation — a portion greatly in need of the light. To be sure the results of 
such campaigning are bound to become disseminated throughout the sur- 
rounding neighborhoods, but at best the greater part of the inhabitants of 
the rural districts must go uninformed for years; just as those in the smaller 
cities throughout the world have for the most part remained in ignorance, 
whereas the larger cities, where the disease is most difficult to combat, 
utilizing the knowledge that science has given to the worlds have, during 
the piLst fifteen years, diminished their death-rates from tuberculosis from 
30 to 50 per cent* 

It is not necessary to w^t until all the facts in the various communitiea 
investigated have been brought to light before we begin an extensive edu- 
cational campaign. "Study should precede action, but it is a poor sub- 
stitute for it," said the prejsident of our section on a former occasion, when 
he enjoined upon us all to get to work at once * ' on the basis of sure knowledge, 
gained in part from the accumulated experience and in part from the obser- 
vation of physicians and earlier reformers." 

Let us then consi<ler briefly some of the more important measures that 
may be employed in getting to work at once on a large and extensive scale 
throughout a State tliat we are attempting to awaken. Moat important 
among these measures are the following: (1) Weekly press bulletins; (2) 
small coutity fair exhibitions; (3) a campaign of correspondence, 

1. Weeklt/ Press Bidletin* — Of first importance is the securing of the 
interest and supixirt of the press throughout the State, especially the papers 
of the smaller cities and villages. To accomplish this, the following method 
is suggestetl: Make up a list of pract-ically all the papers of the State from 
Rowell's Newspaper Directory; write a strong personal letter to the editor 
of each, stating as definitely and concisely as possible your purpose^ and 
inclose some carefully selected literature; offer to furnish lum weekly 
tyi^e written pr^s notices of from 400 to 500 w^ords, giving the latest news 
concerning the warfare against tuberculosis. When your final list of papers 
b made up from the replies to this letter, you should send out your *'copy" 
regularly on a certain day each week^ preferably on Saturday^ so that it 
may be used on Monday, a day on which news is slack. This copy should 
be duplicated on a special blank form that contains a standing request for 
suggestions and for marked copies of all papers in which the material fur- 
nished b used. The article should always contain a nucleus of news with a 
pithy introduction, and the whole should be written in the breeziest new*8- 
paper style possible. The information conveyed should be absolutely 
reliable, and cover the various phases of the subject* 

The cost of getting out about 500 such weekly bulletins in New York 
city, where we are prepared to do our own multigraphing, including the 



I 

4 



4 



THE AWAKENING OF A STATE,— KINGS BtTRY* 



107 



at second-class postage rates, doea not exceetl S8.00 a week. If 
hinds are available, a still better plan k to get out "boiler-pbte'' material, 
■which aU small papers are accustomed to use» This^ however, costs about 
$1.00 a page for each paper using the material, and it i^ seldom sent out m 
quantity of leas than a piige of six columns, 

2. Count}/ Fair Ej:kibiHons, — Another method, scarcely secondary to 
the support of the press, is the sending of small exhibitions to county fairs 
throughout the State and to the State fair. In this manner hundreds of 
thousands can be reached in a period of five or six weeks, and to a very 
considerable degree they wll he that portion of the population who would 
not be touched by the other educational work. 

The exhibitions as conducteii in New York State are organized on the 
plan previously described for the larger exhibitions, but considerably 
abridged, there Ijeing from six to nine frames^ 22 by 28 inches, hung in 
rows of threes under each section hea(^ng— €* ^., under *' Section 1. The 
Extent of the Disease," bix frames are hung in two rows of three each. 
These frames contain texts about tuberculosis, and the most striking and 
attractive pictures, charts, and tiiagrams obtainable. The pictures mounted 
in these frames in most cases aro 15 by 20 inches, and in no ease are they 
smaller than 9 by 11, For the display of these frames we have found a 
very satisfactory device to be an adjustable framework of iron piping** 

One of the devices successfully used at county fairs for advertising 
purposes is a large phonograph, equipped with a variety of carefully chosen 
music^ selections, wlilch are to be interspersed by special records containing 
brief, terse talks on tuberculosis* The phonograph is always attractive to 
a rural population, and once the crowd is assembled, an active demonstrator 
in charge of the exhibition can persuade a very large portion of the people 
to view the exhibit systematically, and to carry away the small eight-page 
pamphlet that describes more in detail the same facta to which their 
attention has been called by means of the exhibition, the subject matter 
following the same organization as the exhibition. 

Our reports from the demonstratei's who are connected with these 
exhibitions indicate that the ignorance in country districts concerning 
tuberculods is appalling; all the old ideas about the heredity and fatality of 
the disease still seem to prevail to a very large extent* We are convinced 
that this is one of the most important phases of educational work that 
could be undertaken, for this terrible disease is scarcely less prevalent in 
country districts than in the thickly populated cities. Moreover, in the 
latter it is generally on the decline, whereas in the former, in New York 

• A bluo print of the working-drawing of this fnime can be had by writing the St&t6 
Qukfjties Aid Association, 105 E&st 22d St., New York, N, Y. 



108 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



State at least, the statistics seem to indicate that the disease m becoming 
increasingly prevalent. Such an exhibition brings home to every visitor 
to the county fair who will take the time to examine it casually and out of 
pure curiosity^ the fact tliat the disease that causes the largest number of 
deaths in the State is a curable and, above all, a preventable disease. 

The cofit of sending such exhibitions to county fairs ought not to exceed 
t2O0 a fiur, including the cost of preparing the exhibition, tranflportatlon of 
the same, the printing of half a million copies of an eight-page circular for 
distribution, traveling and living expenses of two demonstrators with each 
exiiibit, and all other minor ejcpenses connected therewith. After the first 
year this can possibly be done for $125 a fair. 

3. Campaign oj Correspondence.— As a result of the wide distribution of 
literature, the constant appearance of press articles pertaining to tuberculosis, 
and especially as a result of the exhibitions at the county fairs, a great 
amount of inquiry will be provokedj and an opportunity b thereby opened 
for a regular campaign of correspondence. In fact, in a State of any con- 
siderable size, the correspondence will become so heavy as to nec^^ssitate a 
special department properly to care for it. In addition to the response to 
inquiries and the more general correspondence, the way is opened to come 
in touch with the leaders of vmtfus communities in which the local cara- 
pjiigns have been conducted, and in which county fair exhibitions have been 
held, thus sustaining the interest that lias been aroused. The people thus 
interested can be persuaded to form small local committees^ through which 
the central associations can work. Through their cooperation atreet-car 
companies can be induct to permit the use of the backs of transfers for 
texts such as those indicated in the case of the hand-bills and pay envelope 
tickets. In New York city, as a result of the efforts of the Chanty Organi- 
zation Society, millions of such transfers are distributed in the course of a 
year, Again^ such texts, attractively printed on signs, containing the 
emblem of the International Congrtes, may be fiirniahed to the people and 
the commumtiea thus interested, who will see that these signs are nailed on 
telephone poles and in other conspicuous places* Finally, the back of all 
stationery used should contdn a printed statement of the most important 
matter that can be put into the limits of a page. It is scarcely possible 
to state definitely the cost of such a correspondence campaign, but we 
estimate that in New York from three to four thousand dollars can be 
expended annually in this direction to very good advantage. 

CONCLDSIOH* 

In conducting a campaign of education, then, with a view to awakening 
the population of a State to the real significance of the ravages of tubercu- 



4 



I 



THE AWAKENING OF A STATE. — KINGSBURY. 109 

Xom, and to stimulate those awakened to immediate action, an enormous 
expenditure of time, effort, and money is required. Moreover, an unceasing 
and continuous propaganda is demanded, for the people must not only be 
awakened, but they must be kept awake. To accomplish this result there 
must be popular education on a large scale, both intensive and extensive. 
On the one hand, the people of every locality must be acquainted with the 
actual conditions in the midst of which they live, and must be told what 
should be done to improve these conditions. If one in every eight or ten 
in the city has diea or is destined to die of this preventable disease, 
every individual living there should be brought face to face with this specter. 
If the people do not know what they should do, they must recdve instruction. 
On the other hand, the people throughout the State should be awakened 
and kept awake by means of continuous press notices, small exhibits shown 
at county fairs, conventions, and various other places where large crowds 
are likely to assemble, by a wide distribution of carefully prepared literar 
ture, and by means of a veritable campaign of correspondence. 

Every possible agency should be interested in this holy warfare. Among 
the various agencies whose mterest is invoked there should be the closest 
possible codperation, bearing in mind the common end in view. Public 
and private effort must join hands and work in perfect harmony. Local 
organizations, official and voluntary, must be brought into intimate touch 
with one another through the State charitable agencies, both private and 
public, which in tiun must be closely afiEliated. By this means such an edu- 
cational campaign as I have attempted to describe may be made most 
effective and the movement, once begun, may be continued, and the way 
prepared for the institution of definite constructive measures for the control 
of tuberculosis. 



A STATE AROUSED. EFFECTIVE CONTROL OF 

TUBERCULOSIS IN SMALL CITIES AND 

RURAL COMMUNITIES. 

By Homer Folks, 

fiHratuy df |h« Now York 8tat« Ch&Htiea Aid ABBocUtion. 



Assuming that an educational campaign has been conducted along the 
lines indicated in Mr. Kingsbury's paper on the "Awakening of a State," 
what are the concrete steps to be taken to secure effective control of tuber- 
eulosia in smaller cities and towns? 

It should be noted at the outset that the title of tliia paper expresses a 
hope, not a fact. Tuberculosis ia not effectively controlled to-day In any 
of the smaller or larger cities or rural communities of the United States. 
Steps have been takenj and other steps are being taken, which should result 
in the course of a few years in such effective control, but let us be watchful 
not to confuse hope with accomplishment, plan with result. 

In most respects the prevention of tuberculosis in the smaller cities and 
rural communities will follow the same general lines as in the larger cities. 
Whether famiUes live a mile apart or 25 fect^ or separated only by a partition 
or floor, has no very great bearing on the steps to be taken by them or for 
them for the prevention of tuberculosis. The differences will grow out of a 
less highly developed local government, less expert and effective hejJth 
officers, less inclination to be governed, less of voluntary organization for 
practical social work. In all these respects the campaign in smaller com- 
munities will be somewhat more difficult. On the other hand, it has its more 
hopeful features: comparative absence of overcrowding, a larger propor- 
tion of out-of-door employment, a smaller amount of continuously severe 
employment, a higher level of material well-being, and less of sordid vice. 

In the smaller tity and rural communitiyj as in the large city, the effec- 
tive control of tuberculosis inevitably follows two lines: treatment and 
prevention. 

I. Theatment. 
The proper treatment of living cases of tuberculosis is fortunately also 
the oumane, the scientific, and the effective method for its prevention* 
The proper care of the sick secures the protection of the well. A program 

110 




A STATE AROUSED. — FOLKS. 



in 



for the treatment of consumptives, to be comprehensive and effective, must 
include the following: 

L Reporting and registration of cases; 

2. Dispensarj' or bureau for diagnosis and direction of treatment ; 

3. Available sanatoriums for incipient eases ; 

4. Hospitals for moderate and advanced cases; 

5. Home treatment, including classes, day camps, and visiting nurses; 

6. Relief for families of both early and advanced cases. 

L Reports of Cases,— Every argument that calls for the reporting and 
re^ratlon of cases in the large city applies with equal force to emaller towns 
and mial communities, although the difficulty of securing such reports in 
these localities is undoubtedly greater. The physicians ai-e less interested in 
questions of public health and a smaller proportion of the sick receive 
medical attention at an early stage. In our judgnient these reports should be 
made to the locai health officer. If he be inefficient, uninterested, unsalaried, 
or practically so, there is no short cut; we must secure local health ofFicers who 
are competent^ interested, and adequately remunerated. Among the urgent 
Mt&odB are more instruction in preventive medicine in medical schools, and 
ffpecial triuning of health officers so that in each community the physicians 
will be interested in public health problems^ and among them there may be 
one or more with special training in public health at! ministration. We need 
not wait, however, the advent of the highly trained public health officer 
before tning to set in motion our machinery of regLstration and our program 
of treatment. To impose the proper duties upon the health officer^ to add 
re-sponsibihty to his pasition, is the surest way to secure for it dignity, 
remuneration, and competent incumbents. 

The reporting of cases is not an end in itself. It has absolutely no value 
unless something is done by somebody about those cases who are reported. 
In securing in each State the passage of a registration law, and there should 
be such a law in every State, our task is likely to be somewhat simplified, in 
my judgment, if we indicate as precisely as possible the purpose to which the 
register is to be put, and more especially if we provide for the register a reason- 
)le degree of safeguard against unnecessary publicity. The duty of report* 
'ing cases should be clearly imposed upon every practising physLcian, and 
the duty of securing the enforcement of the law should be imposed upon 
local health officers, under the general sujiervision of a State health depart- 
ment. The maintenance of the re^ster and the consequent general direction 
of treatment and prevention are inevitably official functions to be performed 
,by the local health department. 

2* Dispenmry. — A bureau for the diagnosts of pulmonary tuberculosis 
is practicable, and in fact imperative, in even the smaller cities and should be 
available to the surrounding rural communities. There should be no indi- 



112 



BtSTH iPfTERNATlONAL CONGRESS ON TUBERCULOSIS. 



vidua! anywhere in the State for whom there is not available within the limits 
of his county and, except in sparsely settled communities, within the limits of 
his town, a place at which, if unable to pay, he can secure gratuituously, if 
be has any cause to believe that he may have tuberculosis, an expert exami- 
nation^ and £rom wliich he can be directed wisely. For illustration of the 
operations of an active and effective tuberculosis dispensary, reference may 
be made to that in the city of Yonkers, population 70,000, maintained by a 
private corporation, the Sanitary League, with assistance from the city; or 
to Rome, N. Y., population 18,000, where the dispensary or bureau Khonld 
be maintained by the municipality or other local authority, or by a hospital 
or charitable association. It is my strong conviction that the preference 
should always be given to making it a municipal function, so that it will 
have the prestige and authority of government, the ampler and more constant 
resources of the public purse, and be subject to and sensitive to public criti- 
cism. If, however, local conditions are such that a municipal dispensary 
is difficult to obtain, or if there be in existence dispensaries with endowment 
or adequate income, or if there be hospitals or charitable associations able, 
willing, and competent to untertake this additional task, it is possible to 
effect cooperation between a privately controlled dispensary and a publicly 
controlled registration, 

3. Aimlabk Sanaioriums for InctjnentCases. — Wlien the physician reporta 
a case of tuberculosis, or when a positive diagnosis is made at a tuberculosis 
disi:>ensary, we are face to face with the most difficult and expensive part 
of our program. Unless we measure up to the task of actually providing for 
the treatment of all positive cases, of what avail is all our machinery of 
registration and diagnosis? We must therefore make available to every 
square foot of territory within the State provision for the treatment of the 
various classes of patients, early, moderatej atlvanced, destitute, of modest 
means, well-to-do; persons without families and persons with large families; 
men, women, and children; black and white, of every race and nationality; 
orderly and disorderly; competent and incompetent. There must be sanato- 
rium treatment available for the incipient case, able to leave home, or whose 
home surroundings are such that he should or must leave home. There 
should be, in our judgment, one State ganatoriumj and in many eases se\T!ral, 
in every State. Not every city need maintain its own sanatoriuma^ but the 
larger cities should certainly do so, say cities with a population in excess of 
200,000* The machinery for gettiiig into these aanatoriums should be as sim- 
ple as will ensure incipiency. The terms, conditions, and procedures of ad- 
mission should be made known, not once, but many times through the entire 
community. In a State even as well advanced aa New Y'"ork, the securing 
of sanatorium treatment for a patient from one of the smaller cities or rural 
communities is a baffiing task. Especially do we need sanatoriuma in which 



4 

ri 



1 



A arrATB aroused, — tovka. 



113 



patients oT moderate means may pay a stated sum, less than the actual 
cost of maintenance in most cases, so that the feeling of economic indepen^ 
dence may be preserved. 

4. Moderate and Advanced Cases, — Unfortunately moet of the recognized 
cases will be moderate or advanced cases. Rarely do incipient cases realize 
that they need examination. The number of ndvant-ed cases in everj' com- 
munity is appalling. Nowhere to my knowledge ts anytliing like adequate 
provision made for them, though great progress has been made in the last 
decade. This is clearly a local and a public duty. The munidpality or the 
county, according to the plan of local government in the State, must be 
petitioned, threatened, entreated, persuaded, browbeaten^ bullied into doing 
its duty. In the almshouses will be found many consumptives, not admitted 
usually as coosumptiveSj frequently not recognised as consumptives. Tuber- 
culous, occurring in the wage-earning class, rapidly produces poverty and 
pauperism. Poverty tends to produce tuberculosis. So the poor law 
official finds on his hands a far greater number of cases of tuberculosis than 
any otiier public official^ coming to him not primarily as consumptives, but 
ns public dependents; not because they are sick, but because they are poor. 
To care decently, and in accordance with the present scientific knowledge, 
for these patients ia the first duty of the local poor authorities, but when 
this has been performed, and at the county or city almshouse there b estab^ 
lished a suitable ward or wards, or pavilion, or hospital for consumptives, 
it will be found that only a small minority of those neetUng hospital care will 
ibccept its shelter. We must deal here with what is at once a priceless 
postiession, a prejudice, and an almost unsuperable obstacle — the fierce 
opposition to accepting the shelter of an almshouse. In all considerable 
conununities, there should be provided^ by public funds, under public 
auspices, hut either under health officers or under a newly established author^ 
ity, hospitals for tuljerculosis, entirely separate from almshouse institutions 
and from almshouse administration, in which the patient or his friends or 
relatives will be expected to pay» so far as possible, the cost of maintenance* 
Extremely interesting is the provision of the Illinois statute, which has just 
taken effect, authorizing a referendum in each county upon the establishment 
of a county consumptives' hospital, under a special board to he created for 
this purpose. The practical operation of this statute should be studied with 
the greatest care by all other states. 

5, Hotne Care. — Unfortunately home care for many consumptives is, and 
will long be, inevitable. I regard it as in most cases a necessary evil. As 
I read the reports of home care of consumptives, as carried on in various local- 
ities and under various auspices, it seems to me almost imiformly to spell 
failure. Not that it is impossible for a consumptive to receive proper treat- 
ment at home and to protect the other members of the family. It is pomblSf 



• 



114 



SIXTH INTERNATIONAL CONGRESS ON TtTBERCULOSIS. 



but it Ib extremely improbable. The physical limitations of the home; the 
impossibility of escape from the cares and worries of home; the probability 
that charitable agencies, public and private, will fail to provide adequate 
relief in case of poverty; the difficulty of securing effective sanitary over- 
sight; the deplorable overcrowding that exists in even some of the smaller 
cities ; these and other ill-defined social facta make home care anything 
but a hopeful measure. 

So long as it is inevitable, however, we should make it as good as we can. 
The supervision of the attending physician, or in his absence of the local health 
official^ the organization of day classes, the establishment of day camps; 
all these mitigate the hardships of home treatment. Early provision should 
be made for thero, pending the larger opportunities (for which plans should 
be made at the same time) for increased hospital and sanatorium care. All 
these adjuncts to home treatment may properly be municipal f mictions, 
though the day class and the day camp lend themselves readily to private 
management and support and to cooperation with a general system of 
public supervision and control. 

6, Belief. — The absence of an elastic and adequate relief system for the 
families of consumptives has been one of the most serious obstacles in securing 
hospital care as well as adequate home care. In many instances, the relief, 
whether given by public officials or private agencieSf has been woefully in- 
adequate, being determined in amount and character too largely by the 
traditional fear of fostering pauperism, and too little by the modem knowl- 
edge of the exceptional requirements of the consumptive and of his family. 
Prompt, adequate, and considenite relief must be provided for the family of 
the incipient patient as well as of the advanced patient. If the incipient 
patient is to profit by hospital or sanatorium care, he must be able to rest 
assured that his family is well provided for. The sums of money required 
to provide really adequate relief for the families of consumptives is much 
greater than is commonly supposed, but is vastly less than the waste caused 
by our present neglect of consumptives and their families. It should not be 
necessarj' to organize new relief machinerj^ for the families of consumptives. 
Where public outdoor relief is given there is every reason for having the relief 
suited in amount and method of administration to the special circumstances 
of the consumptive and his family. Bacon and beans may be well enough 
as outdoor relief for the semi-vagrant or habitual pauper^ but can hardly be 
considered as a proper relief to be furnished by a municipality to a con- 
sumptive and his family. Besides radically revising relief as to form, amount, 
and method, there should also be a relief fund from which loans may be nmde 
in suitable cases to families who might hesitate to accept relief, but who 
would hope to be able at some subsequent date to return a loan. The all 
important thing is that the consumptive and his family shall have healthful 



A STATE AROUSED. — ^FOLKS. 



•lis 



liring quarters, adequate food of the right eort^ opportunity for rest, and 
proper medical treatment. All other relief consideration should be subordi- 
nate to these fundamental requirements, 

IL Pretention. 

We have thus far considered the control of tuberculosis through the treat- 
ment of patients. The e£Fective control of tuberculosis requires also a wide 
mnge of preventive effort, principally along three lines: 

L The protection of the faniDy of the known consumptive* 

2- The enlightenment of the largest possible number of persons in the 
community as to the nature of the disease and the method of its spread. 

3^ The building up of the general health of the community and the en- 
forcement of sanitary measures directly affecting the spread of tuberculosis. 

1. TreatTnent arid pretention go hand in hand in the household of the con- 
sumptive* Upon the attending physician rests a heavy burden of respon- 
eabiUty. To him primarily we must look for the instruction of the consump- 
tive aod his fellow househoklers, not once, but many times, as to these 
methods which they mmrt pursue in order to secure protection. The educable 
having been educated to the point of voluntary compliance with suitable 
precautions, the confirmed careless must l^e coerced. We must look to the 
local health officiala to see to it that the attending phy^clans actually per- 
form these duties, or in case of unwillingness or inability so to do, that they 
DOtify the health authorities, in order that the work may be done by them. 
We must look to the State department of health to see to it that the local 
boards of health perform these duties eiTectivelyj and it remains for voluntary 
associations of citizens to demand a high standard of efficiency on the part 
of State authorities, and to assist in creating public sentiment which will 
make possible the securing of suitable legislation of adequate appropriations 
and of effective administrative action on the part of the State. 

2. The enii^htenmeni of a vast number of persons in the various towns 
and rural communities as to the nature of the disease has been alluded to in 
the paper on an " Educational Campaign," It remains to be said here that 
this educational campaign must be a continuing one; a State will not stay 
arouaed if the arousing agency discontinues its efforts. The exhibits, leo- 
turas, distribution of literature, and preparation of articles for the press 
must be renewed from time to time. Line upon line, and precept upon pre- 
cept, the essential facts must be made a part of the social consciousness of 
the community until they become not simply a matter of mental perception, 
but have their full force in the intuitive shaping of conduct. 

3. General SanUary Precautions. — However widely we may scatter our 
literature^ send our exhibits, and otherwise extend our educational campaign, 



116 



SIXTH ENTERNATrONAL CONGEEB8 ON TUBERCULOSIS. 



the number of carelesa consumptives is so great that it seems likely that for 
some years to come every human being in the community will be exposed 
again and again to the Inroads of this disease. It is therefore of the utmost 
importance that, in addition to the measures addressed directly to the control 
of the transmisijion of the disease^ there should be added every possible effort 
for securing healthful conditions of hving, of recreation, and of work. Thia 
will be to some extent a matter of education of employ^, In larger degree the 
education of the employer, but to a still gi-eater extent, a matter of municipal 
or State regulation. It would l^e strictly pertinent and proper to include 
here, as a part of a working program for the prevention of tuberculosis, a 
wide range of effort, happily becoming wider and stronger in these days, for 
the promotion of public health by the Inspection of food supplies, by the 
regulation of the sale of drugs, narcotics and liquors, by preventing the erec- 
tion of houses which are inconsistent with healthful living, by securing cleanly 
conditions in factories and other places of employment, by preventing the 
breaking down of the physical energies by premature labor or by excessive 
hours of labor, by securing healthful conditiona in the public schools, by 
securing bealtlxful conditiona in churches, theatres, and all other places of 
public assemblage, by sanitary oversight of railway stations, street-cars, 
sleeping cars, and other means of transportation. All these and many 
related lines of work find their place in any comprehensive program for the 
prevention of tuberculosis. 

Who is equal to carrying on this comprehensive program? It is evident 
that no one agency^ public or private, will be sufficient to the task. The 
great weight of responsibility for administrative action and the heavy end 
of the financial burden must, and should be, borne by the municipality, 
acting principally through its health and charity officials, but, in order to 
make possible effective action on their part, there must be the strongest 
possible support by voluntary organizations of citizens. There should, 
therefore, be in each considerable center of population, and even in the most 
sparsely settled communities in each county, an organization of citizens 
formed for the prevention of tuberculosis. If there happen to be already 
in existence an organization whose field of work might naturally be extended 
to include this work, such as a public health association, a charity organiza- 
tion society, or aimiliar body, if it be virile, not too traditional, and com- 
mand the confidence of the people, it will doubtless be a saving of time 
and of administrative expense to look to this body to take up the prevention 
of tuberculosis as one of its activities. Usually this should be done through 
the appointment of a special committee, and that committee, if sufficiently 
representative and strong for its task, will not unlikely outweigh in impor- 
tance, influence, and financial requirements the parent oi^gani^tion* 



■ 



« 



A STATE AROUSED. — FOLKS. 



117 



If there be no such voluntaiy oi;ganization in existence, a locaJ society 
or committee on the prevention of tuberculoais^ with the widest possible 
bdsis of representation of the important elements of the community, must be 
formed. Above all, such a voluntary organization should be animated by 
^A spirit of cooperation with its local officials. No spirit of narrowness or 
[jealousy, no desire to take over to itself the duties which should be im- 
[pgaed upon the municipality, should find place in its councils. It should 
work in the spirit which for thirty-five years has animated the State Chari- 
ties Aid Association of New York in relation to public charitable administra- 
tion — that of not taking upon itself the duties which public officials should 
perform^ but of seeking, by everj' proper means of cooperation and support, 
to induce public officials to undei'take such duties, and to make it easier 
lor them to perform their duty in the most efficient manner. 

In a great State, however, there muat needs be some means of coordina- 
tion both of the work of local officials ancl of the work of local societies. 
The State departments of health are properly charged in some States, and 
should be m all, with the duty of suggestion, investigation, oversight, and, 
in extreme cases, of direction and control of the work of local officials. There 
are many things which a centralized State department can do to aid local 
officials without depriving them of a pro}>er degree of authority. 

Similarly, there should be a bond of union between the various local 
voluatarj'- as.sociations in each State* This again may mean the organiaa- 
tion of a State as-sociation for the prevention of tuberculosis if there be no 
existing society State-wide in its scope, and otherwise adapted to take up 
the work. If, as in the case of the State of New York outside of the city of 
New York, there is alreatly in exist-ence an organization, commanding public 
confidence, witiely organi5£e<l, experienced in the promotion of legislation 
and in inHuencing public administration, time and means will be conserved 
by utilizing its serv^ices. Such an organization, in our judgment, should 
not attempt to control, in any formal manner, the work of local agencies. 
It should rather endeavor to inspire them with a sense of comradeship in 
a State campaign, secure for them a certain uniformity of aim and of method, 
provide them with certain facilities which can more economically and 
advantageously be provided in large quantities, and afford to them opportuni- 
ties for intexchange of experience and for the inspiration which comes from 
personal contact. Local organizations gain enormously from perioiiical 
visitation by representatives of a parent central body* The bond must b© 
a voluntary onej that which rests most lightly is the moHt effective. 

To these factors, theUj we must look for the effective control of tu- 
berculosis in the smaller cities and communities of the State: local health 
officials, working under the supervision of a State health department; volun- 



118 



SIXTH INTERNATIONAL CONaREBfl ON TUBERCULOSia, 



tary associalioiiB, widely representative of local groups, working together^ 
through a voluntary State organkation. 

The program above set forth involves a very considerable exercise^ by the 
legislature and by local authorities, of the police power of the State^ and 
also very substantial appropriations from public trea-gurieSj both State and 
local. In the efforts thus far made to secure such public action, the cluef 
difficulty appears to be a certain skepticism on the part of the public official. 
He has the impression: 

Fi^rstly, that the task is one of impossible proportions; that the expense 
involved is so great that it is a matter, not of years, but of decades or genera- 
tions; andj secondly^ he is not convinced that if he accepts our advice and 
acts on our recommendations the desired results will be secured. 

As to the fii-st, we should have no serious difficulty in disabusing him 
of the impression that the campaign for the prevention of tuberculosis is 
impracticable by reason of its magnitude. Both on its educational side 
and in the actual care of consumptives our program is enthely feasible and 
workable. It is, in fact, much less difficult and much less expensive than 
many other movements which have been successfidly brought t^^ fniition. 
For instancCj the educational campaign is much leas difficult than the edu- 
cational campaign with which the country found itself face to face on the 
shortest of notice twelve years ago. It became necessary at that time to 
carry out an educational campaign, ns wide as the nation, involving the 
intricacies of the currency system, the wisdom of a double standard of value, 
the world's production of gold^ etc. Within a brief perioti of some four 
months, by public meetings, circulars, newspaper discussion, and in other 
ways^ a majority of citiKens accepted the view which now substantially 
all accept. A small fraction of the sum, expended in demonstrating the fal- 
lacy of sixteen to one, would finance a far more comprehensive educational 
campai^ on tuberculosis than has ever yet been outUned. 

The hospital care of consumptives is ordinarily regarded as involving 
impossible sums. This, however, is far from the case. If every consump- 
tive dyuig in the State of New York were given hospital care for the period 
of one year prior to his death, the number thus brought under care would be 
only about half of the present number of the insane supported at the public 
expense. Acceptmg as correct the estimate of the total number of con- 
sumptives in the State as made by the State Department of Health, if all 
these consumptives were cared for in sanatoriums or hospitals, the number 
of pubUc dependents would be increased less than 50 per cent. The ex- 
penditure thus involved would be, in fact, much less than other enterprises 
to which the State haa from time to time committed itself. Within the past 
decade the people of the State of New York, by popular vote, have committed 



A STATE AROUSED. — FOLKS. 119 

themselves to two projects involving a much larger expenditure; neither of 
which could compare for a moment in beneficial results with the prevention 
of tuberculosis. For good roads, the State and the localities have entered 
upon the expenditure of ten million dollars per annum. For the deepening 
of the Erie canal, the State has authorized the issue of bonds in the sum of 
$101,000,000. The adoption of each of these enterprises, as a matter of 
public policy, was secured by an organized agitation directed and maintained 
by interested groups of people. Who can doubt that an equal degree of in- 
terest and organization, on the part of those already concerned about the 
prevention of tuberculosis, could easily secure the needed funds and the 
needed legation? 

It can easily be demonstrated that there is no enterprise in which the 
public can engage, and public money be expended, comparable in the mag- 
nitude of its returns with the prevention of tuberculosis. 

As to the second factor, the skepticism of the average legislator as to 
whether the results will be secured if he accepts om- recommendations, 
I think it must be admitted we are somewhat at a loss for an adequate reply. 
So far as I have been able to understand the statistics of the decrease in mor- 
tality from tuberculosis, I have not been able to connect that decrease with 
the adoption of any specific measures for the care of consumptives or for 
educational work. This decrease seems rather to extend over a long period 
of time, and to be due to more general and far-reaching causes than those 
which have been consciously and purposely set in motion for the prevention 
of tuberculosa. If, indeed, we could point to some particular city in which 
we could trace a direct relation of cause and effect between specific measures 
entered upon for the prevention of tuberculosis and a considerable decrease 
in the mortality from that disease, our cause would be won. Nothing can 
withstand our campaign when once we are able to point to a positive demon- 
stration that the adoption of our program has led to a notable decrease in 
mortality. 



STANDARDIZATION OF INVESTIGATIONS. 
By John R. Commons, 

Uoiversit;^ of Wiwoofifl, Mndboa. 



It is now nearly thirty yearg since the first Bureau of Labor Statistics was 
created in tliis country. Thirty States and nearly all foreign countries, aa 
well aa our federal government, have followed the example of Massachusetts 
and have estahiished similar bureaus. Of the hundreds of reports issued by 
these bureaus in this country, it can scarcely be said that the number having 
substantial value is as large a^ the number that have no value. 

The States and the federal government have expended large sums of money 
In the collection of statistics of labor and industry, but it is within caution to 
say that much of this money has been wasted* Perhaps, under the circum- 
Btancesj thh could not have been avoided, but it is time to consider whether 
this waste is to go on. Giving due allowance to all criticisms, respecting 
politics, civil service, inefficiency, lack of codperation, disregard of uniformity^ 
and so on, it seems to me that the fundamental defect upon which all othei^ 
rest is an incorrect view of the purpose of a bureau of labor statistics. These 
bureaus were established to meet the demand of the labor element of the com- 
munity for facts and statistics with which to carry on their agitation. So- 
called *' friends of labor'' were placed in charge, and, naturally^ when employ- 
era discovered the trend of the bureaus, they used their influence to sub- 
stitute others. InefBciency, for purposes of scientific investigation, was, 
therefore, the result and even the object of the appointments. Where efficient 
men were appointed^ the bureaus were loaded down with aimless investiga- 
tions or routine statistics that required much of their time and money. This 
was the inevitable outcome of the idea that a bureau of labor should be an 
aid to ai^tation. 

Now that they have failed in agitation, perhaps we can take a different 
view of their purpose. I contend that, properly understood, the true purpose 
of a bureau of labor statbtics is to sej^e aa an aid to legislation. The legis- 
lature is called upon to enact social and labor legislation. Its members repre- 
sent all points of view and many conflicting interests- The bureau of labor 
should be their legislative reference department, where all members and com- 
mittees could have investigated and placed at their disposal all the legislation 

120 



STANDARDIZATION OF INVESTIGATIONS, — COMMOKS, 



121 



of other States and countries, all the results of that legislation, and all the 
industrial facts and conditions bearing npon the particular piece of le^lation 
in hand or proposed. Suuh a bureau would necessarily be in the position of an 
expert. It would not formulate policies, would not press reforms, would not 
ftptate, but would aid the lawmakers in exactly the same way that an account- 
ant or a gas engineer reports to his employer on the condition and value of a 
gas-plant under consideration for purchase. It would be an aid to legislation 
just as the engineer is an aid to business. 

Legislation at the present time is in woeful need of such expert advice. It 
needs exact knowledge, acientific comparisons, precise measurements of social 
fcM'ces and of the effects of legislation on those forces. Confronted by tech- 
nical and abstruse problems of workmen's insurance, eniployera' liability, 
Regulation of hours of labor, housing reformj and many others, the members 
[of the legislature are at the mercy of importunate Iobh}dst6 or political pre^ 
ware. They have no standards to guide their judgment or discfetion. More 
bewildered than the lawmakers of any other country, they are hedged about 
by supreme courts, with power to declare their efforts unconstitutional. The 
courts themselves are not provided with authentic official investigations of 
which they can take judicial knowledge in passing upon laws. This is seen 
in many of the recent decisions on acts regulating the hours of labor of men 
and women^ and in decisions declaring tenement-house laws unconstitutionalp 
Tlie courts acknowledge the right of the legislature, under the poUce power, 
to re^gulate the hours of labor or the construction of tenement-houses where 
health la at stake. But in drawing the line beyond wluch regulation ceases 
to be necessary in the intere^ of health, they are compelled to rely upon their 
own information, or what they call ^'common knowledge,'' and this may 
[toean tbeir own bias or the cleverness of lawyers in ma-rshaling or eliminating 
^evidence. A bureau of labor statistics that is truly an aid to legislation will 
fill the even more important office, under our constitutional system, of an aid 
to the judiciary — a much-needed expert "friend of the court." 

It ia^ however, evident that, in filling so important a position, the personnel 
of the bureau must be modified, lis problem is no longer the mere compila- 
tion of wage and industrial statistics; it is the field of public health. The 
•eourte, under our constitutional limitations, have greatly restricted the legis- 
latures in matters of wage regulation, so that investigations along that line 
are relatively of little value. But they have left the field wide open for 
the regulation of hours of labor and for the regulation of housing conditions 
in the interest of health. The bureau of labor, therefore, in becoming an 
aid to legislation, must become a buneau of experts in industrial hygiene. 
fThis evidently means that it is encroaching upon another branch of adminis- 
tration, namely, that occupied by State and municipal boards of health* 
But it is a field which boards of health have not covered. Only withia 



122 



SIXTH INTERNATIONAL CONGRESS ON TCEERCULGSIS. 



the past two years has thia overlapping of jurisdiction been recognized ia 
a practical way. 

The State of Massachusetts has provided for a number of sanitary factory 
inspectors under the health department of the State^ who insjxict the same 
factories as those covered by the State factory inspectors. The State of 
New York has approached the problem in a different way, and has added 
a medical expvert to the force of the factory inspection department. Evi- 
dently the problem b beginning to be appreciated, but there is no definitely 
accepted idea of the way in which it is to be met. 

I take it that the problem regarding State boards of health is similar to the 
one I have already mentioned regarding bureaus of labor. It is a question 
as to the purpose for which boards of health exist. At the present time the 
jurisdiction of State and national boards is practically limited to matters of 
epidemicity, contagioiif and quarantine. Outside this 6eUl the health of the 
people haa been left to personal initiative. With our theories of individualism 
and our ignorance of conditions, it seems simple and self-evident that if a per- 
Bon is weak in health, it is the fault of his parents, or his habits, or his doctor. 
The only remedy is the merciful caprice of natural selection and survival of 
the fittest. But the wonderful discoveries of the laboratory during the past 
few years are revolutionizing this view. These discoveries have revealed the 
hidden life of bacteria. As long as the mosquito could hide her microlie, 
malaria was a personal matter for quinin and the doctor, but when the mos- 
quito was found out, she became a matter of vital solicitude for govermnent 
through its boards of health. Every up-to-date community has abandonei.1 
its doctrines of indi\'iduali5m and natural selection, and has begun to treat 
malaria as a social problem of organization and police. 

More revolutionary still are the discoveries of the tubercle bacillus and 
the organism of malaria. These discoveries are bound to go to the very foun- 
dation of our beliefs, and to reconstruct our philosophy of government The 
malaria microbe flourishes in frontier communities, in suburban districts, 
and generally in neglected spots of the physical environment. By cleaning 
up this physical environment, the mosquito disappears, and the human 
being escapes the infection. The tuV»ercle bacillus, however, flourishes in 
the very heart of the social environment. There is, indeed, much debate 
among the medical fraternity as to the part played by contagion and the 
part played by environment, but tliis is only a question of degree and pro- 
portion. There is no question but that, along with contagion^ there are also 
the two great facts of social environment, namely, occupation and housing. 
These together surround and control nine-tenths of the life of the individual 
from birth to death. The only factor of importance b food, and this is largely 
A matter of wages derived from his occupation* It is occupation, housing, 
And food that furnish the seed-bed, the predisposing conditions^ that permit 



STANDARDIZATION OF INTISTIGATIONS*— COMMONS. 



123 



to take hold. Overwork, exhaustion, long hours of labor, tlark, 
dosiyi and crowded places in which to work and live — these are factors that 
boftrds of health must take into account in the fight against tuberculosis. 
But these are precisely the factors that bureaus of labor are dealing with. 
Nothing more need be added to show that, in one way or anotherj boards of 
health and bureaus of labor must cooperate. K the need of tliis cooperation 
has not been apparent heretofore, the tubercle bacillus now makes it 
apparent. This invisible plant drives boards of health into social and 
industrial problems. Cooperation of the two departments is the conclusion. 

The practical question is the method of this cooperation. Plainly, it 
cannot be by consolidation. Even should the two branches be united into 
one, there would still be fifty States and the federal government all working 
independently* Furthermore, the two branches overlap only in part, and a 
large part of their work still remains peculiar to each. It must be remem- 
bered, too, that there are thousands of local boards of health, and hundreds 
of private and voluntary associations, in many localities, and that there 
ought to be hundre<la more in all localities^ cooperating with these govern- 
mental agencies in social, industrial, and hygienic work. 

The greatest prog^-ess will always be made when thousands of individuals 
and bodies are working independently along similar lines. But tliis indejien- 
dence gives rise to the same problems tliat have arisen anrl been settled in 
Bome of the mechanical and engineering sciences. These are the problems of 
nomenclature and the standardization of units. The problem needs only to 
be stated in order to be appreciated. As soon as any science passes beyond 
the speculative and theoretic stage and becomes the basis of practical engineer- 
ing, the question of uniformity in its nomenclature and its units of investiga^ 
tion must be settled before anything further can be done. The social and 
hygienic sciences are just entering on this stage. It is a very significant fact 
that in two of the great departments of our work the matter of nomenclature 
has been taken up seriously within the past year. These are the nomencla- 
ture of diseases and that of occupations. The American Medical Association 
a committee on nomenrlafure, and when their work is finished and 
►ruught together iu a manual, it will be possible for State boards of health to 
promulgate the same, and thus to place vital statistics on a sound basis of 
uniformity liitherto unknown. The Census Office has begun t!ie long-needed 
work of establisliing uniformity In the names of occupations. Every econo- 
mist and statistician knows the hopeless confusion of our wage statistics 
through the enormous changes in division of labor which have been going 
on, and the failure of the old names to represent the new work. Now that 
industrial hygiene is a recognised field, it becomes just as e^ential that 
vital statistics be equipped with a nomenclature of diseases. 

Nomenclature, however^ La only half the problem; standardization of the 



< 



124 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



unite is the other half. A thousand cubic feet of gas seems like a simple unit 
of measurement^ but the great queaition of municipal versus private ownership 
b uncertain because the unit is not simple. It is a most complicated unit, 
depending for accuracy on standard measurements of nitrogen, hydrogen, 
sulphur^ temperature, moLsture^ rate of flow, pressure, and other elements. 
In the social and economic ficiences the units are even more complicated and 
elusive. To say nothing of the individual human being as an uncertain 
unit, there are the three great divisions of his environment that have not 
been standardised, namely, footi, occupation^ and housing. Food has l>een 
partly standardized, and the pure food laws have made the completion of 
the work necessary. Tenement-house and factory legislation have made it 
necessary to atandardize housing and oceupatiun. The hygienist is interested 
in these three factors from the standpoint of health. The economist ia inter- 
ested from the standpoint of comparative cost of living in different cities and 
countries. It is the first business of both to join together in arriving at 
fltandard units and methods of measurement that both can use. This is 
fundamental to any program of cooperation. 

I have ventured to lay before you a tentative scheme for standardizing 
the investigations of houidng contlitions. This, I t^elieve, is the simple.^ of 
all the units previously mentioned, and if it can be worked out, the others 
will follow. The model that 1 have taken is that which is employed in stand- 
ardizing and grading agricultural products, such as wheat, com, oats, butter, 
cheese, horses, cows, pigs, and so on. The problem is different in detail, but 
1 believe the method necessarily to be adopted is the same in principle. It 
turns on the fact that the unit to be measured is a complicated one, composed 
of many variable factors, and that no two individual investigators or exjierts 
attach the same weight to all the factors. On this account the method of 
measurement must be such that the margin of error shall be reducetl to a 
minimum^ 

To illustrate by means of the score-card used in the department of Animal 
Htisbandry of the University of Wisconsin : A draft horse, perfect in every 
particular, is represented by 100 potnt^s. Those are subdivided into a detailed 
and complete survey of the animal, involving 36 specifications. To each of 
these specifications is given a weight or value of from 1 to 10, corresponding 
to its proportionate importance in making up the perfect animah This 
weighing is arrived at by the consensus of opinion of experts throughout the 
country. Thus, the "general appearance" of the horse is given a weight of 
29 points, and tliis is subdivided into ** weight" 6 points, "'form" 4 points^ 
"quality" 6 points, '"action" 10 points, and *'tem[>erament, " 3 points; 
**head and neck*' are ^ven 8 points, subdivided into *'head," "forehead," 
"eyes/* "Mower jaw, " and **neck, "with one or two points each, and so on, 
each figure is the possible score or limit within which that particular spedE- 



8TANT>AEM£AT10N OF INVESTIGATIONS. — COMMONS, 



125 



cation on any particular animal shall be graded. These standard weights 
or values are printed in a column opposite each specificationj and a second 
or blank column is provided under the caption "point-s deficient/' In using 
the score-card the student or "scorer" goes over the horse, noticing in 
detail all the points specified, and then simply marks down opposite each 
his judgment of the degree to which the animal before him is deficient in 
that particular point. The total of all points deficient is then deducted 
from 100, and the result is the grade of the animal scored. 

Now, in applying this device to housing conditions, certain difficulties 
arise. The first is the presence of two different objects to be served. The 
economist has for his object the comparative cost of living, while the hygienist 
has for his object the conditions of health. Although both of these objects 
turn on the same analysis and list of specifications, the economist is likely to 
^ve a different weight or value to some of them from that given by the hy- 
gienist. A similar difficulty in scoring agricultural products Is met by provid- 
ing 3 different score-card for each breed or type of animal or grain, such as a 
score-card for draft horses, another for carriage horses, and so on* I l:>elieve 
this difficulty will have to be met in a different way in social investigations, 
because there should he only one score-card. But in order tosimplify the prob- 
lem at its present stage, I assume that the economist and the hygienist will 
agree on the points and their value, Furthermorej 1 assume that the hygien- 
ist, for practical purposes, concentrates his attention on tuberculosis as being 
the disease of environment par excellence, and epitomizing all other diseases 
springing from housing conditions. This score-card, therefore, is a card for 
valuing a house with reference tcj its predisposition toward tuberculosis. If 
the weighting can be agreed upon for this purpose, it will be a simple matter 
of calculation if desired to establish a different weighting for economie 
purpoaee. 

Closely connected with this difficulty is a second one, namely, that we are 
dealing with two parties to a transaction — the owner anil the occupant. 
Sometimes these are combined in one. Sometimes they are separate. Evi- 
dently in valuing the hygienic condition of a house it would be incorrect to 
cut it tlown where the tenant ami not the owner is at fault. For example, 
"congestion of occupancy" is a matter of much weight, but a household of 20 
Slavs or Italians might crowd into a house that only 5 Americans would 
consent to occupy* The hygienic condition would be much lower with the 
former than witli the latter class of tenants. On the other hand* the owner 
would doubtless profit greatly by congestion. A similar interaction occurs 
in the case of "structural condition" and "cleanliness," which may be due 
in part to the neglect of repairs by the owner and in part to the slovenliness 
of the tenant. 

Evidently the investigation must take the two sources of menace into 



126 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS, 



consideration, and one advantage of the score-card method lies in the fact 
that it requires him to do this, and to exercise his judgment in apportioning 
the weight of blame between owner and occupant. 1 have attempted to 
provide for this overlapping by separating the score-card into two parts, 
giving a weight of 100 points to those specifications tliat primarily dei>end 
on the owneTj and 100 points to those that proceed from the occupant. 
With this division it will be impossible for investigators to separate the two 
factors, or even to combine them in different proportions afterward, and thus 
to reach definite conclusions aa to whether legislation should bear upon the 
owners or the tenants. 

Other points of significance will come out in examining the proposed 
score-card, I do not pretend that in offering this as a method of standard- 
izing our investigations I am proposing something that is simple and offhand. 
The subject matter is itself complicated* The real question is whether it ia 
worth while to bring our science to a basis of measurement as exact as possible. 
Any one who consults the standard work of John A. Craig on '* Judging Live 
Stock" * will see at once that our problem is no more complicated than it is 
in the case of animals. 

There is, however, a central point of technic which, if attended to, will 
simplify the uee of the card. Each specification is supposed to represent a 
perfect condition with reference to the object In view. The investigator must, 
therefore, acquaint liiniaelf with the ideal condition of each feature of the house 
as a protection against tuberculosis* In the words of Mr. Craig, f speaking of 
live stock: "To formulate an ideal is absolutely essential^ and in doing this it 
is imperative to familiarize one's self with the good qualities of animal life, 
correct conformation, and the highest types, so that the least variation from 
these at once attracts the attention. When a distinct ideal, based on the 
best types and their highest qualities, has been formed in the mind, and this 
is supi>orted by a discriminating eye, it is but another st^p to render a correct 
judgment" 

Surely ttiis much at least can be claimed for the score-card method — that 
it systematizes our observations and trains our powers of discrimination. If 
it were made a basis of instruction in our schools of medicine and sociology^ in 
our training-schools for chanty organization workers, in the field work of 
bureaus of labor and boards of health, there would remmn but a few years 
until a generation of exact investigators of social conditions would be upon 
the ground ready for the progressive work of the future. 

I think^ also, it would stimulate investigations throughout the country 
in localities that have not the advantage of trained instruction. The fact 
that the score-card b available, with its specifications of the things to be 

* Published by the author, Texas Agriculture and Mechanical College, AujjtiQ, Texaa^ 
t "Judging Live Stocky" intfoduction. 



STANDARDIZATION OP INVESTIGATIONS. — COMMONS. 127 

looked for, with its valuation of each specification according to the consensus 
of experts, and with its ideal standards, would of itself be enough to encour- 
age individuals and associations to use it. They would recognize that, 
however amateuiish and untrained their work, they could not get far out of 
the way because the margin of error has previously been reduced to narrow 
limits. With investigators throughout the world using the same instrument, 
they would feel themselves a part of a grand scientific and humanitarian 
movement, and would have the satisfaction of making a relatively exact 
comparison of their own local conditions with those of other places. 

Other advantages and possibilities will occur to the statistician, the econ- 
omist, or the hy^enist who has struggled with the incomparability of our 
investigations and statistics. It is my intention to submit the annexed 
tentative draft of the score-card to experts in various lines — ^to physicians, 
architects, real-estate dealers, engineers, to instructors in economics and 
hygiene, to charity organization societies, tenement-house commissions, and 
other associations, in the hope that by many tests and trials in actual field 
work its technic may be perfected, and that, by the consensus of opinion of 
experts, the relative weights of the factors specified may be corrected. If 
this could be done in a more authoritative way by this tuberculosis congress 
or other scientific medical and sociologic bodies, so that eventually an ofiicial 
score-card for both the hygienic condition and the cost of housing could 
be worked out, the advantage would be apparent. We should then have not 
only an authentic basis for the cooperation of bureaus of labor and boards of 
health, but should take a forward step toward carrying sociology out of the 
speculative into the exact sciences. 

DWELLING-HOUSE SCORE-CARD. 

Applies to a single Family or Household. 

State City Street No 

Name of Owner Name of Occupant 

Name of Investigator Date 

Instructions for Discrediting when Depending on Judgment. 

Deduct from possible 6; very slight, 1; slight, 2; marked,3; very marked,4; extreme, 5. 
Deduct from possible 3; very slight, i; slight, 1; marked, Ij; very marked, 2; ex- 
treme, 2§. 

I.— Dwelling— 100 Points. „ble Defi- g^*"- 



Location— 18 Points. (18) ( ) ( ) 

1. General Character of Neighborhood, villa, farm, residence, 

park. (Discredit for factory, slum, neglected district.) . . 

2. Elevation, high ground, sloping away on all sides 

3. Condition of Street, width (ft.)- ■ - ., clean, smooth, hard, 

free from dust, sprinkled, flushed, free from refuse, 
(Indicatewhetherasphalt, block 8tone,macadun, cobble, 
wood, dirt.) 



POBSI- 


POINTB 


BLB 


Defi- 


Score. 


CIENT. 


(18) 


( ) 


3 




3 


•• 


3 





12S 



SDCTH INTERNATIONAL COKGHESB ON TUBERCULOBIS. 



I.— Dwelling— 100 Poijfrs. 



4. Smoke, fr^ (tdid (indicate source} 

6. Odors, free rroro nauseous (mdicate source)..,.. ....... 

6» DuJit, free from (indicate* source) . . . . » ■ 

CoNQESTioN OF BuiLDtNOB — 26 Points. 

7. Charnctcr of Duifliinga — 10 PointB. 

Detached ..*,,..,...,*.*...,<■ 

Attached, separate entraDce, discredit 1 point. 
Attached, common eiitmncp, discredit 2 point*. 
Flat (entire floor), diacrcdit 3 points. 
Apartment (2 or more on wmie floor), discredit 4 points 
Basement (over | above street lovel), discredit 5 points 
Cellar (over ) below strwt level), discredit 6 points. 
Additional diecredit^ for flat or apartment without elevator, 
2d floor 2 points, 3d floor 3 points, etc 

8. Sunlight— m Paints. 
Height and distance of next building (u£:e foot of its own 

window in case of flat or apartment, otherwise foot of 
lower window, tis base line above which to measure 
height of next building). 
Directtan, Hfcij[hc, DifitAficie« Per C^dU 

(Iijd, ^Lrvel or aUey) (feet) (fmt> <Hei«ht - 100) 

North 

Bouth. 

East 

Woat. - ^. 

(If diatanee ecixials or exceeds height, no points deficient — 
distance is leas than height, actual score is aame per cent, 
of iKJssible score as distance to height, e. g,^ if distance 
=20% of height, actual acore=20% of possible aeore, 
etc.) 
Window OPENiNoa — 11 Pointa. 



Rgonu. 
(IiHliemla hJU 
cheb, alMp- 
ibf , bftth, etc.} 

1 , 

2 ,, 



Window 

Space- 

(flQ. Ft.) 



Floor 
Space. 

{Sq. Ft,) 



Per eent^ 
Window Spnco. 
(Floor Spaeo- 

lotfS 



4 

5 

6,,.... ...,, 

Total 

Number of Roomfi (including dark rooms) 
ha^'ing window space less than 20% 

Per cent, of same to total rooms . . . 
Number of Dark Uooraa , , , . . 

Per cent, of same to total rooma . . 



9. Total Window Space, not less than 20% of total Floor apace. 

(Discredit \ point for each deficiency of 1%, e. g,, window 

apace 16% of floor space, discredit 1 point, leaving actual 

score 4.) 

Diitribuium of Wiiidow Space — 6 Pointa. 

10. DcfkietU Rooma^ no room less than 20% 

(Discredit same per cent, of po^ible score a& per cent, of 



POMJ- 

BLE 
SCOBX. 



3 
3 
3 

(26) 

10 



ACTUHi 



( ) ( ) 



STANDARDIZATION OF INVESTIGATIONS. — COMMONS. 



129 



L— DwxLLma — 100 Points. 



rooms having windov space less 20 per cent., e. g.j 6 
room house, 2 rooms deficient, discredit i of 3 — 1, leaving 
actual score 2.) 

11. Dark Roonu, no room without window openings 

(Discredit same per cent, of possible score as per cent, of 
dark rooms, e, g,, 6 room house, 1 dark room, discredit | 
of 3=^, leaving actual score 2).) 
Notice: daik room is discredit«Kl also above as "deficient 
room." 
Air and Vkntii.ation — 13 Points. 

12. Heating Arrangeynents, adapted to secure circulation of fresh 

air, such as open fire-place, hot air furnace, stove (con 

nectin|; directly with cnimney in same room) 

(Discredit 1 point for steam or hot water, ^ point for each 
stove connecting with chimney in another room.) 

13. Temperature, adapted to secure even temperature, not 

excessive heat or cold, equal in different rooms 

(Discredit proportionately for each room without heating 
appliance.) 

14. Dampn^, freedom from (indicate whether cellar, kitchen, 

sleeping rooms, other rooms) 

STRncTUBAL CONDITION — 6 Points. 

15. McUerial (indicate whetherwood, brick, stone, concrete), no 

decayed wood, walls, floors, ceilings in ffxm condition . . . 
(Discredit J point for papered walls or ceilings.) 

Sixe of Rooms, height of ceiling, not less than 9 feet 

(Discredit \ point for each foot deficient.) 

17. Floor Space (no room less than 120 sq. ft.) 

(Discredit proportionately for each room less than 120 sq. 
ft.) 
HouBX AppuRTENANCsa — 26 Points. 

(Discredit total score in each case if appurtenance not pro- 
vided.) 

18. Bath 

(Discredit 2 points for common bath.) 

19. Closet in dwelling 

(Discredit 1 point for common closet, 2 for outhouse, with 
sewer connection, 3 without sewer.) 

20. Sink 

(Discredit j for common sink.) 

21. Laundry 

(Discredit J for common laundry.) 

22. Running toater in house 

(Discredit 1 point for common hydrant, 2 for hydrant out- 
side, 3 for well outside.) 

23. Condition of Appurtanances, good material and workman- 

ship, all pipes exposed 

24. Quality of water for drinking 

25. Quality of toater for bath and laundry 

DwEUjNa Total 



Poasi- 

BLB 
SCOHE. 



16. 



Cost of Housma, 

Rent per month % Rental value (if occupied by owner)$ . 

Unit of Comparison Nominal Rent Real Rent 

Rent per room S $ 

Rent per 100 sq. ft $ $ 

Rent per 1000 cu, ft $ $ 

Probable income of family per month $ 



(13) 



Points 
Defi- 

CIKNT. 



6 
(6) 



(26) 



6 

3 

3 

100 



( ) 



ACTUAI. 
SCORI. 



( ) 



( ) 



( ) 



( ) 



( ) 



VOL. Ill — 



130 



SIXTH DTTERNATIONAL CONGRESS ON TUnERCULOSlS. 



n. — OCCUPANTB — 100 POIWTS. 



CONOESTTON OP OcCUPANCT— 61 PoUltfi. 

OocupaTtlHf number. 

Family, 10 years oM and over, male. ♦ ^ 

Familjj 10 yftam oM and over, female 

Lodgera, DDincstiea, 10 years old and over, male *..*».., . 

LodgerSf Doniestica, 10 yeaaiB old find over, femaie 

Children under 10 years 

Total (child under 10 aa ^ pei^an). 
I. Cttbic Air Space (average height of ceiling by total floor 

Rpftce eu. ft.) 

Cu. ft- per oee«r>ant* . . * , *No discredit if 1000 or over . . 
(Oij^crodit 1 point for each 20 ft. below 1000, t. tj., 000 cu 
ft. discredit 20 points, leaving actual score 30.) 
2,. Sleeping liofim^ pa- occupani .....,*.,.....,.,...*....., 
(Discredit 1 point for each person in excess of number 
flleepintf mom.s-) 

CONDmoV OF AlK AND VlJNTILATION — IS Poillts. 

Wirv^^>w8^ kept open to fresh air, 

3. Living rooma. ....,«.* ..,,.,,.....,,.. 

4. Sleeping rooms 

5- Temperature, kept e%'en, not exceseivo heat or cold ..,.,., 
6. Du9tt care in avoiding dust by aweeping, no home work.ibop 

OLErtJtLtNX^, c^ro and attention, no rubbii^h, dirt^ grease or 
rpfuse — 21 Points^ 

7« HtUlwajfs , , 

8- Floors , 

9, WtOla,,.,.., .,....., 

10. Plumbing. 

11. Yard 

OccupjJTTS Total, ......,, , .. 

Rent per occupant, nomiuaJ........ . . . .$ 

Real rent p*?r oceupant (coropured with standard) ...,,,.,,.. 



POBU- 

BUk 
SOQKK. 



(61) 



50 



11 



(18) 

3 
6 
3 
ft 

'C21) 
3 
3 
3 

e 

G 
100 



PonriH 
Dsn- 



( ) 



( ) 



( ) 



ACTUAl. 

Boons. 



( ) 



C ) 



( ) 



La Nonna de las Investigaciones. — (Commons.) 
Lo6 trabajos de las Mesas de Estadfsttca de Obreros y los Departamento dc 
Salad, han empesado, necesariamente 6. tener un contacto comuD. 

La tuberculosis es por exelencia la enfermedad de las condiciones sociales, 
incluyendo alimentoa, habitacionca y ocupaciones. Estd es la enfermedad 
que trae en cooperaci6n la mesa de los obreros con ia mesa de &alud< Esto no 
puede lievarse a efecto sin tener una unifornddad en la nomenclatura de las 
enfermetlmles y las ocupaciones. N'osotros debemos tambi^n croer una norma 
unitaria en las bivesti^afionea dc los hop;are3j los alimentos y las ocupaciones. 
Este tipo de unidad puedo rcgularse por medio del uso de las tarjetas de niar- 
cas empleadaa en el criterio de iinimales, en los granoa y lo3 protiuctos de la 
agricultura, Estas tarjetas analizan los varios puntoa de un animal, y da un 
valor 6 importancia A cada punto. El investigador entonccs condena &, el 
ammal de acuerdo d los puntos, y el total da el grade comparado con la norma 
6 unidad establecida. La adopcidn dc este ni^todo en la iiivcstigaci6n de las 



STANDARDIZATION OP INVESTIGATIONS. — COMMONS. 131 

casas, tanto para la sociologfa como significan los modelos de unidad 6 norma 
en lo6 diferentes ramos de la ingenierfa fisica y qulmica. 



Etablissement d'un Systeme d'Unit^ pour les Enqufites — (CoBiMONS.) 
Le travail des Bureaux des Statistiques de Travail et des Conseils de Sant^ 
a commence n^cessairement ^ se recouvrir. 

La tuberciilose est par excellence la maladie de milieu social, comprenant 
nouniture, logement et emploi. C'est cette maladie qui pousse les bureaux de 
trav^ et les conseils de sant^ d co6p6rer. On ne peut pas accomplir ceci sans 
avoir runiformit^ dans la nomenclature des maladies, et des occupations. 
Nous devons aussi nous entendre sur un systeme d'unitfe de mesurements 
pour investiguer les logements, la nourriture etles emplois. On peut 6tablir 
ces unit^ en adoptant la carte de registre employ^ pour classer le b6tail, les 
grains et les produits d'agriculture. La carte analyse les diff^rentes parties 
d 'un animal et donne une valeur ou un poids k chaque partie. Alors Tin- 
vestigateur critique Tanimal sur chaque point, et le total foumit le degr6 de 
quality compart avec le parfait ou Tunit^ module. En adoptant cette m^thode 
pour les examens des logements, nous obtiendrons pour la sociologie le mSme 
r^sultat que T^tablissement d'un systeme d'unit^ a obtenu pour les diff^rentes 
branches de la physique et de la chimie. 



tjber eine Normaleinheitlichkeit bei Untersuchungen. — (Commons.) 
Die Tuber kulose ist eine Krankheit der socialen Umgebimg par excellence; 
dies hat Bezug auf Nahrung, Wohnung und Beschaftigung. Sie bt die Krank- 
heit, welche die oben genannten Verwaltungen zu einer gemeinschaftlichen 
Thatigkeit veranlasst. Dieses gemeinschaftlicbe Vorgehen kann aber nicht 
stattfinden ohne dass wir eine einheitliche Nomenclatur fiir Krankheiten und 
Bescbaftigungen besitzen. Wir miissen uns auch uber Normal-Einheiten fiir 
Untersuchungen von Nahrungs-, Wohnungs- und Beschaftigungsverhaltnisse 
einigen. Solche Einheiten konnen zu normalen gemacht werden, wenn wir 
Bezeichnungs-Karten, wie solche zur Sortirung von lebendem Vieh, Getreide, 
und landwirthschaftlicher Producte gebraucht werden, benutzen. In diesen 
Karten werden verschiedene Punkte in Bezug auf ein Thier angegeben, und 
fiir jeden Punkt eine bestimmte Wert-Einheit festgesetzt. Der Untersuchen- 
de sch&tzt nun jeden einzelnen Punkt am gegebenen Thier ab, und das 
Gesammtergebniss bezeichnet den Wert-Grad desselben, im Vergleiche 
mit der angenommenen vollkommenen oder idealen Einheit. Wenn wir 
diese Methode bei Untersuchungen der Wohnungsverhaltnisse anwenden, 
konnen wir ebensoviel fiir die Soziologie thun wie die Einfiihrung von 
Normalwerten gethan hat fiir die verschiedenen Zwdge der Physik und 
Chemie im Ingenieurfache. 



THE RANSOM OF A GREAT CITY, 
Talcott WelliamSj LL.D. 



The ultimate disappearance and extirpation of tuberculosis exactly aa 
leprosy has disappeared in the past is the final goal to which this congress 
tends. 

Encouragement exists in the decrease of the relative death-rate from 
consumption; but while in Philadelphia the deaths from this cause per 
1000 living have in twenty years relatively fallen one-half, the absolute aggre- 
gate of those dying has remained at about 3000 for twenty years to 1906, 
A reduction in 1907, a year of great prosperity, may or may not prove 
permanent. The average of twenty years shows that while the disease 
decreases in the general community, the growth of want, povertyj and wast^ 
ing disea^ supply it with material to maintain the total of deaths, though 
they are a decreasing share of all deaths. While infection remains, deaths 
will continue in the less fortunate share of society. The infection must 
itself be removed. A city should be held as responsible for suppressing 
preventlble diaease as for keepbg its roads in repair. Its taxable property 
owes as great a duty to the preservation of health as of order, 

Pliiladelphia has to-day about 3000 deaths a year from tuberculo^, 
reduced in 1907. This represents, taking current reports of cases, in the 
opinion of the Health Bureau, 10,000 consumptive persons. Of these, 
3000 will die in a year. Those dying in a year and the 1000 dying four 
months after, 4000 In all, are in a condition needing expert care. The 
ransom of the city calls therefore for hospitals or sanatorium provision for 
4000 in the last stages, and watch and supervision over 6000 more, providing 
food and directions to prevent infecting others. 

The hospitals of Philadelphia have 1500 bed capacity unused. Hospital 
provision for 2500 more would coat in these days of concrete not over $1,250,- 
000. The maintenance of 4000 consumptives certain to die in two years 
and a peril to all about them would cost at the average hospital rate of one 
dollar a day $1,460,000 ammally. The care, food, and superv'ision of the 
remaining 6000 cases^ still, would be about $600,000 a year» ^ving them 
doctors, visiting nurse^ and food. For hospital construction of $1,250,000 
and a yearly expenditure of $2,000,000 Philadelphia could extirpate iiifeo 
tioa and with a law imposing cumulative penalties for failure to report 

132 



THE RANSOM OF A GREAT aTY.— WILLIAMS. 133 

could, in ten years, reduce deaths solely to the cases coming from 
without. This is a small sum to pay for the ransom of a great city, the 
saving of 3000 lives a year, and the removal of a daily peril, yearly sla3ring 
individuals, destro3dng families, and working wide evil. 

The annual cost would be two-thirds the cost of the police, a third the 
cost of schools, and but twice the increase made in the city salary list in 
1907. Extirpation at this cost may be a dream; but unless we dream 
seriously, we shall not act wisely, for the vision will not be ours. 

DISCUSSION. 

Mb. Walter E. Kruesi, Boston, said: 

Mr. Williams has given us a valuable basis of estimate of the extent to 
which we are now meeting our public responsibilites for the relief and control 
of tuberculosis. The city of Boston is spending approximately $300,000 
from the public treasury annually. According to his estimates, it would be 
economy to spend three times this amount per year for the next ten years, 
after which time it seems probable that the amount could be decreased. I 
was particularly interested in the point which he made about the present idle- 
ness of a very large number of beds in hospitals, originally planned for other 
purposes, which might and should be used for tuberculous patients. If 
there were not so much unreasonable prejudice against tuberculous patients, 
and so much unfoimded fear of them as controlled in the hospital, we could 
have these idle beds put to use, and so make oiu: whole system of care of the 
sick more economical. What he says in regard to the idleness of such beds 
in Philadelphia is true in about the same proportion in nearly every other 
dty in the country. 

Some of the burden of expense which he has estimated must continue to 
be borne by private charitable funds. This is especially true of the relief 
involved for patients or their families. I urge favorable consideration on the 
part of all communities of the Chirstmas goodwill stamp as developed last 
year in Delaware, where, I understand, it netted an income of 810,000. It 
has proven a splendid revenue getter in the Sweden campaign, where $18,000 
is raised each year through the sale of such stamps. I have had considerable 
experience in the financial work of different charities, and can see no objec- 
tion to this method of raising money. There is great and well recognized 
need of such a safe and economically accounted-for system of collecting 
voluntary goodwill subscriptions in small amounts from people who cannot 
afford to join a subscription list. I believe it will supplant the objectionable 
"tag day" and perhaps the tambourine girl. 

Miss Emily P. Bissell, TOlmington, Del., asked leave to correct Mr. 
Eruesi's statement concerning the proceeds of the sale of Christmas stamps 
in Delaware in 1907. The amount realized was not $10,000, but only about 



134 SIXTH INTERNATIONAL CONGRESS OK TUBERCULOSIS. 

$3,000. The stamps were put on sale too late in the holiday season. They 
were issued by the Delaware Red Cross Society, and 400,000 were sold in 
Wilmington and Philadelphia in the course of three weeks. The fimd 
realized brought a tuberculosis exhibit to Wilmington and supplied a tuber- 
culosis nurse to visit for the dispensary during 1908. Eggs and milk were 
furnished to the destitute patients of the dispensary. One thousand dollars 
of the fund were set aside toward the purchase of a sanatorium site. 

This year, 1908, the Christmas stamp will be issued by the National Red 
Cross Society, and will be sold in every State for the benefit of the local 
camp^gn. 

The following persons participated in the general discussion of the program : 
Dr. Cressy L. Wilbur, Mrs. Townsend, Mr. Augustin Rey, Mr. W. E. Kruesi, 
Dr. John H. Pryor, Dr. N. P. Wood, Miss Emily P. Bissell, Dr. Munroe C. T. 
Love, Dr. Norman Bridge, Dr. A. Newsholme. 



SECTION V. 



Hygienic, Social, Industrial, and Economic Aspects 
of Tuberculosis {Continued), 



SECOND SESSION. 
ADVERSE INDUSTRIAL CONDITIONS. 
The incidence of tuberculosis according to occupation: overwork and nervous 
strain as factors in tuberculosis; effects of improvements in factory con- 
ditions on the health of employees; legitimate exercise of the police 
power in protecting the life and health of employees; industrial causes; 
hygienic safeguards. 



The second session of Section V was called to order by the President, 
Mr. Edward T. Devine, on Tuesday afternoon, September 29th, at half past 
two o'clock, in the New National Museum. 



THE INFLUENCE OF OVERWORK AND NERVOUS 
STRAIN IN TUBERCULOSIS. 

By George Dock, M.D., 

Ann Arbor, Miob. 



The general idea regarding these factors is that they are detrimental, 
and the general idea is correct, as we shall see; but in the struggle against 
tuberculosis it is necessary to know all details as thoroughly as possible, 
and so I shall enlarge upon the general statement. 

In order to understand why and how overwork and nervous strain are 
harmful we must understand: (o) The general nature of tuberculosis; (6) its 
effects on the body; (c) the possible modifying influences of overwork and 
nervous strain on those processes. 

The most frequent and most characteristic action of tuberculosis is its 
wasting effect on the body. This is well expressed in the popular names 

135 



13G 



BEKTH INTERNATIONAL COKQRESS ON TUBERCULOSIS. 



for the most usual form, consumption, or phthisis, not, as some imagine, 
from the wasting of the lungs by destructive processes, but on account of 
the general loss of tissue — the consumption or wasting. This is rarely 
absent, and often present very early. It is sometimes due to loss of appetite 
or disturbances of the stomach and bowels, and at others to fever. But none 
of these causes explains the emaciation accurately, and we find ourselves 
brought, by investigations that it is not necessary to ^ve in detail, to the 
concluaion that the toxic substances produced by the causes of the disease 
are most important. The cau.ses are not only specific, t, c, the Bacillus 
tuljerculosis, but also in all chronic cases inckide certain others, especially 
the pus-producing genna, and these, from their ubiquity and the lesions 
they produce, are of extreme importance. 

Another almost constant feature is loss of strength. This also may 
begin before the disease is well marked^ and as a result of specific poisons 
acting upon the muscles and nerves. Many persons are able to keep up a 
fair degitx; of work notwithstanding the loss of strength. Sadtler found 
among G70 dispen-sary patients 55.1 per cent, at work a year after the disease 
was tliscovered, and 46.6 per cent, after two years. This is due, however, to 
the well-known reserve force of the body, but many feel the loss of strength 
early and all feel it and show it before the disease is very far advanced. 
The mind also Is often affected, so that we Bee morbid irritability, loss 
of energ>', or depre^ion, and the remarkable contradictions of exaggerated 
hopefulness and hopeless loss of confidence and self-control, so powerful 
for good or ill in the outcome of the disease. Loss of memory and unusual 
tendency to mental fatigue are often added to the other psychic changes. 

It is obvious, then, that the tuberculous patient, at best, assumes the 
condition of an overworked person. Not infrequently ho is overworking 
with insufficient food, so that he cannot, if left to his own resources, regain 
the loss of tissue and nervous strength as he would if he had his usual 
margin of compensation, and the nutritive material to replace his waste. 

The effects of overwork and infection on the previously healthy body 
have l^een known for some time, having been demonstrated by artificially 
inoculating animals made to overwork, as in the classic experiments of 
Cbarrin and Roger. They found that if they made a number of animals over^ 
work on treadmills, the animals succumbed to pathogenic germs that were not 
80 dangerous for control animals not made to work. It has long been known 
to both human and veterinary pathologists that overworked persons or ani- 
mals are much more susceptible to infection than others. The effect upon 
soldiers, nurses, physicians^ and medical students is well known. Immune 
when in gooil condition, overwork puts them in a state susceptible to in- 
fections of various kinds. Comet has shown that a fallacy has entered into 
the statistics of tuberculosis in armies, so that the conditions there are not 



OVERWORK AND WEHVOUS STRAIN* — DOCK. 



137 



BO bad as has been supposed. But they are still bad, notwithstanding the 
many favorable factors m army Ufe, mcluding, even in couBtries with national 
armie&r a certain selection. 

We tannot so easily explain the rflle of nervous strain by esperiment-s, 
but we know, from too abundant observations, in hospitals as in ordinary 
life, how overwork and nen'ous strain, espeeialJy in the form of worry and 
care, are combined in the tuberculous patient. This is important not only 
in the production of the disease, as can be seen in many patients belonging 
to the working classes, but still more so in the course of the disease. We know 
that the disease is usually chronic, with a strong tendency, under favorable 
circumstaDc^* to recovery. But ^'favorable circumstances" have as their 
most important factors fresh air, rest, and proper food. The averagp 
tuberculosis patient cannot acquire these without some sacrifice, and often 
not at all, if left to his own efforts. Bardswell has made a vaJiiabla study 
of the consumptive workingraan. He shows that the conditions of life 
and work to which any consumptive returns after treatment are almost 
as important as any other factor in determining the subsequent history. 
He shows that the factors of suitable and at the same time remunerative 
employment are of cardinal importance. If the partly healed patient can- 
not earn an income adequate to meet his needs, his home conditions and diet 
both become unsatisfactory. Very often the alternatives are resumption 
of an unhealthy but remunerative occupation, with consequent relapse; or 
msufficient food, overwork and worry, and relapse. 

E\^dently, from the philanthropic standpoint, we often need to advise 
or rearrange methods of securing proper occupation for the partly healed 
tuberculous patient or the patient in the early stages. Besides this incen- 
tive, we must clearly realize that the present methods offer a hygienic and 
hnancial danger to the whole population. In order to keep the tuberculous 
patient at the highest point of efficiency, and make him least dangerous to 
others, causing further illness and expense in an ever-widening circle, he 
must be cared for when sick, or when overwork is inevitable. This demands 
a great increase of our hospital faciUties for the tuberculous. As a factor 
in the prevention of overwork and nervous strain, it is just as essential that' 
the family of the patient be so well cared for that he will take advantage of 
facilities for treatment and remain under treatment until his efficiency is 
raised to the highest possible point. Also, when well enough to work, he 
must be supplied with proper facilities for the nearest approach to a living 
wage. 

It may seem to some that these things do not come within the province 
of the tuberculosis problem, but this problem is & social as well m a 
medical one, and society must assist in solving it. I have not attempted 
U> show how this must be done, but merely to give, as brieHy as possible, 



13S SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 

the reasons wby overwork and nervous strain act harmfully upon the tuber- 
culous and why they should be reduced to the minimum. 



L'lnMueuce du Surmeoage et de ta Fatigue nerveuse sur la Tut>erculose. — 

(Dock.) 
Impre^on g^ntSrale concemant le surmenage et la fatigue nerveuse; 
raisons pourquoi ces facteurs ont une mauvaise influence; nature g^ndralc 
de la tuberculose; sea effets sur le corps; influences modlficatives des dits 
facteurs; donnt5es expt^rimentales et cliniques; experiences iir6es du servit'e 
militttire; la fatigue nerveuse et ses effets aur la nutrition; relation §troite 
des tourmcntg et des ehagrina avec !a capacity? de (ravailler et la puissance 
p^cuniaire des malades tuberculeux; importance de cea faits sur le prob- 
I6me gdn^ral du bolu des tuberculeux; le remade* 



Einfluss von kdrperlicher und geistiger Uberaostrengung auf die Tuberku- 

lose* — ^(DocK.) 
Allgemeiner Eindruck in Bezug auf die obengenannten Momontc. 
Griinde fiir ihre sthadJiohe Wirkung; daa allgemeine Wescn der Tuberku- 
lose; ihre Wirkung auf den Korper; die verandernden Einfliisiae von Vor- 
,^ngen, wie Uberanstrengung, etc; experinientelle und klinische Daten; 
Erfahningen im Heere; geistige Uberanstrengung und ilu^ Wirkungen auf 
Ernabrung; enge Besiehung von Sorgen und Scherereien auf die Arbeits- 
f&higkeit und finanzielle Kraft der Schwindsiichtigen; Wirkung dieser 
Tataachcn auf das allgemeine Problem der Pflege der Tuberkuiose; daa 
HeilmitteL 



Infiuencia del Trabaj6 Excisivo y Fatiga Kerviosa sobre la Tuberculosis. — 

(Dock,) 
Impre3l6n general resiiecto 6, los factores ante-dichos; razonea de su 
inHueticia deaf avoruble ; naturateza general de la tuberculosis, sus efectos 
ibre la eeonomfa; influencias modifiradoras de procesoa tales como el 
cxceso de trabajo etc; datos clfnicoa y experimentales; experiencia en el 
ej^rcito; fatiga nervioaay sus efectos sobre la nutrid6n; relacidn imraediata 
laft andedades y fatiga a la dcapaciad para el trabajo y abilidad Enanciera 
le loB pacientes tuberculosos; relac.i6n de 6atoB hecho@ al problema general 
del cuido de loe pacientes tuberculoses. El lemedio. 



THE "PIECE-WORK" SYSTEM AS A FACTOR IN THE 
TUBERCULOSIS OF WAGE-WORKERS. 

By Jane Addams and Alice Hamilton, M.D., 

Hull House. 



It has been shown that excessive bodily effort lowers the resistance to in- 
fection, and that, in consequence, great fatigue must be regarded as one of 
the predisposing causes of tuberculous disease. 

There are at the present time many kinds of factory and household work 
carried on by women which require great muscular effort and are injuriously 
fatiguing, but the women who are employed under the so-called " piece-work" 
system probably suffer, on the whole, the greatest degree of fatigue, because 
the pressure under which they work is so great. It occurred to us, during the 
last summer, that it would be worth while to study the effects of this system 
on factory girls, by inducing them to submit to certain physiological tests 
which are used to determine the degree of fatigue, and then to compare the 
results with those obtained from girls who were working at a normal rate of 
speed. 

"Piece-workers" are paid according to the amount of work accomplished, 
and not by the day. As a rule, in factories where this system is in force, a 
day's rapid work earns an ordinary day's wage, but a very active or skilful 
worker can do more than the standard amount, whereas a slow, awkward 
girl must exert herself to the utmost not to fall below it. There is thus an 
enormous incentive to rapid work under this sj^stem, and the effect is 
especially clear in the case of girls and women, for, as is well known, they 
are more reckless of their health than men are. 

The speed attained by girls doing "piece-work" is often amazing, and is 
usually at the expense of the girls' health. In some factories the nervous 
strain of such rapid work is increased by the use of dangerous machinery, for 
the girl's attention must then be given not only to maintaining her speed, but 
to protection of her hands or eyes as well. In this way it comes about that 
factories which have ample light, space, and air, and which are free from dust 
and poisonous substances, may, nevertheless, have a high tuberculous rate, 
simply because of the "speeding up"— the excessive fatigue — of the work- 
ers. Girls who work each day to the very limit of their strength cannot fully 

139 



I to 



SIXTH INTESNATIONAL CONGRESS ON TUBEKCUIX)8IB, 



rocuiiorate flunng the night, and are therefore constantly in a condition of 
lowctmiJ resisUinc!e to tuberculous infection. 

Wu ohL>30 as subjects of our study four trades, two of them light and not 
oxhuuHting except for the speed rcquired,-*the paper-box makers and the 
glovo-uiakerSf — and two heavier, — the overall-makers and core-makers. 
TU'tti Hummer waa not altogether favorable for such an investigation, because 
riiortt factoriea were working short time — four and a half days or lesa. Still 
the ^irls in some places were showing the eEfects of exhaustion as much as, or 
ovmi more than, when working full time, for they were speeding madly in the 
effort Ut apiiroxiinate their usual wages. Some girls told us that they worked 
witJi a tl()<;k iwttido them^ and tried each day to break their record of the day 
liuforc at a given hour. 

It wan emy to convince ourselves of the fact that the " piece-work " system 
on il IM UMUalJy carried on h the cause of very great fatigue in girls, but we 
failed to secure sdeutific proof, as we had hoped to do* The machine which 
wo wore advised to use, the allograph, which La in use in physiologic labora- 
tiirUiHj failed to give logical and consistent results, 

Kvidinitly the scientific testing of chronic fatigue is a complicated matter. 
The wciarineas of one day extends over to the following day, so that the worker 
d*K^ tiot Imgin the morning in a normal condition, but with a sluggish circula- 
titm and a great disinclination to effort. After an hour or so s!ie *'get3 into 
fcliw Hwing/' her circulation m more active, she begins to work more easily. 
1*hrMi ooruDfl usually a second perifxl of depression, which may last to the end 
of the day, but is often followed by a second burst of activity — ^when the girl 
iiOOH tliat the day is almost over and "apurta" for the last hour or two. Some 
girln ihichtrn thiit the morning b the hardest time; others, the hours from two 
U> f*mr ill the afternoon. 

A well-planned aeriea of tests appHed to a group of "piece-workers" and 
to an oqual uiiinljcr of women employed in work of the same character, but 
without the oxcessivo speed, would, we f^l convinced, show that "piece- 
wnr'k" U far more exhausting than work done at the natural rate of speed. 
And, hliico exccsHive fatigue lowers the resistance to infection, the ''piece- 
work " nynleni ilh it is now carried on undeniably plays a part in the tubercu- 
Uwiitdf factory workers. 



TUBERCULOSIS AS AN INDUSTRIAL DISEASE. 
By FaEDEHicK L. Hoffman, 

Newvk, N, J. 



Tuberculosis as an industrial disease demands the most careful consider- 
ation of all who, by individual or associated efforts, work toward the end 
that the frequency of its occurrence among wage-earners may be reduced to 
a miniiQum. It is- a significant fact that industrial dbeases in general, 
and hbroid phthisis in particular^ are at last attracting attention as social 
and economic problems demanding practical solution. The most su^estive 
evidence in this direction is the extended consideration that haa been ^ven 
to the subject of LDdustrial diseases in England, where the results of a 
parliamentary investigation have recently been publiHhed in connection 
with proposed amendments to the Workmen's Compensation Act of 1906. 
The publication of the report and the accorapanjing evidence mark the 
beg;inning of a new era in industrial hygiene and social reform, in that, for 
the first time, the financial responsibility of employers of labor for diseases 
resulting from health-injurioua occupations is established aa a definite legal 
principle, and employers' liability or workmen's compensation law. 

It is true that the question stili remains open whether fibrt>id phthisb, 
aa distinguished from tuberculous disease generally, is a specific trade 
disease, but the evidence submitted by the committee goes far to sustain 
this point- The committee very properly point out at the outset of their 
discussion that — 

"Many diseases may be regarded as trade diseases, and rightly so re- 
ganied, because they are known to be specially prevalent among the workers 
in particular Industries; but they may not be specific to the trade, since 
they may frequently, although more seldom, attack persons engaged in 
other occupations. Bronchitis, for example, is a trade disease among flax- 
workers: a larger proportion of that class suffer from it than of other i^eople; 
but it is not specific to the employment, for numbers of persona who are 
not flax-workeiB contract it ako. Unless there is some symptom which 
differentiates the bronchitis due to dust from the ordinary type, it is clearly 
impracticable to include it as a subject of compensation; for no one can 
tell, in any individual case, whether the flax-w^orker with bronchitis was 
one of the hundreds of persons in the town whose bronchitis ha<I no connec- 
tion with dust irritation, or whether he was one of the additional tens or 

141 



142 



SDTTH INTERNATIONAL CONGRESS ON TtnJERCUW>SI3, 



scores of persons whose illness was due to that cnuse. To ask & court of 
law to decide wouJd be to lay upon it an impossible task. If the workman 
were required to prove his case, he might be able to show that a larger 
percentage of his trade suffered from bronchitis than of the rest of the popu- 
lation, but he could never show that he Kimsolf was a unit in the excess, 
and not in the normal part, of that percentage, If it were the employer 
who was required to disprove a claim, he could rarely, if ever, show that 
the workman did not contract the illness through his employment, and be 
would be compelled to compensate not only those laborers whose bronchitia. 
had a trade originj but also all those whose bronchitis was in no degree an 
industrial disease. We gather from the debates in Parliament that it was a 
recognition of this necessity of some means of deciding in individual cases 
whether or not the disease was due to the employment which decided the 
Ivegislature not to open the door to claims from workmen suffering from uny 
disease, as the door is open to claims on the score of any accident, but to 
proceed by way of scheduling those diseases which can, in any given case, be 
differentiated as due to the special conditions of a trade/' 

Frequency in Dusty Trades. — The committee recognized that tuberculosis, 
being a widely prevalent disease, lis inclusion within the operation of the 
Acts would not be warranted unless specific e\idence could be produced 
that tuberculosis has directly resulted from the employment, and evidence 
to this effect would be extremely difficult to obtain, for there is no disease 
more witlcly prevalent among all classes than tul>ercuIosis, while at the 
same time the statistical and other evitlence is overwhelming that certain 
trades decidedly predispose to a much higher degree of frequency in the 
occurrence of tuberculosis than in other employments where the surrounding 
oonditions are decidedly more favorable. This applies in particular to the 
80-called '* dusty trades," and it is the object of the present discussion to 
emphasize the employments in which a high degree of frequency in tubercu- 
losis occurrence is coincident with the generation and continuous inhalation 
of large quantities of health-injurious dust of all varieties. I cannot do 
better than quote in this CJ3nnection the observatioiis of Sir Creighton 
Browne, who, in his address before the Sanitary Institute in 1902, on the 
dust problem, said: 

"The mortality of the principal dust-producing occupations, compared 
that of agriculturists who liv^e and work in what is practicidly dustlesa 
■ere, is excessive to a startling degree. It is not suggested that 
368 is to be ascribed to dust alone,^ — no doubt various other factors 
" *o it, — but the facts that it is due mainly to respiratory diseases, 
tributetl among the several occupations pretty much in propor- 
• dustiness^ and that it has diminished in some instances where 
n effectually dealt with, justify the conclusion that it is generally 
I." 

nng bis use of the term "industrial dust/* this distinguished 
observed: 



TXJBERCUL0SI8 AS AN INDUSTRIAL DISEABE.^HOFFMAN. 



143 



*' I select this dust for my further remarks because it is readily recognized 
and defined, because its pernicious effects are well marked and indisputable, 
because It is, to a large extent, if not entirely, preventable or removable, 
and because the efforts already made to prevent or remove it have been 
rewarded with conspicuous benefit." 

The Prevenium of Tuhercuioais in Industry. — ^WHIe emphasizing the 
bopefu] outlook for preventive measures, it, however, is necessary to secure 
intelligent cooperation between employers and employees, for it is a curious 
fact that some of the most beneficial methods and means of sanitary reform 
have been most bitterly opposed by those for whose benefit they were de- 
signed. Dr* Thomaa Oliver, in his recently published treatise on "Diseases 
of Occupation/' very projierly calls attention to this fact, and holds that — 

"No matter what parliamentary legislation may enact, industrial hygiene 
will never be secured until the workers themselves are etlucated in regard to 
the dangcTB incidental to particular trades, and are willing to cooperate in 
making Home Office regulations effective. There must be a greater amount 
of mutual trust and a heartier cooperation of employers and employed. 
Only thus is it possible to remove the stigma that attaches to many occu- 
pations and the cause of their unhealthiness. No person should be em- 
ployed in a dangerous trade until the risks have been explained to him by 
the employers, and the means indicated whereby danger to health may be 
averted." 



Fxbrmd Phthisis as an Oceupntton Disease. — I need not on this occasion 
enlarge upon the social and economic aspects of the problem of tuberculosis 
as an industrial disease, but I include Bome additional observations of the 
Committee on Compensation for Industrial Diseases, with special reference 
to the attempt maile to distinguish industrial phthisis, or fibroid phthisia, 
from ordinary tuberculosis, as met in the general population. The com- 
mittee calls attention to the fact that — 

"The pulmonary disease manifests itself in three kinds or forms — as 
ordinary tuljerculous phthisis, acute or chronic, as '* fibroid phthisis," and 
as a mixed form when a tuberculous process is ingrafted sooner or later upon 
the fibroid. Fibroid phthisis b alwa^Ta a slow disejise. It conasts in a 
chronic reactive inflammation around the many minute foci of dust inhala- 
tion, which, by coalescence, gradually invades large areas, impairing anrl 
strangling the proper lung tissues in corresponding measure. Again, a hm^ 
Bo impaired is very apt to harbor bacilli, especially the tubercle bacillus. 
by the influence of which it may be still furt.her destroyed. Thus both 
fibroid phthisis uncomplicated, an<I fibroid phthisis with the supervention of 
tubercle, are in their nature occupational diseases," 

The Dangers of Industriat Ihisi, — Concetfing the difl^culty of determining 
absolute accuracy in particular cases whether the disease is, in fact, fibroid 



144 filXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 

phthisis resulting from the employment, or ordinary tuberculosis^ wluch, 
ths wu'b, prevails excessively among workmen iii dusty trades, the committer 
heJd thui tlie exoe^ in the mort-ality from ordinary tuberculosis is, in some 
meiufurc at Icftst, due to the injurious infiuence of such dust on the lungs of 
the workmen ufTccteiU 

Thia ImporUvnt conclusion is fully suatainetl by the observation of prac- 
ticjilly every qualified authority on the diseases of occupation, for example, 
Arlidpn* Oliver, Talliam and Newaht>lme, Hirt and Merkel, and Tracey, 
Harrington, atui others reporting upon conditions affecting health and 
InduMtry in the Uriit«tl States. All theise writers have very materially 
InerrfiMod nur knowledge and understanding of the circumstances and con-^ 
dlMtnw ((ovcndnR tUo health of wage-earners in dusty trades, but in a problem 
of Mueh tniriHeiuident iin|M)rtancc it is neoessary that there should be no 
iN^riiiMH rrror in the vididity of the conclusions arrived at, and, as a further 
in<idril*ntiitri U* thn wUidy of the subject of dusty trades in their relation to 
|\iU*niuhwii«i frtMiuoncy, 1 whull diacusa, aa briefly as possible, the degree of 
ililN frpt|nrmiy amnnn men employed in thirty more or less dusty trades, 
itliliid y ii|"tii * fio \)iiH\ji 4if till) industrial mortality experience of the Prudential 
InHUi'tUK^i Cotnpany of America. 

nnNVRAT* Ahpkcts or THE TunERCUtosis Problem, 
I would llrwi, however, direct attention to certain general facta of the 
iMU'r(»ulii«l" piol»leMi wliicli il is always advisable to keep in mind in any 
H^I'tiniliHl iiU(nWrtii»M of the mibject from a special point of view. The 
muiHinnpliiHi Miiirbdity ra(o of northern cities of the United States haa 
diH^lhM'd hiHu 'jnii \»^r KMMKK) of population b ISOO to 185.3 in 1906. The 
(Hk4nwpiii(dlh|( oniiHUiuptiou mortality of the white population in southern 
Miili^ hiM diM'ltitiMl froH] *S^2 U) 170*1 during the same period^ and the con- 
iiMMt|>lloii mmUdily rate of the colored population of southern cities hua 
d(M>iiMtMini from All,7 U» 4^)8.4. It is evident that while the consumption 
iliMd'h lutiw iif both ihn white and the colored population of southern cities 
hnvt* dot^ltiiiMl, Iho dllTrnnicu between the two rates has practically remained 
Mw IMUU^ Tlit* romparullvo ]}roporlionate mortality from this disease in 
\\m\ diltvhM^t mA\i\ v\vnM\{n of the population is a matter of sufBcient interest 
\\\ UAtti^MV Om lnrhi«ion of four statistical tables^ which will emphasize the 
(HVt« u( iHUwiut^I'llou (rtH|UDncy among tlie white, Degro, Chinese, and 
1 "' i * '^ ■ llmltod, luiwcver, to the male element, with which 

ti may lie nmde in the discussion of the occupation 
^H^ktUUVV ditM ^UmU'^mI fiom liiduNtrial experience* 

r ' tt ' Ml por white males of ages fifteen and over, 
,, Ht, tho recorded mortality from all causes was 



TUBERCULOSIS AS AN INDUSTRIAIi DISEASE, — HOFFMAN. 145 

302,335, and of thb number 41,133, or 13.6 per cent., were deaths from 
eoDSumption. The facts in detail are set forth in tabular form below : 

MORTALITY OF WHITE MALES— U. S. CENSUS OF 1900. 

. Deaths fbom Dkatrb pbom Fkb Cknt. 

A®"*' Aii Causes. CoNSnumoM. Conscuftion. 

li5-24 33,903 7,366 21.7 

26-34 39,150 11^1 28.8 

35-44 39,902 8,765 21.9 

45-64 40,788 6,904 14.6 

65-64 45,539 4,082 9.0 

65 and over 103,063 3,756 3.6 

Total 302,335 41,133 13.6 

According to this table, the proportionate mortality from consumption 
among white males was: At ages 15-24, 21.7 per cent.; at ages 25-34, 28.8 
per cent.; at ages 35-44, 21.9 per cent.; at ages 45-54, 14.5 per cent.; at 
ages 55-64, 9 per cent. ; and at ages 65 and over, 3.6 per cent. 

Mortality of Negro Males, — ^For negro males of ages fifteen and over the 
census of 1900 recorded 39,676 deaths from all causes, and of this number 
7821, or 19.7 per cent., were from consumption. The facts in detail are set 
forth in tabular form as follows: 

MORTALITY OF NEGRO MALES— U. S. CENSUS OF 1900. 

. Deaths from Deaths from Peb Cent. 

■'""*• Aix Cadbes. Consumption. Ck)NBuuFTiON. 

15-24 9.361 2,605 27.8 

26-34 7,042 2,019 28.7 

36-44 6.366 1,311 24.4 

45-64 6,200 917 17.6 

66-64 4,473 530 11.8 

66 and over 8 ,235 439 5.3 

Total 39,676 7,821 19.7 

According to this table, the proportionate mortality from consumption 
among negro males was : At ages 15-24, 27.8 per cent. ; at ages 25-34, 28.7 
per cent.; at ages 35-44, 24.4 per cent.; at ages 45-54, 17.6 per cent.; at 
ages 55-^, 11.8 per cent.; and at ages 65 and over, 5.3 per cent. 

Mortality of Indians. — ^For North American Indians of ages fifteen and 
over in the male population the census investigation recorded 1176 deaths 
from all causes, and of this number 353, or 30 per cent., were from consump- 
tion. The census report included, however, but a small portion of the Indian 
population on reservations and in far western States, so that the facts must 
be considered with caution. The details of the mortality are set forth in 
tabular form as follows: 



146 



SIXTH INTERNATIONAL CXJNGRESS ON TUBERCULOSIS* 



MORTALITY OF INDIAN MALE&— tJ, S. CENSUS OF 1900. 

DlEATiW FBOM DBATrtfl FEOK PeR CbHT. 

AOIS. XlX> CaDBXH. CONBDUPnOH. CONSDHPnON. 

\5-24 274 137 fiO^ 

25-34 207 84 40.6 

35-14 174 U 2SJS 

45-54 143 81 2L7 

SS.-64 142 29 20.4 

66 and over 23ft 28 11.9 

Total 1,17ft 353 30X) 

According to this table, the proportionate mortality from consiimplio!'! 
among Indian mules was: At agea 15-24, 50 per cent.; at ages 25-34, 40.6 
per cent,; at ages 35-44, 25*3 per cent; at ages 45-54, 21 J per cent.; at 
ages 55-64, 20,4 per cent.; and at ages 65 and over, 11.9 per cent. 

MortaUiy oj Chinese. — For the Chinese of ages fifteen and over the census 
of 1900 recorded 971 deaths of males from all causes, and of this number, 
350r or 36 per cent., were from consumption. The facts in detail are set 
forth in tabular form below : 



MORTALITY OF CHINESE MALES.— U. 8, CENSUS OF 1900. 

. Dkatha TBfiii Deaths ftloii Fex CehT. 

A^'*- All CAiTBKfi. CoHBuHPTion. CotmaMFTtaH. 

15-24 43 16 37.2 

25-^ 123 && 44.7 

35-44 283 123 43^ 

4S-&4........... . 313 104 33.3 

55-64 139 33 23.7 

eS widovCT 70 19 27.1 

Total 971 350 36.0 

According to this table the proportionate mortality from consumption 
among Chinese males was: At ages 15-24, 37.2 per cent.j at ages 25-34, 
44.7 per cent.; at ages 35-44, 43,5 per cent.; at ages 45-54, 33.2 per cent.; 
at ages 55-64, 23,7 per cent.; and at ages 65 and over, 27.1 per cent. 

Factors to be Considered. — ^These tabulations empha^ze the necessity of 
caution in coasidering the complex problem of tuberculosis in its relation to 
occupatlan, and in particular to dusty trades. While the factor of nativity 
has not been cnnddered, it is well known that race and nativity, both singly 
and in combination, are important factors, wliich require to be taken into 
account. The wide disparity exhibited in proportionate mortality from 
tuberculosis among colored raecfi is in itself a significant and very suggestive 
fact, which is discloseti more precisely by the proportionate mortality at the 
diiTerent periods of life than in the percentages for the summarized mortality 
at all ages over fifteen. 

Age and Freq^iency. — Before considering health-injurious occupations in 
detail, it seems advisable to direct attention to the disproportionate mortality 



4 



TUBERCULOSIS AS AN INDUSTRIAL DISEASE. — ^HOFFBCAN. 147 

of the sexes from coDsumption at ages fifteen and over. The mdustrial 
mortality experience pertaining to thb group of facts is presented in tabular 
form below: 

COMPARATIVE PROPORTIONATE MORTALITY FROM CONSXTMPTION (IN- 
DUSTRIAL MORTALITY EXPERIENCE, PRUDENTIAL INSURANCE 
COMPANY OF AMERICA). 

Uaub and Fxujlub, 1897-1906 

MAI.XB. Feualkb. 

De&tha De&ths Per Cent. Deaths Deaths Per Cent. 

AcBS at Death, from All from Cod- of Con- from All from Con- of Con- 

Causes. sumptioD, sumption. Causes. sumption. sumptioa, 

15-19 8,908 1.960 21.8 8,974 3,185 35.5 

20-24 12,524 4,950 39.6 13,307 5,685 42.7 

25-29 14,012 6,023 43.0 14,703 6,257 42.6 

30-34 15,046 6,197 41.2 13,779 5,072 36.8 

35-39 15,091 5,344 35.4 12,682 3,571 28.2 

40-44 14,665 4,019 27.4 10,132 2,568 25.3 

45-49 14,462 3,144 21.7 12,648 1,685 13.3 

60-54 15,997 2,445 15.3 15,369 1,397 9.1 

65-59 17,106 1344 10.8 17,826 1,149 6.4 

60-64 18,574 1,299 7.0 20,203 900 4.5 

65-69 17,459 807 4.6 20,052 659 3.3 

70-74 13,150 420 3.2 16.900 337 2.1 

75 and over. . 7,567 134 1.8 10,074 135 1.3 

Sex and Frequency, — ^The first decided degree of variation in the propor- 
tionate mortality of the two sexes occurs at ages 16-19, when out of every 
100 deaths from all causes among males 21.S per cent, are from consumption, 
compared with a corresponding proportion of 35.5 per cent, for females. 
The considerable difference in the consumption mortality of the two sexes 
at this period of life is, no doubt, largely attributable to the fact that women 
at this age period spend entirely too much of their time indoors, where they 
are continuously exposed to the inhalation of domestic dust, and at a period 
of life when the destructive effects of such dust are most serious in their 
immediate consequences. 

Of young men at ages 15-19, a much larger proportion than among 
young women lead an active outdoor life, with the result that the propor- 
tionate mortality from consumption is very much less, although even in this 
case much higher than it should be. The differences in the proportionate 
mortality during the next ten years of life are very slight, but after thirty 
the disparity is decidedly to the disadvantage of males, and the differences 
attain to serious proportions after the age of forty-five. This contrast in 
the ratios is, without question, the direct result of health-injurious occupa- 
tions, but in particular the employment of a large proportion of the male 
population in more or less dusty trades. To emphasize the importance of 
this conclusion it is only necessary to point out that at ages 45-49 the pro- 
portionate mortality from consumption was 21.7 per cent, for males against 
13.3 per cent, for females; at ages 50-^ it was 15.3 per cent, for males and 



14S SIXTH INTEHNATIONAL CONQREaS ON TtJBERCULOBIS* 

9,1 per cent, for females; at ages 55-59 it was 10.8 per cent, for males and 
6,4 per cent, for females; and at ages 60-64 it was 7 per cent, for malea 
and 4.5 per cent, for females. At ages 65 and over the numbers are too smaU 
for a safe generalization, but the evidence U conclusive that the exoeaeive 
raortahty from conaumption among males continues subsequent to the forty- 
fifth year of age, in markeci contrast to the corresponding mortality of 
females, and while it is not possible to sustain this view by conclusive statis- 
tical data, it i& more than probable that a considerable proportion of the 
deaths recorded as general tuherculosia at ages forty-five and over are, in 
fact, cases of fibroid phthisiSj which is a well-defined occupation disease, 
chiefly the result of employment in duiity tratles. 

Normal Proportionate Mortaliiy, — The recorded industrial mortality 
experienoej by occupation, includes the ten-year period 1S97-I906, compre- 
hending a field of business operations practically coextensive with the whit-e 
urban population of the United States. The normal proportion of deaths 
from consumption in the mortaUty from all causes in the registration area 
of the United States was 28 per cent* at ages 15-24, 31 per cent, at ages 
25-34, 24 per cent, at ages 35-44, 15 per cent, at ages 45-54, 8 per cent. 
at ages 55-64, and not quite 3 per cent, at ages 65 and over. These normal 
proportions have been calculated from the American mortahty statistics 
for the registration area for the seven years ending with 1906, presented in 
tabular form below; 

PROPORTIONATE MORTALITY FROM CONSUMPTION— MALES. REGIS- 
TRATION AREA OF THE UNITED STATES, 1900-06. 

Pro rann dn atk 
. All OopfBUWP- MoaTALnr — Pen 

***"• Caubbb. TioH, Cknt. or OoN- 

BUHi^nOM, 

15-24 134,700 37.495 27.8 

25-34 186,530 58,424 31.3 

35-44 205,930 48,500 23.6 

4&-54 .205,497 30,781 15.0 

56-64 218,161 17,707 8.1 

65 and over... 425;228 11,949 2J 

The preceding table makes it possible to determine mth appro?dmate 
accuracy the probable excess in the consumption mortality of men employed 
in more or leas unhealthful occupations. While for certain reasons it would 
be more desirable to know the consumption mortality per lOOO living at 
diffeient periods of life, the data necessary for the calculation of siich rates 
are not available for the United States, and the corresponding rates for other 
countries would not be strictly applicable to American industrial life. 

Irn>usT«i\L Insurance MoKTAury Statistics. 
However, for the object in view, that is^ the effort to determine by the 
elatisticai method the proportionate excess in the mortality from consump- 



n 



TUBERCULOSIS AS AN INDUBTRIAL DISEASE.— HOFFMAN. 



149 



Uon in cMcrent trades, the method employed in this discussion is, in fact, 
more practical and useful, and is entirely trustworthy where the statistical 
basis is sufficiently large in numbers and extensive in area. It would not 
have been advisable to use the aggregate induistrial mortality experience as 
a basb, since industrial risks represent almost exclusively wage-earners, 
£ind but a very small proportion of ppofeaaional, mercantile, and agricultural 
risks, among whom the mortality from consumption is much lower. The 
effect of medical selection in industrial insurance may also be referred to as 
a factor that requires consideration, but the effect of such selection is much 
leas than in ordinary insurance, so that no very serious errors can result from 
a possible impairment, on this account, of the value of the data considered. 
It is true, of course^ that by means of such selection the indu.5trial risks most 
liable to consumption have been eliminated, since those suffering from the 
disease in its incipient stage were declined, but the effect of such selection 
would be rather to understate the actual situation as it confmnts wage- 
earners employed in unhealthful occupations at the present time* 

The concentration of the efforts of industrial companies in practically 
limiting the fiekl of their activity to cities and towns of considerable size 
gives to industrial insurance risks the character of an almost exclusive 
urban population, the mortality of which, other things equal , is invariably 
higher from ttiberculosis than the corresponcUng mortality of the population 
in niral districts. 

Frequenaj in Rural Sections.— I may further emphasize the statement by 
referring to the mortality data for 1906, acconiing to which the mortality 
from tuberculosis was 177 for American cities and 121 ytev 100,0CX) of popula- 
tion for the population of the rural regions of the registration States, The 
standard method employed in determining the relative excess in consumption 
frequency in the various occupations considered would, therefore, seem to 
be best adapted to the present discussion, and fully to warrant the fmai 
conclusions arrived at. 

Frequency in Industries and Trades. — In my statistical illustrationg I 
8hftC tliscuaa only the degree of consumption frequency m specified occupa- 
tions, since other tuberculous diseases are, in all probability, not connected 
with the employment. I shall also limit myself in the discussion to the 
itial facts of insurance mortality experience, since any extended review 
of the disease occurrence in different trades would materially enlarge the 
present discussion, I have on other occasions tliscussed in detail the causes 
ftnd conditions affecting the health of men in industrial occupations, but for 
a qualified discussion of the subject of occupation diseases the works of 
Arlidge and Oliver, at least, should lie consulted. My subsequent remarks 
will include specific occupations, with reference to particular kinds of dust 
exposure, but I need hardly point out that no workman suffers exclusively 



150 



BTJCm INTERNATIONAL CONGRESS ON TUBERCULOSIS* 



from the inhalation of any particular kind of dust, but that all are more or 
less exposed to mixed infection, resulting from the varied and complex 
conditions under which industry and life in general are carried on. The 
subdivision of occupations by particular kinds of dust exposure is, therefore, 
merely for the purpose of drawing attention to the principal source of dust 
injury to the lungs. 

OccupA'noN CLABsiFrcATioN BY T}imT Exposure. 
The following convenient grouping has been adopted for the present pur- 
pose, to emphasize the most serious disease hazard in principal occupationSj 
and to facilitate ready reference to the degree of consumption frequency 
in the various employments, considered in some detail in the subsequent 
discussion. 

Group /.^-Exposure to metallic dust: 

1. Grinders, 

2. Polishera, 

3. Braafi- workers. 

4. Tool and instriinjent^niaiteis. 

5. Jewelers. 

6. Engravers. 
7- Printers. 

8. CompoBitfira. 

Group IL — Exposure to aunerai dust: 

9, Stone-workera. 

10. Marble-workera 

11. Glass-blowtira. 

12. GUsfl-Cdtters. 

13. Pottere. 

14. Plasterers. 

Gro^tp til. — ExpoHUr© to vegetable and fiber dust: 

15. Spinners. 
IG. Weavera. 

Gfvup fV, — Exposure to anim^ and mixed fiber dust: 

17. Furriem, 

18. Halters. 

19. Woolen and worsted woAers. 

20. Carpet and rug-makers, 

21. Silk-mill workers. 

22. UphoUterers. 

Orftup V. — Exposure to oipuuo duft: 

23. MiUen*. 

24. Bakera. 

25. Buttun-m^erH, 
20. Leathcf^worketB. 



I 



Group VL — Elxposure to mumcipal duat: 
27. Street-oleanera. 
2$. Cabmen and hackmen. 
29. Ijetter-carrierB. 
30- Street-car motormen. 



Frequency in Dmty Trades, —When all the occupations for which the in- 
formation ia available, mcluaive of many other than the thirty employments 



TUBERCULOSIS AS AN INDUSTRIAL DISEASE,— HOFFMAN. 



151 



considered in this discussion, are combinedj the proportionate roortality 
from coDsumption is 28 per cent, of the mortality from all causes at ages 
fifteen and over. In the group of occupations exposing chiefly to the inhal- 
ation of metallic duat, the proportionate mortality from consumption was 
37.4 per cent*; in occupations exposing to animal and mixed fiber dust, 
32.3 per cent,; in occupations exposing to mineral dust, 28.6 per cent.; in 
occupations exposing to municipal or street dust, 27.5 per cent.; in occupa- 
tions exposing to vegetable fiber dust, 27.4 per cent.; and in occupations 
exposing to organic dust, 23.7 per cent. These percentages of consumption 
Ireqiiency are derived from an analysis of about 22,087 deaths from all 
causes in the occupntions included in the investigation. 

Mortality at Ages 15-24. — ^The analysis may be extended to divisional 
periods of life, to emphasize the more immediate effects of health-injurious 
dust inhalation, and, beginning with ages 1&-24, the prop>ortionate mortality 
from consumption wjis highest in occupations exposing to the inhalation of 
animal and mixed fiber dust, or 49.6 per cent, of the mortality from all causes. 
In occupations exposing to metallic dust it was 47.1 per cent.; to organic 
dust, 40.9 percent.; to municipal or street dust, 30,8 percent.; to vegetable 
fiber dust^ 39.1 per cent.; and to mineral dust^ 31.7 per cent. 

Mortality at Ages 25-34. — At ages 25-34 the proportionate mortality 
from consumption was highest in occupations exposing to the inhalation of 
metallic dust, or 56.7 per cent, of the deaths from all causes. In occupations 
exposing to the inhalation of vegetable fiber dust it was 53*3 per cent.; of 
organic dust, 50,1 per c«nt.; of animal and mixed ftber duet, 49.7 per cent.; 
of mineral dust, 47.6 per cent.; and of municipal or street dust, 43.5 per cent. 

Morkdity at Ages 3.5-44.— At ages 35--44 the proportionate mortality 
from consumption wa.s highest in occupations exposing to the inlialation of 
metallic dust, or 43.0 per cent, of the tleaths from all causes. In occupations 
exposing to the inhalation of animal and mixed fiber dust it was 40.4 per 
cent. ; of vegetable fiber dust, 39.8 per cent. ; of mineral dust, 36,3 per cent. ; 
of organic dust, 36.2 per cent.; and of municipal or street dunt, 34,6 per 
cent. 

Mortality at Ages 45-54. — At ages 45-54 the proportionate mortaJity 
from consumption was highest in occupations exposing to the inhalation of 
mineral dust, or 27.9 per cent, of the deaths from all causes. In occupations 
exposing to the inhalation of motallic dust it was 23.6 per cent.; of animal 
and mixed fiber dust, 23>2 per cent.; of vegetable fiber dust, 22.9 per cent.; 
of organic dust, 21,9 per cent.; and of municipal or street duat, 14.2 per 
cent. 

MarUdity at Age^ 55-64. — At ages 55-64 the proportionate mortality 
from consumption was hif^hest in occupations exposing to the inhalation of 
mineral dust, or 16.2 per cent, of the deaths from all causes. In occupations 



■Tfi ::.-3 per cent.; of 

-'•• t*"c.; «.u' animal and 

- -• -Tr»ti: dust, 10.8 per 

~ . v-:r the proportionate 
• ^.;a::- -jj exposing to the 
.- :e:iths from all causes. 

:*__:• rjsi it was 4.6 per cent. ; 

..:;?.; fiber dust. 3.7 per cent.; 

-:;icipal or street dust, 2.9 per 

r.phasizes the dep^ee of dif- 

r' ',;i:fcr liic resulting conse- 

;•> VAi-n "liiero is a consid- 

_:^;ri., ,<: ^ri::!^ and mixed 



ir.:.ii: PrsT. 

.-.tf -."hiUdtion of metallic dxist 
."jKi^il. including — (1) Grinders; 
.Mid instrument-makers; (5) 
>! compositors. The aggregate 
'ccupationa are presented below 
[M deaths from all causes and of 
sii'ii the resulting proportionate 
^< :i life and the corresponding 

NS WITH EXPOSURE TO ME- 



,<.•! 



XtS^-HSnON *,TK 


Normal rnoroR- 


,-x!*. «moN 


■now IN General 


v-fttwrtvii.. 


rOPrLATJON. 


r.i 


27.8 


.v.: 


31.3 


k50 


23.6 


:o6 


15.0 


". 5 


8.1 


.«S 


2.8 



r 4 14.9 

., .,, .H tho grinder is usually 

^.,^ -''v rwvrvletl mortality of 

. » no! ■v.or4Mix^r cent., were 

.».^Ai> •*^^*"-- rt\«piratory diseases, 

vi>.»iK'hi:itf. and 12 from other 



... *.v 



TUBERCULOSIS AS AX INDUSTRIAL DISEASE* — HOFFMAN. 



153 



teapiratory diseases. If the deaths from consumptiom and respiratory dia^ 
eases are combined, a total of 85, or 66.4 per cent., o{ the mortality of grinders 
was from diseases of the lungs and air-passages. The excess in the consump- 
tion mortality of grindera is still more clearly brought out in the tabular pres- I 
entaiion of the proportionate mortality from this disease by divisional periods 
of life. While the consumption mortality waa excessii'e at all ages, the excess 
was most pronounced at 25-34, when, out of every 100 deaths from all | 
causes, 70.8 were from consumption, against a normal expected pros)ortion of 
3L3. The analysia of the consumption mortality of grinders in detail La 
presented in Table No J of the Appendix. ■ 

MorialUy of Poliahers. — The recorded mortality of polishers includes 
279 deaths from all causes, of which lOS, or 38,7 ]>er cent, were from 
consumption. Of the mortality of polishers from respiratory diseaseSj 25 I 
were from pneumonia, 5 from asthma and bronchitis, and 5 from other res- 
piratory diseases. If the deaths from consumption and respiratory diseases 
are combined, SL2 percent, of the mortality of polishers waa from diseases 
of the iun^ and air-passages. The excess in the consumption mortality of 
polishers is still more clearly brought out in the tabular presentation of the pro- 
portionate mortaLty from this disease by divisional periods of life. While 
the consumption mortality waa excessive at all ages, the excess waa most 
pronounced at 25--34, when out of every 100 deaths from all causes, 56 were 
agdnst a normal expected proi->ortion of 31.3. The analysis of the consump- I 
tioa mortality of polishers in detail is set forth in Table No. 2 of the AppendLx. 

MortalUy of Brass'ivorkcrs. — The reconled mortality of braas-work- 
era includes 414 deaths from all causes^ of which 161 ^ or 3S.d per cent., ■ 
were from consumption. Of the mortality of brass-workere from r^pir- 
atory diseases, 36 were from pneumonia, 3 from asthma and bronchitis, 
and 12 from other respiratory diseases. If the deaths from consumption and I 
respiratory diseases are combined, 51.2 per cent, of the mortality of braes- 
workers was from diseases of the lungs and air-passages. The excess in the 
consumption raortahty of braes-workers is still more clearly brought out in 
the tabular presentation of the proportionate mortality from this disease by 
divisional periods of life. Wliile the consumption mortality was excessive at 
all ages, the excess was most pronounced at ages 15-24, when, out of every 100 
deaths from all causes, 59 were from consumption, against a normal expected 
proportion of 27.8. The analysis of the consumption mortality of brass- 
workers in detail is set forth in Table No. 3 of the Appendix. I 

Mortality of TooU and Instrumeni-makrrs. — The recorder! mortality of 
tool- and instrument-makers includes 303 deaths from all causes, of which 
101, or 33.3 per cent., were from consumption. Of the mortality of tool- ■ 
and instrument*makers from respiratory diseases, 25 were frt>m pneumo- 
ma, 9 from asthma and bronchitis, and 6 from other respiratory diseasesp 



i 



. jj 



154 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



If the deaths from consumption and other respiratory diseases are com- 
bined, 46.3 per cent, of the mortality of tool- and instrument-makers was 
from diseases of the lungs and air-passages. The excess in the consumption 
mortality of tool- and instmment-makera ia still more clearly brought out 
in the tabular presentation of the proportionate mortality from this disease 
by divisional periods of life* While the consumption mortality of tool- and 
instrument-makers was excessive at all ages, the excess was most pronounced 
at 25-34, when, out of every 100 deaths from all causes, 59 were from 
consumption, against a normal expected proportion of 3 1 ,3. The analysis of 
the consumption mortality of tool- and instrument-makers in detail is set 
forth in Table No. 4 of the Appendix. 

Marialit^ of J ewiiers.— The recorded mortality of jewelers includes 
403 deaths from all causes, of which 113, or 28 per <Knt., were from eon- 
sumption. Of the mortality of jewelers from respiratory diseases, 37 were 
from pneumonia, 10 from asthma and bronchitis, and two from other respira- 
tory diseases. If the deaths from consumption and respiratory diseases are 
combined, 40.2 per cent, of the mortality of jewelers was from diseases of 
the lungs and air-paaaages. The excess in the consumption mortality of 
jewelers is still more clearly brought out in the tabular presentation of the 
proportionate mortnlity from this disease by divisional periods of life. While 
the consumptiom mortality of jewelera was excessive at all ages, the excess 
was most pronounced at 25-34^ when, out of every 100 deaths from all causes, 
59.5 were from consumption, against a normal exixjcted proportion of 31,3, 
The Einalysis of the consumption mortality of jewelers in detail is set forth in 
Table No. 5 of the Appendix. 

Mortality oj Engravers. — ^The recorded mortality of cngravei^ includes 
192 death from all causes, of which 67 or 34.9 per cent., were deatlis from 
consumption. Of the mortality of engravers from respiratory diseases, 18 
were from pneumoniii, 1 from asthma, and 3 from other respiratory diseases. 
If the deaths from consumption and respiratory diseases !4re conibined, 46.4 
per cent, of the mortality of engravers was from diseases of the kmgs and air- 
pjLssages. The excess in the consumption mortality of engravers is still more 
clearly brought out in the tabular presentation of the proix>rtionate mortality 
from this disease by divisional periods of life. While the consumption mor- 
tality was excessive at all ages, the excess was most pronoimoefl at 25-34, when 
outof every KHJ deaths from all causes, 6 L7 were from consumption, agamst 
a normal expected proportion of 31 ,3. The analysk of the consumption mor- 
tality of engravers in detail is set forth in Table No. 6 of the Appendix. 

Mortaiity of Printers, — The recorded mortality of printers was excep- 
tionally large and representative of the trade^ including 1,590 deatlis from 
all causes, of which 613, or 38.6 per cent., were from consumption. Of the 



4 



TUBERCULOSIS AB AN INDUBTRIAL DISEASE. — HOFFMAN. 



155 



tnortality of printers from respiratory diseases, 169 were from pneumo- 
nia, 28 from asthma and bronchitis, and 24 from other respiratory diseases. 
If the deaths from consumption and respiratory diseases are combined, 52.5 
per cent, of the mortality of printers was from diaeam^ of the lungp and air- 
passages. The excess in the consumption mortality of printers is decidedly 
BU^estive of a typical indcfor employment, where the expoaure to the inhal- 
ation of metallic dust in minute particles is continuous and more or less un- 
avoidable. While the consumption mortality of printers was excesaive at all 
ag^, the excess was most pronounced at 25-34, when, out of every 100 deaths 
from all eausca, 56.4 were from consumption, against a normal expected pro- 
portion of 31.3. The analysis of the consumption mortality of printers 
in detail is set forth in Table No. 7 of the Appendix, 

MoTtQliiy of Compositors.'— TYie recorded mortality of compositors 
affords an op[Jortimity to consider this employment separately, as dis- 
tinct from that of printers* The mortality from all causes was 168, of which 
59, or 35, 1 per cent., were from consumption. Of the mortality of compositors 
from respiratory diseases, 19 were from pneumonia, 1 from asthma, and 5 from 
other respiratory diseases. If the deaths from consumption and other res- 
piratory diseases are combined, 49,9 per cent, of the mortality of compositors 
was from diseases of the lungs and air-passages. The excess in the consump- 
tion mortality of compositors is still more clearly brought out in the tabular 
pretsentation of the proportionate mortality from tliis disease by divisional 
periods of life. While the consumption mortality was excessive at all ages 
under 55, the excess was most pronounced at 25-34, when, out of every 100 
deaths from all causes. 66 J were from consumption, against a normal ex- 
pected proportion of 31.3. While at this periotl of life the proportionate con- 
mjmptlon mortahty of compositors was higher than the corresponding mor- 
tality of printersj the proportions wereaomewhat less atotherdivisioruil periods 
of life, and at ages 55 and over the numl>era were too small for a safe con- 
clufflon. The analysis of the consumption mortality of compositors in detail 
is set forth in Table No, S of the Appendix* 



I 



OccuPATIo^ra Exposing to Mineral Dust* 
In the group of occupations exposing to the inhalation of mineral <h\st, 
six occupations have been considered in detail, including: (1) Stonc-workei's; 
(2) marblo-workcra; (3) glass-blowers j (4) glass-cutters; (5) potters, and (6) 
plasterere. The aggregate mortality data available for this group of occu- 
piitions are presented below in tabular form, including a statement of the 
deatlis from all causes and of the mortahty from consumption, together with 
the resulting proportionate consumption mortality by divisional periods of 
hfe, and the corresponding averages for the general population. 



tm 



SIXTH INTERNATIONAL CONGRESS ON TtTBEHCULOSlS. 



CONSUMPTION MORTALITY IN OCCUPATIONS WITH EXPOSUBE TO BOH- 

ERAL DUST, 

. MOflTAUTT MORTAUTT FROPOBTiaNATB NoMIAIi PBdliOll- 

T> t- man Ali* froh Com- Cdhiuhption now iw Gbne&al 

ItKJk-rn. C*l]»I»* BUHfmOH. PKBCINTAaE. POPVIATIOK. 

15^24 413 131 31.7 27^ 

25-34 821 891 47.6 31.3 

35-44 93G 340 36.3 23.6 

4/^54 950 S85 27.9 15.0 

55-64 795 120 16.2 8.1 

65anJover , 623 43 6.8 2^ 

Total 4,543 1,299 28.6 14.9 

Morialihj of Sione-worktrs, — The recorded mortality of stone-workers 
includes S5S deaths from all causes, of which 302, or 35.2 per cent, were 
from consumption. Of the mortality of stone workers from respiratory 
disea^s, 95 were from pneumonia, 13 from asthma, 30 from bronchitis, 
and 24 from other respiratoiy diseases. If the deaths froni consumption 
and I'eapiratory diseases are combined, 54.1 percent, of the mortality of stone- 
workers was from diseases of the lungs and air-pass^^. The excessive 
mortality from lung diseases among stone-workers is notorious, and sustained 
by all the numerous investigations that have been made into the health con- 
ditions of this employment. The excess in the consumption mortality of 
stone-workers is still more clearly brought out in the tabular presentation of 
the proportionate mortality from this disease by divisionat periods of life. 
While the consumption mortality was excessive at all ages, the excess was 
most pronounced at 25-34, when, out of every 100 deaths from all causes^ 52.6 
were from consumption, against an expected normal proportion of 31.3, The 
analysis of the consumption mortality of stone-workers in detail is set forth in 
Table No. of the Appendbt. 

Mortality oj Marhlc-workers. — The recorded mortality of marble-workere 
includes 200 deaths from all causes, of which 56, or 28 per cent,, were from 
consumption. Of the mortality of marble-workers from respiratory diseases, 
26 were from pneumonia, 7 from asthma and bronchitis, and 3 from other 
respiratory diseases. If the deaths from consiimption and respiratory 
diseases are combined, 46 per cent, of the mortality of marble- workers was 
from diseases of the lunge and air-passages. The excess in the consumption 
mortality of marble- work era is less than the corresponding excess in the 
mortality of stone-workera generally, and this fact h still more clearly 
brought out in the tabular presentation of the proportionate mortality 
from this disease by divisional periods of life. While the consumption 
mortality was high during the entire active working lifetime of marble- 
workers p the excess m the mortality was most pronounced at 25-34, when, 
out of every 100 deaths from all causes, 50 were from consumption^ agamst 
a oonoal expected proportion of 31.3. The analysis of the consumption 



4 



TUBERCULOSIS AS AN INDUSTRIAL DISEABE.^HOFFMAN. 



157 



mortality of marble- workers Ln detail is set forth in Table No. 10 of the 
Appendix. 

MoiialUy of Glass-biowers.—ThQ recorded mortality of glass-blowers 
includes 282 deaths from all causes, of which 85, or 30.1 per cent., were from, 
oonsumption. Of the mortality of glass-blowers from respiratory disease, 
17 were from pneiimoniaj 3 from asthma and bronchitis, and 6 from other 
respiratory diseases. If the deaths from consumption and respiratory 
diseaaes are combined, 39.3 per cent, of the mortality of glass-blowers was 
from diseases of the lungg and air passages. The excess Ln the consumption 
mortality of glass-blowors is stili more clearly brought out Ln the tabular 
presentation of the proportionate mortality from this disease by divisional 
periods of life. While the consumption mortality was excessive at all ages 
under 55, the numbers at ages 55 and over are too small for a safe generaJi- 
zatioQ* The excess in the mortality was most pronounced at ages 25-34, 
when, out of every 100 tleaths from all causes, 56.4 were from consumption, 
against a normal expectetl proportion of 31,3, The analysis of the consump- 
tion mortality of glass-blowers in detail is set forth in Table No. II of the 
Appendix, 

Mortality of Glass-cuUera. — The recorded mortality of glass-cutters 
includes 116 deaths from all causes, of which 40, or 34.5 per cent., were 
from consumption. Of the mortality of glassn^utters from respiratory 
diseases, 12 were from pneumonia, 1 from asthma, and 2 from other respira- 
tory diseases. The numlDers are rather small for a safe generalization, but 
if the deaths from consumption and respiratory diseases are combine<l, 47.4 
per cent, of the mortality of glass-cutters was from diseases of the lungs and air- 
passages. The excess in the consumption mortality of glass-cutters is more 
clearly brought out in the tabular presentation of the proportionate mortality 
from this disease by divisional periods of life. While the consumption 
mortality was excessive at all ages under 55, the numbers being too small 
for definite conclusions for older ages, the excess was most pronounced at 
25-34, when, out of every 100 deaths from all causes, 46.7 were from con- 
sumption, against a normal expected proportion of 31.3, The analysis of 
the consumption mortality of glass-cutters in detail is set forth in Table 
No. 12 of the Appendix. 

MariaiiUf of Potters. — The recorded mortality of pottere bcludes 3S4 
deaths from all causes, of which 127, or 33.1 per cent., were deaths from 
consumption. Of the mortality of potters from respiratory diseases, 21 
were from pneumonia, IS from asthma, 12 from bronchitig, and 6 from 
other respiratory diseases. If the deaths from consumption and respiratory 
diaeaaea are combined, 48 per cent, of the mortality of potters was from dis- 
eases of the lungs and air-passages. The excess in the consumption mortality 
of potters is gtill more clearly brought out in the tabular presentation of tl^ 



: 



156 



SIXTH IN-Ti:i; 



CONSUMPTION MOlt'lAi 



AcKfl AT 
I>KATH. 



3r>-4J . . 
45 r>4 . . 

Total . 

Mortalt'fj/ 
includes sr>- 

(li.seasos, 'J'. 

and 24 fi- 

andi-osj)!!'. 

workoi's '■ 

inortalii;. 

hynW tl,' 
ditions . 
stono-^\ 
the pr. ■ 
While : 
mo.sf : 

worv ' 
aiial\ 

Tal,!. 

incJ 

CO/. 



20 

re.s; 

di.M 

mm 
nu>y 

morr 
worj,. 
out «■ 
a nor 



• ..■ ::.-Ast 

- ^ -. 52.9 

.: olA 

. T-:-. r'.trth 

. . .-:< .577 

:-T .::::■: inn. 
:: :.^ j'lifu- 
::-=; iraiory 
:? ;.re ami- 
..sos of the 
:y vf pla:<- 
'.'f the prt.!- 
:v. While 

::.- tX^V?:; 

f IT ::. ;;1I 
;■'. r":i':i uf 
•:. .ieuiil is 



: vc'jetable fi!>er 
\-: 15. .1) s|.unncr:5 
.:::. :\r this jrroup 

::.o manufacture 
•'•; ;-Cirrc^ato nior- 
'vsL'iuod l)elo\v in 

:«U5os ami of the 
••.: projMH'lionalc 
:l-.o coiTcspondiit;; 



,.vsruKTo vKci-: 



NoltMM. rKOI'OK- 


TION IN Ul.M'H.Vl 


rorri.AiluN. 


27.K 


31.3 


23.(> 


15.0 


S.l 


•2.H 



14.9 



TOBERCULOBIS AS AN INDUSTRIAL DISEASE. — HOFFMAN* 



159 



MoTtaliiy of Spinjiers. — The recorded mortality of spinners includes 189 
deaths from all causes, of which 56, or 29.6 per cent-, were from consumption. 
Of the mortality of apinnera from respiratory diseases, 17 were from pneu- 
monia, 6 from asthma and bronchitiSj and 5 from other respiratory diseases. 
If the deaths from consumption and respiratory diseases are combined, 
444 per cent, of the mortality of spinners was from diseases of the lungs 
and air-passages. Spimiers, as grouped for the purpose of this investigation, 
include spinners of textiles generally, but chiefly those in the cotton industry. 
Because of the fact that the large majority of spinnemare women, the raor- 
tAlity experience with this class of labor h comparatively small. The excess 
in the consumption mortality of spinners is more clearly brought out in the 
tabular presentation of the proportionate mortality from this disease by 
divisional periods of life. Wliile the consumption mortality was excessive 
at all ages under 55, the excess wjia most pronounced at 25-34, when, out of 
every 100 deaths from all causes, 50 were from consumption, aga.inst a normal 
expected proportion of SL3* The analysis of the consumption mortality of 
spinners In detail is set forth in Table No. 15 of the Appendix, 

Mortality of Weavers^ — The recorded mortality of weavers includes 915 
deaths from all causes, of which 254, or 27,8 per cent., were from consumptionr 
Of the mortality of weavers from respiratory diseases, 78 were from pneu- 
monia, 10 from asthma, IS from bronchitis, and 13 from other respiratory 
diseases. If the deaths from consumption and respiratory diseases are com- 
bined, 40.8 per cent, of the mortality of weavers was from diseases of the lunga 
and air-passages. The number of deaths of weavers under consideration is 
exceptionally large and strictly representative of this important occupation. 
It 13 difficidt, however, t^ determine the kind of dust exposure to which this 
class of labor was most subject, since the term is a general one, including 
employment in every branch of textile manufacture* The excess in the 
consumption mortality of weavers is more clearly brought out in the tabular 
presentation of the proportionate mortality from this disease hy divisional 
periods of life. While the consumption mortality was excesdve at all a|^ 
under 65, the excess was most pronounced at 25-34, when, out of every 100 
deaths from all causes, 63.4 were from consumption, against a normal ex- 
pected proportion of 31.3, If the proportionate mortality of weavers is 
compared with the corresponding mortality of spinners, it appears that while 
for spinners the proportion was 46.4 per cent, at ages 15-24, it was 39.8 per 
cent, for weavers; at ages 25-34 the proportion w-as 50 per cent, for spinners, 
against 53.4 per cent, for weavers; at ages 35-44 the proportion was 44,4 per 
cent, for spinners, against 38-1 per cent, for weavers; and at ages 45-54 the 
proportion was 25.9 per cent, for spinners, against 25.7 per cent, for weavers. 
At ages 55 and over the numbers for spinners arc too small for an entirely 
sale conclusion. The comparison would warrant the opinion tlmt the occu- 



I 



; 



160 



SIXTH INTBHNATIONAL CONQRESS ON TUBERCULOSIS. 



pation of spinners is somewhat more exposed to health-injurious conditions, 
resulting in a somewhat higher proportionate consumption mortality from 
this disease. The analysis of the consumption mortahty of weavers in detail 
is set forth in Table No. 16 of the Appendix. 

Occupations Exposing to Animal and Mixed Fiber Dust. 
In the group of occupations exposing to the inhalations of animal and 
mixed fiber duat, six occupations have been considered in detail, including 
(1) furriers and taxidermists; (2) hatters; (3) woolen and worstetl worl^ers; 
(4) carpet and rug makers; (5) silk-mill workers, and (6) upholsterers. The 
aggregate mortality data aviulable for this group of occupations are pre- 
sented below in tabular form, including a statement of the deatlis from all 
causes and of the mortality from consumption, together with the resulting 
proportionate consumption mortality by divisional periods of lifej and the 
corresponding averages for the general population. 



CONSUMPTION MORTALITY IN OCCUPATIONS WTTH EXPOSURE TO ANI- 
MAL AND MIXED FIBER DUST. 

. MOHTAUTT MoHTAUTT PaOl^KTIONyLTB NnkUAL PtOPOB- 

n» t^i'" fftOK AU. TBDM CoM- CONBUIfPTlOtir TIuN IN GrMkHAl^ 

UJBATrt, CAUaBft. fttrUmOH. PKBCKPTtAOR. FOPULATION, 

15-24 417 307 40.6 27.S 

25^4 730 363 49.7 31.3 

35-44 728 2M 40.4 23.0 

45-54....... 547 127 23.2 15.0 

55-64 473 6S 11.2 8.1 

65 and over , 3H3. 14 3.7 2^ 

Total 3 278 1,053 32.3 14.g 



4 



Mortality of Furriers and Taridermists. — The recorded mortality of 
furriers and taxidermifita includes 105 deaths from all causes, of which 34, 
or 32,4 per cent., were from consumption. Of the mortality of furriers from 
respiratory diseaaes, 9 were from pneumonia, 5 from bronchitis, and 3 from 
other respiratory diseases* If the deaths from consumption and respiratory 
diseases are conil:»jned, 48. 7 per cent, of the mortality of furriers was from 
diseases of the longs and air-passages. The excess in the consumption 
mortality of furriers is still more clearly brought out in the tabular presenta- 
tion of the proportionate mortality from this disease by divisional periods 
of life. While the consumption mortality was excessive at all ages, the excess 
was most pronounced at 35-44, when, out of every 100 deaths from all causes, 
63.3 were from consumption, against a normal expected proportion of 23.6. 
The numbers are rather too small for other periods of life to warrant entirely 
safe conclusions. The analysis of the consumption mortality of furriers in 
detail h set forth in Table No, 17 of the Apfjendix. 

MorUdihj of Hatters, — The recorded oioi-tality of hatters includes 832 



1 



TDBERCDL08I8 AS AN INSUBTHIAL DISEASE. — HOFFMAN. 



161 



deathfi from all causes^ of which 27Sj or 33.4 per cent., were deaths from con- 
Bumption. Of the mortality of hatters from respiratoiy diseases, 71 were 
from pneumonia, 4 from asthma, 12 from bronchitis, and 10 from other 
respiratory diseases. If the deaths from consumption and reepiratoTy 
diseases are combined , 45 per cent, of the mortality of hattem was from dis- 
eases of the lungs and mr-passages. The excess in the consumption moi^ 
tality of hatters is still more clearly brought out in the tabular presentation 
of the proportionate mortality from this disease by divisional periods of 
life. \Maile the consumption mortality was excessive at all ages, the excesa 
was most pronounced at 25-34, when, out of every 100 deaths from all 
causes, 55.4 were from consumption, against a normal expected proportion 
of 3L3. Very few deaths from consumption occurred among hatters at 
ages 65 and over, and the proportionate mortality is exceptionally high at 
young ages, having been 53.S per cent, at 15-24. The analysis of the con- 
sumption mortality of hatters in detail ia set forth m Table No. 18 of the 
Appendix, 

Moriolity oj Wool and Worsted Workers. — The recorded mortality of 
woolen mill workers includes 106 deaths, of which 26, or 24.5 per cent., were 
from consumption. Of the mortality of woolen mill workers from respiratory 
diseases, S were from pneumonia, 7 from asthma and bronchitis, and 2 from 
other respiratory di^ases. If the deaths from consumption and respiratory 
diaeaees are combined, 40,5 per cent, of the mortality of woolen mill workers 
was from diseases of the lunga and air-passagea, The excess In the consump- 
tion mortality of woolen mill workers is still more clearly brought out in the 
tabular preaentation of the proportionate mortality from this disease by 
divisional periods of life. While the consumption raortality was excessive 
at all ages, the excess was most pronounced at 25-34, when, out of every 100 
deaths from all causes, 43.8 were from consumption, against a normal ex- 
pected proportion of 31,3. The analysis of the consumption mortality of 
woolen mill workers in detail is set forth in Table No, 19 of the Appendix. 

Mortality of Carpet- and Rug*mak€rs, — The recorded mortality of carpet- 
and nig-makers includes 155 deaths from all causes, of which 37^ or 23.9 per 
cent., w*ere from consumption. Of the mortality of carpet- and rug-makers 
from respiratory diseases, 16 were from pneumonia, 6 from asthma and bron- 
cbitiSi and 4 from other respiratory diseases* If the deaths from consump- 
tion and respiratory diseases are combined, 40.6 per cent, of the mortality 
of carpet- and i-ug-makers was from diseases of the lungs and air-paasagM, 
The excess in the consumption mortality of carpets and rug-makers is still 
more clearly bought out in the tabular pre^sentation of the proportionate 
mortality from this dissease by divisional periods of life. While the consump- 
tion mortality was excesdve at all ages, the excess was most pronounced at 
15-24, when, out of every 100 deaths from ail causeSj 52*9 were from consump- 
TOL. in— 6 



* 





ON TUBERCUy^SIS, 

of 27.8, The analysis of the non- 
:er3 in detail is set forth in Table 

: — The recorded mortality of silk-mill 

ail csoaes, of which 106, or 35.9 per cent., 

ty of silk-mill workers from respira- 

5 from asthma and bronchitis, and 

U the deaths from consumption and res- 

t tfLl per cent, of the mortality of silk-mill 

4£ tfat tun^ and lur-pagsagea. The excess in 

vorkers is still more dearly brought out 

t^l'tite proportionate mortality from this disease 

CQDsumption mortality was excessive 

at 35-^, when, out of every 100 

on, against a normal expected 

^ ihb eocksumption mortality of silk-mill 

cA^IMk )£». 31 of the Appendix. 

mortality of upholsterers in- 

1^1^ 4t^ 31 pvr cent., were from consumption. 

wspiratory diseases, 33 were from pneu- 

S from other respiratory diseases* 

respiratory diiseases are combined, 

jj^tuillilnn I was from diseases of the lungs 

^ fioosumption mortality of uphol- 

- jk th» tabular presentation of the pro- 

by JivUionai periods of life. While 

^v» at aU ages, the excess was most 

.fltjf iOO dejiths from all causes, 5&.5 

expected proportion of 3L3. 

«^^]r of uphclBterers in detail is set 



j^^sT ^u. Organic Dust» 

. '•^ ■»> iHo inhalation of organic dust, 

iniail, including (1) millers; (2) 

The SLggregate mor- 

are presented below in 

from all causes and of the 

l^iwulting proportionate; con* 

lit Ki^ *^^ ^^^ corresponding 




TOBERCULOSIS AS AN INDUSTRIAL DIBEABE. — HOFFMAN* 



163 



CONSUMPTION MORTALiry IN OCCUPATIONS WITH EXPOSURE TO GEN- 
ERAL ORGANIC DUST, 

. MofcTALiTT MOKTAUTT P»0F0RT10M ATJB NoBXAL PKOPOS- 

AOEi AT rftoH Al,L moH Con- CoNffOuraoM tion im Gjcmxhal 

LJEATH* CaMI*, ettUi-nOH. PEfiCENTAQE, PoPULATlOW. 

16-24 506 207 40.9 27.8 

25-34 853 427 50,1 31.3 

35-44 938 340 36.2 23.6 

45Si 905 218 2L9 mO 

65-54 1.163 132 11,4 8.1 

65 and over .1,423 65 4.6 2^ 

Total 5^S 1.389 23.7 14,9 

Martaliiy oj Millers. — The recorded mortality of millera includes 257 
deaths, of which 40, or 15.6 per cent*, were from consumption. The age 
distribution in this occupation is a rather exceptional one, which impairs the 
value of conclusions based upon average, irrespective of age. At the younger 
ages the proportionate mortaHty from consumption is very high, and while 
it continues high to older ages, the number of deaths above age fifty-five is 
quite large, warranting the conclusion that the health-injurious effects in this 
indufitry are not as serious as generally assumed. No doubt there is an 
occupation selection that has its effect and that results in a low mortality 
from all causes at ages under thirty-five. Of the mortality of millera from 
respiratory diseases, 29 were from pneumonia, II from asthma and bron- 
chitis, and 1 from other respiratory diseases. If the deaths from consump- 
tion and respiratory diseases are combined, 31.6 per cent, of the mortaUty 
of milters was from diseases of the lungs and air-passages. The excess in 
the consumption mortality of millera is still more clearly brought out in 
the tabular presentation of the proportionate mortaUty from tliis disease 
by divisional periods of life, Millera, as the term is used in this analysia, 
include all millers, irrespective of the process employed, but it may be said 
on this occasion that the modem rolling-mill process has reduced the degree 
of flour-dust exposure to a minimum, and that health conditions in this 
industry have decidedly improved. The proportionate mortality from con- 
sumption, however, is comparatively high, and decidedly excessive at ages 
under twenty-five. The number of deaths considered, however, for this 
age period is rather too small for an entirely safe generalization. Out of 
every 100 deaths from all causes at ages 25-34, S7.5 were from consumption} 
against a normal expected proportion of 31.3* For a final opinion a larger 
experience would Irm required, but, on the whole, it may safely be asserted 
that health conditions in the flour-miUing industry are very much better at 
the present time than under the conditions that prevailed in the past. The 
analysis of the consumption mortality of millers in detail is set forth in Table 
No, 23 of the Appendix, 

Mortality of Bakers. — The recorded mortaUty of bakers includes 1357 



d 



164 



SIXTH INTERN ATIONAIi CONGRESS ON TUBERCULOSIS. 



deaths from all causes, of which 277, or 20.4 per cent,, were from consumption. 
Of the mortality of bakers from respiratory diseases, 124 were from pneu- 
monia, 17 from asthma, 23 from bronchitig, and 21 from other respiratory 
diseases. If the deaths from consumption and respiratory diseases are 
combined, 34 per cent* of the mortality of bakers was from diseases of the 
limes and mr-passages. The excess in the consumption mortality of bakers 
is still more clearly brought out in the tabular presentation of the propoi^ 
tionate mortality from this disease by divisional periods of life. While the 
ct>naumption niortaUty was excessive at ages under 55, and high at 55-64, 
the numbers at 65 and over are rather too small for an entirely safe conclu- 
Bion* The excess in the consumption mortality was most pronounced at 
25-34j when, out of every 100 deaths from all causes, 42.8 were from consump- 
tion, against a normal expected proportion of 31.3. The analysis of the 
consumption mortality of bakers in detail is set forth in Table No. 24 of the 
Appendbt, 

Mortality of Button-makers. — ^The recorded mortality of button-makers 
includes 127 deaths from all causes, of which 48, or 37.8 per cent., were 
from consumption. Of the mortality of button-makers from respiratory 
diseases, 11 were from pneumonia, I from asthma, and 2 from other respirsr 
tory diseases. If the deaths from consumption and respiratory diseases are 
combined, 48.8 per cent, of the mortality of button-makers was from diseases 
of the lungB and air-passages. The terra button-makers as used in this 
analysis includes a considerable proportion of peiBons employed in the 
manufacture of metallic buttons, where they are ejtposed to the risk of 
continuous inhalation of metallic dust. In the manufacture of ivory and 
mother-of-pearl buttons the risk of exposure, of course, is to the inhalation 
of organic dust. The excess in the consumption mortality of button-makers 
is more clearly brought out in the tabular presentation of the proportionate 
mortality from this disease by dimional periods of life. While the consump- 
tion mortality was excessive at all ages, the excess was most pronoimced at 
25-34, wheUj out of every 100 deaths from all causes, 51 S were from con- 
sumption, against a normal cxjjected proportion of 31.3, The analysis of 
the consumption mortality of button-makers in detail is set forth in Table 
No, 25 of the Appendix » 

Mofialiiy of Leather Workers, — The recorded mortality of leather- 
Trorkera includes 643 deaths from all causes, of which 206, or 32 per cent., 
were from consumption. Of the mortality of leather-workers from respira- 
tory diseases, 63 were from pneumonia, 6 from asthma, 11 from bronchitis, 
and 10 from other respiratory diseases. If the deaths from consumption 
and respiratory diseases are combined, 46 per cent, of the mortality <rf 
leather-workers was from dseases of the lun^ and air-passages. The term 
leather-workers, as used in this analysis, does not include shoemakem^ or 



4 



4 



4 



TDBERCTTLOSIS AS AN INDUSTRIAL DISEASE. — HOrFMAN, 



165 



persona employed in the boot and shoe industry generally, but only such as 
are engaged in the manufacture of leather generally. The excess in the 
oonsumption mortality of lealher-workera is atill more clearly brought out 
in the tabular presentation of the proportionate mortality from this diseafie 
by di\isional periods of life. While the consumption mortality waa excessive 
at ail ages under 65^ the excess was most pronounced at 25-34, when, out of 
every 100 deatlia from all cauaee, 50 were from consuroption, against a normal 
expected proportion of 31.3. The analysis of the consumption mortality of 
leather-workers in detail is Bet forth in Table No, 26 of the Appendix, 

OccuPATioNB Exposing to Municipal or Street Dust. 
In the group of occupations exposing to the inhalation of municipal or 
street dust, four occupations have been considered in detail, including — (1) 
StreetrKjIeaners; (2) cabmen and hackmen; (3) letter-carriers; and (4) 
8tpeetr^!ar motormen. The aggregate mortality data available for this group 
of occupations are presented below in tabular form, including a statement 
of the deaths from all causes and of the mortality from consumption, together 
with the resulting proportionate consumption mortality by divisional 
periods of life, and the corree ponding averages for the general population. 

CONSUMPTION MORTALiry IN OCCUPATIONS WITH EXPOSURE TO MUNI- 
CIPAL OR STREET DUST. 

. itoKt/kUTT MottTAUTT PlIOf^MtTIONATIC NoRUaL PbOIpOB- 

A^^* ^"^ ntou Aex noil Cqn- Conaduftidn tiom u4 Genxhal 

L>EATH. CaDBM. flUMmOH^ PBBCEKTAQB. POPULATION, 

16-24....... 113 45 39.S 27A 

25-34 449 194 43.6 31.3 

35-44 , . 382 132 34,6 23.6 

45-54 310 44 14.2 16.0 

65-d4 222 24 10.8 S.l 

eeondoi'-er. . 138 4 2.9 2M 

Total 1,611 443 27.5 14,8 



I 



Mortality/ of Stred-ckaners, — The recorded mortality of streetr-cleanera 
includes 179 deaths from all causes, of which 32, or 17.9 per cent., were 
from consumption. Of the mortality of street cleaners from respir- 
atory diseases , 23 were fro ra pneu moni a, 8 from aathraa and bron- 
ehi^, and 2 from other respiratory diseases. If the deaths from con- 
sumption and respiratory diseases are combined, 36.2 per cent, of the 
mortality of street-cleanere was from diseases of the lun^ and air-passages. 
The excess in the consumption mortality of street^leanere is more clearly 
brought out in the tabular presentation of the proportionate mortality from 
this diaeaae by divisional periods of life. The only decided excess in 
the mortality from consumption in this occupation occurred at ages 2&-34. 
There was no death recorded at ages under 25. The employment is one that 



IM 



SDCTH INTERNATION'Aii CONGRESS OPf TtTBERCULOSIS, 



attracts men in declming physical vigor, whose active years have been spent 
in other occupations, and who, perhaps, have survived other health-injurioua 
conditions because of an originally sound and strong constitution. The 
number of deaths is too small for an entirely conclusive opinion, but at agea 
25-34 the proportionate mort^ality from consumption was 44.4 per cent., 
at ages 35-44 it was 33.3 per cent., and at ag^ 45-54 it was 14.0 per cent. 
The analysis of the consumption mortality of streetrcleaners in detail is set 
forth in Table No. 27 of the Appendix, 

MorUUUy of Cabjiien and Hackmai. — ^The recorded mortality of cabmen 
and hackmen includes 654 deaths from all causes, of which 165, or 25.2 per 
cent., were from consumption. Of the mortality of cabmen and hackmen 
from respiratory diseases, 94 were from pneumonia, 6 from asthma, lO from 
bronchitis, and 12 from other respiratory diseases. If the deaths from 
consumption and respiratory diseases are combined, 43J per cent- of the 
mortality of cabmen and hackmen was from diseases of the lungs and air- 
passages. The excess in the consumption mortality of cabmen and hackmen 
is more clearly brought out in the tabular presentation of the proportionate 
mortality from this dbease by di\nsiGnal perioda of life* The proportionate 
mortality from consumption was excessive at all ages under fifty-five, but 
the excess was most pronounced at ages under twenty-five, when, out of 
every 100 deaths from all causes, 47,4 were from consumption, against a 
normal expected projxjrtion of 27.S. The analysis of the consumptica 
mortality of cabmen and hackmen in detail is set forth in Table No. 2S of 
the Appendix. 

Mortality of Letter-carriers. — ^The recorded mortality of letter-carriera 
includes 213 deaths from all causes, of which 59, or 27.7 per cent., were 
from consumption. Of the mortality of letter-carriem from respiratory 
diseases, 16 were from pneumonia, 5 from asthma and bronchitis, and 5 from 
other respiratory diseases. K the deaths from consumption and respiratory 
diseases are combined, 39,9 per cent, of the mortality of letter-carriers was 
from diseases of the lungs and air-passagea. The excess in the consumption 
mortaJity of letter-carriers is more cleariy brought out in the tabular pres- 
entation of the proportionate mortality from this disease by divisional 
periods of life. While the proportionate consumption mortality was exces- 
sive at all ages under 45^ it was high at 45-64, while at 65 and over the 
number of deaths b too small for a safe generalization. The excess in the 
mortality from consumption was most pronounced at 35-44, when, out of 
every 100 deaths from all causes, 42,1 were from consumption, against & 
normal expected proportion of 23.6* The analysis of the consumption 
mortality of letter-carriers in detail is set forth in Table No. 29 of the 
Appendix. 

Mortality af Street-car Mot^^rrrwn. — ^The recorded mortality of streetr-car 



tITB&RCULOSra A3 AN DIDDStTMAL DISEASE. — HOFFUAK. 



167 



motonnen includes 375 deaths from all causes, of which 121, or 32,3 per cent.; 
were from ctiasumption. Of the mortality of street-ear motorxnen from 
respiratory diseases, 33 were from pneumonia, 2 from bronchitis, and 5 
from other respiratory diseases. If the deaths from consumption and 
respiratory diseases are combined, 42.9 per cent, of the mortality of street- 
car motormen was from diseases of tlie lungs and air-passages. The excess 
In the consumption mortaHty of street-car motormen is more clearly brought 
out in the tabular presentation of the proportionate mortality from this 
disease by divisional periods of life. While the proportionate consumption 
mortality was excessive at all ages under 65, the excess was most pronounced 
at 25-34, when, out of every 100 deaths from all causes, 45.5 were from 
consumpllonj against a normal expected proportion of 31.3. The analysis 
of the consumption mortality of street-car motormen in detail is set forth 
in Table No. 30 of the Appendix. 

Conclusions, 

Summarizing these statistical observations regarding the approximate 
degree of consumption frequency in selected oc(?upations, the most important 
conclusion deducible from the facts is the extraordinary mortality from con- 
sumption among men in dusty trades during the age period of 25-34, At 
this age perifKl among the employments considered, from 3S.9 per cent, to 
87,5 per cent, of the deaths from all causes are from consumption, in contrast 
to a normal expected proportion of 3L3 per cent. The mortality from 
respiratory diseases in these occupations is also, almost without exception, 
above the average^ and combining the deaths from consumption with the 
deaths from respiratory diseases, from 31.6 per cent, to 66.4 per cent, of the 
deaths from all causes in these employments are from diseases of the )un^ 
and air-pflssages. The normal proportion of <leatli3 from consumption at 
a^QS 25-^4 is, however^ for the male population as a whole, including all 
employments, quite considerably above the average for exclusively outdoor 
occupations, in which the degree of exposure to dust inhalation is reduced 
to a minimum. The contrast in the proportionate consumption mortality 
in indoor and outdoor occupations is truly startling. It requirE^ no very 
extended or detailed statistical analysis t^ determine with approximate 
accuracy the amount of waste of human life resulting from present conditions 
in oertwn trades, and all who have written upon the subject of occupation 
diseases have emphasized the extraodinary degree of consumption frequency 
in dusty traded. 

The problem of occupation mortality and tuberculosis, with special 
reference to that period of Ufe at which the degree of consumption frequency 
is most excessive, may now be briefly restated as follows: The oeDsus 
mortality rate of 1900 for men in gainful occupations was 15 per 1000, 



d 



16S 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



and the consumption death-rate 2,4, or 16 per cent., of the mortality from 
all causes. Among men in manufacturing and inechanical industries the 
general death-rate was 13.8 per 1000, and the consumption death-* 
rate 2.6, or 18.8 per cent., of the raortality from all causes. Among 
men in agricultura!, transportation, and other outdoor occupations 
(including^ however, a considerable proportion of persons of advanced 
years), the general death-rate wbb 15,8 per 1000, and the consumption 
death-rate K5, or 9.5 per cent., of the mortality from all causes. Con- 
trasting the consumption death-rates in these two groups of employments, 
the enormous waste of human life La industry l^econies readily apparent. 
If the consumption mortahty in dusty trades could be r^uced to the cor- 
responding proportion for men in outdoor occupations, a very largp number 
of Uvea would be saved and continue for many years, which are now, to a 
large extent, needlessly wasted. 

The problem may be emphasized by a few specific illustrations of occu- 
pations exceptionally exposed to the risk of dust inhalation. The census 
mortality rate for marble- and stone-cutters was 14.9 per 1000, and the 
consumption death-rate 5.4, or 36.2 per cent., of the mortality from all 
causes. The general death-rate of cigar-makers w^as 187 per 1000, and the 
consumption death-rate 4,8, or 25,7 per cent., of the deaths from all causes. 
The general death-rate of printers and compositors was 12.1, and the con- 
sumption death-rate 4.4, or 36.4 per cent., of the mortality from all causes, 
while for the strictly outdoor labor class, that is, farmers, planters, and 
farm ]abon?rs, the general death-rate was 17.6 per 1000, but the consumption 
death-rate was only 1.1, or 6.25 per cent, of the mortality from all causes. 
Granting that these rates an3 not entirely trustworthy, and that the census 
method of mortality investigation at that time was not as technically perfect 
as it is at present, and granting, further, that all occupation mortality data 
have their inherent defects when derived from general methods of population 
enumeration and the methods in vogue in the registration of deaths, there 
b not the slightest reason to question the approximate accuracy of the 
foregoing rates and conclusions, which are in strict conformity to the other 
facts previously presented. 

Estimating the wage^arning population of the United States at agee 
fifteen and over for 190$ at 32,088,000, and assuming a consumption death- 
rate among this element of the population of 2.4 per 1000, the estimated 
number of deaths from consumption among wage-earners would be 77,000. 
Since it is possible, by intelligent factory inspection and control, and with 
special regard to local ventilation (that is, the removal of injurious dust- 
particles at the point of their oripn), to eliminate almost entirely the con- 
ditions injurious to health and life in factories and workshops and industry 
generally^ it is not going too far to advance it as a fundamental principle of 



.J 



TOBERCUIiOSIB AS AN INDU8TBIAL DISEASE. — ^HOFFUAN. 169 

sanitaiy I^bslation that the consumption death-rate among male wage- 
earners can be reduced, by intelligent methods, to at most 1.5 per 1000. 
If such a reduction should result, there would be an annual saving of 28,880 
human lives. Since the average age at death of persons d3dng from consump- 
tion is 37.4 years for all occupations, and probably not much more than 
32 years for men employed in strictly dusty trades, and since the normal 
average age at death in the mortality from all causes is 52.8 years, there 
would be an expected gain of at least 15.4 years of life for every person 
whose death from consumption was avoided by rational conditions of in- 
dustrial life. Such a gain would represent a total of 444,750 years of addi- 
tional lifetime, and by just so much the industrial efficiency of the American 
nation would be increased. If we place the economic value or net result of 
a year's lifetime at only $200, the total economic gain to the nation would be 
$3080 for eveiy avoidable death of a wage-earner from consumption, repre- 
senting the enormous total of $88,950,400 as the aggregate annual financial 
value in the probable saving in years of human life. With such results 
clearly within the range of practical attainment, nothing within reason 
should be left undone as a national. State, and individual, or social, duty 
to prevent that needless, but now enormous, loss of human life from con- 
sumption in American industry. 

APPENDIX.* 
TABLE 1.— MORTALITY OF GRINDERS FROM OONSUMPnON- 

DeaTHB DbaTBS PsOPOItTIONATB 

Aaxs AT Dbatu. frou All fbou Con- Conbumption 

Caubes. BVumoH, Pbbcbntaos. 

15-24 7 4 67.1 

25-34 24 17 70.8 

35-44 38 24 63^ 

45-64 30 12 40.0 

65-64 20 6 26.0 

65 and over 9 1 11.1 

Total 128 63 49.2 

TABLE 2.— MORTALTTY OF POLISHERS FROM OONSUilPTION. 

DsATHB Deaths PsoroBTioNATH 

AOBS AT DCATR. FHOU AlX THOU CoN- CONSUHPnON 

Causes, sviipnoH. Fbbcentaok. 

15-24 48 22 45.8 

26-34 75 42 56.0 

36-44 68 29 42.7 

45-64 48 11 22.9 

65-64 19 4 21.1 

65 and over 21 

Total 279 108 38.7 

*The tables in this Appendix are aU based on Industrial Insurance Mortality 
Experience, 1897-1906. 



170 



BIXTH INTERNATIONAL CONQBEBS ON TUBEKCtJLOSlS. 



TABLE 3.— MORTALITY OF BRASS-WORKERS FROM CX>NSUMPTION. 

Deat^ DsAfsB Pbofobtionatk 

AawB AT Dbath. fbdh All. fkom Con- CottBUumofr 

Causeb. fluuraoH. Pkpckhtaqr. 

15-24 66 39 fiS.l 

25-34 112 m SOJ) 

35^4 91 41 45.1 

45^54 58 14 24.1 

55-64 54 11 30.4 

65 and over... 33 

Total 414 161 38.9 



TABLE 4.— MORTALITY OF TOOL^ AND INSTRUMENT-MAKERS FROM CON- 
SUMPTION. 

Deatob Deatks Pro poutionate: 

Aa^ AT Death. f*dii Au. moM Con- CoNBt;ypnoK 

Cadbcb. BVumoH. Pehcentaqb. 

15-24 40 13 32-S 

25-34 59 35 S»JS 

35-H.. ......,., 68 34 35.3 

45-54 m 21 37JS 

55-64. 32 4 12JS 

65 and over 48 4 6^ 

Total 303 101 33^ 

TABLE 5.— MORTALrry OF JEWELERS FROM COKSUMPTION. 

DtATRB DelaTHS FBOrOBTION AT* 

AaE4 AT Death nu>u Au. moM Com- C«ttBtrHPXtoH 

CAUBBi ai^MJ^JON. FmCKKTAOK. 

15-24.. 60 24 40,0 

25-34... 74 44 SdJB 

35-44 Bft n 44.0 

45-54 SO 13 22.0 

65-64... 77 7 9.1 

65 a.niJ over 83 3 3.6 

Total .,. 403 113 28.0 

TABLE 6.— MORTALTTY OF ENGRAVERS FROM OONSUMFTION. 

Deaths Deaths Propohtiokatk 

Aan Ai Dkata. rvoM Alc rROM Com- CoMtpim'ioit 

Causui. BfUifmay. PcticEivTAaK, 

15-24 31 12 38.7 

25-34 47 2& 61 J 

35-44 _ 42 1» 45.2 

45-54 34 5 14.7 

55-64 19 2 lOJS 

65 and over ,.. 19 

Total 192 er 34.9 

TABLE 7.— MORTALITY OF PRUvTFERS FROM CONSUMPTION. 

Deatii« DfATa« PiFiorotrtioMATa 

Aaia AT Dkatv. moH Ax^i. raoii CoN'< Co.sfii^uTTioN 

CAOaiC. •tTKFtKlH. PEnCEHTAOa. 

15-24 344 ie7 4S.6 

25-34 439 247 56,3 

36-^4 346 140 40.5 

45-54.... 211 42 19.9 

55-64 142 18 9.3 

65 and over 108 4 2,7 

Tot«l 1.500 012 3S.6 



■ 



J 



TUBERCULOSIS AS AN INDUSTRIAL DISBASE.— HOFFUAN. 171 

TABIE 8 — MORTALmr OF COMPOSITORS FROM CONSUMPTION. 

Deaths Dsatbs Pbopobtiohatb 

Aon AT Dbath. from All pbou Con- ComnHPnoN 

CauBM. ftUHPTSON. PkBCBNTAOS. 

16-24 21 6 28.6 

26-34 64 36 66.7 

36-44 32 12 37.6 

45-64 19 3 16.8 

66-64 33 1 3.0 

66 and over 9 1 11.1 

Total 168 69 36.1 

TABLE 9.— MORTALITY OF STONE-WORKERS FROM CONSUMPTION. 

Dkathb Dbatbb Pboportionatb 

AoEB AT Dzath. fsoh All moM Con- Conbuhption 

CaTOIS. BUHPnON. Fsbcentaob. 

16-24 21 10 47.6 

26-34 114 60 62.6 

36-44 172 82 47.7 

46-^ 232 91 39.2 

65-64 199 52 26.1 

66 and over 120 7 5.8 

Total 858 302 35.2 

TABLE 10.— MORTALITY OF MARBLE-CUTTERS FROM CONSUMPTION. 

Deaths Deaths Pboportionats 

AoEB at Death. fboh All fboh Con- Conbum ption 

Caubis. smcpTiON. Pbbcentaob. 

15-24 3 

26-34 30 15 60.0 

35-44 40 16 40.0 

45-54 ; 46 16 34.8 

65-64 60 7 14.0 

66 and over 31 2 6.6 

Total 200 66 28.0 

TABLE 11.— MORTALITY OF GLASS-BLOWERS FROM CONSUMPTION. 

Deaths Deaths Propobtionate 

AoEB AT Death raou All rsoH Con- Conbuuption 

Caubm. sumption. Percbhtaqb. 

15-24 24 11 46.8 

26-34 78 44 66.4 

35-44 69 15 25.4 

46-54 55 11 20.0 

56-64 26 1 3.8 

66 and over 40 8 7.5 

Total 282 86 * 30.1 

TABLE 12.— MORTALITY OF GLASS-CUTTERS FROM CONSUMPTION. 

Deaths Deaths Pboportionatb 

AoEB AT Dbath. fboh All fbom Con- Conbdhption 

Caubis. sumption. Pbbcentaob. 

15-24 26 7 28.9 

26-34 30 14 46.7 

35-44 27 11 40.7 

46-64 20 6 26.0 

56-64 8 1 12.5 

65andover 5 2 40.0 

Total 116 40 34.5 



^H 172 FITXTH IKTEHNATIONAL CONGREBd 


OK TLBERCUL0S1B* ^^^^^^| 


^■^^^ TABLE 13 


—MORTALITY OF POl'lliRS FROM CONSUMPTION. ^^H 






DEAtOA 


Deatds 


Pbohbttohat* I 


^^^^^^^B Ages at 


FROM Atl, 


raPH CoH- 


OQimVHFTlOIf 






Causes. 


■ DHPnDH 


Vmc^tTKaw. 


^^^^^^ 1&-24...... 




. 46 


11 


23,9 


^^^H 25-34 




. 68 


96 


52.9 


^^H 36-14 




. 84 


ST 


44i> 


^^^H 45-54 




. 78 


22 


2B,2 


^^^H 55-64 




. 72 


14 


19.4 


^^^^H 65 &nd over 




, 36 


7 


19.4 




^^^1 




, 384 


127 


33.1 


^^^ TABLE 14.— 


MORTALITY 


OF PLASTERERS FROM OONSUMPriON. 1 






Dejlthb 


Deaths 


Fropobtiof<atb 1 


^^^H AOBB 


t/T DlUTB. 


FftDU ALU 


rsoM Con- 


CoN'HUMPTtON 1 






Causes, 


suiipnoN, 


Pemcentaok. 1 


^^^1 




. 25 


7 


2S.0 ^J 


^^^H 25-34 




. 78 


35 


44.9 ^M 


^^^H 35-44 




, 107 


3ft 


35.5 ^M 


^^^I 46-54.,^.., 




. 127 


35 


27.6 1 


^^^1 55^^ 




. 121 


16 


13.2 J 


^^^^H 65 and over 




. 119 


6 


m 


^^H 




. 677 


136 


23.6 .^^ 


^^H TABLE 15. 


-MORTALITY OF SPINNERS FROM OONSUMPTION. j 






Di^ATOa 


DtATns 


PHOPOHTIONATE 


^^^H 


*.T Dkatq, 


FSDM All 


moM €oN- 


GONnrMmoN 






CAtiSEIt, 


fiUHPnOK. 


PCHCENTAQK, 


^^H 1^-24 




. 28 


13 


46.4 


^^H 25^34 




. 38 


19 


50.0 


^^^1 35-44 




. 36 


16 


44.4 


^^^H 45-54 




. 27 


7 


25.9 


^^^H 55-64 




. 37 


1 


2.7 


^^^^^B 65 aiid over 




. 23 




_ 




^^^1 




. 189 


56 


29.6 ^M 


^^^H TABLE 


-MORTALITY OP WEAVERS FROM OONSUMPriON. ] 






Durns 


DEATtIS 


P»OPOTmOK*TB 


^^^H Aan 


kT Duth. 


nioH All 


mou Cos- 


CONSl-'UPTION 






CaV»K8. 


SUlUTiaBf, 


Pelrciintaok, 


^^^1 15-24 




. 108 


43 


39.8 


^^^1 25-34 




, 174 


93 


53.4 


^^^H 35-44 




. 155 
. 144 


59 
37 


38,1 
25.7 


^^^1 45-54 




^^^1 55-^ 




. 137 


15 


J0.9 


^^^^H 65 ^Dtl over 




. 197 


7 


3.6 


^^H Total 




. 915 


254 


27.8 


^^^TABLE 17.— MORTALITY OF FURRtERS AND TAXIDERMISTS FROM OON- 1 






SUMPTION. 










Dbathi 


Dkatbb 


Pnoi^nnoNATi 


^^^^^1 Aom At DuTH. 


FROH AU. 


mom CoH- 


Cos^VtfPTJOH 






Caitses, 


SUHimO?!, 


FEHrKNTAOE^ 


^^^1 1&-24 




3 


I 


33^ 


^^^I 25-34 




18 


7 


38.9 


^^^1 35-44 




. 30 


Id 


63,3 


^^^H 45-54 




. 13 

24 

, 17 


i 

1 


acs 

8^ 
5,9 


^^^H 65-ft4 




^^^^H 66 and over. 






^^H Total 




. 105 


34 


22.4 



TTTBSBCULOBIS AB AN INDTTSTBIAL DISEASE. — HOFFMAN. 173 

TABLE 18.— MORTALITY OF HATTERS FROM CONSUMFnON. 

Deaths Dkaths Fbopobtionatb 

Aois AT DsATH. raoH Aui froh Com- CoNBUHpnoir 

CaUSBS. SCHPTION. PEHCCMTAaS. 

16-24 78 42 63.8 

26-34 176 97 65.4 

36-44 186 84 46.4 

46-64 127 34 26.7 

6&-64 135 20 .14.8 

66 and over 132 1 0.8 

Total 832 278 33.4 

TABLE 19.— MORTALITY OF WOOL AND WORSTED WORKERS FROM CON- 
SUMPTION. 

Dbatbb Deaths Pbopobtionate 

AoEB AT Death. from Aix froh Con- Comsumptioh 

CaUBIS. SnCFnON. PEaCSNTAOS. 

16-24 20 7 36.0 

25-34 16 7 43.8 

36-44 14 6 35.7 

46-n54 19 4 21.1 

66-64 24 3 12.6 

65 and over 13 

Total 106 26 24.5 

TABLE 20.— MORTALITY OF CARPET- AND RUG-MAKERS PROM CONSUMP- 

TION. 

Deaths Dbatms PBoroanoHATB 

Aan at Death. vsou Aix vroh Con- CoNsimmoN 

Causes. buhfhon. PEBCBMTAaB. 

15-24 17 9 62.9 

26-34 22 10 45.5 

36-44 17 6 36.3 

46-64 24 6 20.8 

66-64 34 4 11.8 

66 and over 41 3 7.3 

Total 156 37 23.9 

TABLE 21.— MORTALITY OF SILK-MILL WORKERS FROM CONSUMPTION. 

Deaths Deaths Pbopoetionatb 

AoES AT Death. rBOK An. rBOM Con- CoNstmmoM 

Cactes. STTMFnoN. Feecemtaob. 

16-24 82 28 34.1 

25-34 61 32 62.6 

35-44 55 33 60.0 

46-64 31 7 22.6 

65-64 37 4 10^ 

66 and over 29 2 6.9 

Total 296 106 35.9 

TABLE 22.— MORTALITY OF UPHOLSTERERS PROM OONSUMPnON. 

Deaths Deaths Phopoatiomatb 

Aois AT Death. feoh All from Con- Conbdhption 

Causes. suhphon. Pebcentaob. 

15-24 39 16 38J$ 

25-34 66 38 68.6 

36-44 79 38 48.1 

46-64 73 18 24.7 

66-64 62 3 4.8 

66 and over 03 6 9U( 

Total 381 118 31.0 



174 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



TABLE 23 —MORTALITY OF MILLERS FROM CONSUMPTION. 

Aawm AT Dbath. FnoH All tboh Con- Consuuption 

15-24,,,. 7 a 2S.6 

25-34 8 7 87,5 

35-14 ..*. 27 8 a.6 

46-64 39 11 285 

55-64 « 9 14.1 

6S and over. 112 3 2.7 

Total , 257 40 15,G 

TABLE 24,— MORTALITY OF BAKERS FROM CONSUMPTION. 

Deatbb Deaths FnopoBTtoitATB 

Aawm AT DiATH rmoii An. mau Cdn- CoNBumnoH 

CAUSiS. BtTlWFtlON PlLRCeNTAQB 

15-24 112 43 38.4 

25-34 201 8fi 42.8 

35-44,, 259 76 29.0 

45-54,. 248 43 17^ 

56-64 250 23 9.3 

65 and over 287 7 2.4 

Total 1 ,357 277 20.4 



TABLE 25.— MORTALITY OF BITTTON MAKERS FROM CONSUMPTION. 

DeATAA DkaTRB PxOPOIlTIONJkTB 

Aosa AT Du^TH. nou All mou Coh- CoNeuMPnt^N 

CAPKCa. SUHFITON. PkRCKITTAOV. 

16-24 24 12 50.0 

25-34 3i 16 61.6 

35-44.. 32 12 37.5 

45-54 24 6 25.0 

55-54 6 1 16.7 

65 and over 10 1 10,0 

ToUl 127 48 37.8 

TABLE 26.— MORTALITY OF LEATHER-WORKERS FROM CONSUMPTION, 

Dkatsb Death! PnoHiBTiaHATB 

Aan AT DukTB, rmou Au. nou Cos- Cott»c«moK 

CU DflW HDli PrtOHt. PXKCKKTAOK. 

15-24.. 92 35 38-0 

25-34 154 77 fiO-O 

36-44 156 65 35.5 

45-54 100 29 29.0 

65«ft4 SO 9 113 

eS and over 63 1 1.6 

Total 643 206 32.0 



TABLE 27.— MORTALITY OF STREET-CLEANERS FROM CONSUMPTION. 

DeATKA DeATHI PaOPDirTIOKA'tll 

Aawm AT DsATM. r«aii Au. rmou Cok- CoKBuvprtoN 

Catb^ ■uHRiQii. PxscnDrTAio& 

15-24 

35-34 18 8 44.4 

35-44 36 12 33.3 

45^54 47 7 14.9 

66-64 44 3 6.8 

65 and over H 2 5.9 

Tbtal 179 33 17.9 



TUBEBCULOBIS AS AN INDUSTRIAL DISEASE.— ^HOFFUAN. 175 

TABLE 28.— MORTALITY OF CABMEN AND HACKMEN FROM CONSUMPTION. 

Deaths Deaths FBOPOKnoirATa 

Aoie AT DZATB. FBOH AxL VBOM CON- CONSUMPHON 

CauSM. BVHRIOM FamCBNTAOB. 

15-24 38 18 47.4 

2&-34 136 58 42.6 

35-44 166 63 34.2 

45-54 162 24 15.8 

65-64 105 11 10.6 

65 and over 68 1 1.6 

Total 664 165 25.2 

TABLE 29.— MORTALITY OF LETTER CARRIERS FROM CONSUMPTION. 

Deaths Deaths Pxoportiomatb 

Aam at Death. proh All tbou Con- Coksuuptioh 

Causes. suhption. PxB<»MTAaB. 

16-24 10 4 40.0 

25-34 58 23 39.7 

45-44 57 24 42,1 

45-54 29 3 10.8 

55-64 34 4 11.8 

65 and over 25 1 4.0 

Total 213 50 27.7 

TABLE 30.— MORTALITY OF STREET-CAR MOTORMEN FROM CONSUMPTION. 

Deaths Deaths Pbopobtionatb 

AoES AT Death. fboh Atx ntoH Con- CoMSTTHFnoM 

Causes. suMpnoH. PsiicsifTAOH 

15-24 30 13 43.3 

25-34 145 66 46.5 

35-44 92 27 29.3 

45-54 63 9 14.3 

56-64 36 6 16.7 

65 and over 9 

Total 375 121 32.8 



La Tuberculosis como una Enfennedad Industrial. — (Hoffman.) 
Para que los esfuerzos activos en reducir la mortalidad consecuentes & 
la tubercxilosis sean efectivos, se reqmere el reconocimiento de que dicha 
enfermedad proviene de las ocupaciones, y tambien hacer la necesaria 
diferencia entre la tisis fibrosa y la tuberculosis general, de la cual la primera 
puede conciderarse como una enfermedad especi&ca de ciertos modos de 
vida. Se hace ima estadlstica de la mortalidad en los Estadoe Unidos 
debida i la tuberculosis, entre los diferentes elementos de la poblaci6n, con 
referenda especial de la edades y el sexo, 6 incluye un cuadro de la propord6n 
de la mortalidad por consundon entre los varones, por divisionee peri6dica8 
de la vida, como modelo para oomparar la mortalidad correspondiente por 
esta enfennedad en treinta ocupaciones en las cuales el obrero estd expuesto 
al polvo, y que son cuidadosamente escojidas. Los datos de la mortalidad 
consecuente i la ocupaci6n, son tomados de las memorias, todavfa no 
publicadas, de la Experiencia Industrial de la Prudendal Insurance Company 



176 



8IXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



of America, durante el perfodo de diez aaoa haata 1906. Los datos es* 
tadfsticos estdn ilustrados por medio de disenoa grdficoa colorados en uso 
en la exhibici6n de la Aaociacidn Nadonal, Leis ocupaciones e3t6.n agrupadas 
de cuerdo con k clase de polvo al cual iaa personaa Jian estado expuestaa, 
a saber: met4Uco, mineral, de fibraa vegetales, fibraa animales y mixtas, 
organico en general, y polvo de la calle. Cada ocupaci6n esta considerarda 
en detalle A f£n de indicar la taortalidad excraiva en ciertas ocupaciones en 
particular, y comparada con la mortalidad normal en las ocupaciones 
generalea de la poblacion. Se presentan numeroaos cuadroa que repre- 
sentan los hechos actuales que forman la base de esta discuci6n. Los 
aspectos econ6micos del tema son indicadoa, lo cual demuestra que mis o 
m^nos 70,000 obreroa fallecen inneceaariamente en los Estadoa Unidos de 
esta enfermedad. La mortalidad preaente consecuente 4 la tuberculosis 
entre los hombres de ocupaciones lucrativas, sc dice ser de 2.4 por 1,0CK) de 
poblacion, 6sta, en la opini6n del aiitoFj puede reducirse d L5 lo cual significa 
el ahorro de 30,000 vidas utiles al ai5o. Pueato que la muerte de tuberculosis 
ocurre como t^rmino medio d la edad de 37.4 ailos, contra 52.8 afios en las 
otras enfermedads, es de esperarse una ganancia de 15.4 aiios de vida por 
cada persona cuya muerte de tuberculosis pudiera prevenirse por medio de 
con di clones racionales de la vida industrial. Tal ganancia tendrla un valor 
equivaleate financial de casi SOO^OOOjOOO, 



n 



Tuberculosis comni€ une maladie industrielle. — (Hoff&ian.) 
B est n^ceasaire pour le succfra dea efforti* entrepria pour r^duire la mor- 
tality due k la tuberculose, d'envisager cette maladie comma une maladie 
industrielle et de faire une distinction entre la tuberculose en gt'm^ral et la 
phtisie fibreuse, cette derni^re pouvant ^tre consideriSe comme une maladie 
caractdristique de certains mdtiere. En tenant compte de Tdge et du sexe, 
comprenant une table pnjportionelle de la mortality parmi lea hommes 
durant les diff^rentes pdriodes de la vie, une statistique a 6t^ faite de la 
mortality due k la tuberculose dans les Etats-Unis, qui sert de module de 
comparaison avec la mortality due k cette maladie dans trente diMrents 
metiers soigneusement choisis parmi ceux expos^ aux poussi^res. Lea 
renseignements relatifs i la mortality parmi les m^^tiers out ^t6 pris dans lea 
archives jusqu'^t pr^nt incites de V Experience Industrielle de la Pruden- 
tial Insurance Company of America. Cea renseigncmenta sont illustrfia 
par des courbes en couleur pour Tusage de I'exposition ambulatoir (traveling 
exhibit) de la National Association. Les metiers aont groups suivant le 
getu*e de poussi&res auxquela ils sont expos^-s, ra^talliques, fibres v^g^taleSi 
Ebres v^g(5taJes el animaies m^langte^ organiques en gfin^al, pouasi^res 
des rues. Chaque metier est considers en detail durant un temps suffisament 



4 



TtTBERCtJLOaiS AS AN INDtTSTHlAL DISEASE.— HOFFNCAK. 

long poiiT faire bien ressortir Texcessive mortality due h, la tuberculoee dans 
certmns d'entre eux, et donne le contraste avec la raorlaJit^ nomiale due k 
la tuLierculose dans !a population en g<!n^raK Attach^es A C8tte statiatique 
se trouvent de nombreuses tables pr^sentant lea faits aur lesquela reposent 
ces conclusions. Enfin le c6t^ social du sujet est accentu6 par I'exposition 
de la perte annuelle de 77,000 viea parmi les ciasaes ouvri^res dea Etats- 
UniSj due h. la tulierculose. La mortality due k cette maladie parmi lea 
hommes actuellement employes dans diff^rents metiers est de 2.4 pour 1000 
de la population. Dans I'opinion de I'auteur il serait possible, par remploi 
de m^thodes rationelles de prevention de r^luire la mortalit6 k 1.5. Ce 
pfeultat serait ^uivalent h plus de 30,000 viea utiles sauvfes. 

La moyenne de V^ge d'une personne mourant de la phttsic est de 37.4 
aas, GcUe d^une personne mourant de toute autre cause 52. S ans; 11 s'en suit 
que pour rhaque personne gudrie de la tuberculose par Tadoption de inesurea 
pationelles de vie industrieUe il aerait fait un gain de 15,4 ans tie vie. Un tel 
rfeultat signifierait une valeur de presque iDO|000,000 dollars, L*auteur 
arrive k la conclusion que "un tel rdaultat pouvant fitre atteint^ rein ae 
doit ^tre ndglig^, de la part de la nation, des ^tats et dos individua pour 
^conomiser cette ^norme et inutile perte de vies due k la tuberculose, dans 
rLndustrie am^icaine. 



Tuberkulose als ein« Industrie-Krankbeit. — (Hoffman.) 
Aktive Bemiihungen, die Sterblichkeit der Tuberkulose zu reduzieren, 
verlangen ilire Erkeniiung als eine Beschaftigungskrankheit und die notige 
DiSereniiemng von fibroider Phthisis und allgemeiner Tuberkulose, von 
weichcn tiic erstere als eine sjiecifische Betrieb^krankheit angeschen werden 
mag. Es ist eine statistische Vorlage der Sterblichkeit von Schwindsucht 
in den Vereinigten Staaten unter den verschiedenen Elementen der Bevol- 
kerung vorhanden, mit besonderer Bezugnahme auf Alter und Geschlecht, 
mnsehilGssend eine Tabelle der proportionalen Sterblichkeit von Schwind- 
gucht unter mfinnllchen Indi\iduen wahrend einzelner Lebensabschnitte, 
ala eine Verglcichseinheit mit der korrespondierenden Sterblichkeit von 
dieser Krankheit in dreissig sorgfiiltig ausgewahlten staub-exponierenden 
Bclneben. Die Daien, welche die Betriebs-Sterbliehkeit erlautem^ aind von 
den bisher unveroffentlichten Tabellen der industrieUen Erfahrungen der 
Prudential Insurance Company of America fiir das mit 1006 schliessende 
Jahrzehnt abgeleilet worden. Die statistischen Daten, illustriert durch 
mne Scrie von colorierten Zeichnungcn, aind fiir den Gebrauch in der am- 
bidatorischen Ausstellung der National Association bestimmt. Die Betriebe 
sdnd nach der Art der staubgcbenden Verhaltnisse in metallischo, minera* 
lische, Pflaiizenfasem, tierischc und gemiscbte Fasem, oUgemdn organische. 



i 



d 



FACTORY LEGISLATION AND TUBERCULOSIS. 
By John Mahtik, 

New York, 



Our campaign should be earned vigorously into the factories^ workshops, 
bakeries, stores; for there, while men and women are at work, the bacillus 
against which we war often finds his best opportimity. 

Conditions that Invite attack prevail in many industriea. The proof 
of this statement must be taken chiefly from foreign iuvegtigations, because 
medical examination of the effects of industrial processes has not been 
made in America a^ thoroughly aa in western Europe. But we know that 
like conditions breed like results, regardless of nationality. Disease germs 
are no respecters of race. They will bring down an American with as little 
compunction as an Englishman or a German, entirety oblivious to the fact 
that, &s a sovereign citizen^ he is entitled to the immunities of royalty. 
And since, taking the country through, our factory legislation is less strin- 
gently drawn and more laxly enforceti than the lawa of England and Ger- 
many, it Is clear that whatever toll disease exacts in the mills and factories 
of those countries is being paid in full also by the workers under the stars and 
stripes. Dr. Doehring'a report to the Labor Department of the United 
States, on "Factory Sanitation and Labor Protection/' shows that a good 
proportion of the factories he visited were unsanitary, and of one he says: 
" The only proper measure of improvement would be the complete supprea- 
Kon of the whole factory.*' 

To teach us how our campaign is going we need investigations of all 
occupations such as Dr, Doehring made into a few occupations. At present, 
as he pointti out, " statistics give proof of the regretable hygienic conditions 
of our factories, regarding which people are still In a state of childish un- 
concern. Statistics show that improvement of the air in factory sanitation 
is one of the most pre.ssing demands of private and public life.'' 

Specially perilous are the industries that fill the air of the work-place 
with dust. Dust of all kinds, when taken into the lungs, causes irritation 
and leads to little erosions which provide a favorable soil for the growth of 
the tuberculoajs bacillus. And few factories are as free from the dust peril 
as they could be made by scientific precaution. Dr. Doehring enumerates 

179 



d 



180 



SIXTH INTERNATIONAL CONGRESS ON TDBERCtJLOSlS. 



the following trades in which the work-people are exposed to the various 
kinds of dust., viz: 

1. Metallic dust: Brass-founders, braziers^ coppersmiths, cutlera, dyersj 
engravers, file-cutters, gilders, griudersj lacquer-workers, lithographers, 
locksmiths, molders, nail-makerSj needle-grinders, needle-ma kers^ painters^ 
printers, eieve^raakera, smiths, tinmen, tool-smiths, type-founders, watch- 
makers, and zinc white workers. 

2. Mineral dust: Carpenters, cement-, diamond-, and flint-workers, 
masons, millstone-workers, paintefsj porcelain-workers, potters, stone- 
cutters, workers in basic slag-mills. 

3. Vegetable dust: Bakers, candy-makers, chimney-sweeps, cigar- 
makers, coal-dealers, etc.^ joiners, millers, ropemakers, weavers, and wheel- 
wrights. 

4. Animal dust: Brush-makers, button-makers, cloth-makers, furriers, 
hair-dressers, hatmakers, paperers, saddlers, and lumera. 

5. Mixtures of dust; Day laborers, glass*grinders, glaziers, street-cleaners. 
Those of us who live during the summer months in any big American 

city know that he might have included among the people exposed to mixtures 
of dust, not only the street cleaners, but all who walk the sl.reets. How- 
ever, the list is sufficiently appalling as a catalogue of trades dangerous by 
reason of the dust that the workpeople breathe. 

Of the deadly effects of dust, evidence is conctiisive. According to 
Oldendorffj while of the whole male adult population of certain industrial 
districts in Germany 46 per oent.^ — a sufficiently appalling proportion — died 
of pulmonary consumption, among the iron-workers the proportion rose to 
59.1, and among the grinders to the terrible height of 78,3 per cent. Perlen 
reported that of 1425 consumptives treated at the Munich Polyclinic, 74 
per cent* had been exposed to metallic, mineral, or vegetable dust — of 
couree, at their occupation. Of the flint-stone workers SO per cent., and of 
millstone-workers 40 per cent., were attacked by tuberculosis. 

Dr. Thomas Oliver writes in " Disea^ses of Occupation" that pulmonary 
phthisis is regarded as the principal disease affecting the workers in the 
Limoges potteries, where dust clouds the air. Dr. ArUdge found in England 
that the mean age at death of men potters was 46,5, while other men in the 
same djstricta who had the good fortune not to be potters hved on an average 
to 54, 

Of the total deaths among lead-workers, reports Dr. Doehring, one^third 
are from pulmonary diseases, i. e., from pulmonary phthisis and diseases 
of tlie respiratory system taken together. Since the mortality among the 
venturesome workers in this death-dealing industry is 90 per cent, higher 
than among workers in general^ the toil of life exacted by pulmonary diseases, 
which are aggravated by the dust takon into the system, is truly terrible. 



FACTORY LEGISLATION AND TUBERCULOSIS.^ — MARTIN. 



ISl 



As certainly as the extermmation of typhoid fever requires the purifica- 
tion of drinking-water, the extermination of tuberculosis requires the pun- 
hcatlon of factory air. How can this be secured? Partially by an appeal 
to the enlightened selfishness and humanity of employers and by the educa- 
tion of employees. 

Even educated employers sometimes slay in ignorance. A medical 
friend of mine was taken over a settlement for women that a benevolent 
manufacturer had established, where working-girls found comforts and 
healthy surroundings which the founder was proud to provide lavishly as a 
free gift* Later the admiring friend went through the textile mill owned by 
the same philanthropist* He was struck with the foulness of the air that 
was clouded with lint^ and with the pallid, thin faces of the young women 
workers; a fair proportion of whom were evidently doomed to suffering 
from tuberculosis. The windows were closed. " Why are not the windows 
thrown open and the health of the employees preserved?" he asked. " Be- 
cause the draft would blow the colored fluff over the white goodjs and spoil 
them." "Then why not, at least, put up a partition to separate whita 
from colored material?" That simple expedient had not been considered. 
The employer was generous and humane out of business hours. It had not 
occurred to him that it was better to spend money on making the working 
conditions for his women healthy than to spend the money on a settlement* 
He was not really conscious of the frightful harm he was permitting. He 
thought at was a business maxim to subordinate every other consideration 
to making the biggest profit. 

So occa^ionaJly ^^^th the workpeople. **The workmen themselv^ have 
no conception of the danger of their occupation/' writes Dr. Doehring of 
one case. Doubtless it happens sometimes that ignorant workpeople, fresh 
perhaps from a peasant life in southern Kurope, find the respirators, etc., 
which are provided for their protection hot and irksome, and refuse to use 
them. By lectures, printed instructions , and rigorous discipline they must 
be taught the risks they run and the painful death that lurka for them — 
not only from consumption, but fmm poisoning and other dtuigers. We 
have found by experience how feasible is the education of whole communities. 
A few yeara ago only a small percentage of the population realized the risks 
of tubercular infection. Now the fear is sometimes foolishly eJtaggerated, 
and victims of the plague are shunned like lepers. Similarly workpeople 
can be educated about the dangers of their employment. 

But, when every allowance has been made for the carelessness and dare- 
deviltry of the employee, the truth remains that the chief responsibihty 
resto with the employer and the community. Employers proud of their 
welfare department may build light, airy workrooms, may instal effective 
systems of ventilation, may provide special flues and drafts to carry off dust 



„iJ 



182 



SIXTH INTERNATIONAL CONGRE^ ON TUBERCULOSIS, 



aod fumes, and may furnish clean clothes and baths for the workers in lead 
and other poiaonoufl materials. Unfortunately, however, relatively few 
employers are so enlightened; only the strong arm of the law can protect 
the employees of the remalndeF^ and make our goal, the suppression of 
tuberculosis, attainable. 

That we may review altogether the le^lative measures requisite, let me 
remind you at this point that, in addition to the dust specially r^sed by 
industrial processes, inadequate ventilationj dirty walls and ceiling, or 
overcrowding may invite tuberculosis. 

Id idl such matters the individual employee ia helpless. He cannot 
bargain as to how many cubic feet of air he shall be allowed, how many 
exhaust fans shall be installed, how often the walls shall be whitewashed, 
bow many windows shall let in light, and what toilet facilities shall be 
furnished. Though he spend from a third to a half of his life at the bench, 
loom^ or forge, he cannot practise there the maxims of antituberculosis 
societies. At home he may sleep with windows wide open, he may select 
nourishing foods, he may camp in the back-yard or on the roof during the 
summer, and avoid infection as he would the pestilence; but at work he 
must accept conditions as he finds them or throw up his job. And to-day, 
if he sacrifices his work for his health, he may suffer as much from Starvation 
as he might have done from dust and foul air. So, like Touchstone's shep- 
herd, he ia in a "parlous state," All he can do is to act with his fellow- 
citizens in the enactment and enforcement of adequate factory legislation. 
In America he will find plenty of work for hia hands. 

Out of our forty-six States, but seventeen provide by law that factories 
shall be well ventilatedj and, so far as is practicable, the ventilation shall 
render harmless all gases, vapors, dust, or other impurities generated by the 
inrlustrial processes conducted in them. The seventeen fortunately include 
the leading industrial States. They are; California, Connecticut, Indiana, 
Kansas, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, New 
Jersey, New York^Ohio, Pennsylvania, Hhotie Island, Tennessee, Washing- 
ton, and Wisconsin. But nearly two-thirds of the States do not even 
nominally guard agoinst disease by compelling fit ventilation, and in the 
enlightened seventeen the standards covered by such a phrase as **so far aa 
practicable" are not high. When independent investigation is made, we find 
generally that such sentences as this of Dr. Doehring's occur in the report: 

"The insanitary conditions in this establishment are very eWdent, and 
are similar to those found in the preceding factory." Rarely is the value of 
the employee's health to himself, his employer^ and the commimity fully 
estimated; while in the newer industrial States of the south — Alabama, 
Geor^a, West Virginia, etc, — the short-sighted or inhuman employer 13 
altogether unchecked by law. 



■ 



4 



FACTORY LEGISLATION AND TUBEBCULOBIS. — ^UARTIN. 183 

Again, only seventeen States, mainly those I have mentioned, prescribe 
that exhaust fans of sufficient power, or other proper devices, shall be pro- 
vided to cany away poisonous fumes and gases, and the dust from emery 
wheels, grindstones, and other machinery that creates dust. In most of the 
other States some factories are already established, and States which are en- 
tirely bucolic to-day may be invaded by the manufacturer to-morrow. We 
know that it is the heart's desire of every district in our broad land to become 
a manufacturing center in order that real estate values may soar along with 
chimneys and town excitement exile rustic peace. So it would be quite 
fitting that every State should write its health charter for factories at once 
against the day when looms will rattle and chimneys belch forth smoke 
within its borders. 

Only six States — New York, New Jersey, Pennsylvania, Indiana, Missia- 
dppi, and "V^consin — require by law the lime-washing or painting of walls 
and ceilings at certain intervals, and even in this progressive sextette the 
law applies sometimes to bakeries only, and is enacted for the safety of the 
consumer rather than for the protection of the producer. We can picture 
how dirty and dusty, how crowded with disease germs, are the walls and 
ceilings of many work-places in the other forty States. 

Only eight States — Maryland, Mississippi, New Jersey, New York, Ohio, 
Pennsylvania, and Wisconsin — provide for a riiinimum air-space per em- 
ployee in a factory or workshop. Some of these enact that there shall be 
250 cubic feet in the daytime and 400 at night for each person; others leave 
the amount required to the judgment of the factory inspector. All but 
these eight allow any degree of overcrowding by day or night totally una- 
ware, it would seem, that fresh air and plenty of it is an essential precaution 
ag^nst the spread of tuberculosis. 

Plainly, in America there is a vast territory as yet unthreatened by the 
gathering army of fighters against disease. Our campcugn cannot be won 
unless we pursue our microscopical enemy into the mills and mines, the 
factories, furnaces, and stores, of every State. No matter what the money 
cost, the heavy toll of disease and death now being exacted from the workers 
should be at once reduced and finally abolished. 



THE CASH VALUE OF FACTORY VENTILATION, 



Br C -K A. WiNSLOw, 

MwiliiiimllB Iziftttule of Tectmology, Boston. 

Conthbutba from Uie Research Department qf the Boston School for Sodftl Worker. 



Statistics presented before this section this afternoon emphasize the 
important fact that tubercuJosia is largely an occ\ipational disease, \\lien 
one finds the tuberculosis death-rate in certain minor industries four and 
five timea the normal, and in large and important industries 50 per cent, and 
100 per cent, higher than the normal, it is clear that the campaign agfidnst 
taberculosb b incomplete without a systematic attempt to improve the 
conditions of factory life. 

Improved factory conditions mean, first and foremost, improved ventila- 
tion, including the removal of dust and furaes; but this is an eJtpensive 
luxury under many conditions. The employee and the community are 
gainers by pure sat; both humanitanan motives and the compulsion of the 
law may be invoked to secure it. If, however, it can be shown that the 
employer him^lf is a direct gainer by the improvements which he initiates^ 
the path of reform will be made much easier. This b the point to which 
I wish briefly to call your attention — the practical return to the factory 
owner from the improved factory conditions which make for the elimination 
of tuberculosis, and of various minor illnesses of a less serious nature. 

It is not, 1 think, difficult to show that the diseases which prevail among 
working men and women, as a result of unsanitary conditions in the shop or 
factory, besides their general bearing upon the prosperity of the community, 
directly affect the industrial prosperity of the employers concerned. The 
living mactune is as important a factor in many shop processes as the lifeless 
Doachine which he operates* Efficient production requires skilled and 
practiced workers, in good physical condition, applying themselves, with 
energy and enthumasmt to their tasks. Irregularity of attendance, and the 
ph5^ical sluggishness and nervous inattention which accompany lowered 
^'itaUty, mean direct money loea to the employer of labor, as well aa a burden 
a the community at large. 

Th^e facts have been recognized by the ablest and most progressive 

kufacturers. In many parts of the country model factories have been 
»cted in various lines of industry; and in Massachusetts new legislation, 

U4 



CASH VALDB OF FACTORY VENTILATION. — WTNSLOW* 



ia5 



creating a force of expert district medical inspectors of factory conditions, 
has led to a remarkable awakening in this regard. In general those employers 
who have made improvements report most satisfactory results. In *' Amer- 
ican Industries" for June 15, 1907^ a case was cited in which the coat of 
installing a ventilating system was six thousand dollars; the reduction of 
the percentage of absences due to illness was so great that the employer 
was compensated for his outlay; and while previously the employees were 
likely to become stupid in the latter part of the afternoon, the new system 
maintained alertness during the entire day* 

Evidence of this sort of tangible return ia of the greatest value in pro- 
moting the improvement of the conditions of industrial life^ which must 
always rest so largely on the initiative of the employer. The attempt has 
therefore been made, during the past summer, under the au<5pices of the 
Research I>epartment of the Boston School for Social Workers, to study 
similar cases of factory betterment, with a view to their reaction upon the 
industry itself* The plan of work was to find cases in whicli a marked 
improvement in factory ventilation, dust removal, etc., liad taken place, 
without other disturbing changes in social or economic conditions; and to 
study the attendance of the workers before and after the improvement, 
An investigation of this sort must be made with the greatest caution in order 
to exclude the effect of factors other than ventilation. The ^subject there- 
fore presented great practical difficulties. In many eases investigated the 
improvements proved to be trivial* In othet^, important changes had been 
made, but so recently that no appreciable effect could be manifest as yet. 
Sometimes^ on the other hand, the improvements were of such long standing 
that no records were available. In other factories no records of attendance 
were kept at all in such shape that they could be utilized. The piece-work 
sy^stem, fluctuations in economic demand, and imwillingness to permit 
inspection of lime sheets, eliminated otherwise promising cases. Finally, 
in a few instanc^es, marked improvement in attendance and efficiency coin- 
cided with new ventilating systems; but other changes in policy accompanied 
the sanitary betterment and discounted its effect* 

One case alone, of the many which were more or less thoroughly investi- 
gated, seemed to offer a fair test of the effect of improved ventilation alone. 
Fortunately this was a case of ventilation for the correction of ordinary 
vitiation, without complications due to fumas or dust. Fortunately^ too, 
the improvements were of so simple a nature that the lesson as to the ac- 
cruing gain has the wid^t possible application* 

The operating room of the New England Telephone and Telegraph 
Company at Cambridge, Melss., ia a long room, extending from front to back 
of a business blocks It is seventy-one feet long and thirty-four and a half 
feet wide, with a jog three and a half feet wide taken out of the rear thirty- 



J^ 



186 



BCCTH INTERNATIONAL CONGKESS ON TUBERCULOSIS* 



two feet on one side. The room is thirteen feet high and has a capacity of 
thirty thousand cubic feet. 

Fifty or sixty women are employed in this room as operators, seven- 
dghths of them being on the day shift. During the warmer months of the 
year no difficulty has ever been experienced in ventilating the room, by 
means of large windows at each end^ and by the use of electric fans. In the 
winter time, howeverj it was impossible to secure adequate natural ventihw 
tion without undue exposure to drafts. 

In the spring of 1907 a simple but efficient system of artificial ventilation 
was installed, A galvanized iron duct was constructed, of>Gning to the air, 
over the front door of the operating room, and running along the ceilmg 
through the center of the room for a distance of forty-tliree feet. The duct 
was two feet wide by one foot deepi and was perforated along each side by one 
hundred and fifty inch-and-a-quarter holes. Two sixteen-inch electric fans 
were placed in the wall at the back of the room to discharge the vitiated 
lUTj forming, with the inlet duct, a vacuum system of ventilation, 

A marked improvement in the comfort and general condition of the 
operators followed this change; and the betterment was sufficiently marked 
to show itself in a notably greater regularity of work* The statistics of 
attendance for two years prior to the change, and for sixteen months sub- 
sequent to it, are given in the table below. They have been compiled from 
the records of the chief operator, who has been in charge of the room during 
the entire period. The average number of daily absences, in the first of the 
three columns for each year, were calculated from the actual records of all 
unexplained minor absences; long illn^^ses, vacations, etc, being omitted. 
*he absences which remain are, of course, due to many causes; but mainly 
to slight illnesses of various sorts. 



RECORD OF ATTENDANCE— CAXfBRIDGE OPERATING ROOM. 

TILATED. 



UNVEN- 



VOOTW, 



April., 

my., 

June , ^ . - 

July 

Augufit «... ^ ....,,.... . 

September 

October 

FNovemtH?r...... ....... 

'I)et'enil>er.. 

Jtknuary ^ | 2.6 

February , J 3 .0 





lOOy^. 






lWC-07. 


AVESAQE 




Pm 


ATKRAai 




DAji,r 


FwUCK, 


Ceht. or 


Daily 


FoHOft, 


AlMllllCV*. 




AnEMCA. 


AHfllCMPE». 




.0 


50 


1.8 


L2 


56 


.0 


50 


1.3 


1.9 


56 


1.4 


51 


2.6 


2.0 


56 


1.5 


54 


2,8 


1.9 


56 


2,0 


54 


3.6 


IJ 


56 


2-6 


54 


4.9 


1^ 


56 


1.1 


54 


2.0 


2.0 


56 


2,1 


54 


4.0 


1.3 


66 


1-6 


54 


2.9 


IJ 


56 


2.6 


54 


4-9 


2.9 


56 


3.0 


54 


5-6 


2^ 


55 


2-2 


54 


4.1 


2.0 


68 



CvHT, or 
Ahshcii. 



2.1 
3.3 
3.6 
3.3 
3.0 
2.4 
3.6 
2.4 
3.3 
5.2 
5.0 
3,4 



< 



: 



CASH VALUE OF FACTORT VENTILATION, — WINSLOW, 



isr 



RECX>RD OF ATTENDANCE— CAMBRIDGE OPERATING ROOM.— VENTI- 

LATED, 



Montr. 



April. . . . . 

aiay 

Junen. 

July 

August 

September 
Octx^ber , , . 
Kavembcf 
DeoeiDber. 
Jftnuary . . 
February.. 
Haicb... . 



ldQ7-0S. 



AfBtAGK 

DAii-r 

ABB£NCfS, 



2,0 
LS 
1.7 
2.0 
2.3 
2A 
1.9 
1J2 
12 
1.2 
1.0 
1.0 



FoACB. 



5S 

m 

58 
58 
58 
63 
63 
63 
66 
65 
65 



Pern 
Cbnt. or 
Ahence:. 



3.6 

3.1 
2.9 
3.4 
3.9 
4.1 
3.0 
2.0 
1.8 
1.8 
2.4 
1.5 



i«oe. 



AVBRAOH 

Dailt 
ActsRNces, 



16 
1.2 
1.2 

1,0 



FofeCB. 



67 
67 
67 
65 



Feb 

Cent, or 

ASQENCK. 



2.4 
1.8 
IJ 
1.6 



The perceatagea of absence, from the table, have been plotted in the ap- 
pended diagram, which shows the relations nioi*e clearly. The upper curve is 
for the two years from April, 1905, to March, 1907, when the room had no 
special ventilation. The lower cun^e shows the conditions from April, 1907, 
to July IMS, after the new system had been installed. 

In each year absences diminish in spring and fall, and show an increase in 
winter and summer. At the extreme seasons of the year heat and cold, re- 
spectively, undermine vita! resistance, produce minor illnesses, and accentuate 
any constitutional weakness. In summer the troubles which arise are largely 
digestive ones, while in winter colds and pulmonary affections are most com- 
mon, and the general seasonal curve of disease is fanullar to all students of 
vital statistics. 

The change in ventilation did not affect the attendance in the operating 
room during the summer of 1907. No direct effect could be expected at this 
season, since in warm weather, with windows open, natural ventilation of the 
room could scarcely be improved upon. During the winter of 1907-OS, how- 
ever, a marked improvement was manifest, as indicated by the table and chart. 
For the first three months of 1906 the average percentages of operators absent 
were4.9, 5.6, and 4.1, respectively; for 1£K)7 the figures were 5,2, 5.0, and 3.4; 
for 1908 they dropped to 1,8, 2.4, and 1,5, Comparing the three winter months 
only (January to March), it appeara that 4,9 per cent, of the force were absent 
in 1906, 4*5 per cent, in 1907, and only L9 per cent, in 1908. This means a 
net saving for the three months of 2.8 per cent, of the force employed, corres- 
ponding to one and eightrtenths the entire time of one operator. 

The original cost of installing the system of ventilation was in the neighbor- 
hood of 175. The saving In operators' time during the three winter mont-bs 



4 




188 



aiXTa ZNTEBNATIONAL OONGBBSS ON TUBERCULOSIS. 



6*0 
5.0 
4.0 

8*0 
1.0 
0*0 



4.0 
3.0 

e.o 

1.0 
0*0 



FSROtlTAOt or ABSSirOBS* 



.1905 _r^i 



OAMBRtDOt TOLL'-RDOir. 




flprln^unntr. *"*«^ 



Intel 



Spring Autunn 

Baaamr Wlnt«P 



CABH TAXjUE of FACTORY VENTILATION. — WIN3LOW. 



180 



amounted to twenty-three workiBg weeks, as indicated above (13 weeks X 1 .8). 
Since the average pay of an operator is IS.50, this meant a saving of 8195 to 
the employees in wages^ and the increased efficiency due to the regularity of 
attendance paid good interest to the company, 

.\nother suggestive point, brought out by the chart, is the continuance of 
good attendance through June and July of 190S. Both were exceptionally 
hot months this year, and, judging by the three earlier years plotted^ the 
ffliraraer increase in absences should have begun to manifest itself. As pointed 
out above, the ventilating system has no direct effect in hot weather, when all 
the windows can be kept open. It may well be, however, that vital resistance 
has been built up by a year of breathing good air, so that the operators are 
better able to stand the general strain of hot weather conditions. 

This is a single case, and in some respects* an exceptionally favorable one. 
The employees are women ^ and therefore, more susceptible to unfavorable 
influences than men would be. In a couple of cases studied by me where 
exhaust fans for removing dust were placed in polishing rooma, the statistics 
of attendance for the small number of men exposed failed to show* any im- 
provement. No doubt vigorous male operatives under such conditions may 
continue to work mih fair regularity as long as they are able to work at all. 
Where axpensive local dust removal, as from polishing lathes^ is requireil, 
it may coucelvably make for the immediate financial profit of the employer 
to let tuberculosis and other lung diseases do their work unhindered, and to 
fili up the ranks with new material. Here, an appeal must be made to the 
humanitarian iniitinct; and if that fails^ the State must step in to protect 
its members^ in the common interest. Without laying undue emphasis upon 
one unusually favorable case, 1 think, however, that the experience reported 
indicates that the ventilation of factories, under certain conditions, may bring 
a tangible return to the employer, in regularity of attendance and efficiency of 
Bervice. 



tjber dea Baarwerth eiiier FabrikrentilatioD. — (Winblow.) 
Prof, Winslow berichtet irber ein Studium des Effects einor verbesserten 
Ventilation auf die Thatigkeit der Fabrikarbeiter. Diese Untersuchung 
wurde unter den Auspizien des Research Department of the Boston School 
for Social Workers ausgefiihrt. Ucr gewahite Plan bestand darin, Platze 
zu Bnden, in denen merkliche Verbessehingen in der Einriehtung der Ventila- 
tion vorgenommen wurden, aber keine andcren wichtigen Verbesserungen 
atattgefunden habenj und bier statistische Untersuchungen anzustellen iiber 
die Arbeitstage der Angestellten, vor und nach Vcntilationsverbcsserung. 

Der Aufnife-Raum der New England Telephone and Telegraph Company 
in Cambridge, Mass., ist ein langes schmales Zimmer, mit Fensfcern nach vorne 



I 



190 



SIXTH INTEHNATIONAL COKGRESS ON TDBEKCULOSTS. 



Bowohl, aJs nach hinten herauH. Im Winter, wean die Fexister nicht ge- 
offnet werden konnten, war die Luft schlecht. Im Fruhjahr 1907 wurde an 
der Decke eine Rohre angebracht, welche nach vorne heraus, zur Strasse, 
offen war und durch angebrachte ein und ein Viertel Zoll grosse Lqcher Luft 
ins Zimmer hmeinbracbte. An der hinteren Waad wurden Facher ange- 
bracht, urn die verdorbene Liift aus dem Zimmer zu entfemen. Der ganze 
Kostenaufwand betrug 75 DoUarB. 

Diese Veranderung verursachte eine merkliche Verbessemng in der 
Behaglichkeit und im Allgemeinbefinden der darin Arbeitenden. Im Winter 
1907-08 ist der durchschnittiiche Proaentsatz von Abw€®endsein unter den 
liber 60 dahier arbeitenden Jladchen auf die Halfte gesunken, Wahread 
der ersten drei Monate im Jahre 1906 waren durchsctmittlich 4,9% der 
Angestellten abwesend; in 1907 waren es 4.5%, aber in 1908 waren es nur 
1.9%. Im Sommer 1908 war der Prozentsatz der Abwesenden bedcutend 
niedriger als in friiberen Jahren^ was auf eine allmahliche Verbessemng in 
den allgemeinen Lebensverhaltniasen hinweist. Nur in den drei Winter- 
monaten allein betrug das Er^pamisB dn und acbt Zehntel der gan^^en Zeit 
eines Angestellt^n. 



4 



TUBERCULOSIS. 
By Me. Feank Dufft, 

Gcfieffc) Seer^tuT Uuted Brotherhood of Carpvaters nod Joinvn of HAjnerlcL 



Tbe writer as a layman has not sufficient knowledge to discuss the 
above question from £lq academic or scienti&c Btandpoint, but muat^ 
perforce, simply give his personal views from observation and a study of 
eeonomic conditions existing in this country. If he errs in his conclu- 
Bions, be trusts the medical brethren will pardon him and enlighten him, 
as he stands ready and willing to afisiat to the best of his humble ability 
to entirely eradicate this "dread white plague" from the American con- 
tinent, if possible. 

To begin, he believes consumptiou in its true analysis is not a disease^ 
but a condition^ brought about by improper food, insufficient raiment and 
impure and infected air. If people could only realize or know to a certainty 
that the ''dread white plague'' has fastened itself on them, they could take 
the proper preventive measures to eliminate it from their systems. Many 
an autopsy has developed that a man has been afFlicted, by the scars found 
and the air-cells eaten away, but the only solution to arrive at in such in- 
fitances Is that his physique, his constitution, the kind of food he ate, 
his daily lifei and his raiment were eul^cient to throw off the germs be 
was inoculated with at some indiscreet moment, A great many people 
eeem to think (immediately they learn from some honest physician that 
they are so afflicted) that their case is hopeless, and that it is only a 
question of sitting down and waiting for the ''call.'' This inertia is what 
aggravates; is what hastens; is what causes many untimely deaths, 
Hope should "shine eternal" in the human breast, and if* when persons 
learn to a certainty that the germ is there, they would take time by the 
forelock and use preventive measures, our statistics would show a marked 
decrease of deaths from such causes. 

Give up your sedentary pursuits, if so engaged, and work at manual 
labor until you eliminate the germs. Give up your position in the factory, 
mill, workshop, or wherever you may be employed, and seek employ- 
ment bi the open air. 

In the estimation of the writer, drugs are the worst possible things 

191 




192 SIXTH INTERNATIONAL CX^NGRESa ON TUBERCULOSIS. 

to take in trying to effect a cure in tuberculosis. The onlj' possible 
cure is plenty of fresh air, good wholesome food, ^ moderate aniount of 
healthful exercise, and fre^om from vices that tax the physical strength. 
Our records show in the Death Claim Department of this organization 
that over 37,3 per cent, of our members died with consumption during 
the past two years, and of this number over 50 per cent, were employed 
in mills, factories, etc., or had insufficient nourishment or the disease 
was brought about by expoeure^ dampness, and continuing their work 
in wet clothes after a rain, thereby contracting colds and bringing on 
pneumonia which later developed "uito consumption* 

From my argiuoent it should be a^umed that consumption Is a con- 
dition and not a disease* for^ primarily, it is the conditions which cause 
the disease and the disease which causes the death. 




Tuberculosis. — ( Ddfft. ) 
El autor oomo tin hombre lego, no pretende tener conooimientos suficiea- 
tes para discutirel problemabajo un puntode vista acad^mico y cientlficOjSino 
que pretende solamente exponer su pareeer personal baaaclo sobre las obaer- 
vaciones y cstudios econ6micos de las eondiciones e^stentes en estepa£s. 

EI autor cree que la tisia en, su verdatiero analfsis, no es una enfermddad 
sino una condieion debida i la nuiricidn inadeeuntla 6 toola, no solamente de 
la pobre aliraentaci6u duo tambien de Is insuficiencia en la vestido y el aire 
inpuro 4 infecto. Si al pueblo le fuera dable reaJizar y saber que, hastA 
derto punto, la terrible enfemiedad de la tuberculosis ha tomatlo pos^on de 
€it entonoes stn p^rdida de tiempo tomarfa las medid^ preventivas par& 
kaoer desapareoer la enfermedad del Esstema. 

Abanddneee los hAbitos sedentanos, si estos existcn, y eetimiSlese el trabajo 
fieieo. Aband6ne9e el empleo en las factorfas. taleres 6 cualquier otra 
oc«pad6n perjudidal y biisquese el trabajo al aire Ubre. 

Ed la opinion del autor, las drogas es lo peor que puede daise en la cura 
efeetiva contra la Tuberculosis, EI re^ro del Dcpartamento de Defudon^ 
de esta OrgauLsacton demuestra que mas de un 37.3 por ciento de nuestros 
miembvios fallederon de tuberculosis durante los lihtmos dos aSos y de este 
ndmem mas de un 50 por ciento fueron empteadoe de fnctorias, tallcres, etc., 
6 bien insuficiencia en laalimentacion, 6 bit^nla enfermedad fuecontrafda por 
medio de escpoeicioneB, humedad, eontinuaci6n de! trabajo eon los vesiidos 
lsiiD)edo6 despues de la Uuvia lo cual fue la causa de una neumonta que mas 
'tarde 8e dectar6 en tuberculo^. 

De toe argumentos expuestoe puede deductrse que la tisEis es una condid6a 

Qo una enfermedad, par que pnmerameate es la condiei^Q la causa de la 

B'stertKiedAd, y la enfermedad es la causa de la muerte. 



TUBERCULOSIS- DUFFY. 



193 



La Tuberculosc. — (Dufft.) 

L'auteurest un profane d^pourvu de la science n^cessdre pourdiacuterla 
question ci-tiesaus au point de vnie acad^mique ou scientifiqiie; il ne peut done 
que donner les vues personnelles que lui ont sugg^r^a robservation et T^tude 
des conditions ^conomiques existant dans ce pa3^-ci. S'il sc trompe dana 
ees conclusioDS, il eepore que La fratemitd m^dicale lui pardotmera et I'^clair- 
era. 

II croit que la phtisie^ dans son eeseneej n'eet pas une maladie, tnais une 
oondUion amen^ par une mauvaiae alimentation qui ne vient pas seulement 
de mauvaise nourriture, mais ausai d'une insuflisance de vetements et d'ua 
air impure et mfect^. Si lea gens pouvaient seulement se rendre compte 
d^une mani«^re certaine que la "terrible peste blanche," c'eat cramponn^ k 
eux, ils pourr^ent prendre de bonnes mesurea prdvenlives pour I'^liminer 
d& ieur corpe. 

Laissca vos occupations s^entaires, ei telles sont lea vdtrea, et adonnez- 
V0U8 k un travail manuel j'usqu'S. ce que vous aycz <^limin(S lea germes. 
Laissea votre position dona la manufacture, dans la fabrique, dans I'atelier 
ou n'tmporte oii voua ^tesplac^ et cherchez un emploi en plein air< 

Dans I'opinion de Tauteur, Ice dmguea sont la pirr chose b> prendre quand 
on t^che de ee gu^rir de la tuberculose. Nos registres montrent dai^ le 
department des r^lamations mortuaircs de cette Organization^ que plus de 
37 J pour cent de nos membres sont morts de phtisie pendant los deujc derni- 
^rcs anne^ et de ce nombre plus de 50 pour cent ^taient employ^ dans des 
fabriques, manufactures, etc. ou avaient une nourriture insuffisante^ ou bien 
la tnaladie Ieur 6tait venue de I'exposition aux intempdries, de rhumiditd et 
du fait qu'ils eontinuaient Ieur travail dans des v^tenients moultlcs apr^ la 
pluie, contractant ainsi un rhume qui amenait une pneumonie, laquoUe plu3 
tard amenait la phtisie. 

On devrait conclure que la phtisie est une condition et pas ime maladie j 
car premitfreraent c'est la condition qui cause la maladie, pub la maladie qui 
CAUse la mort. 



Die Tuberkulose.— (Duffy.) 

Ala ein Laie muss der Autor sich darauf baschrflnken, seine personlichen 
Ansichten mitzuteilen, die er durch Beobachtung und durch das Studiura der 
wirtachaftlichen Bedingungen dieses Landes gewonnen hat. Wenn er in sei- 
nen Schliiasen sich irren sollte, hofft er, dass die Aerate ihn aufklaren wiirden, 

Der Autor glaubt, dass die Sch^iindsucht nicht eine Krankheit, sondem 

ein durch ungeeignete oder schlechte Nahnmg, durch ungeniigende lOeidung 

und durch unreine und infizirte Luft hervorgerufener Zui^tand sei. Konnten 

cUe Leute mit Sicherheit wiaaen, dfl£3 die Tuberkulose sich in ihxem Korjx^ 

voit-m.— 7 



194 SDCEH INTEBNATIONAL CONGRESS ON TUBERCTTIiOSIS. 

festgeseUt hat, so wurden sie die gedgneten VeThutuiig&-Ma8sregeln nehmen 
koEiDen, um sie zu vertreiben. 

Wer dne sitzende Beschaftigung hat, der soUe, wenn erkxankt, dieselbe 
aufgeben und eine Handarbeit annehmftn; wer in der Fabrik oder in der 
Wetkstatt beschaftigt ist, soUe eine Arbeiteteile in der h&en Luft suchen. 

Nach des Autors Meinung waren die Medikamente das schlimmste, das 
d^ Kranke nehmen konnte, wenn er eine Heilung der Schwindsucht er- 
ziel^i wilL Die Todesbeiichte unseres Vereines zeigen uns, dass mehr als 
37.3% unserer Mitg^eder in den letzten zwei Jahren an Schwindsucht starben 
und dasB von diesen 50% in Fabiiken, etc., angestellt waren, oder batten unge- 
nugende Emahrung, oder die Krankheit wurde durch Aussetzen der Feucb- 
ti^dt, durch Arbeiten mil nassen Kleidem (nach einem Regen) hervorgeni- 
fen. Die betreffenden Arbdter bekamen Lungenentzundungen, von welcher 
sidi spater die Schwindsucht entwickelte. 



ECONOMIC ASPECTS OF TUBERCULOSIS IN 
MILWAUKEE. 

By Thomas W. B. Craper, A.M., LL.B., 

HilwMikee, Wis. 



The work of which the following paper is a brief description was under- 
taken by the writer as holder of the Vogel Fellowship in the University of 
Wisconsin. 

The tenure of this fellowship is conditioned upon the performance of 
certain duties in connection with the University Settlement of Milwaukee, 
as well as the investigation of such economic and industrial problems as 
may be deemed of special interest and importance by the President and 
Regents of the University. 

The investigation which was carried on in Milwaukee during the scholas- 
tic year 1907-08 may be resolved into two leading divisions: first, the con- 
struction of a chart of the city, showing exactiy the distribution and location 
of the deaths from tuberculosis during the quinquennial period covered by 
the investigation; and, secondly, the ^dsitation of about a thousand homes 
in order to ascertain the factors most serviceable in throwing light on the 
prevalence of the disease. 

The five year period 1903-08 inclusive was selected for the purposes of 
thb investigation for several reasons, but chiefly for the following: 

1. It was deemed inadvisable to select a period too reinote, inasmuch as 
bousing conditions change very rapidly in a growing city like Milwaukee, 
and, consequentiy, buildings occupied by tuberculous families a decade or 
more ago would not necessarily — not even likely — be in the same condition 
at the present time. 

2. A period of greater length than five years would involve so many cases 
of death from tuberculosis that a map of the city showing the distribution 
of the disease would be littie more than a blur, and, consequentiy, very un- 
satisfactory, if not useless, for the purpose of illustration. 

3. The great mobility of the population would render it very diflicult to 
obtain any reliable data as to the economic status of the families in which 
death had occurred. 

The foregoing period, therefore, was selected as being the most serviceable 
for the work in hand. The work being entirely new to him and, so far as 

196 



196 



6TXTH INTERNATIONAL CONQRESa ON TUBERCULOSIS. 



known, entirely new in Milwaukee, necossarily mvolved conaderable hard- 
ship in the outset, as well as difficxilfcies and obstacles that manifested them- 
selves as the work advanced. 

The following schedule of questionSj used as a basis for the investigation, 
may g^ve some conception of the information sought as well as the difficulty 
in prociuing the sanie. 

1. Industry of deceased at the time of giving up work? 

2. Occupation of deceased? 

3. Wages obtained in occupation? 

4. How long in occupation? 

5. Occupation when disease was first noticed? 

6. How long in this occupation? 

7. Wages obtained in this occupation? 

8. Occupation after disease was first noticed? 

9. Time in this occupation? 

10. Wages in this occupation? 

11. Description of the work? 

12* Number in family of deceased, adults, children, lodgers? 

13. Total earnings of family during illness of deceased? 

14. Other sources of income, including public or private charity, benefit 
allowances, rents, etc*? 

15. Numljer of rooms in houjse or apartments occupied by deceased? 
16- Did deceased sleep alone? 

17. Did the deceased or family of deceased own the house or apartments 
in which he tDed? 

18. If premises Avere rented, amount of rent paid? 

19. General sanitation and envh-onment of premises in which the person 
hftd died? 

20* Personal habits and family history of deceased? 

Of the 2220 deaths which occurred in private homes during the period 
covered by the investigation^ it was found possible to gain information con- 
cerning but lOCiO. In but few casea was the investigator able to obtain 
what might be termed full and adequate answers to the above schedule of 
quefitioHB. Questions concerning the personal habits of the deceased, es- 
pecially when he was addicted to dissipation^ generally met with abrupt, or, 
At best, evasive answers, although in not a few instances plain statements 
were made on such delicate matters. 

The questions concerning the financial standing of a family during the 
lllnees of a deceased member met with con^derable evasion, as the sua- 
plcioD was raiaed that the ulterior purpose of the investigator was to deter- 
mine whether the family, at the time of investigation, was or was not earning 
more than the statutory exemption from debt. 



■ 



ECON(»aC ABPECT8 OP TUBEBCULOBIS IN MILWAUKEB. — CBAFEB. 197 

Upon the whole, tolerably complete answers were obtained, and the in- 
vestigator was brought into very close contact with the actual living condi- 
tions of the families in which tuberculous had been most fatal. 

Distribution of the Diseasb, 

An analysis of the 2309 deaths from tuberculosis within the city limits of 
lOwaukee during the period 1903-08 shows that the disease is widely dis- 
tributed, being found in each of the 23 wards of the city. 

The mortality varied from 26 deaths in ward 7, to 185 deaths in ward 11. 
Of the above total number of deaths, 89 occurred in hospitals and other 
public institutions, but the investigation was concerned primarily with 
deaths in private homes. 

The following table gives for the whole city and for each ward, for the 
period covered by the investigation, the average annual death-rate per 
10,000, and the average denaty of population. 

_, Dbathhutb Populatiom 

"*«*• Peb 10,000. Pm AcHB. 

1 ;.... 11.87 31.9 

2 11.04 38.5 

3 16.06 22.6 

4 18.91 27.1 

5 14.09 18.6 

6 18.06 26.9 

7 7.96 26.0 

8 16.48 18.8 

9 15.31 66.2 

10 15.47 43.0 

11 16.69 33.1 

12 17.66 18.0 

13 16.95 34.6 

14 .•...13.91 32.0 

16 10.66 26.0 

16 9.62 16.4 

17 9.30 11.6 

18 12.27 10.2 

19 16.80 22.2 

20 14.30 17.2 

21 13.64 18.0 

22 13.07 16.5 

23 9.96 14.0 

City 14.74 21.8 

In general, the wards which show high death-rate per 10,000 — that is, a 
death-rate exceeding the average for the whole city — also show a greater 
density of population. 

For example, wards 9 and 10 show death-rates of 15.31 and 15.47 per 
10,000, respectively, which are considerably above the average death-rate 
for the whole city; and those wards have a denaty of population of 66.2 
per acre, and 43 per acre respectively; the first more than double, and the 
second almost double, the average dendty of population for the city. 



193 



SIXTH tfTTERNATlONAL CONGHESS ON TUBERCULOSIS. 



Ward 17 shows a death-rate of 9.3 to the 10,000~very much less than the 
death-rate for the whole city — ^and a density of population of 11.6 per acre, 
or just oae-half the density for the whole city. 

Ward 18 shows a death-rate of 12,27 — considerably less than the average 
for the whole city — and a density of population of but 10,2 per acre, much 
less than oae^half the density for the whole city* 

If we take out of this ward the small Polish dkttict which contains but 
one-tenth of the area, and in which occurred 50 per cent, of the deaths from 
tuberculosis of the whole ward, we find the death rate in the better readen- 
tial section to be less than 4 to the 10,000; and the density of population but 
3 to the acre. 

In this Polish district the density of population is over 100 to the acre; the 
hou^ng conditions, compared with the rest of the ward, are decidedly poor, 
and the death-rate not only from tubercuioaa but from all conta^ous dis- 
eases runs high. 

In the northern section of ward 18, facing the lake, are located the resi- 
dences of many of Milwuukoe's wealthy citizens; here may be seen magnifi- 
OMit residences occupjTng a whole block, and there are entire streets which 
were free from tuberculosis during the period covered by the investigation. 

Death-rate from Tuberculosis among the Different Population 

Elements, 
The following table gives the average annual death-rate per 10,000 from 
tuberculosis for Milwaukee; for the native-born populationj for the formgn- 
bom population, and for each element of the foreign-bom population, during 
the period covered by the investigation (1903-08). 



EUEHKXT. PeB 10.000. 

City ...14.4 

Kfttive-l:iorti 13.1 

Foreifp ..17.9 

Aufitnaa , 19^ 

CanAdku 21^ 

Dflniah 15.& 

BritiBh. 12.8 

Fr«Dch 2$.l 

Gennan.. 19.0 



PottrUHos De*TM- 

Greek 9J> 

Dutch 30^ 

Irish 16.3 

IialiaJ3..««.. ,.*... 8jO 

Norw«riAn..., , .,,19^ 

PoUah 14.7 

Kuasian , 10.3 

8w«dkh 20^ 

tJndaamfied 37.3 



While the death-rate per 10,000 for the whole city was 14.4, the deaths 
mte for the native-bom element of the population was much lower» bdng 
13J per 10,000, and the death-rate for the whole foreign-bom element was 
very much higher^ being 17.9 per 10,000. 

In general, the poor showing for the foreign-bom element — that is, its 
high death-rate — may be accounted for by the fact thut when immigrants 
arrive in a Urge dty, their resources are usually so limited that they must 



ECONOMIC ASPECTS OF TUBERCULOSIS IN MILWAUKEE. — CRAFER, 199 

betake themselves, perforce, to the poorer residential quarters, where housing 
conditions are extremely bad, and general sanitation and environment are 
of an inferior quality. It not infrequently happens that they occupy build- 
ings which for years have been infected with tuijerculosLs. Under such con- 
ditions, then, it is not at all eurpriaing that the mortality among the foreign- 
bom should be high. 

The British foreign-bom in Milwaukee show a slightly lower death-rate 
than the native-bom, probably becaiLse the small British population con- 
tains a relatively large number of well-to-do persons. The homes of the 
British-bom visited by the writer were, with a few exceptioas, comfortable, 
and evidently possessed by persons of considerable means- 
Holland,* France, and Canada show the highest death-rates, while 
Greece and Italy show the lowest, 9,9 and S.O per 10,000^ re^jpectively, 
Investigation into the causes for such a favorable showing for the two latter 
countries elicited the fact that Greeks and Italians in many instances^ when 
affected with tuberculosis, return to their native lands, where climatic con- 
ditions are believed to be better, and where, at all events, living b vastly 
cheaper than in Milwaukee, 

The recent school census for Milwaukee shows that dnxing the year end- 
ing June, 1907, 1500 Italians left Milwaukee for Itiily, and during the same 
interval 1000 arrived in Milwaukee from Italy, The great majority of the 
Italian imnjigrants are single men in the very prime of life, and, doubtless, 
this has a very important bearing on the death-rate from tuberculosis of the 
Italian element of Milwaukee's population. 

The recently published volume t of the United States Census Office on 
lortality statistics shows that the death-rate from tuberculosis in Italy is 
but 11.8 per 10,000, — eonaiderably lower than the rate for the native-born 
population of Milwaukee* Possibly the relative immunity from the disease 
among the people of Italy may be another factor worthy of consideration 
in accounting for the low death-rate among the Italian immigrants to Mil- 
waukee. 

So far as economic conditions are concerned, the writer is of the opinion 
that the Italians in Milwaukee are among the poorest of the fore)gn*bom 
population. They live in a district of the third ward formerly occupied by 
Irishj and certainly have no advantage over other elements of the foreign- 
bom population so far as housinfj conditions are concerned. 

Of the native-bom population of Milwaukee it is estimated that 56 per 
cent, are of German parentage, and, as above stated, the death-rate for the 
native-bom population is relatively low. The German foreign-l>om popula- 
tion of Milwaukee shows a very high death-rate, namely 19 to the 10,000^ — 

* Dedth-ratea for the Dutch and French are ba»ed on very amall popul&tionB' 
t Mortality Statistica, Oenaua Office, 1000, p. 50. 



A 



2CX) StXTH OrrS&NATIONAlf CONGHEaS OK rtJB£BCtrLQBtS. 

▼BsUj in excess of that 5f the native-bom^ or of the entire city, and ranking 
among the highest of the rat^ for the foreign-bom elements of the popul&- 
tiOD. It vould seem, therefore^ that nationality has not so much to do with 
tlie prevalence of tubereuloda as economic status. The German immigrant 
Is usually possessed of 00 greater resources than the Immigrant from other 
countries, and* consequently^ b exposed to the hardships that almost in- 
variably Eoeet the immigrant in a great city. 

EcX)NOMic Status ov Famujes Visited. 

As stated above, it was a rather difficult undertaking to get reasonably 
aecorate answers as to the economic status of the families during the illoesB 
of members effected with tuberculosis^ but in 7$6 cases definite answers were 
obtained on tlus specific point. 

The following table shows the resources of families that had one or more 
members affected with tuberculosis during the Eve year period 1903-OS: 

„ Ntnti^Kii or 

Pubtif^ charity .., , 22 

Beoefit aUowanoe 38 

Bank acoDiuit ,..,,, ,,, SS 

$2Q to t25 per week 96 

$15 to 130 per week .,. 110 

f 10 to lis per *«ek 185 

$5 to $ 10 per week 206 

$1 to *5pef w«dc... 12 

The average size of those families, counting rich and poor, was 5,3 mem- 
bers. One hundred and seventy-seven of the above families had an average 
weekly income of $7,29, and an average membership of 5.8. Deducting & 
mnall sum for rent^ it will be readily eeen that the resources of this group of 
families av^lable for living expenses were such as to make e:usteuoe barely 
poaabte, and to render it absolutely imposdble to procure for a member 
affected with tuberculosis ordinary medical attendance — much less the bene- 
fits of sanatorium treatment. 

CLASSmCATIOK OF IIoM£8 VlSTTED IN WHICH PkBSQNS Ha£> Dl£I> OF 

Tuberculosis. 

The classiiicatton of the homes visited was made with reference to access 
to sunlight and pure air, number of houses to the block, size and condition 
of the pretnises, proximity to industries, and general sanitation and euviroo- 
ment, Occa.3iona!ly other factors, such as personal habits of the occupants, 
had an important bearing on the classification. 

There were 22 homes considered as excellent; 3S3 considered as good; 
297 as poor; and 200 as very bad. It will thus be seen that the classifica- 
tion of the hoi^ in which persons had died of tuberculosis i^rr^pomis with 



ECONOMIC ASFEXTTS OF TUBERCULOSIS IN MILWAUKEE, — CRAFEB. 201 

the above table eettiog forth the resources of families during the illness of 
members suffering with the same disease. 

Child Labor. 

The following fig^ure^ are significant as throwing some light upon the 
baneful effecta of child labor. 

Of 167 housewives who dicci of consumption in some form^ and who had 
not worked in industries nor as domestics prior tr> marriage, the average age 
at death was 34,0 years; the average age at death of 48 housewives who had 
worked in industries or as domestics prior to marriage^ was 27 years. 

The investigator could not visit all the industries of the city in which 
girls worked, and he ia not in a position to affirm that the industries of Mil- 
waukee are either more or less unhealthful for the employees than those to 
be found in other great industria! centers. The point to he notedj however, 
is that girls of tender years are forced into factories^ owing to the economic 
k«DDditions of their families. At a time when those girls should be conserving 
energy they are fast exhausting their vital jx^wcrs^ consequently when they 
do marry, their weakenetl constitutions are found unequal to the burdens of 
ijnatemity. For them the change from the factory to the marital relation 
is but a change of burden, and^ possibly, all things being considered, a changjs 
for the worse. 

To remedy the evils incident to child labor in the great induetries is by 
no means an easy matter* Of course, legislation directly raising the mini- 
mum age limit * and providing for a shorter working day and better work- 
ig conditions, may do much to promote the health of employees; but, after 
all, it would seem that nothing short of a general advance in the wages of 
adults can accomplish much in the way of amelioration of home conditions 
of a very large percentage of the industrial population. 

Fatality or the Disease. 

Buring the period covered by the investigation no more than three deaths 
were recorded in any one family; but going back beyond the period^ say ten 
to fifteen years, it was found that five or eIk deaths to a family were not 
uncommon. In one family as many as twelve deaths were reported within 
fourteen years; eight of these primarily from tuberculosis^ and four In wliich 
tuberculosis was a contributory cause. The father of this family, who was 
a janitor earning thirty dollars per month, was the first to be stricken with 
the disease, but be labored on during several years of Ins illness^ and spread 

* The elimiimtion of chltd labor from the industries naturally tends to raise the 
WtiLgDB of adulu, but tt eoldoni happ<jns that the iiirrea^ in the wago^ of adtiltjs is In 
direct proportion to the w&^es formerly esimt^l by children. For this TT?fbfon a law 
^ihibiting chiki labor in the indtiwIricK nci-csaiariiy diminifihi^ the total iocome of a 
Lily in which cbildrca and &dult« arc wagc-caraerB. 



SIXTH DTTERNATIONAli CONGRESS ON TUBERCULOSIS. 

the oonta^on among his children, mth the result that eleven out of thirteen 
fell victims to its deadly ravages. 

The apartments in which they lived consisted of three sm^, damp, 
wretchedly ventilated rooms in a bademetit. Tbeir aHJity to gr^ple with 
like dbeaae, when once a member of their family had contracted it, may be 
readOj una^ned from the foregping ^atement of the family income. At 
like prcseaki tune the widow and the two remaining children occupy a three^ 
loom baaemeait, worse, if poesibte, than the one in which the other members 
cf the family had died. One of thotse children, a lad of fourteen, is evidently 
afiected with tuberculosis, but by ^^rking as a mesaenger boy at $2.50 per 
week, helps hk aged mother to eke out a miserable existence. 

AnoUier famSy vtsHed reported four deaths from tuberculosis in dx 
jeuB, The eorrowful tale of this family's affliction is g$\*en in the despair- 
ing wtvds of tiie tDother^ who volunteered the information: ''We live hard, 
and we waik hazd, and all that we earn ^oes into the grave." One thousand 
doflan spent by this family in funeral expenses and doctors* bills during the 
ahoi>ie period reduced the survivors to the xBTgs of pauperism. 

In 180 families \'isited it was found that 2 members had died of tubercu- 
losb; in 31 famines from 3 to 5, and in 25 families more than 5 had died of 
•tlie sftHie disease. 

So much for ^ ravages of the disease; It now remains to consider the 
ways and means of overcoming this greatest scourge of the human race. 

Treatment- 

The wei^t of opinion at the present time is in favor of sanatorium treat- 
mefit as betog the only pract ical and effective remedy for tuberculo&is. That 
tabefftmkttiB la both a curable and pre\^ntable didetase is no longer open to 
f oa n iiov e i sy; but, it must not escape attention that very many families in 
which tuberculosis is found are not in a position to avail themscli'es of private 
BUuUotium treatment for their afMcted members. Private s&natoriums are 
not, pnmarily^ philanthropic institutions, but are rather designed as money- 
<"jdcTng uKstitutioEkSr and usually they admit only incipnent c^^^es^at least 
tins statement holds true for Wisconsin. The schedule of chargps for treat- 
ment in private sanatoriums varies from $20 to $30 per week. Clearly, 
then, of all the families \isited by the writer but 55 — those reported as hav- 
ing "bank accounts" — would be in a position to procure pri^'ate sanatorium 
treatment. 

Dike sanatorium near Ifilwaukee which may beclassed as a semi-charitable 
izkatatution has reduced the cost of tre^atment to aomethtng below $12 per 
week, aDd reports that with a larger number of patients the cost may be 
reduced bo $10 per week. 

Even at this reduced rate lees than half the families \isited by the writer 



EOONOMIC .ASPECTS OF TUBERCULOSIS IN MILWAUKEE. — CHAFER. 203 

would be able to avail themselves of sanatorium treatment — ^the more es- 
pecially if it were necessary to continue it for any considerable time. Nor 
could those families improvise home treatment approximating sanatorium 
treatment, for the simple reason that they occupied apartments so cramped 
and confined that, up to a few days of death, the afflicted members were 
forced to share a room, and even a bed, with other members of the family. 

Hopeful Signs. 

While the death-rate from tuberculosis for Milwaukee is still much higher 
than it should be, if all its citizens would exert their utmost endeavors toward 
stamping out the disease, it is encouraging to note that within the last two 
years there has been a decided falling-ojf in the total number of deaths from 
tubercular diseases, in the ratio of such deaths to deaths from all causes, and 
in the death-rate per 10,000. 

In 1903 the deaths from tuberculosis amounted to 10.82 per cent, of the 
total deaths; in 1904, they amounted to 11.71 per cent.; in 1905, to 12.09 
per cent.; in 1906 to 10.19 per cent.; and in 1907 to 9.34 per cent. The 
total number of deaths from tuberculosis in 1903 was 443; in 1904, 490; 
in 1905, 494; in 1906, 472; and in 1907, 433. 

The deaths recorded since the beginning of 1908 show a marked decrease 
over the deaths recorded during the same period last year. In 1903 the death- 
rate per 10,000 from tuberculosis for Milwaukee was 14.06; in 1904 it was 
15.07; in 1905, 14.74; in 1906, 13.68; and in 1907, 1237. It was in the 
year 1905 that the real campaign against tuberculosis was inaugurated in 
Milwaukee. 

Compared with other great American cities, the death-rate of Milwaukee 
from tuberculosis is relatively low. In the volume on the " Mortality Statis- 
tics" recently issued by the United States Census Office, the death-rates of 
a number of the leading cities from tuberculosis are ^ven as follows: 

San Francisco 27.5 per 10,000 

Denver 45.4 " " 

Washington 25.4 " " 

NewOrieans 28.0 " " 

Baltimore 23.6 " " 

Boston 19.9 " 

Detroit 11.5 " " 

Minneapolis 10.0 " " 

St. Paul 9.8 " " 

St. Louis 19.3 " " 

New York 21.7 " " 

Philadelphia 22.6 ** 

Cleveland 12.7 *' 

JereeyCity 23.0 " " 

Providence 16.4 " 

MUwaukee 13.3 " 

Compared with all the Atlantic and Gulf cities, the death-rate of Milwau- 



EtrrH ZKTE&XATIONAL CONGBESS ON TCBEECTLOeiS. 

ktt k lov, iod eomp&red with San Francisco azid Denver, the same is tine* 
The hi^ destb-nte of DeoTer is^ no doubt, to be aocouDted for by the fact 
that manj tuberculous pftUents go there for tzeatment from other States 
and oountriea. 

To a<»ount for the bi^ death-r&te from tuberralodb m San Frandaoo, 
the writer takes the liberty of quotiog from a communieatioii reee&tly te- 
tttred from the Department of Public Hedth of that rit y : 

"We are iDorally certain that at least 40 per cent, of the deaths in this 
(Ttr from tabercokiaB are those of non-residents who have been lured to 
Um n^oo by Tarioua fonna of advertaaiiig, etc*, in tbe hope of effecting a 
cme for Uiis ooonpiabii. This (^liiiioo is based upcm the Qw^tality statistics 
y tfacw d ID these cases, whereby the nativity of the x-ictims is segregated 
tato four daases: namely, San Francisco, other part^ ol California, L nit^ 
Hiatrw, and foffcigru The two latter classes greatly pTvdominate. Our City 
and Gmmtj Hospital has^ in tino^ past , handled, and do doubt at the pTesent 
time is hMMftfrig^ many cases of tuberculoeds foisted upon us by the authori- 
ties in other counties m this State^ as we are weU known for our generosity 
IB caring for the sick and <BBablBd. We can safely say that if o^er States^ 
and also eoantieB m tfais S4at«, would care for their own tubercular patieatB, 
the mnctafity £n»D the '^e&t white phgue' in this city would be fnatmaHy 
rcdneed." 

Tbe baghcBi death-rate recorded in an American city in 1906 was that of 
Colorado ^prin^ Cokn^do — 59.6 per ten thouf^and. 

In past yean H has been the oinaiot) of many that a hitter altitude, such 
as Colorado, or a warm dimate, such as southern California, was particularly 
h*"**fi»**J to tuberculous patients^ but of late years tlus theory is bdng 
aotBewhat disoeditecS. 

The investigator found caaes v^iere tuberculous patients had left Mil- 
waukee for various beahh-fesoita m Nevada, New Mexico. Colorado, and 
aoothem Caiifomia; and, after ap«MUiig large sums of money, returned to 
their native city to die. It may be that the cUsease had leached its advanced 
rtaflcg when they went to those heaJth-resorts. but one can securely resist 
the eoDchiaoo that many tuberculous patients aie thoughtiessly advised 
to try other dimates for tie^tment without due eoDaderatiou of their 
powecs of adaptkm to those climates. Theold ada^e that "far-off hilb look 
green '' may be apphcable to those ctimat^ supposed to be specifics for 
tubercular disease. We hear a great deal about the cures th&t are ^ected 
among patients who avail themselvceiof those health-resorts^ but not so much 
about tbe enonnoos mortality among such palaei^ts. The death-rates in 
those health resorts spcAk for thems^ves. 

It would seem, then, that if tbe cnasade against tttberculosis is to be 
waged effeotivdy, it must l>e wa^ stmuHaneousbr by e\'ery ^State and 



ECONOMIC ASPECTS OF TUBERCULOSIS IN MlLWAUSEB*^ — CRAFER. 205 

civilized country. It will not do to selfishly shift the burden from one State 
or country to another* Each State or country should and must, eventually, 
eare for its own tuberculous patients. 

Experiments in Germany and Great Britain, and in New York, Wisconsin, 
and many other American States, show, beyond a shadow of doubt, that 
tuberculosis can be successfully treated in northern climates. The results 
of the treatment in the private sanatonuros of Wisconsin are most gratifying 
and encouraging, although^ it is true, those institutiona, as yet, treat only 
incipieat causes. 

COKCLUSrOK. 
Granting, then, that tuberculosis^ in certain stages, can be eucceasfuUy 
treated in Wisconsin, it now seems fitting to consider how sanatorium 
treatment — the only effective treatment — can be brought within the reach 
of all classes affected with the disease. 

The investigation in Milwaukee, based on the careful canvass of the 
entire city, and exact answers in 786 cases, shows that more than 50 per 
cent, of the families bad a weekly income of li^^s than $15 per week during 
the illness of members adlicted with tuberculoaiBi and an average membership 
of 5.3 persons. 

The cost of treatment in a State or municipal sanatorium might be re- 
duced to 17 per week, provided a sufficiently larg^ number of patients was 
treated, but even at this rate there would be a very considerable number 
of patients in Milwaukee unable to avail themselves of sanatorium treatment. 
It is a very conservative estimate that 40 per cent, of all the families in 
^lilwaukee having tul^erculous members are absolutely incapable of affording 
the proper conditions of light, pure air, good housing, freedom from worry, 
nouriahing food, and competent medical attendance for a successful cam- 
paign against the disease- 
While tuberculosis abounds in the poorer districts of our cities, those 
living in the better residential quarters are not safe. The danger of contagion 
may not seem to them to be immediate, but nevertheless this danger is 
constant. So great an authority as Dr. Flick, of Pennsylvania, has stated 
that 'Huberculoais requires a long and intimate exposure for implantation;'* 
but, nevertheless, thii^ very exposure reaches the rich man's family in ways 
of which he may be unaware. Nurse-giris and domestics coming from poor 
homes enter into the closest association with the famiUesof the rich. In many 
cases those employees come from families in which there are one or more 
tuberculous members. In one notable instance the writer found that a 
consumptive girl from a home in which seven brothers and sisters had died 
of tuberculosis had worked as domeatic in the family of one of Milwaukee's 
wealthy citizens up to three months of her death. 



i 




H SIXTH DrfsmunoxAj. ookghebs o^ TUBxacuuxm, 

The anmx&l km to tlie cs^, the Sute, or the oAtioci attribotAbfe to 

fwsiwiinBM it m ififfieult to computet. Htun&a Etva eamut jukd riuuld oot 

Tilued in tenns of doH&rs aod o^ita; but even aoeb enkhtttioii fe&ves out 

eouidenition entirely the protracted bodilj and mental euffering of the 

, the cWerred and defeated hopes of r^athres, the not inhequecft 

in social atatos of faioiUes aa a direct result of this gttw'*«»- 

In the great cniaade against tuberculoos the rich must be wilhng to lend 

hdinng haad to their ina fortunatety situated feOoiF-raiB. Strict enfonse- 

ci aaoitary regalatioiia, and free dispensaries, haw their proper plaee 

function^ but pubfie aaaatoriums for tbe treatment of incipient eases of 

among the poor, and public isolation bospitab for incurable 

mcild aeem to be the most elective me&ns to be aBpk^ed in diminiah- 

ing and uitimatefj eUmiBating the greatest scourge of the human race. 




Aspecto Bconomico de la Tubercokids.— {Cbafel) 

1. La mortaitdad ocaatonada por la tubermkiais en loe nacidm en el 
pais, en la ciudadr es menor que la mortahdad eo [qq naddoe en el extenor^ 
eato ea ddsido al hecho de que, por lo general, se ven obligados 4 vivir en 
laa aecciooee pobres de la ciudad. 

2. Lea recunos de las famiiias en donde ttiK> 6 mas miembros estaban 
afeetadoa de tuberculosis, durante el peHodo de ^a mvesti^d6n, fueron 
taJea que, en poooe caeoe solAmente, el procuramienta de la asistencia mi^ca 

podble. 

3^ La clasificaci6n de laa caaaa en donde defunciooea de tuberculoeoa 
ban ocurrido, durante et periodo de la iBVestigacion, fu^ becba ecHt refereneia 
al acceso de loe rayoe solares, aire puro, Dtimero de casas en la cuadra, 
tamaSo j copdiaones de la babitacion, proxiniidad de eetas 4 las f&brieafly 
floodidoiiea aanitariaa en general y coDtomos de la hatntaddn, kn leanltadoa 
aoo loa Bguiente9:'-excelentcs, 22; buenas, 383; pobres, 297; muy mal^ 
200. 

C Entre laa oeupaciones en las cuales el mayor nlimeFo de defundonas 
ae encuentran sod laa fflguientes; Eabradores descuidados, empleados de 
factorfflSj escriblrates dom^icos y de tiendas^ en el orden nombrado. 

S* La estadistica siguiente es aigniEcatlva ea relaci6D al efecto ben^oo 
dd trabftjo de loe niiSoe en loe tatleres. De 167 amas de casa que sucum- 
bienm i U tuberculosis, durante el perfodo de esta investigacidn, las cualea 
no babian trabjijado eo laa factoHa ni en aervicios domesticos antes do 
e) t^rmino medio de la edad al tiempo de la muerte fue de 34.9 
; mientras que de 48 amas de casa, las cualea habian trabajado en laa 
aa 6 en servicios dom^ioge antes de caaarae, el Usrwioo medio a la 
edad de b muerte fue de 27 afioa. 



ECONOMIC ASPECn^ OF TtTBEaCtTLOSlS IK MILWAUKEE. — CBAFER, 207 

6. Aunque la tuberculosis esta estensamente distributda en la ciudad de 
Milwaukee, esta es mas fataJ en los lugares donde cxigte mayor congestion 
de poblaci6n. El t^rmino medio de la poblacidn en la ciudad es menoa de 
TOnte y dos por acre de terreno; pero en ciertas partes de la ciudad, en 
donde la tuberculosis es mas abundante, la densidad de la poblacidn es maa 
de cieato por acre. 

7. De las familias afectadas de tubercuSosls en Milwaukee, un 40% de 
elias son absolutamente incapaces de gozar de los efectoa ben^ficos de la 
lux del t5ol, aire puro, buenas habitaciones, libertad de las penas moraleSi 
propia alimeutacion y de una competente aaiatencia m^ca. 



Aspects ^conomique de la tuberculosa. — (Chafer,) 

1. La mortality due h. la tuberculose parmi les personnes o^ dans la 
Yille <^t beaucoup moina ^lev^ que parmi les personnes 6trang6res. Cela 
resulte du fait que les Lmmigrants sont oblig^ d'aller hablter dans les plus 
pauvres quartiers de la ville, 

2. Durant cettc enqu^te it quelques exceptiona pr^, les families ayant 
un ou pluaieurs memhres atteints de la tuberculose ne po9s6daient pas les 
reasources n^ceasaires pour Jea soina ordinairea k donner aux maladea, 

3. Lea maisons o(i durant notre enqufite des personnes ^taient mortes 
de la tuberculose ont 6iA classfes, en tenant compte de la lumi^re, de I'air 
pun du nombre de maisons dan* le squarCf des diniensionjs et conditiooB 
de.s locaux, du voidnage des uaines, des conditions g^n^rales et dea alentoura. 
22 ont ^t4 trouv^ excellente^; 383 bonnes; 297 mauvaises; 200 tr^ 
mauvaises* 

4. La mortality la plus ^lev^ e^obscrve parmi les ouvriers sans metier 
special, le^ employes dans les usines, les domestiques et les garcona de 
magaain, dans Tordre cit^, 

5* Les chiflfres suivants font ressortir d'une fagon frappante les funestes 
effete du travail des enfants dans les usines. Pour 167 m^nag^rea qui 
moururent durant cette enqufite, et qui n'avaient point ^t^ employed 
comnie ouvri^re^ ou domestiques avant leur manage, T^ge moyen de la 
mort ^tait de 34.9 ans; tandis que pour 48 m^nag^res ayant ^t^ domes- 
tiques ou ayant travailld dans des usines avant leur mariagp, Tdge moyen 
de la mort 6tait seulement de 27 ans. 

6. Bien que la tulierculose suit tr65-r^pandue dans Milwaukee, elle est 
le plUB fatale dans les quartiers populeux. La density moyenne par acre 
de la population pour tout« la ville est de 22, mais elle atteint plus de 100 
dans certains quartiers. 

7. 40% de toutes les families de Milwaukee, ayant des mernbi^a tubercu- 
leux, aont inoapables de se foumir les conditions d'aeration, ^claira^, 



208 



SIXTH INTERNATlONAlj CONGK£8S ON TUBERCULOSIS. 



logement, nourritui-e^ exemption de soucis et soins compfitants nec^ssaires 
poui* line victorieus6 campagne contre la maladie. 

Okonomische Gesichtspunkte bei der Tuberktilose. — (Crafek.) 

L Die Todesratc von Tuberkulose fiir die im Lande geborene Bev5l- 
kerung der Stadt ist vie! niedriger als die der FYemdgeborenen* Dies 
resultiert aua der Tatsache, dass die Kinwanderer, da sie kleine HiUsquellen 
haben^ gezmingen sind, sich in die arnilicheren Wobnquartiere der Stadt 
au begeben, 

2. Die Hilfsquellen von Familien, in deneti ein oder mehrere Mitglieder 
von Tuberkulose befallen waren wS,hrend der durch die Ausforscliung 
gedecktcn Pcriode, waren aolche, dasa in sehr wenig Fallen gewohnliche 
arztliche Aufinerksamkeit fur den Kranken vorgesehen werden konnte. 

3. Die folgende Klsissifikation von HeimstMten^ in welchen Personen an 
Tuberkulose gestorben waren wahrend der durch die Ausforschung bedeckten 
Periode, war gemacht worden mit Bezug auf den Zutritt des Sonnenlichtes 
und der friscbeu Luft, der An^ahl von Hausern in dem Block, des Ausmasses 
und der Bedingungen der Gehafte und Gmndstiicke, der NShe von Indus- 
trien, der allgenieinen Gesundheitaverhaltnisse und Umgebung: auage- 
zeichnet, 22; gut^ 383; armaelig, 297; sehr schlecht, 200. 

4* Die Beschaftigungea, welche die h6chsten Todesraten seigten, waren 
die ungeachiitzter Arbeiter, Fabriksangestellter, hauslicher und Laden- 
bediensleter in der genannten Reihenfolge- 

6. Die folgenden Statistiken sind hezeichnend, da sie etwas licht auf 
die verderbliche WLrkung der Kinderarbeit in den Industrien werfen. 
Von 167 Hausnnittern, welche wahrend der durch die Ausforachung bedeck- 
ten Periode starben, und welche vor ihrer Heirat weder in Industrien noch 
als Dienstboten gearljeitet hatten, war das Durchschnittsalter !:)eim Tode 
34<9 Jahre; wogegen das Durchschnittsalter dea Todes von 48 Haus- 
miittem, welche in Industrien oder als Dienstboten vor der Heirat gcarbeitet 
batten, nicht mehr ala 27 Jalu^ war. 

6, Obwohl Tuberkulose in der Stadt Milwaukee weit verbreit^t ist, 
tat gie am fatalsten in den iiberfullten Bezirken, Die durchschnittliche 
Dlcht^ der Bevolkening pro Acker fiir die ganze Stadt ist nicht wcniger als 
22; aber in beetimmten Teilen der iiberfullteren Bezirke, wo Tuberkulose 
rciclilich vorhanden ist, ist die Dichte der Bevolkerung pro Acker 100. 

7, Es ist eine sehr konservative Schatzung, dass 40% aller der Familien 
in Milwaukee, welche tuberkulose Mitglieder haben, absolut ausser Stande 
fflbid, die richtigen Bedingungen von Licht^ reiner Luft, guten Wohnungen, 
Freisein von Sorge, kraftiger Nahrung und massgcbender arztlicher Fiir- 
Borge fiir einen erfolgreiuheu Feldzug gegen die ICrankheit erschwiugen eu 
kOnneo, 



■ 



PULMONARY TUBERCULOSIS AMONG PRINTERS. 
Bt Jabcbs Alexander Miller, M.D., 

New York. 



All authorities agree in placing diseases of the respiratory organs, and 
especially pulmonary tuberculosis, at the head of the various causes of 
fflckness and death among printers. It is also noteworthy that, comparing 
the mortality from tuberculosds in other occupations with that from the 
same cause in the printer's trade, a larger mortality from this disease is 
found in only two other trades — ^the stone-cutters and the tobacco-workers. 

The cause of this high death-rate from tuberculosis among printers has 
been variously assigned. In general, it has been attributed to the long and 
confining hours of work in a sedentary and cramped portion, to poor ven- 
tilation, overcrowding, dust, metal fumes, and other unsanitary conditions 
in the shops, or to irregularities in the habits of the men themselves, often 
caused by the necessity for considerable night work, or to carelessness in 
exposing the body to colds and drafts after confinement in overheated rooms, 
and also to the prevalence of alcoholism. 

The fact that printers earn good wages, var3dng from $25 to $35 a week, 
enables them to live, as a rule, in comfortable homes and under good hygienic 
surroundings, so that among these workers the usual factors in the home life 
wluch so often predispose to tuberculosis are apparently not operative. 
It would therefore seem that the explanation of their susceptibility to tuber- 
culo^ should be found in the work-shop rather than in the home. 

Practically all of the investigations that have been made upon this 
subject are based upon mortality and morbitity statistics, and, while of 
value, they lack the personal equation, and can be considered as only 
approximately acciu*ate. Nevertheless, the fact that they all agree in 
placing pulmonary tuberculosis so nearly at the head of the causes of sick- 
ness and death among printers is conclusive evidence that this disease is very 
prevalent, and this is substantiated by the personal impressions of all who 
are closely in touch with this trade. 

In this study it was proposed to take up the problem from a different 
point of view, and to base our conclusions upon a series of very thorough 
physical examinations made upon a limited number of printers, who should 
be, as far as possible, representative of the trade as a whole. For this 

209 



210 



B££TH iNTEaiNATIONAL COKGRESS ON TUBERCULOSIS. 



purpose the Committee on the Prevention of Tuberculosis of the Charity 
(Organization Society authorized the writer to arrange for the examination 
of 200 printers, these examinations to be made under his supervision by a 
number of competent physicians to whom a nominal per capita fee should 
be paiti. We were fortunate enough to secure for^'this work the services of 
Dr, Haven EraersoUj Dn Curteoius Gillette, Dr. I. 0, Woodruff ^ and Dr. 
R. A. Fraser* 

We were also fortunate in enUsting the active interest and cooperation 
of the Typographical Union No, 6, through whose officers, and especially 
through their committee on tuberculosis, Messrs. J> P. Cahill, J» A. Gardiner, 
and A. D, Carmichael, we were able to secure volunteers for our examination. 
From the fact that these candidates were volunteers, the suspicion is jus- 
tified that a representative selection of cases may not have resulted. Care- 
ful inquiry among the men, however, elicited the fact that those who volun- 
teered because they were sure they could pass the examination were quit^ 
as many as those who feared they might be ill. It is our opinion, therefore^ 
that this series of cases is as representative of the phj'sical contUtion of men 
in the printing trade as is possible in a series of such limited size. Two 
hundred and three men volunteered, and it is upon the results of theee 
examinations that this report is based. 

Elxaminations were conducted in rooms kindly placed at our disposal by 
Mr. Paul Kennaday, then Secretary of the Committee on the Prevention of 
Tuberculosis, and the facilities were excellent for careful and thorough 
work. The examination coasisted in a complete physical examination 
including the upper air^passages, the taking of a careful medical history, 
and also a complete description of the IJ^-ing and working en\ironment. 
both past and present, in each case. The examinations have yielded the 
following results, which will be classified according to — 

1. The social conditions. 

2. The pre\'ious physical condition before becoming printers, 

3. The working conditions. 

4. The pre\dou5 medical history. 

5. Present physical condition. 

1. The Social Covditionb, 

Of the 203 printers examined, 149, or nearly three-fourths, were bom in 
the United States. The majority of the others were either English or 
Scotch* Only 9 were Hebrews* One hundred and thirty-seven were 
married. As to age, 48 were between twenty and thirty years of ^e, 89 
between thirty and forty; 50 between forty and fifty; and 16 between 
fifty and sixty years. 

A study of the home coaditioBS under which these printer lived shows 



4 



n 



PUUWONABY TUBERCULOSIS AMONG PRINTEK3. — MILLER. 



211 



that 72 lived in private houses, 123 in apartments, and only 44 in tenements. 
A large majcjrity of th«5e homes were in Brooklyn and the Bronx. The 
hygjenic conditions In these homes were described as good in 196^ and the 
charocter of the foo(i to which the men were accustomed was good in 192. 

An inquiry into personal habits in the use of alcohol and tobacco elicited 
the information that alcohol was used in excess in 40 cases, and tobacco in 
excess in 51; alcohol in moileration in 97, and tobacco in moderation in 80; 
alcohol occasionally in 48, and tobacco occasionally in 24. Forty-five men, or 
more than 20 per cent,, were total abstainers both from alcohol and tobacco. 

It will thus be seen that we have to deal with a type of comparatively 
yoimg men, mostly native-bom and married, living in good homes and 
under good hy^enic conditions, among whom the use of alcohol and tobacco 
is quite general, it being noteworthy, however, that about 20 i^er cent, are 
total abstainers, and about 20 per cent, admit indulgence to distinct excels* 
Probably many of those classified as moderate drinkers should be included 
among those who drink to excess. 

2. Physical Co^mTnoN Before Becomtno Printers. 

This was d^cribed as excellent or good in 189, ss poor in only 1 case, 
and as fair in the remainder* 

One hundred and fifty men, however, admitted to having lost time 
from illness, of greater or less duration, before they took up the printing 
trade. This in the majority of cases would mean while they were boys, 
as the 150 men had had no other occupation but printing. Of the others, 
10 had clerical positions, 15 were tradesmen of some sort, 11 had had some 
sort of outdoor occupation, and 17 gave no record. 

3. Working CoNnmoNS. 

Character of TTorfe.— One hundred and fifty-six men, or more than three- 
fourths, had been in the printing trade more than 10 years. The majority 
of the men, 1 17, were hand compositors, 58 were employed on linotype 
machines, 5 in both machine and hand work, 3 were lithographers, 12 
proofreaders, and 8 had miscellaneous employment. 

Hours of Work.— Th^ regular hours of work, for all of these men, was 
eight, hours out of the twenty-four, and the majority of them, 179, were 
employed in day work, though many of them were shifted, from time to 
time, to night work, so that the hours of work of a large number were more 
or leas irregular. Only 19 were accustometl to work more than eight hours 
a day for any conmderable space of time. Eighty-one w^ould occasionally 
do over-time work, but 114 never did over-time work of any sort. Almost 
all of the men had steady positions, and, with few exceptions, were employed 
in the composing rooms of one or another of the large newspapers of New 



I 



its 



ADCra DTTERNATIOKAL CONGRESS ON TUBERCULOSIS. 



York, The wnges varied from S20 to 140 per week, with &d a\^rage wage 

of $26.60. 

Shop CoTidiiianft. — Each man was asked to state the individual shop 
oouditioiis uH«lcr which he was accustomed to work, and the following in- 
forrnfltioii wiw obtained. The very large majority worked in large builiiings, 
ftt A fewl (*f iho sixth floor or above. Ventilation was secured, in most 
ca^rv, simply by windows, which were controlled entirely by the men them- 
(lelnYt. In f^l iiistancca there wos also some sort of forcod ventilation. 
Th« «ihojw were di«crilx?tl as being dusty in 107, and as not dusty in 76; 
ai tmcwtircly hot hi 93, and as not excessively hot in 97. Conditions 
OQMidertNl b>' ttio men tr» be unfavorable to health were said to exist in 124 
dUNW, tvnd tUi'wo wore simcifically designated as follows: poor ventilation, 
4((; itjobd fumes fn>Tn nnpii^eil machines^ 27j unsanitary water-closets, 19,- 
|»M«il(ifh'Hoy i*r ftlwcnre of cuspidors, 14; dirty walla and ceilings, 8; metal 
%\\m\, ^> t*\vrcr()wdrd rooms, 7; poor light, 5, 

U v^lll ibuH U» Hoen that, from the standpoint of the men, the objection- 
nl*k* f^^Umw ui>i nlwohitely unnecessary and easily remediable, and that of 
mII tnuutUUi^lut Ihi* id»Hence of good ventilation aeems to be the cliief cause of 
ly^ui^nlut. The fiu't that in 27 cases complfunts are made of unpiped 
(t^m'^ttiu^ U noteworthy, hifwmuch as this condition is contrary to law, and 
\ki$0k \xMH>i\v-i\ Np«H>lal attention from the State Department of Labor. 

4. Fhicvious Medical History, 
||«l«i b hloUldfHl Iht^ history of all diseases which occurred from the time 
lit l^uuitkit wwtk w priulerH up to the time of the examination, excepting 
^yjt, .U4 wli^i^h |H^r^i irj at the time of the examination, and were 

ll^M I- K'l^ nr^Ji-r 'M'lr v[it Physical Condition/' 

. ..[, \|".'.uti- In tuljerculosia ia intereatingfrom the stand- 
u^u^ **( **'W un**UHfHl*'n. Suc'Ii exjxisure was present in 62 cases, and of 



w -■■ 



V^t '.M; U'.Vi' V'V^.y. 



V xUiv to *o»*iiil^^rH of the immediate family. Very few instances 

vxuwurt^ Inuii luwvriiition with tuberculous workers in the shop. 

{\\\H\ «tnt^» ?h*4t they had had no serious disease of any sort 

1 ' ' ' \\Av oroui^Uion as printers. By far the largest number 

»i^d i4 erttiirrh of the upper air-paaaagcs- The next 

\i\\\\\ of viiriourt (.listurbances of the digestive system. 

. M\i\ vkf Ihiwe, 21 complained of chronic constipation, 

lu, \ \4 1 lm*nh^ diarrhea, 4 of biliousness, 2 of intestinal 

' <. Hud ^ k4 Vvphttid fever* In the 2 cases of intestinal 

i,.. ., , ,..^..^l '^Mujitoiui* or signs which pointed in any 

anic; tmd while the absorption of smalt 

Ut do with the rather numerous Instancea 

^^, M^^^^^^K^, *. ^•>^^^ u^d ■*•*■'(» Ukcly, as thcse disturbances 



POUiONART TUBERCTLOSIS AMONG PRINTERS. — MILLER. 



213 



codd be perfectly well explained by the sedentary life and irregular habits 
of living of these men. It would seem that lead poisoning among printers 
is now very infrequent. 

Some acute disease of the respiratory HyHtem other than catarrh had 
occurred in 21 cases; of these, 11 were pneumonia and 6 pleurisy. Nervous 
Bymptoma had been noticed in 17 cases. In 7 of these it was a history of 
neurasthenia, in 9 of persistent and troublesome headaches^ and 1 of epilepsy. 
A history of the rheumatic conditions was obtained in 12 cases; of these, 
8 were articular rheumatism, 2 sciatica, 2 lumbago, A hifitory of nephritis 
was obtained in one ease. One hundred and twenty-four men said that 
they bad lost no time from work by illness since taking up the printing 
trade. 

It is interesting to note the personal opinions of these men as to their 
comparative physical condition before becoming printers, and at the time 
of their examination. This condition was considered to be unchanged in 
137 cases, to Ixs better in 9, to be worse in 52^ and in 5 cases no opinion was 
e^reesed. It may therefore be stated that, in the opinion of the men them- 
selves, their occupation is not particularly unhealthfuL Their statements 
on this point are to a certain extent born out by the fact that 129 men had 
either retained thetr normal weight, or gained in weight, during the time of 
their work in the printing trade. 



5, Present PHraiCAL CoNnrnoN, 

Sixty-three men, or over 31 per cent., were found normal upon physical 

examination. Catarrh of the upper air-passage in some form was present 

in 57 cases as followB: Chronic pharjTigitis, 14; chrome rhinopharyngitis, 

20; chronic rhinitis, 22; chronic laryngitis, 1; hypertrophied tonsils, 5; 

l^enoids, 2. 

Some disease of the internal respiratory organs was present in 86 casefl 
as follows: Bronchitis, 11; pulmonary emphysema, 8; pleurisy, 33; pul- 
monary tuberculosis, 34, 

Of the cases of pleurisy, 31 had alight dry pleurisy, 1 acute fibrmoua 
pleurisy, 1 extensive pleurisy with adhesions. 

In the cases of pulmonary tuberculosis, 5 were incipient, 14 were moder- 
ately advanced, 10 had healed lesions, and 3 were merely doubtfid or aus- 
picious cases. Of the moderately advanced ctuies, only 9 were active, and 
5 were in an arrested stage of their disease. The large proportion, nearly 
one-half, of healed and arrested lesions is very interesting, and should be 
taken into consideration in drawing conclusions as to the unhealthfulnesa of 
his occupation. The majority of these healed cases gave histories of un^ 
niistakably active tuberculosis in the past wliich had been treated under 
proper hygienic conditions in the country or at some health resort, and then 
the men had returned to take up their occupation again, with increased 




214 



BDCTH ENTEBNATIONAL CONGRESS ON TUBERCULOSIS, 



knowledge of persomil hygiene and care of their health. In the 5 incipient 
cases the disease was unsuspected in all but one, and 4 of these eases were 
sent to sanatoriuma; the 2 far advanced cases were advised to ^ve up work, 
and one of them was sent to a hospital. 

Tuberculous laryngitis was present in one case, and fistula in ano, prob- 
ably tuberculous, in 2 cases. 

Disturbances of the circulatory sj'stem were distwvered in 9 cas^ ; of these, 
6 had chronic endocarditis, all of which were fuDy compeDsated. Two had 
cardiac neurosis and 1 bad marked endarteritis. 

One case gave a histor}' of nephritis, but no routine examinations of the 
urine were made at the time of the examination to determine the condition of 
the kidnej'g* 

Disturbances of the digestive system were discovered in 13 cas^ da^£ed 
as follows: chronic gastritis, 2; cirrhods of the liver, 3; inanition, 1; hemor- 
rhoids, 3; hernia, 4. 

Exteinai diseases of the eyes were present in 6 cases; of these^ 3 had 
blepharitis, and 3 conj unctivitis. One man was markedly deaf, and 2 showed 
evidences of distinct neurasthenia. 

Diseases of the skin were present in 4 cases; of these^ 2 were pustula acne, 
1 acne rosacea, and 2 tertiary syphilis. ScoUods of the spine was present in 
1 case. 

Very oiarked anemia was found tn 2 cases. 

It was remarked, in a large nimsber of cAses, that the men had unhealthy, 
pasty complexions, attributed to indoor Ufe> irregular habits, and the lack of 
recreation and outdoor exercise. 



SumiABY, 

The results of our examinations tend to show that pulmonary tuberculoiiB 
is very frequent among printer^ as the mortality statis^es had abeady in- 
dicated. 

That printers are very subject to catarrh of the upper atr-passages, 
whether more so than other workers in any large city is open to doubt- 
That disturbances of the digestion are fre<juent, and probably plaj an 
important r6le in determining the health of the trade. 

That funetional disorders classified luider the general head of neurasthenia 
are not in&equent, as are also various rheumatic conditions. The large num- 
of caaes of dry pleurisy is not as significant to the writer as would appear 
''on the surface, for investigation among a large number of dispensary patients, 
-nod patients in other occupations, h^ revealed a similar Urge perceota^ 
[pt eaaea of dry pleurisy. The explanation is probably in some way aa^odaied 
with the inhalatioc) of dust, but that the presence of such dry pteuiisy is 
UKficatire of a tuberculous infection is not proved 



PULMONARY TTTBERCUIjOBIS AMOKO PRINTERS. — MILLER. 



215 



Conclusions* 

Investigation of the conditions in the printing shops, especially the com- 
posing rooms of many of the large metropolitan newspapers, leads to the 
conclusion that many of the unfavorable conditions complained of by the men 
do actually exist. This b particularly true as to ventilation, excessive heat, 
dust, and overcrowding at certain hours. No instances of mipiped metal 
pots were found, although undoubtedly some such exist. 

Notwitlistanding these facts, conditions at the present time in these 
shops must be remarkably improved. Much has been accomplkhed in tliis 
direction in the past ten or fifteen years; and it would appear that further 
improvement in the future would occur along the lines of more exact com- 
pliance with the regulations which have been from time to time put in 
force. There is no evidence, at the present time, of wilful and absolute dis- 
regard of the health of the printers on the part of the managers of these large 
oSices. The printers' union has undoubtedly been the chief agent in bringing 
about these reforms, and at present it would seem that what is most needed 
^|b adequate supervision of shop conditions and enforcement of the existing 
;utations. A possible exception to this is the question of ventilation. 

If the rooms could be more thoroughly cleaned, the walls as well as the 
floors; if overcrowding, especially at certain times, could be prevented; if 
the rooms could be emptied of workers and thoroughly ventilated once in 
every twenty-four hours; if the windows could be regulated in the interest of 
the shop, and not of that of the indiiidual; if spitting could be absolutely 
prohibited, and the method of lighting, esf:jeciaUy by artificial light, could be 
made uniform and satisfactory, most of the evils which now exist would be 
ited. On the other hand, it would seem that the printers themselves 
A great deal to learn in regard to the care of their health, and are largely 
iponsible for their susceptibility to disease, especially to tuberculosis. 

Irregular habits of liWng are so general among printers. Irregular hours 
of work , with the large proportion of night work which is required, especially 
of newspaper men, is probably largely conducive to these habits. Outeide 
of this, printers are prone to many indiscretions which are detrimental to 
their health. 

Foremost among these is alcoholism, which is probably responsible for 
much disease among printers. The use of tobacco goes with this, and 
although less harmful, undoubtedly exerts an injurious effect upon the health, 
Carelessness and irregularity in eating, particularly in eating luncheon in 
the shop, is also a contributing factor. Becoming rapidly chilled by open 
■windows, or running out of doors improperly clad after long hours in 
overheated rooms, and the surprisingly small amount of outdoor exercise 
taken by the printers, must also have their influence- 

The responaibility for the prevalence among printers would therefore 



J 



216 



SIXTH INTERNATIONAL C0NGBE6S ON TUBERCULOSIS. 



appear to be about equally divided between the unfavorable conditions in the 
shops, all of which were preventable, and the habits of the printers themselves^ 
which certainly are alao susceptible to improvement. 



Tuberculosis Pulmooar Entre los Impresores. — (Miller.) 

Examen fJsico de 203 impresores, quienea voluntariamentc se ofp^ieron 
al examen. 

La mayor parte de loa hombres examinadoe fueron jovenos, naturales de 
America, ganaban buenos aalarios y viven bajo condiciones favorables; 
la mayor parte de ellog usan el alcohol y el tabaco; 20% loa usan en exocso y 
cerca de 20% son abstinentes* 

Ciento veinte y cuatro se quejan de las condiciones desfavorables de los 
talleres las cuales son la siguientes: ventilacl6n es escasa, 49; vapor de 
metal debido a la ausencia de chimineasen las roaquinas,27; insalubridad en 
las letrinas, 19; insuficieneia 6 falta de escupideras, 14; paredes y cielo raso 
sucios, 8; polvo de los metalcB,5; exeso de emp!eatloseuel mismo taller, 7; 
luz insuficiente, 5, 

El exdmen m6tiico y ia historia de los mdhiduos demue^tra la frecuencia 
de catarros en la ]iarte suj^rior del aparato respiratono tanabien pleuresfa 
seca y tuberculosis pulmonar* Tuberculosis pulmoaar se encuentra en 34 
casos 6 sea en 17% de loa casos examinados. 

Desarreglos del aparato digestive se encuentra con frecuencia, lo tmsmo 
que neurastenia y condiciones reumaticas. 

La tuberculosis pulmonar es muy frecuente entre loa impresores y esto es 
debido: 

1. A loscondicioncs deafavorablesde loa talleres, especialmente insuficiente 
ventilacion, exeso de empleados en el mismo cuarto, polvo y 8uciedad| al 
habito de escupir y faJta de escupideras ^ insuiiciente luz. 

2. A los habitos irregulares del Impresor imsmo^ especialmente alcoholis- 
mo, descuidoe en el habito de comer, y Losuficiencia de ejercicioe al aire Ubre. 



I 



La Tuberculose Pulmonaiie Chez les Imprimeurs* — (Miller,) 
Un examen ph>'sique tres-s^rieux a ^t^ fait de 203 imprimeura qui ont 
bienvoulu s'y soumettre. 

II a (H^ constats que presque tous ces hommes ^tdent jeunes, n& am^ri-^ 
eains, gagnaient un bon salaiie et vivdent dans de bonnes conditions; la 
plupart faisaient usage de Talcool et du tabac: 20 pour 100 en fakaient un 
usage excessif, et en\Tjon 20 pour 100 s'en abstenaient totalement. 

Gent ^ingt quatre hommes se sont plaints de certalnes conditions dMa^ 
vorablesdans leux ateliers, comme 11 suit: ventilation insuffisante, 49; vapeoBB 
m^alUques 6manaat de machines non tubulmres,27; waterclosets insalubres 



^.fJL 



FULUONAST TUBERCULOSIS AMONG PHINTEES, — MILLER. 217 

19; peu ou point de crachoir, 14; mure et plafonds malpropre3,8; poussi^re 
m^talUque, 5; encombrement des salles, 7; lumi^re insuffisante, 5. 

L^histoire m^icale et TexameTi des sujets ont montr6 la grande fr^uence 
du catarrhe des voies respiratoires^ de mitme, la pleurae eiche, la bronchite 
et la tubereulose pulraoiiMre. Celle-d a ^t^ constats cb**?! 34 sujets, c, k, d. 
17 pour 100 du nombre total. 

Les troubles digestifs dtaient aussi tr^Wquent^, et aussi mafs k un 
moindre degr6 la neurasth^nie et un 6tat rhumatismaL 

La tubereulose pulmonaire, chez les imprimeurs, c^t due piincipalement: 

1. A des conditions d^favorablefi dans les ateliers, surtout une aeration 
insuRisante, I'encombrement, la poussi^re et la ealet^, Thabitude de cracher 
n'importe 06, et un mauvais 6clairage; 

2. Aux habitudea irr<5guli^res des imprimeurs eux-mtoeSj surtout I'alcoo- 
lisme, une grande negligence dans le regime aHmentairSj et I'insuffisaace de 
I'exerciae au grand air- 

Ltmgentubfirknlose uiiter Buchdnickem. — (Miller.) 

Grundliche ph^-Bikalisclie Untcrsuchungen waren an 203 Buchdruckern 
gemacht worden, die sich freiwillig zur Untersuehung hergabeB. 

Eb wurde gefunden^ dass fast allc diese Manner jungCj gcbiirtige Amerika- 
ner waren, die gute Lohne verdienten und unter guten Verhaltiiisseji lebten. 
Die Mehrzahl von itmen war deni Alkohol und Tabok erpben; 20% von alien 
in exceasiver Weise und ungefahr 20 % von Lhnen waren Total-Abstinenten. 

Einhundert \'ienindawanzig itanner klagten uber ungiinstige Bedingungen 
in ihren Arbeitspliitzen wie folgt: Schlecbte Ventilation, 49; Metalldampfe 
infolge unverachliesabarer Maschinen, 27; ungesunde Abtritte, 19; ungenii- 
gende oder nicht vorhandeue Spucknapfc, 14; echmutzige Wande und 
PlafondSj 8; Metallstaub, 5; iiberfiilUe Riiume, 7; schlechtcs Licht,5. 

Die Krankeng^chichte und Untersuehung zejgt-e^dass Catarrh deroberen 
Iiuftwege sehr hau fig war. Ebenso trockene Pleuritis, Bronchitis und Lungen- 
tuberkulose. Lungentuberkulose war in 34 Fallen^ oder 17%, der Gesammt^ 
zahl vorhanden. 

Sionuigen der Venlauung waren auch auaserordentlieh haufig und ver- 
ursachten einengeringeren Grad Neurastbeme und rhcumalische Zustiinde. 

Lungentuberkulose ist sehr vorwiegend unter Druckem und ist grossen- 
teils abhiin^g von : 

K Zu ungiinstigen Bcdingnngen in den ArbeitsplatzeUi bosonders schlech- 
ter Ventilation, Uberfiillung, Staub und Schnautz, ungenirtes Spucken und 
Bchlcchte Beleuchtung. 

2. Von den unrcgelmassigen Lebcnsgewohnheiten der Drucker selbst, 
besondera Alkoholisraua, unsorgfaltige Angewohnheiten beim Essen, unnot- 
wendiges sich der Zugluft Auasetzen und ungeniigende Bewegung im Freie-n, 



NOTES ON MORTALITY FROM TUBERCULOUS PHTHL 

SIS IN ENGLAND AND WALES, AND ON THE LOSS 

OF LIFE BY THIS DISEASE IN THE VARIOUS 

OCCUPATIONS, 

By John Tatkam, M.A., M.D., F.R.C.P., 



Ever since the last census much of my leisure time has been spent in 
studying the prevalence of fatal phtMaia in England and Wales; my object 
being to ascertain, with the help of data obtained at the census of 1907 andi 
since that year, the relative incidence of that scourge on the cliief occupa- 
tions of the adult male portion of the community. 

At the outset, I desire to direct special attention to tliis circumstance, — 
that the rates of phthisis mortality, herewith presented, differ matJ^rially from 
those already publishedj especially as regards the earlier years of the last 
century. Revision of these rates has been fovmd necessary for the following 
reasons : The death-rates already published were necessaiily based on the age 
and sex constitution of the population at the successive census enumeration* 
If the death-rates of the past years had been calculated throughout on a pop- 
ulation of constant age and sex constitution, they would, of course, have been 
fairly comparable, and the labor involved in their recalculation would have 
been saved. But in the course of the hist half century the age and sex 
constitution of the living has changed so materially as to seriously irapiur the 
comparability of the earlier rates with those of the present day. Consequently, 
for the purfKvses of recent vital statistics the deaths registered during each 
of the last fifty years have been recalculated on a population of uniform coa- 
atitutionB, viz., that of the enumerated population at the census of 190L 
In connection with each of the last four ce nausea, attempts have been made to 
ascertain the influence of occupation on the health and vitality of the people. 
The earlier investigations of Dr. William Farr, F.R,S., which were based on 
the census population and the deaths in 1S61 and 1S7I, w'cre limits to the 
mortality from all causes incidental to men engaged in certain industries — 
only incidental reference being made to the diseases producing that mor- 
tality. In the supplement for lSSQ-82, however, Dr. Opel supplied this omis- 
sion by abstracting and analyzing the deaths in connection with ages, causes, 
and occupations. Hitherto investigations respecting occupational mortidity 
have been for the most part limited to the male sex; but, now that the ia- 

21S 



PBTHISIS MORTAUTY IN ENGLAND AND WALES. — TATBAlC. 



2ig 



dustrbJ employment of women away from home has come to be so largely 
legukited by the factory legislation^ the need for defiiiite information re- 
Bpecting the hygienic aspect of female industry has become urgent. As long 
ago lis the year 1890 the practicability of investigating this question was ser- 
iously comsidcrcd, but the attempt at that time was abandoned for reasons 
which appeared conclusive. Among other reasons may be mentioned the 
uncertmnty attaching to the statement of female occupation, both in the cen- 
sus returns of the living, and in the death registerj it frequently happens that 
the bdustrial occupation of a woman is only temporary, and ceases at 
marriage, bo that any injurious effect of occupation would be less acutely 
felt by her than it would be by a man. Recent experiences abound with 
evidence of anomalie^j and inaccuracies of this kind. To take as a single 
example the case of a domestic servant^ daughter of a bricklayer, who has 
returned to her father's house in the country, permanently invalided- She 
Is thenceforward regarded as unoccupied; and, in the event of decease, her 
death will be reported as that of a bricklaj'^r's daughter^ no mention being 
made of her prewus occupation as a domestic servant. In the case of a 
married woman this cause would appear to operate even more forcibly, the 
deceased woman being described simply as a wife or a widow, with mention 
of her husband's vocation, but without mention of her own. Again, it must be 
borne in mind that many women who follow casual occupations, such as that 
of char-woman, drift into workhouses when no longer able to earn their own 
living, and are recorded there as of no occupation. In the course of the last 
decade, so fast has been the advance of public interest concerning female 
occupation, especially in relation to the closely allied question of excesdve 
infantile mortality, that in making preparation for a recent work on domestic 
mortality it was decided to submit thia portion of mortality among occupied 
females to a searching preliminary investigation. Although much labor has 
lately been expended on this investigation, which involved the examination 
of more than half a million certificates, I regret to say that the attempt to 
obtain useful information on this important subject has proved disappointing, 
and has of necessity again been abandoned. Dealing first with the incidence of 
phthisis upon the entire English population, without distinction of occupation, 
recent statistics tell us that of all forms of tuberculosis, pulmonary tuber- 
culosis, is by far the most fatal; the death-rate for which disease, in the 
decennium ended 1900, averaged 1S91 per million, as against an average of 
2730 per million in the decennium 1S51-60. Phth&is mortality has therefore 
fallen by 45 percent* within the last half century. Ever ance the year 1857 
phthisis fatality has varied remarkably with respect both to sex and to age. 
Fifty years ago phthisis was more fatal to females than to males, while la 
recent years the reverse has been the case* The real liability to excessive 
fatality from phthisis in males as well as in females begius with the advent of 




iso 



SIXTH INTERNATIONAL CONGSESS ON TUBERCULOSIS. 



puberty. From the fifteenth to the twentieth year young men succumb to 
this disease in the proportion of 995, and young women in the proportion of 
1290, per million living of the respective sexes. From this age the mortality 
increases steadily, and attains its maximum at the age group 4.5-^55 in men, and 
ten years earlier^ viz., 35^5, in women, at which ages respectively the rates 
are 3144 and 2121 per million. The mortality thereafter declines, down to 
the close of life. Recent statistics show that in this country, as a whole, 
females are less liable than males to die of phthisis at ages under 5 years, more 
liable at ages from five to twenty years, and again less Eable at subsequent ages. 
Within the last half century phthisis mortality in both sexe^^ has fallen remark- 
ably; the decline having amounted to two-fifths, and among males to more 
than half of the former rates. Generally speaking, the amount of retluction is 
greatest among the young, and least among the middle-aged. Among young 
cliildren the mortality in the deceoniura ended 1900 was only a tlurd of that 
in the decennium ended I860. 

In what follows, my observations will be limited to the male sex, and to 
men above the age of fifteen years. The phthhis mortality of men employed 
in various occupations is seriously affected by the surroundings in wliich they 
work, and in different parts of even the same country their conditions vary 
considerably in the several occupations. In order to ascertain the e:xtent in 
which phtldsis mortality varies according to locality, the following plan has 
been adopted. A selection has been made from among the counties of Eng- 
land and Wales, showing in one group counties which at the last census were 
mainly urban in character, containing the chief centers of imlustry, and, in 
another group, counties which, although containing some considerable urban 
communities, were nevertheless mainly rural in character For these groups 
deatfi^rates have been calculated, and as far as possible corrected for differ- 
ences in age and sex constitution of the population. The following table 
shows the local distribution of fatal phthisis in the two selected areas, here 
referred to as representing urban England and rural England respectively. 
The 6ugres indicate corrected rates of phthisis mortality at all agea per 
miilion living of each sex in the ten years 1891-1900. 



UnsAif Commr Omoup 

Male*,,.,, , ..,1763 

Femalee 1250 

Both sexes , .,..,.., 1493 



RtrftAL CotTNTf 

Gmoup. 
1347 
1240 
1292 



From this table it appears that in both areas phthisis is more fatal to males 
than to females^ but that the excess is by far the greatest in the urban county 
group, the male rate exceeding the female by not more than 9 per cent, in the 
rural area, while the corresponding excess b the urban area amounts to 40 
per cent. 



PHTHISIS MORTALITY IN ENGLAND AND WALES. — TATHAM, 221 

notes sur la Mortality de la Phtisie tuberculeuse en Angleterre et Galles; 

et sur la perte de vie resultant de cette maladie dans les 

differentes Occupations. — (Tatham.) 

Dans le cours des cinquante derni^res ann^, la constitution d'&ge et 
de sexe de la population k chang6 si essentiellement qu'il n'est plus exact 
de comparer la mortality d'autrefois avec oelle des temps presents. Par 
oons^uent, pour les statistiques vitales r6oentes, les morts enregistr^es 
pendant chacune des cinquante demiferes ann6es ont 6t^ recalculte sur 
ime population de constitution uniforme, c'est k dire sur la constitution 
de la population de cens de 1901. 

La mortality de la phtisie, pour la population anglaise enti^re, sans 
distinction d'occupation, k diininu6 de 49 pour cent pendant les cinquante 
demi^res ann6es. II y £k cinquante ans, la phtisie 6tait plus fatale aux 
femmes qu'aux hommes, tandis que ces demiSres ann^es, c'est le contraire 
qui a lieu. La susceptibility k une fatality excessive de la phtisie conn 
menoe chez les deux sexes k la puberty. 

La mortality de la phtisie chez les hommes employes dans diverses occu- 
pations est affect^e consid^rablement par Tenvironnement dans lequel ils 
travaillent. On a felt un examen special de la mortality des hommes en- 
gages dans deux groupes d'industries dont les conditions sont regard^es 
commun^ment comme 6tant nuisibles k la sant^, ohf par exemple^ Tatmos- 
ph^ est contamin6e par diverses sortes de poussi^re ou est vici^e par d'au- 
tres moyens sans 6tre sensiblement charg^ de particules de poussi^re. 

On constate un exc^ de mortality dans chacime des occupations de ces 
deux groupes sur celle des agriculteurs; et aussi une augmentation ou, dans 
quelques cas, une diminution, dans la mortality des dix ou vingt demidres 
ann6es. 

Dans ces demi^res amines, le public a pris un plus grand int^r^t dans les 
emploiements industriels des femmes, et on a fait des efforts considerables 
pour essayer d'obtenir des renseignemente utiles sur le sujet si important 
de la mortality parmi les femmes employees, mais il a 6t6 impossible d'ar- 
river k des r^iiitate exacts. 



LEGITIMATE EXERCISE OF POLICE POWER FOR THE 
PROTECTION OF HEALTH, 

By Hexry Baikd Favill, M-D., 

Of tbe Aiaerican A4Dcu£iun for Labv LcgtaUitiaa, 



In aD effort to exerciae legal mandates and restraints, as between em- 
ployers and the employed, there ia a difficulty which must not be over- 
looked nor underestimated. 

The antagonism which has developed out of superficial and apparent 
conflict of intci-est permeates the entire fabric, Wliile social philosophy 
would demonstrate the identity of mterest in almost every instance, it is 
unreasonable to expect that an ideal conception could prevail, upon both 
Bides of this controversy^ as an initial step. Experience teaches that con- 
tention and compromise are the steps by which progress ie made. While 
it is not Ijeyond hope that an understanding and fair agreement will ulti- 
mately reduce differences to the minimum, there are many objections to 
the exercise of unlimited patience during the working out of this problem. 
To any extent that portions of the subjects in question can be made to appear 
more important and more obvious than others^ an attempt should be made 
to deal with them as individual factors, separating them if possible from 
the general mass of industrial questions and particularly striving to escape 
the hindrance, from both sides, wliich naturally attaches to industrial disputes. 

If it can be made to appear that society as a whole demands, for its own 
preservation, the carrying out of a definite policy, its mandate upon both 
capital and labor can be supreme, resirling far above the level of factional 
or class controversy. It is upon tliis ground that the interpretation of 
" police power " must operate. 

In the industrial world, health is the foundation of productiveness and 
the bulwark of economy. That society and progress depend utterly upon 
these factors can hartily be questioned. It is hence only necessary to reach 
a conclusion as to the fundamental importance of healthy as related to the 
product of any individual, or to have a comprehensive grasp of the elements 
of wastfi and dissipation In social affairs, to at onc« put tbe question of public 
lealtb as a thing apart^ to be dealt with as a social problem, irrespective of 

particular bearing upon any class of citizens. 

2Z2 



LEGITIMATE EXERCISE OF POLICE POWER. — PAVlLL. 



223 



From this point of view, what labor demands will be quite as irrelevant 
as what capital refuses. The question will be more simple and more difficuSt. 
What is the sound position to take with regard to public health necessities? 
What is the wise course to pursue in the development of operating plans? 

It must be apparent that the question of sound doctrine as to sanitary 
facts is not only preliminary, but fundamental, to any broad and radical 
exercise of police power. It is, however, ob\nou6 that, pending the develop- 
ment of substantial knowledge, extensive regulation must proceed, more 
or less temporarj^ in its character, and it is also manilest to those who are 
studying the prablera that large police cooperation is essential in the estab- 
lishment of the facts underlying public disability. It is important, there- 
fore, to reeiignisie that the imraaliatc structure will he temporary^ anti that 
much of the police power, necessary to invoke, will be for purposes of re- 
search rather tljan finally satisfactory for purposes of sanitation, 

la common with other statutory functions in its jurisprudence, police 
power in the United States has aspects which are not prominent in the legal 
administration of European government. In the United States legislative 
enactment is not paramount^ but is subject to construction and ciestruction 
through judicial review. This is a feature of national policy, fundamental 
and, so far as we know, permanent. There is no doubt that it exerts a dis- 
tinct retardation upon what might be r^arded as progressive legislation. 
It 18 not likely, however, that legislation which is directe<i primarily to the 
preservation of health is going to l^e seriously hampered by our constitutional 
limitations upon arbitrary legislation. The trend of judicial statement is, 
on the whole, clean The broad interests of society, if they can be defined, 
upon the side of healthy seem to be of paramount importance in judicial 
opinion. It is well to observe, however, that the court-s will not sustain 
legislation for the correction of even admitted abuse which can be interpreted 
as distinctly class legislation. For example, the bakers of New York 
failed, upon this ground, to secure the relief obviously important. On 
the other hand, the interests of the body politic, represented iJi the phy.'ilcal 
well-being of women, were recognized as imperative in the decision affecting 
the recent Oregon cases. For our purpose, as advocates of legislative assis- 
tance in sanitary reform, this distinction is of the utmost importance. 

The interest that the State can show in the movement in question will 
carry greater weight than any degree of interest of imnicdiute beneficiaries. 
It ia noteworthy, moreover, that the courts are susceptible to demom^tration 
aa to the essential facta. Ex calhedm statement receives and deserves scant 
consideration. Painstaking accumulation of relevant data carries the utmost 
weight. The handmaiden of public interest, therefore, is breadth and ac- 
curacy of statement. With these grounds properly covered the prospect is 




22« 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOBIS. 



that legislation can proceed fully as rapidly as tbe necessary basis in fact 
can be established* 

The health of the people stands as a subject of administrative scrutiny 
without question. In view of that fact, and the further fact that police 
power in American law is so recent as to have no deeply rooted traditions, 
it seems probable that the future of this question will rest to a large extent 
ujx>n those branches of the medical profession which are active in sanitary 
research. Cooperation between the pliysicians and sociologists, with the 
development of a zone between them which shall have the characteristics 
of both, seems to be the method of attack. 

At this point we may well ask, "Upon the basis of our present knowl- 
edge, what are we justified in pointing out as public necessities? " 

Tul>erculosis presents, on the whole, the most cotnplex and most import 
tant example of social evil. No other disease has the economic importance; 
no other is so interwoven with industrial contlitionsj none has such relation 
to habitation. The fact that measures of correction in one direction do not 
reach a full result, while evils continue uncorrected in other directions, is not 
ground for hesitation in urging legislation. Experience shows that reform 
breeds reform, and that a wise standard is effective in its influence upon 
correlate*! matters* 

It is but necessary to realize how complex is the habitation question, to 
recognize the liifficulty of starting from that aide. Ideal habitation, asso- 
ciated with bad habits, would have slight results. The task of reeducation 
of the masses in their hygiene sh colossal, and will take more systematic 
effort and far greater time than all the other phases of tuberculosis warfare. 
Wliile it is perfectly obvious that, na long as there is lack of good habitation 
conditions and reasonable hygiene, the benefit of improvement in the condi- 
tions of industry will be to some extent neutralisied, it is^ nevertheless, 
true that it is the point of advantage from which to undertake reorganization. 
Not only is it possible to establish physical conditions in which the workers 
will be comparatively safe, but it is inevitable that the reflex upon their 
(rsonal views, tastes, and habits will profoundly affect their habitation 
ices. 

The argument that has been and will continue to te urged against the 
regulation of working conditions, that such legislation h futile, in view of 
the home conditions, appears to me to have no considerable weight. 1 
believe that close scrutiny and regulation of working conditions anj^where, 
and to any extent that can l^e made to square with a rational statement 
of economic necessity, are right to demand and reasonable to expect. It is 
for this reason that educational propaganda should be universal. While 
it is true that the masses are the great sufferers from tuberculosis, and 



LEGITIMATE EXERCISE OF POLICE POWEH. — PAVILL. 



225 



need the utmost industry for their education, it is also true that the forces 
which influence legislation at present arise in quarters where the consciousness 
of the need is far less personal and consequently slow to develop. The 
task of securing legislation affecting working conditions in our present system 
of industry can hardly be accompliahed without cooperation of employers. 
Whether that could be done or not, wisdom requires that cooperation be 
assiduously sought. The economic soundness of the whole proposition 
ultimately will prevail, and the more teachers of economics concentrate 
upon this demonstration, and the more powerful commercial forces are 
enlisted in this effort, the speedier will be the result. 

It is not likely that mere voluntary or even co6perative regulation is the 
best solution. Rules applied to an industrial establishment, which are not 
purely related to the immediate product of industry, are difficult of enforce- 
ment and liable to controversy. There is no prospect of such general develop- 
ment of intelligence and cooperative spirit among emplo^^ers as will insure 
sufficient uniformity of process. There is no way to insure the acceptance, 
on the part of laborers, of cjonditions which may be to them distasteful, 
except through authority backed up by univemal custom. There is no 
reasonable doubt that it is in the interest of employers, not only from an 
economic standpoint, but in respect to the practicability of instituting reform, 
that these measures be tn^idatory and the expression of a very radical State 
policy. 

The ordinary regulation of on establishment fix>m the standpoint of conta- 
gion 13 comparatively easy to effect. Once the facts can be established, 
and a practicable method of meeting the requirements determined ^ it is 
quite within the powers of existing authorities to carry into effective opera- 
tion the necessary measures. Although this will meet a demand made by 
the characteristics of tuberculosis as an infectious disease, it will, after all, 
encompass a ver>' small part of the good that can be done in the workshop. 
Infection resulting from contagion is a very late step in the tuberculosis 
cycle. There will probably always be enough tubercular matter in exist- 
ence to infect all the people w^ho can be found susceptible to it. Though 
not at all underrating the importance of diminishing the opportunities for 
contagion, while the vast majority of people are still in a state unduly 
susceptible to the infection, it must be recognized that the foundation 
of irammiity is not protection, but vigor. The idea is far too prevalent 
that the fresh-air element in the tuberculosis question is related to the 
purifying value solely. Granting that, at any value you may, it is etill true 
that the value of fresh air is as a physiologicjd stimulus to the individual^ 
and that it is inexpressibly more potent for that reason than for all others. 
This does not g^nsay the enormous danger of concentrated polluted air, 
VOL m,— 8 



226 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS, 



but again and again it is necessary to emphasize the phy^ological 
of imraunity as against the fortuitous escape from contact. 

With this in mind one reaches a conclusion as to what must be done for 
the race. Conditions of social existence, perhaps fairly to be caUed civUizedi 
have a strong bearing toward enfeeblement. With possibilities for comfort 
comes self-indulgence, to the extent of modifying normal tastes and stifling 
activities upon which bo<lily vigor depends. This is true at all levels of 
society. The reawakening of air-hunger, the establishment of standards 
of air distribution, and the creation of a morale with reference to air pri^Tiege, 
are radical and imperative necessities before substantial progress can be 
made. At no point in the experience of any worker can the^se thin^ be 
more advantageously achieved than in his workshop. For him who has 
no initiative and scant opportunity^ it is the duty of the Stat-e to declare that 
conditions reasonably calculated to secure these benefits shall be the standard 
conditions of labor. Upon that basis, lus a primary flemand, the State can 
and should exercise its police power and establish standards of air exposure 
sufficient to accomplish these results. 

It is by no means a simple proposition. The most superficial considerar 
tion of what it involves shows a prosp>ect of some struggle with the employers 
of labor. From the mere standpoint of expense, the aggregate demand 
would be great. The tlifficulty of determining the proper type of mr 
expos\ire for different industries would be very considerable. The world- 
wide prejudice against low temperatures and free circulation of air is deeply 
rooted. One can hardly conceive an innovation fraught with more diffi- 
culties. It is, however, fundamental, and by no possibility, so far as we 
now see, can great results be otherwise achieved. 

If the proposition is sound, it may well answer the first question which 
I have propounded as to what position to take in this matter. We are not 
here to look for superficial or temporizing measures. If there is a radicjd 
standpoint with respect to which we can confidently speak, we must occupy 
it. Not only are all other sanitary adjustments more or less ancillar)*, but 
this in itself constitutes a basis for agitation lai-gc enough to occupy the 
entire attention of sanitary and sociolo^cal effort in the direction of protection 
of the health of laborers. 

The second question is, what is the wise course to pursue in the develop* 
ment of operating plans? 

It needs no argument to maintain that abundant data and welbconsidered 
demonstration will be necessary to bring to pass this great reform. It is 
not the purpose of this discussion to go into the detail of the research leading 
to this end. It is agreed that labor legislation must have its foundation m 
clear economic advantage^ It is perhaps not so well agreed, but the idea 




LEGTTIMATB EXERCISE OF POLICE POWER. — FAVILL. 



227 



I 



I 



is rapidly growing, that, of aJI the factors of econoniic advantage, health is the 
most crucial. Upon that h>'potheais, therefore, the comrlusion may rest, 
that the logical primary step is the establishment of broad and effective 
study oi health aa related to laboring conditions. 

While we must mlvocate and work for temporary and half-way measures 
of relief, in the interest of those now endangered by unsanitary conditions^ 
we must hold in view constantly a deeper and more important purpose: 
the establishment of an entirely new conception of what are sanitary con- 
ditions. To what extent a^regated masses can be made to accommodate 
themselves to artificial ways of Ufe is, of course, a question, but there is no 
reason to suppose that this can take place to any great extent^ and we have 
absolutely no warrant in acting at all upon such an assumption. 

The world has got to reach a decision as to how to offset the detrimental 
influence of urban life. At no point in the entire discussion m\\ there be 
opportunity for more valuable contribution to the solution of that question 
than at this: a fight for fresh air duiing working hours as preventive of 
tuberculosis. 

I believe firmly that the State may legitimately exercise its police au- 
thority over this question, I believe as firraly that it can never be accom- 
plished otherwise, and I believe, finally, that there is no greater obligation 
resting upon sanitarians than to prove conclusively the necessity and point 
out cleai'ly the way. 



Ejercicio Legitime del Poder de PoUcia Para la Protecciidn de la 

Salud.— (Favill.) 

1. Las medidas para la regulaci6n de laa cuesttones induatriales en 
beneficio de los obreros llevan consigo, inevitablemente* mucho de la con- 
troveraia entre el capital y el trabajo yo son de defJcil establecimiento. 

2. Se estd volviendo generalmente aceptado que la salud es el factor 
esencioj de la productibilidad y prosperidad y por lo tanto del avance de 
la civilizac-i6n, Se deduce de ahf, por consiguiente, que el Estado, en la 
prosecuci6n de sua funciones primordiales, debe tener conocimiento de las 
necesidades fundamentales. 

3. Las condicionea bajo laa cuales el trabajo debe ejecutarse^ en relaci6n 
con la salud, se vuelve un asunto de inter^ priraario para el Estado y sobre 
esta base debieron fundara* tos mandatos de una legialaci6n decisiva. 

4. En tanto que toda legislacion esta sujeta A la revisi6n judicial de lo 
que es conbtituci6nal, se debfa prestar interfe a las tendencias de la opinion 
judicLal, 




SIXTH INTERN ATIONAI, CONGRESS ON TUBERCULOSIS. 

Asf, tres cosas parecen de tal importancia: 

(a) Que el tema debiera ser claramente una cuesli6n de salud. 

(b) Que sea le^Iaci6n gieneral y no de clases. 

(c) Que la causa se apoye en datos acreditables. 

5. La tuberculosis es el asuato mas imperioso que confroutamos. Los 
datos son escasos y deben adqiurise por la investigacion sisteinatica. Para 
llevar ^ cabo este prop^sito se tieceaitard la cooperaci6n de la policfa en graa 
€scata. 

6. Hablando en general, la reeducacidn de las masas respecto al valor del 
aire.puro y la practicabilidad de adquiriHo es una empreaa colosal pero de 
importancia fundamental. 

7. La importancia del aire pure cx>nio estfmulo fisit>16gico que acarrea 
vigor individual detw recalcarse. Su valor, corao puricante atmosferico, 
es de importancia aunque decididamente secundaria. 

S, La reforma de las condicionea Lndustriales para el abastecimiento 
adecuado y distribud6n tie aire puro es la cuesti6n mas importante que debe 
llevarse d la prdtica. 

Las dificultades son tan grandee que espantan; la neoe^dad tan palp- 
able que so impone. 

9. Los higienistaa y soci^logos deben combinar sua eafuerzaa para reall- 
Kar eata reforma. Tal como hoy se presents, nada que sea menos que el 
ejercicio de todo e! poder y jurisdic€i6n de poUciaj serA efestivo. La ley de 
salud subordinada sigue naturalmente. 



Die gesetzmdssige AusUbung der Polizeigewalt fUr den Schutz der 
Cesimdheit. — (Fa vill.) 

1. Industrielle Massregeln zum Beaten der Arbeiter bringen unvermeid- 
lich Uneinigkeiten ^wiscUen Kapital und Arbeit mit sich, uud sind sehr 
schwer einzufiihren. 

2. Es wird allgemein angenommen, dass Gesundheit ein wesentlicher 
Faktor in der Erzeugungsfahigkeit und dem Gedeihen und folglich in der 
F<5rderung der Kultur ist. Daraua folgt, dass der Staat in Vollziehung 
seiner ersten Funktion von den fundamentalen Notwendigkeiten Kenntnis 
nehmen muss. 

3. Die Zustaade, unter welehen Arbeit vollfiihrt werden soil, werdea in 
Beziehung zur Geaundheit Gegenstand ersten Interesses fiir den Staat, 
und auf dieser Basis sollten sie Gegenstande von entschei deader Rechtsge- 
bung werden. 

4. Insofem, ala alle Rechtsgebung der richterlichen Meinung unter- 
worfen ist, ob sie verfassungprnasssg ist, sollte man der Neigung der rich- 




LEGITIMATE EXERCISE OF POUCE POWER. — ^FAVILL. 229 

terlichen Meinung Riicksicht tragen. Soweit scheinen drei Dinge wichtig 
zusein. 

(a) Dass die Sache rein ein Gesundheitsvorschlag ist. 

(b) Dass es eine allgemeine und nicht Klassenrechtsgebung ist. 

(c) Dass die Streitsache durcb verlassliche Daten unterstiitzt wird. 

6. Die Tuberkulose ist die dringendste Sache vor uns. Diesbeziigliche 
Daten sind sparlich und miissen durch systematische Forschung erworben 
werden. Um dieses zu vollfuhren, wird viele polizeiliche Mitwirkung not- 
wendig sein. 

6. Im Allgemeinen ist die Wiedererziebung der Massen in Bezug auf 
den Wert der freien Luft under der Tunlicbkeit sicb derselben auszusetzen, 
ein kolossales Untemehmen, aber von fundamentaler Wichtigkeit. 

7. Die Wichtigkeit der freien Luft als ein pbysiologischer Reiz, der zur 
individuellen Kraft fuhrt, muss betont werden. Ihr Wert als ein Reiniger 
der Atmosph&re ist wichtig, wenn auch sicberlich an zweiter Stelle. 

8. Die Regulierung von industriellen Zustanden gegeniiber binreichen- 
dem Yorrat luid geniigender Yerteilung von frischer Luft ist die eine grosse 
Sache zu vollfiihren. Die Schwierigkeiten sind zum Erstaunen gross. Die 
Notwendigkeiten sind unbedingt erforderlicb. 

9. Hygieniker und Soziologen miissen sicb vereinigen, um diese Reform 
herbeizufiihren. Wie es jetzt steht, wird nicbts ausser der weitesten Au&- 
iibimg von Polizeiverwaltung wirksam sein. Untergeordnete Gesundheita- 
geaetze wilrden natiirlich folgen. 



THE LEGITIMATE EXERCISE OF THE POLICE POWER 
IN THE PROTECTION OF HEALTH. 

By David J. Brewer, 

AesooaCfl JustJoe Supremfl Court of the United Staten. 



Notwithstanding the varied array of tuberculosis statistics which have 
been presented to us^ I premise by sajing that 1 consider myself a reasonably 
healthy man, and that I hope no such longing medical eyes will be cast upon 
me as will prevent my leaving this room in the same good health. 

The police power. \Vliat is it? It is easier to say what it ia not than to 
furnish a complete and satisfactory definition. It is sufficient for the present 
discussion that it ia the power which the State exercises to regulate the relar- 
tions of one inLlividual to another. 

There are^ speaking generally, three great powers of government: taxa- 
tion, eminent domain, the police power. Taxation and emment domain 
have sfiecial regard to the State as an organized entity, a quasi-mum eipal 
corporation^ and are exercised primarily for the welfare of that entity — 
that corporation. Taxes are levied that the State may discharge its func- 
tions of government. Eminent domain is invoked when the State needs 
ground upon which to erect some public building or to carry on some public 
work. It is only indirectly that the iikdividual is benefited by the exercise 
of either of these powers, but w^ith the police power it is just the other way. 

The police power aims primarily at the good of the individual, and it is 
only incidentally that the State, as an organized entity, is benefited* It 
cares for the healt!i, the safety, the life, the good morals of the community. 
In each of these casea it is the individual who is directly affected, the indi- 
vidual whose health, safety, life, and morals are cared for, while the State, 
as an organized entity, receives it^ compensation only in securing^ through 
the exercise of the police power^ strongs healthy, moral citizens. 

Although these three great powers are powers of sovereignty, there are 
limitations on each. Take taxation. You may not tax unless to tbjso funds 
for some public puriK>se. No tax would be sustained which was levied upon 
you as an indi\ddual to raise money to be put into my pocket, as an indi- 
vidua!. There must be some public purpose, some purpose of a governmental 
character, to be subserved by the money collected. So with eminent domain. 

230 



LEGITIMATE EXERCISE OF POLICE POWER. — BKETWEH. 



2ai 



It can never be exercised to merely transfer the title to real estate from one 
indlviJual to another. The taking must be for the government, as an 
organized entity, and in order to help In the discharge of some public funt^ 
tion. If in any statute these limitations are ignored, the courts of this coun- 
try, where we have a constitutioHj will strike down the act as beyond the 
power of the legislature. 

The police power is often delegated to cities, towns, or other municipal 
organizations, and when done so l>y only a general grant of power, the actions 
of the municipality must be reasonable or tiiey will not be sustained* There 
is, therefore, a special limitation on those lower political organizations by 
which so much of the police power is exercised, as well i\s the general constitu- 
tional provisions which are designed to protect the individual from wrongful 
action by the government. 

Mr. Justice Matthews said in Yick Wo w. Hopkins, 118 U, S*, 356, 369, 
a famous case from California: 

"When we consider the nature and the theoryof our institutions of gov- 
ernment^ the principles npon which they are supposc<i to rest, and review the 
histor>" of their development, we are constrained to conclude that they do 
not menu to leave room for the play and action of pnrnly jjeraonal and ar- 
bitrary power. . . The fundamental rights to life, liljerty, and the pur- 
suit of happiness, considered as individual pos-sessions, are secured by thoae 
maxims of constitutional law which are the monuments showing the victor- 
ious progress of the race in securing to men the blessings of civilization under 
the reign of just and equal laws, so that, in the famous language of the Massa- 
chusetts Bill of Rights, the government of the commonwealth **may be a 
government of laws and not of men." For the very idea that one man may 
be compelled to hold his life, or the means of living, or any material right 
essential to the enjoyment of life, at the mere will of another, seems to be 
intolerable in any country where freedom prevails, as being the essence of 
slavery itself." 

Witli these preliminary observations, let me say that it is well ruletl that 
a reasonable exercise of police power may require of an employer that he 
provide safe places, machinery, and tools for his employes to work in and 
with. Of this^ speaking generally, there can be no tloubt. T do not mean 
that the law demands that the employer guarantee safety, but that he must 
make reasonable efforts and take reasonable precaution to provide a safe 
place, safe machinery, and safe tools. 

As said by the present chief justice in a railroad case, Union Pacific 
Railway v, O'Brien, 161 U» S., 451, 457 (and I am not giving my opinion of 
what the law ought to be, but only stating what has been decided) : 



"The master is not to be held as guaranteeing or warranting absolute 
B&fety under all circumstances, but is bound to exercise the care which the 



232 



SIXTH INTERNATIONAL CONGRESS OH TUBERCULOSIS. 



exigency reasonably demands in furnishing proper roadbed, track, and other 
stnictureSj including sufficient culverts for the escape of water collected and 
accumulated by its eoibankmenta and excavations/' 



This 13 a primary — a most important — duty that the employer owes to 
his employes, and if he does not willingly and properly attend to it, legisla- 
tion may be invoked to compel his action. When I speak of safe places, etc., 
I mean safe in all respects — fire-escapes for the emergency of fire, wholes 
some amounts of light, air and ventilation, and other like reasonable pro- 
visions to secure the safety and health of the employees while doing the 
work of the employer. 

Further, there are certain emplojinenta that are specially hazardous — 
employments in which alight neglect may result in great destruction of life, 
as well as of property. The manufacture of djiiamite or powder and under- 
ground mining are illustrations. In order that work in these emjiloyments 
may be safely carried on it is of importance not merely that the employees be 
habitually careful^ but also that they should not be burdened with excessive 
hours of labor, for, as the body grows weary, the power of attention dim- 
inishes, omissions of proper care are more frequent and come more eaaly. 
In such cases the employer should t-ake the extra risk into account id fixing 
his employees' hours of lal>or, and the legislature may, in the proper exercise 
of its police power, forbid continued labor beyond some reasonable limit. 
The freedom of contract may properly be reduceti in the interest of life and 
safety. 

In the same line are cases in which the facts impose a special duty upon 
the employer. On the action of the employee may depend the lives and 
safety of many. Take railroad employees, for instance. Carelessness on 
their part may wreck a train, whereby lives or property may be destroyed. 
The master owes a special duty, not merely to the employees, but to those 
who are to use the conveniences which he has provided for transportation 
and travel — owes to them the duty of seeing that the employee's time of 
labor Is not so prolon|?ed as seriously to impair his ability to do the w^ork 
safely. He must l>c compelled to stop his employees from further toil when- 
ever it appears that a continuance thereat may reasonably be expected to 
result in injury because of sleepiness, weariness, or inability to pay proper 
attoiition. It is not merely the hfe :ind sjifety of the employee, but the great 
interests placed in his care which justify the State in saying to the employer: 
"You must not let that employee work more than a certain length of time^ 
so that while he is at his post of duty his faculties shall be under full 
control." 

To-day we are facing questions of a different charaeter. Shorter hours of 



LEOmMATE EXERCISE OP POLICE POWER. — BREWER. 



233 



labor are demanded in behalf of all laborers. Now, as I have indicated, when- 
ever (he work is one attended with apccial risk to the safety or health of the 
cmployeCj or others properly brought into contact with that work, the State 
may say to an employer: You shall not permit any employee to work above 
a prescribed and reasonable length of time. But suppose the work is not 
freighted with any special danger to the employee or other parties, is as free 
from risk as any ordinarj^ employment, can the legislature forbid the em- 
plo3^er from contracting for or accepting other than prescribed hours of 
labor from his employee? *Supposo the legislature should conclude that the 
moral condition of the community would be improved if no one were per- 
mitted to work over four houra. Possibly it might be right; the extra hours 
mi^ht be passed by the employee in improving his mind, in associating with 
his family and to his advantage; or, on the other hand, they mi^ht be si:>ent 
in dissipation; who can tell? But these are questions which, if the occupa- 
tion ia not freighted with special danger to the in<lividuab or to those de- 
pendent upon his action, are beyond the power of the legislature to decide. 
We have constitutional provisions which no legislature can ignore. The 
Declaration of Independence, which is the Magna Charia of our system of 
government, speaks of unalienable rights of life, liberty, and the pursuit of 
happiness. That means the right of each one to pursue happiness according 
to his own ideas of what will bring happiness. If he thinks that working 
for twelve hours is better for hiin, and will inure to hia happiness, to a greater 
extent than labor for a le^ time, and if his work be attended with no special 
risks, then he has the rlj^ht to work for that length of time, and the employer 
has a right to contract with him on that basis* We had a case which came 
from New York (Lochren i\ New York, 198 U. S., 45, 61) where it appe-ared 
that the l^slature had passed an act prohibiting bakers from requiring or 
permitting any of their employees to work more than a certain length of time. 
I think I may safely appeal to all of the gentler sex before me, and ask them 
if making and baking bread is a specially hurtful and unhealthy labor. 
We held that the law could not be sustainedj because both employer and em- 
ployee had the right to contract for more hours of labor than those pre- 
scribed, and Mr. Justice Feckham^ delivering the opinion of the court, said: 



*' Statutes of the nature of that under review^ limiting the hours in which 
grown and intelligent men may labor to earn their hving, are mere meddle- 
some interferences with the rights of the individual, and they are not saved 
condemnation by the claim that they ape passed in the exercise of the police 
power and upon the aubJ€[:t of the health of the individual whose rights are 
interfered with, unless there be some fair ground, reasonable in and of itself, 
to say that there is material danger to the public health or to the health of 
the employees, if the hours of labor are not curtailed. If this be not cleariy 



2^ 



StXTH INTERNATIONAIj CONGRESS ON TUBERCULOSIS. 



the case, the indi\idua]s^ whose rights are thus made the subject of legislative 
interference, are under the proteftion of the federal constitution regarding 
their liberty of contract as well as of person; and the legislature of the State 
has no power to limit their right as proposed in this statute," 

And why should it not be so? Here is a man; strong, vigorous, hedtby. 
Why should he not be permitted to contract for more (han eight hours' 
labor — for nine, ten, or a dozen if he .wishes? There is scarcely a man 
in charge of any department at Washington who doe^ not work over ten 
hours a day. There is not a justice of our court who does not work longer, 
and all of us look reasonably healthy. The Declaration of Independence 
and the constitution give us the right to determine these questions for our- 
fielves. As Mr. Justice Peckhain well said, any other rule is a mere meddle- 
some interference. 

1 wish to refer to one more decision: that in regard to the employment 
of women in factories, I had the honor to write the opinion of the court 
in that case (Muller v. Oregon, 20S U, S,, 412, 422) and I said: 

"The limitations which this statute places upon her contractual powers^ 
upon her right to agi'ee with her employer as to the time she shall labor, are 
not imposed solely for her benefit, but also largely for the benefit of all* 
Many words cannot make tliis plainer. The two sexes differ in structure 
of body, in the functions to be performed by each, in the amount of physical 
strcngthj in the capacity for long-continued labor, particularly when done 
standing, the influence of vigorous health upon the future well-being of the 
race, the self-reliance which enables one to assert full rights, and in the 
capacity to maintain the struggle for subsistence." 

That language was used in no disrespect to the other sex — not in the 
sneering spirit in which it has been sometimes s^d, that women, like infants, 
and lunatics, are unfit to vote. It was written with the utmost respect for 
them, by one who knows the blessings which come from the sex, and in tlie 
firm belief that there was something in her place and w^ork in life which justi- 
fied the legislature in forbidding her to contract for factory work beyond a 
limited time. The race needs her; her children need her; her friends need 
her, in a way that they do not need the other sex. I had and have no doubt 
that the decision was correct. The Supreme Court unanimously assented. 
But while that is so, it is equally good law that a man in full health and 
strength is at liberty to contract to perform any ordinarily healthy work 
for as many hours as he sees fit. 

DISCUSSION. 

Dr. Helen C, Putnam (Pro\idence): All through the s^sion this after- 
noon we have come up against the same problem which Dr, Favill put in 



« 



LEGITIMATE EXERCISE OF POLICE POWER. — BREWER. 235 

Bomething like these words: "How to educate society as a whole; to estab- 
lish new conceptioxis of what are sanitary conditions; how to educate people 
to be good fathers and good mothers; how to educate employers to provide 
sanitary conditions for their employees; and how to educate the working- 
man to use the sanitary conditions which the employer provides." 

I feel confident that there are three distinct steps that this Congress may 
take that would help to bring about the conditions that we are working for. 

I have two resolutions to offer which may be considered during the next 
two days, when we are going to ^ve still closer study to the solutions which 
the resolutions propose. 

I suggest, Mr. Chairman, that they be acted upon Thursday afternoon 
by this Section, when they will go to the Committee on Resolutions, which 
will act upon them with reference to presenting them in the general session 
of the Congress. 

The first resolution is this: That national societies for the prevention of 
tuberculosis should have central standing committees on school instruction 
on hygiene and sanitation to assist in the proper coordination and extend- 
ing the present efforts in this line. 

Second: That colleges and other institutions preparing teachers should 
offer courses including practical work in hygiene and sanitation, and also 
should have these subjects among their entrance requirements, in order to 
stimulate useful elementary instruction in the lower schools. 

Dr. Adolphe Smith, Mr. Horace Bushnell Cheney, Mr. James A. Leonard, 
Dr. Ch. Wardell Stiles, Mr. Christopher Easton, Dr. Julius Halpem, and 
Dr. E. H. Bayley also participated in the discussion. 



SECTION V. 



Hygienic, Social, Industrial, and Economic Aspects 
of Tuberculosis {Continued). 



THIRD SESSION. 

Wedn^day morning, September 30, 1908. 

THE SOCIAL CONTROL OF TUBERCULOSIS, 

National, State, nnd Municipal Governments^ Departrnents of IhaUh and De- 
pariiticidB oj Public Relief; Private Endowments; Voluntary Associa- 
lions for Eduaitiofial Propaganda; In^titviions^ such as Relief Agencies, 
which Exist Primarily for Other Purposes; Insurance; F€alures in an 
Aggressive Campaign against TnherciUosis, 



The third session of Section V was called to order by the President, Mr, 
Edward T. Devine, on Wednesday morning^ September 30th, at half past 
nine o'clock. 



A COMPREHENSIVE PROGRAM FOR THE PREVEN- 
TION OF TUBERCULOSIS. 

By Livingston Fahrand, M.D., 

ExBraitiv« Socretftry Natiooml AModrntlon for tbe Study m^ Pnroation of Tnberculons, 

New York. 



It 18 evident that a subject as wide as that indicated by the announced 
title of the present paper can only be sketched on the broadest lines. It may 
lie possible, however, to summarize certain of the lessons to lie derived from 
the complex experient^s of the last few years^ and such will be my task. 

The basia of the campaign is the logical corollary of the pathological 
and dinical discoveries of the p£U3t twenty-five years. If tuberculosis la an 

236 



A COMPREHENSIVE PROGRAM OP PREVENTION. — FARRAND* 



237 



infectious disease^ the cause of which is known and con be isolated, it is 
necessarily preventable. The organized effort, therefore, of the present day 
is in the direction of thia prevention. 

That one means of prevention is the deatruHion of the cause is obvious j 
that an equally important adjunct in accomplishing the same end is the 
ability of individuals to resist the attack is a matter of observation and 
e^tperlenoe. Our efforts, therefore, must be directed along either or both 
of these two lines^to eliminate centers of infection and to increase the re- 
casting power of individuals. It is the more definite attack upon centers 
of infection and the immediate procedure necessary to reduce the dangers of 
the situation that present specific opportunities and permit of a relatively 
definite program. 

Upon one point particular emphasis should be laid at the outaet, and 
that 13 that in order to accomphsh results in any degree commensurate 
with the importance of the problem and the expenditure of energy involved, 
the rraponsibility for action must be placed primarily and squarely upon 
the local public authorities. The private measures, other than those of 
education, initiated by voluntary associations or individuals, the inspiring 
efforts toward the care of suffering consumptives, are all to be regarded as 
temporary expedients only, justifiable so long as the public authorities fail 
to make proper provision, or as means of educating those authorities to a 
sense of their responsibility. 

With our political organization such as it is, it seen^ impossible to attack 
this disease in its recognize<l strongholds on a national scale under the 
direction of the national government. With the heartiest sympathy for 
the present promising movement for the establishment of a National Bureau 
or Department of Health, the chief promise of such a foundation in the 
tuberculosis campaign must be regarded as one of education and stimulation. 
As a distributor of information and authority and a coordinator of lines of 
effort of interstate or wider scope it vAW prove an adjunct of great value in 
the work. Such problems as those of infection in transportation, immi- 
gration, and similar fields of national significance could best be handled 
by such an agency. 

Experience is showing that much the same state of affairs holds true 
of governmental effort directed from State capitols. The agitation for 
State sanatoriums, which for some years occupied the attention^ and appar- 
ently filled the horizon, of those interested in the tuberculosis campaign in 
many of oiu" commonwealths, has proved of chief value as an educational 
stimulus. As factors in the direct attack upon the disease these institutiona 
may in most instances be regarded as practically negligible* 

That there is a State responsibility cannot be denied. With our pollticaJ 
oonatitution such as it is, It is clear that certain general regulations must 




SIXTH INTERNATIOKAL CONGRESS ON TUBERCULOSIS. 

be adopted by our legislatures and by State Ixtarda of health in order to 
legitimize, and later stimulate, the local authorities to a performance of 
their normal tasks. Sach State laws, therefore; as specify the duties of 
municipal boards of health, and provide means of insuring at least the pos- 
sibility of their fulfilment^ constitute a preliminary demand of immediate 
necessity. 

Legislation enabling municipalities and counties to establish institutions 
for the care of consumptives is also a present need. The outlook for ade- 
quate legislation of tliis character has never been so promising as during 
the current year. 

Another distinctly encouraging sign of the times is the awakening of 
certain State boards of health to their opportunities along educational lines 
in the tuberculosis campaign. The recent activity of the boards in Marjdand, 
Ohio, Minnesota, New York, and other States ^ves promise of results which 
could not be accomplished in equal time with any other machinery available 
or iikely to become available in the very near future* 

It is, however, an axiom that tuberculoaia h a social disease, a disease of 
housing and working conditions; in other words, of local environment; and 
this would seem to be sufficient to indicate that the successful fight must be 
made along local lines. 

From the varied methods that have been tried out in recent years there 
has resulted practical agreement upon the essential features of the anti^ 
tuberculosis program in any official municipal campmgn. They are these; 



■ 



I* Knowledge of Conditions, 
It is evident that effective activity must rest upon acquaintance with 
the situation* As a prerequisite to this knowledge, it is now agreed that 
compulsory notification and registration of all cases of tuljerculosis are 
necessary. This procedure has now been in operation in our larger cities 
long enough to disprove the objections constantly raised to its introduction 
by the medical profession or the more timid of the huty, and has established 
its usefulness to a degree which insures its extension to practically every 
community in the United States, It is therefore presented as tlie first 
essential in the specific program. 

II. Adequate Phovision for the Care op CoNstiMPrivEs. 

If I interpret rightly the experience of recent years, it is in this field that 

we must expect our greatest results. It seems obvious enough that in order 

to prevent new infection the simplest method is to remove the infecting 

center. There should be^ other things being equals an inverse proportion 

l>etween the amount of institutional treatment of tuberculosis and the degree 

of tuberculosis morbidity. 






A COMPSEHENSIVB PROGRAM OT PHEVENTION. — ^TAKRAND, 



239 



Tn the past the chief attention, not only of State and local authorities, 
but even of those most interested in the campaign along private lines, has 
been devoted to the establishment of sanatorinms. The cure of curable 
cases, the restoration of the sick to a wage-earning capacity^ has presented an 
appeal to legislators and philanthropists of such force that it seems tohavo 
overshadowed the demand for other provisions of even greater significance. 
The growth of the sanatorium movement has been so rapid, and we have 
congratulated ourselves upon the interest so mdicated to sucjh a degree, 
that we have overlooked the shocking lack in our equipment presented by 
the almost total absence of provision for advanced and hopeless cases. 

Of almost equal significance, and as an obvious preliminary to sanatorium 
treatment^ is the provision for early diagnosis aud intelligent advice in those 
cases where most needed that ia furnished by the special tuberculosis dis- 
pensary. 

In the field under dlaoussionj therefore, the order of importance of the 
different classes of provision for consumptive patients demanded by the 
present situation is^ 

(a) Hospitals for advanced and hopeless cases. 

(6) Dispensaries for early diagnosis, advice, and treatment. 

(c) Sanatoriums for curable cases, 

(rf) Provision for day camps, night camps» and home treatment. 

With the momentum already gained by the movement for the establish- 
ment of sanatoriums under various auspices, this class of foundation may 
Bafely be left, for the present at least, to look out for itself. It is upon the 
increase of hospital facilities, either by new establishments or in existing 
institutions, that ener^ must be concentrated in the immediate future, 

IIL Education of the CoMMUNrry. 

While educational effort is a perfectly proper line of officio! activity, it 
eeems certain that for some time to come voluntary organized work will be 
demanded before official responsibility has been roused to the point of efficient 
operation in many if not most of our communities. It is here, therefore, 
that the assoriation for the prevention of tuberculosis fimls its specific task, 
and it should be emphasized that the function of such associations is pri- 
marily and always educational. Their object is to create a public sentiment 
which will support and demand official action of an efficient character, and 
carry to every individual in the community the knowledge of a few simple 
facts regarding tuberculosis and the means of its avoidance and prevention. 

It is this second phase of the educational problem which calls for the 
intelligent cooperation of all the available forces and for all the methods 
which the ingenuity afforded by an organization can devise. 

It may be worth while to outline briefly certaia of the methods of educa- 



: 



240 



SIXTH INTERNATIONAL CONGHBISS ON TUBERCULOSIB. 



tion which have been toiind effective in reaching those claasea of the cam- 
munity hardest to touch, but precisely the ones most in aeed of the infor- 
mation in question. 

Literature, — The preparation and distribution of suitable literature takes, 
for many reasons, the leading place. Here the first point of consideration 
should be the character of the groups to be reached. There is not, and 
never will be, any leaflet, pamphlet, or book adapted to all types. 

(a) Always necessary La some shorty pithy, striking statement which 
can be printed in inexpensive form and distributed freely. There are now 
in existence a large number of such leaflets prepared by local associations^ 
and it is hoped that the competition of this Congress will produce models for 
many more. It is most often desirable, however, that the form and wording 
should be adapted to the peculiar conditions existing in the given locality. 

(b) A somewhat more extended statement should al^ be prepared which 
gives in greater detail the reasons for caution, the principles of hygienic 
living, the rules to be observed by consumptives and those living with them, 
and specific instructions with regard to methods of living, necessity of medic^ 
care, disinfection, the dangers of patent medicines, etc. This can best be 
issaed in pamphlet form, and preferably of a size that can be easily carried 
in the pocket, 

(c) Of more pneral books written for the laity there are a number more 
or less well adapted to their purpose which need not be mentioned in detail. 

{d) Literature for special classes of the community, such as teachers, 
school children, workers in special trades, etc., is increasing in amount, and 
by constant revision in different quarters is gradually adapting itself to its 
ends. 

Exhibitions.— The extraordinary success which has met the establishment 
of the so-called tuberculosis exhibitions during the last few years hiis proved 
this the most valuable single educational agency now at our disposal. It 
is an effort to show in graphic form the same simple facts that the literature 
just mentioned sets forth. 

We have in these halls so striking a demonstration of the organization 
and installation of these exhibits that detailed discussion seems needless. 
The leason t-o be imparted is so simple that the precise character of the 
material shown is of little importance, provided the visitor's attention is 
caught and held. We are seeking to impress upon the public the infectious 
character of tuberculosis, the extent of the danger, the importan(^ of 
hy^enic living, the possibility of cure in early cases, and, above allj the fact 
that the diseaae ia preventable. These points can be and are made in con- 
nection with practically any object or view connected with the diseaae which 
'"may be installed. 

A certmn logical sequence in the arrangement of the material is, however, 



A COMPREHENSrVE PROGRAM OF PREVENTION. — FARRAND. 



241 



advisable, and any one of several methods may be followed. Whatever 
plan is adopfcefi there should be: 

(a) A demonstration of conditions. This can be accomplished by maps 
and charts setting forth the prevalence of tulierculosia in the country, State, 
or city, in different tr^ules^ racial groups, etc. Maps and charts for repro- 
duction and enlargement may easily be found. Statements of the economic 
loss to the country or community through the deaths from tuberculosis can 
be put in atich striking form that they will inevitably engage the attention 
of the visitor. 

(b) The conditions which favor the development of tuberculosis and the 
Infectious character of the disease can be shown by photographs^ models^ 
pathological specimens, colored plates, and other devices. Chief stress 
should be laid on housing, social, and industrial conditions which favor 
infection^ and heixi a wide field is open. Photograplis and views of darkj 
unventilated homes and workshops and of unhealthy environments should 
be shown in contrast with what can be accomplished under similar conditions 
by hy^enic treatment. This phase of the subject shades into — 

(c) Prevention. Here should be brought in views of mode! tenementSj 
playgrounds, the work of various organizations for the betterment of social 
conditions, the results of proper health regulations, and the methods which 
have been found effective in communities where the campaign has already 
been undertaken. 

(d) Treatment and cure. Tliis aspect is capable of more effective exhibi- 
tion than any other. Photographs, models of sanatoriuma, open-air sleeping 
shacks, tents, etc., may be utilized to whatever extent is deemed desirable. 
It should always be remembered in this connection that it is the human 
aide which appeals, and that the average man, woman, or child will notice 
with interest pictures of patients and their life, where ground plans or 
elevations of buildings will be passed by without attention. Striking 
photographs of outdoor life in winter, treatment on sleeping porches or 
roofs, where better facilities are not avjulable, will be found desirable. 

In connection with the exliibitiona it is ob\'ious that constant demon- 
strations and informal public talks should be arranged, and lantern slides 
will bo found of indispensable aid in drawing and holding the audiences 
which it is particularly desired to attract. 

It is difficult to present an estimate of the cost involved in organizing 
such an exhibition. Much can be accomplished by a small but effective 
collection which can be shown in one large room of, say^ 30 by 40 feet. 
With the facilities available in any community a fairly effective exhibition 
of such proportions could be gathered together for from three hundred to 
five hundred dollars. Naturally the more money available, the more attrac- 




om tunEscmjjmt^ 



is ^betdf bemg dooe 

ijM sMfar the coDtral of SUIe ndetiei or SMe boank Gf 1k^ 
be nm£if tnaafiorted nod aeoi lo maaSkr towns are proring 

to nflet tlie ■'******'** pRBCOled by tboBB <*i^wi«mtMw afaiuc. ftn in- 
or pCfBMoeot exhifaitioti nwj not be caBed for, or eooki not be 



I\Mjrilj tte noH MPport— i fi^tor in tiw c onne c tiop b tltt pbce of 
■cfOHBee of mttem is the efaief HHwiihiiitiiBi^ aid ifc k Cu- 
te cboov » vvant Aopaooatoi the b u ane a rtrecte of ft 
dHj thiB note ioip oM g q uar t e r a in sosne pubGc boldbig, viwrfa emnoflai 
tmlf obUBOed. It is leco^abcd that tin ecfancatioDa] icaolts am 
p r opo rtl oMte to thede^^eol ptkHaiy oblaond, and aa a ooaae- 
Ike exfaAit Aodd be nulalM in aoeli a atnaliDa that it eaonot be 



Latana amd Medin^. — The third method of education eomparable to 
■ heady m c D taoned, and poanUy one which afaoukl take io^cal pceoe- 
of Ibem, IB the pobKc meelmg and fecturc. In small eoraflRPnties it 
I often not oniy the easiest to anan^, bat the most immediate in IIb leautta. 
real <filBcalty in this eonnection is in proeming cdooi^ speakera of foree 
ifliecttreneai to insote a systematic senes of meetingfB. It is too often 
cane that Intense fnteiest win be aroused for a sio^ evening or a an^ 
and then be aflowed to lapse for burk of origani^ed ptans and petB^ent 

Where cfiec tiv e medical edcq can be aecurod for pubfic krtures, ih^ 
always be otiliied. Tfae entbusissm of the layman can deldoni nrsl 
autbofity of the phyadan la Its eSect upon tfae public mitid^ 
In certain citiea success haa followed a systematic <firanm of the eom- 
dty into gmopa for the puipoaes of pabHc lectmes. ^>ecaal tatts have 
been anrsngBd fen- Bcbool-teschers, school children, churches, women's clubs, 
trades anions, etc,, and where they hai-e been followed up with a definite 
for an entire winter or year, the results have been most encouragjii^ 
Time wiD not pennit a diacooion of tbe detailed methods which have been 
effective m this movement^ but if a systematic ''*^p"eF* of pofa&e 
public exhibitioDs, and the drculation of sdected hteratmn be 
tbKNigh in any except our very larg^t cities, it will be found poHihie 
leacfa practkaOy every intividuaL 
H ii ahrays dangaoos to indutge in predidicna as to ^lecific results^ and 



AssociatioDB established before 


1905 


during 


1905 


ti it ft 


1906 


U tt It 


1907 



A COUPaEHENSIVE PROGRAM OF PREVENTION. — FARRAND. 243 

I have no intention of laying myself open to the charge of unreasonable 
optimism. It can be said, however, that if the basis of our campaign is 
sound, the extent of its organization and the rapidity of its growth afford 
groimds for sincere congratulation. We are now seeing the effect of the 
propaganda which has been carried on by the national, State, and local 
societies for some years past. From what has been said it is clear that the 
materia! results of the work will first appear in the number of organizations 
for the prevention of tuberculosis, in the increa^d provision for consumptive 
patients, and in the response of the public authorities to the demand for 
more enlightened legislation. 

The increase in the number of antituberculosis organizations is particu- 
larly striking. During the year 1907 and up to August 1, 1908, 134 new 
societies have come into existence. The rapidity of the growth is evident 
from a comparison of the figures of the last few years: 

24 

13 

25 

49 

" " " 1908 (To August Ist) 85 

Tota! 196 

As to provision for special sanatoriums and hospitals for the care of 
tuberculous patients, it may be stated that during the year 1907 and the 
first seven months of 1908, 93 such special institutions have been established, 
the comparative figures being as follows: 

Tuberculosis sanatoriums and hospitals established before 1905 115 

during 1905 115 

" 1906 17 

" 1907 35 

" 1908 
(To August 1st) .. . 58 
Total 240 

The tuberculosis dispensary, upon which energy has been especially 
concentrated in the immediate past, has also responded to the same encour- 
aging degree. During the last nineteen months 123 special tuberculosis 
dispensaries have been opened in the United States. The comparative 
figures are as follows: 

Dispensaries established before 1905 19 

" " during 1905 5 

" " " 1906 11 

" " " 1907 ' 51 

" " '* 1908 (To August iBt) 72 

Total 168 

It is impossible to summarize in a few words the enactment of tubercu- 
lous legislation or the plans for legislative action which are now in operation. 



244 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 

The general laws relating to notification and registration which have been 
in operation in Maryland and Wisconsin have recently been strengthened by 
the passage in New York of a comprehensive act to the same effect which 
it is hoped will serve as a stimulus to other commonwealths. The plans 
have been laid for presentation to nearly every le^ature which will be in 
session during the coming winter of antituberculosis bills adapted to the 
particular needs in each State. 

With the interest already existing and the impetus which will be given 
to the cause by the present Congress there is little doubt that many, if not 
most, of these plans will eventuate in law. 

It is certain that the increase in the provision of all sorts which has been 
BO marked in the year just passed will continue for some time to come, and we 
may reasonably expect that before the convening of the next International 
Congress the United States will have provided an equipment sufficient to 
test the legitimacy of our methods and offer hope of a second drop in the 
mortality curve to that of the last quarter of a century. 



THE FUNCTION OF RELIEF AGENCIES AND ITS 

VARIATIONS IN THE CAMPAIGN FOR 

SOCIAL CONTROL. 



By Francis H. McLean, 

Natioiul Fietd S«nil&ry fdr Orsiuiiied Charity, U. B. A.. 



Viewing the campaign for social control from the nation-wide point of 
view, it is well to remember that in only eight States is anything resembling a 
sysstematic educational effort by the BUiie boards of health being carried 
out. Upon the basia of the 1000 census the population of the States that 
have any right to appear in this column amounted to a little over 17,000,000 
people. By the term *' systematic effort" is not meant, necessarily, a 
comprehensive campaign. Passing on to another group, and permitting 
all States to be entered here whose boards have even shown an appreciation 
that education h a pubtic health question, and who have attempted anj^- 
tliing in the way of diHtribution of literature and the like, we find that^ hy 
the same census^ we would have a total of between 15,000,000 and 16,000,000 
persons who may be more or less affected by the efforts of these particular 
boards. There is another small group, composed of four States, whose 
official educational campaign is very weak. The total population in these 
States is a little over 4,000,000. It b thus evident that in commonwealths 
containing a majority of the population of the country there b no official 
State-wide campaign. In only twenty-three States is there anything re- 
sembling such public effort* 

Yet if one turns to the imposing list of local private antituberculods 
associations he will find over 100 such associations scattered over at least 
37 States, It is difficult to say how many of the 113 associations just men* 
tioned are alive and active. It is not difficult to see that there is something 
wrong with a line of conduct in which the local associations do not plan out 
such a course of action as will lead to certain e<lucational responsibilities 
being assumed by the State boards of health. Here is the vital pf^int. To 
my mind there has been a lack of understanding as to how the function of 
the relief agency must vary according to the size of the social surplus. In 
other wordsj there has Ijeen a too obvious attempt to copy the niethoils of 
the great tuberculosis associations of the country, and too little appreciation 
of the fact that if anything effective is to be accomplishedj there must be 
greater activity on the part of our State health authorities. As an mdica- 

2i5 



246 



SIXTH INTERNATIONAL CONQRESS ON TUBERCULOSIS. 



tion as to just where State legislation stands, it is interesting to note, on the 
rudimentary and primary point of compelling practitioners to roister all 
cases with the local authorities, that it is Eow only required in a group of 
States having a p^Jpulatioll, in 1900, of a little over 28,000,000 people. It 
is probable, though the data at hand do not peraiit of an accurate statement, 
that there are local ordinances in many towns and cities in other States 
wliich make the same regulations. But even at the best the road to be 
traveled to accomplish this initial precaution is a long one. 

It is necessary to expliun, at this point, why we have associate local 
tul>erci]losis societies with relief agencies* Thia has been done for the 
BJrapte reason that in a great many places tuberculoaia work has been under* 
taken by a committee of the local relief agency, rather than by a sei^arate 
organisation^ In the monthly ** Bulletin," published by the Field Departs 
ment for the Extension of Organized Charity, I suggested that tliis form of 
organization appears to be the best in many smaller communities^ where 
a multiplicity of organizations is to be avoided. So far as this country is 
concenied, it is undoubtedly true that the associated chaiities and cliarity 
organization societies are more likely to carry on efficient work in the smaller 
communities than is the ortiinaiy Independent antituljerculi>sLs association. 
Striking examples of effectiveness on the part^ of smaDer, separately organized 
associations may, of course, be cited. Nevertheless, I believe, from my own 
observations in the field, that the hope of wide extension of private effort in 
smaller cities and towns rests in the formation of effective special committees 
organized by charity organization societies. I believe, however, that many 
of these societies liave taken up the wrong tasks, and have thus limited — in- 
deed seriously limited — the extent of their influence. They liave not ob- 
served that the function must vary. 

The great associations can be both experimenters and educators. The 
smaller associations should adopt the distinct policy of using constant pres- 
sure to have their various State boards of health assume responsibility not 
only for such repressive measures as the passage and enforcenjent of legisla- 
tion requiring the regbtratian of all cttses, but for the carrying on of the 
educational campaign. One should also include the task of placing more 
responsibility upon local health authorities- This^ it would seem, b the 
most important duty of the smaller £issociations* In a seconilury way they 
can conduct educational propaganda of their own. But they should reahze 
that this privately managed system of education is overshadowefl in im- 
portance by the larger and more comprehensive measures that it is possible 
to carry on when the financial support comes from the public treasury, and 
not from private subscriptions, often collected with difficulty. 

This can, perhaps, best be exemplified by an illustration of the conditions 
existing in a certain southern State during the past winter. In tins State 
there was a committee of the State Medical Society, especially appointed to 





THE FUNCTION OF REUEP AGENCIES. — MCLEAN. 



deal with the subject of tuberculosbs. There were also two local societies 
These associations had distributed literature anti had held a number of public 
meetings. I doubt if any member of the State committee or of the local 
associations would have claimed that much had beeu accomplished, taking 
mto cosiHideration the total population of the State. In this State it was 
strongly sui?|.'»e€tei;], though no one oould give reliable statistical data^ that 
tuberculosis was prevalent in the country districts, among both whites and 
blacks. Yet so far as I could observe, not a gleam of enlightenment flowed 
from the organizationa mentioned into these neglected district-a. Inquiring 
&8 to the function of the State board of health, it was learned that so far 
it had not possessed much authority or influenRe. Yet the program of the 
State committee and of tlie more powerful of the local associations provided 
for the eariy presentation of legislation only for the establishment of a State 
sanatorium at the coming session of the legislature. Again, in one city an 
offer iiad been made to put five tuberculosis nurses into the field from the 
city hospital under public auspices. This was being combated by the local 
association, which was ur^g forward a plan to obtain subacriptions by 
wliich one nurse, under private auspices, could be put into the field. 

Now thfi attitude of these associations — an attitude that is common 
throughout the United States — is the result of American political conditions, 
or rather, political ideas. In the minds of many Americans there is no 
association between constructive work and public agencies. Of course, this 
feeling existed in the larger centers only a few years ago. The inefficiency 
of govemmentiil agencies was responsible for this general prejudiL-e. But 
in the larger centers It had come to be realized that the public agencies must 
be pumnieled into efficiency, and that it was a wrong development to under- 
take too mucli permanently under private initiative. As we have seen, th© 
larger societies, with their larger resources, have found it possible to lead in 
some lines of experimentation, and in a few instances to carry on a very 
effective educational campaign. But the larger societies have never for- 
saken the idea that much of their work will be carried on, eventually, as it 
should be, through public agencies. 

On the other hand, in the smaller centers we have these peculiar con- 
ditional with a social surplus proportionately less, and therefore with 
restricted means there has been an attempt to carry on small lines of 
work^ excluding any serious consideration of plana for developing more and 
more the power and influence, particularly on the educational side, of 
public health officials. It may be necessary to reform some of the public 
agencies. This should be done. But if a certain public agency is inefficient 
or corrupt, it is all the more necessary that increased effort should be made 
to bring it up to a standard of reasonable purity and efficiency. 

If a smaller society finds it possible not only to agitate for larger power 
and efficiency for public agencies, but also to carry on an efficient local edu- 



SnCTH INTERNATTONAL CONGRESS ON TUBERCULOSIS, 



wunpnign, let it do sOi But ^t m importance, a& has been said, 
ahaold be the atrefigthemng of the bands of tboee in public places. 

Thb pofiey does not mean, however^ that local relief societies should 
BO p*rt in cnliglU^Miing a coiumuiiity. It means that they had better 
ftOioB with a State or local Ixiard of health than attempt to do the 
vUe tiu&^ For iostaiico, » Slate board of health may be providetl with 
metDS and machinery for the printing of various kinds of literature 
for advertising, for stipplying slides and apparatus for illustrated 
III onkr to m^e the fullest use of this equipment, there is, of 
crkknt need of securing the cooperation of local Iwdies over the 
SMito aflnst in the wise distribution of the printed matter, and to 
ita for addresses Iwfore the proj^er kinds of audiences. In 
^^Ji^lft ff iBBOciations would be of the utmost Lm|x>rtance. They 
^^M ^^ bt servins ii* the c^apacity of committees whose object it would 
^^1^^ 1^ public money was mast judicioaaly expended. Indeed, in 
K^^d «sr tbvf nAAi, in the educational field, from their direct contact, 
tJh^^fiaeacy of different methods and to s«gge-st improve- 
Thus they would return to a modified kind of lead- 
to vIhA of the lufar societies. But it would be because they 
^ InMcte of their ofBcials and boards. 

8(HMewbat more particularly with referenec to 

Y^en abould be no variation of the function as between 

it oomes to agitation for general legislation. 

.^lol^llOQg these lines have l:)eeD niside on the part of 

f^otD the 1 1 3 societies previously mentioned 

cm the primary question of registration, 

ities: 




L 

II 

1' 

1. 
tlij 

existii 
there 




THE FUNCTION OF RELIEF AGEKCIKS. — MCIiEAN, 



245 



Analyzing thia table, and adding to the cities where it is claimed that 50 
per cent, or more of the causes are registered cities in which, in a general way, 
fair or good enforcement is recorded, one obtains a total of 40 cities. This, 
it will be remembered, is not a raiacellaneous list of cities or cities of a certain 
population^ but cities in which there are antituberculosis committeee or 
societies. There is a screw loose somewhere in the municipal machinery 
of these cities. Possibly the health authorities are not sufficiently strong in 
personnel, or adequately backed up by the city administration, or held in 
sufficient respect by the medieal profession. There can be no question that 
each one of these local societies, wherever there is legislation to cov^r the 
Bubject, should be aroasing their particular communities to the need of 
efficient health administration; Ln other wor<ls, it should be strengthening 
the health department of the city or of some other adminbtrative di\ision. 
Indeed, if one takes the evidence of this table as a sign of progress maile in 
the smaller cities that progress must be acknowledged to be small. Yot 
is it unfair to take this as a measure? For here m ono of tlie .simplest of 
nidiments, the thing that must precede the \dsualization of the si7.e of the 
local problem. Yet groas inelTicienoy is revealed. It is true that a local 
society may claim that the health department is worthless and that, there- 
fore, it has been devoting its attention to other lines of work tlirectly imder 
its own eontroL This seema to me to be lieg^ng the question, to he displac- 
ing the important by the unimportant. If this conception of the fvinction 
of the relief agency is a correct one, every such agency would consider that 
the inefficiency of a health department was a matter that seriously reflected 
upon its own usefuln^5s as long as the conditions remained unchanged. 
Their great^t efforts would be in the direction, as we have again and again 
stntefJ, of strengthening the public health agencies, a strengthening that 
would mean not only the enforcement of law, but intelligently planncil and 
comprehensi\'e eflucational campaigns. It is tnie that we may Ijc aceuseil 
of assuming too much upon the basis of the table previously given. The 
societies may claim that, of course, they are endeavoring to secure enforce- 
ment of the law. But my experience of some local organizations makes me 
extremely skeptical in accepting a contention that in this field there is any- 
thing resembling a sense of personal resi>onsibility on the part of local or- 
ganizations with reference to conditions of local health Iwartls. Until they 
do feel that very close connection; until they do feel that an inefficient 
health board is a constant and daily challenge to their efficiency as alleged 
leaders in the movement — until that time comes their efforts will be more 
or less ineffective. 

Coming to the field of curative effort, there is perhaps a more general 
llingness to bring about as large efforts as is possible on the part of public 
ithorities. The question is, whether the working principle is adhered to 




250 



BDCTH INTERNATlOlSrAIj CONGRESS OX TUBERCULOSIS. 



of having public authorities undertake what they can undertake. The illus- 
tration of the southern State previously given is apropas of this. It will be 
remembered that a society was opposing a plan for city nurses for fear of 
injecting politics iota the work, whoi^as at the same time it was endeavoring, 
with painful efforts^ to get sufficient contributions to put one nuiBe into the 
field. In speaking about the variation of functioHj we have indicated that 
euch experiments oould be carried out proportionately on a larger scale by 
the great societies than by the smaller ones. Lest I be misunderstood, I 
would cite the policy that has been adopted by the better grade of social 
settlements of the coimtry as one that should be followed by local relief 
agencies in the fight for soeial control. The settlement policy is that it will 
undertake various educational features, but that w^henever the value of such 
features has been demonstrated and taken up by school boards, library 
boards, and similar undertakinip starte<l in the neighborhood, then the 
settlements will withdraw from that particular fiehl and enter new ones. 
Distinctly opposetl to duplication of effort, the settlement recognises that 
nothing undertaken through private auspices can equal in extensive value 
the same thing undertaken with the resources of the municipality or the 
State behind. This should be the policy of relief ageodea with reference to 
tubercult>sis. There is aknost an infinity of thinp that need to be done, and 
no matter how muny lines of effort are taken over by public authorities, 
there will still be lai^ uncovereti fieUls into which the well-organiaed private 
societies may enter. I hnve indicated that I belie\'B that there was this 
much variation Ln the function as between the strong and the weak tubercu- 
loais societies^ that even in experimentation the local societies may find that 
thoy wQ] serve better ^roply as alli^ to and ablators of public authorities 
tliAn ao indepeodent experimenters. 

So far nothing has been sakl of the field of curative effort ha\ing to do 
with CDfliterial relief. There b a pretty general acc^^taDce of the idea that 
V> far 6& iDiioor relief of tuberculosis patients is eonceroed. It should be 
relegated vaott and more to public agenoes. But with refcRSce to cases 
in which borne cure is presoibed, there ia, of course, room for ^peoditure 
of largt asmmts of money. Tills woM seeiD to be a field into whidi private 
oluuity ahouk! euter^ not only l^erause it is a fiekt in which the daoygeis cf 
public n^ief would be «K«ggeTftted, bat becMiae the mtfirklaal idkf affonled 
ID such ceMB win serve to educate the pubfic on the whole qocEtiaii of tuber- 
culosis. This, it will be oI«€t%^, does not limit the funttioo of public 
Mithorities with rdemoee to tubereoloae vi&d, else we could wdl be 
of inco naia teaey. 

A much gTBAter number of eaees wiD ahn^ys be cared for in public ok 
.«titixtaof0 than at honir. The home cases are s^ of the expetiiDeDtal soft^ 
they should be tpeated with all the nfivkiBal variation thai is 



\ 



i 



I 



THE FUNCnOK OF REUEF AGENClEa, — MCLEAN, 



251 



in organized charity work. Then, too, it should be very strongly stated 
that actual relief work involves far more and different factors than do the 
other forms of social acti\ity, such as social education, about which I have 
epoken. These other forms of activity involve perfect equality of treatment 
for aU members of the social polity. On the other hand, actual relief involves 
inequality, and, therefore, the personal touch is necessary to bridge the gap. 
Our conclusions would be, then, first: that in the educational field the 
smaller societies should form, as soon as jxtssible, plans for enlar^ng the 
power of boards of health and increasing their efficiency. Second, that the 
smaller societies should feel greater responsibility in strengthening the health 
authorities, with reference to better enforcement of laws and towanl better 
Jegislation. Third, that the same policy should apply in curative work to 
*a less degree, except that outdoor relief connected with home care should 
still be the specia] function of relief agencies. Fourth, that the variation 
in the function lies in this, that while the larger societies may lead in educa- 
tional work and experimentation as initiators, the smaller societies can serve 
in a great-er degree as inciters to activity on the part of public authorities 
and as allies of such authorities^ rather than as initiators. 



La Functidn dc las Agendas de Socorro. — (McLean.) 
El autor presenta Ciena's ewtadisticiis obtenidas de las publicaciones del 
nuevo "Hand Book on Tuberculosis" en las demostrando el limitado trabajo 
que se hacc en el trabajo educatlvo en las afueras de laa grandes ciudades: 
tambien base ver cumo aim laa cosas rudimentariaa tales como el eumpli- 
miento de la ley del re^stro obligatorio de los casos, no es debidamente 
obaervado en muchoa lugares en donde en donde exi^ten Asociaciones de la 
Tuberculosis. El concidera que es una funci6n particular de laa agencias 
de aocorro, particularmente la asociaciones de caridad en las ciudadea 
pequenas, el organizer el trabajo de la tuberculosis en vez de tener aaocia- 
dones separadas. 

En las grandes cindadcs la asociaci^n puede servir como inlciadora del 
trabajo educattvo. Eu laa ciudades pequeiias la asociaci6n delsera esfor- 
zarae en conseguir la autoridad publica para inagurar el trabajo educativo. 
Las asociaciones pequenas ban atentado su propia canipana educativa, y 
han conseguido relativamente j)OCo, mientras que ^llas no han fomentado el 
des&rroUo de la salud en el Estado, y en las Mesas Locales de Salud. 




Funktion der Unterstiitzungsvereine. — (McLean.) 
I>er Verfasser bietot gewisse statistische Angaben, die in den Antworten 
fur die Veroffcntlichung der neuen Ausgabe von "Hand- Book on Tubereu- 



^2 



SIXTH INTERKATIOIf All CONGRESS OH *nmEfiCirU)«HL 



losb " gegeben worden dnd, wobei sie auf den klemen TeO von Erziehimgv- 
Albeit hindeutet, der Ausserhalb von gewissea grossen BdJttelpimktea aib- 
gefuhrt worden ist; er zeigt auch, wie eine so rudimentare Sache, wie die 
obligatorische Ausfuhrung des Gesetzes, welches Mel dung der Falle verbLDgti 
in ^ner groaic Q Anzahl von Hatzen vemachlaasigt worden ist, wo groase 
Tuberkuloae-Geaellscluiften aind. Er glaubt, dass es eine Sache der Unter* 
stutzungavereine, besonders der vereinigfcen Wohlt^tigkeit^^ellscbaften ist, 
in kleinea Stadtea Tuberkuloee^Arbdt zu organisieT'en, anfitatt getreante 
Gesellschaften zu haben. 

In grossen Stadben katin die Geselkchaft die Imtiative In Eruehinigs- 
arbeit nebmen. In Ideineren 8tadten sollte die Gesellsch&ft sich sehr 
bemubenf dass die OffentlicheD Behorden das Erziehungswerk inaugurieieti 
eollten. Die ganze Unordnung in die^en Sachen war der Umstand, dass 
die kleinereri Geselbchaften Ihren eigenea Erziehungsfeldzug versucht haben 
uod verhaltnismasaig wenig erwirkt haben, wahrend an der anderen Seite 
sie das gesunde Wachsen der staatlichen und lokaten Sanitatsbehordett 
nicht ermutigt haben. 



Fonction des Associations pour la Soulagement des Pauvres,— (McLean.) 
L'auteur pr^^nte certaines statktiques obt«nues des rapports fails pour 
la publication de la nouvelle edition du "Hand Book on Tuberciilosja'* 
tnotitraot lu quantit'^ limits du travail d'instructioa ex^ut^ en dehors de 
certains grands centres; montrant auasi comment une cho^e m^me, aiisd 
rudimentaire que Tob^issance aux loia qui exigent Tenr^istrement des cas 
de tuberculose^ est n^glig^ dans un grand nombre d'endroits ou il y a des 
associations contre la tuberculose. 11 estime que c'est un devoir des asso- 
ciations pour le soulagement des pauvres, particuli^rement des associations 
charitables, dans les villes plus petites, d'organiser la lutte contre la tubercu- 
loae, plutdt que d'avoir des associations a?parfes. Dans les grandes \TlIes 
raaaociatjon peut ^tre i'initiatrice du mouvement d^ *' instruction/* Dans 
lea villes moins grandea Tasaociation devroit faire tons ses efforts pour faire 
inaugurer pa,r leg autorit^ pubUques un grand mouveinent d'6ducatJ0n, 
Les associations plus petites ont entrepria leur campagne d'instruction 
ellea-ro^mes et ont accompli aasesf pen de chose, tandis qu'elles n'ont paa 
encourage le progrSs vigoureux des Coaseila de Sant6 Locaux et de I'Etat, 



PRESERVATION ANTITUBERCULEUSE CHEZ LES 

JEUNES FILLES DANS LES CENTRES 

MANUFACTURIERS, 

Par Madaub Bi^ot-Bebqer, 

da St. Quentin (Alsne), FVanoe. 
(Pr^ndoite — Fondatrioe de TOeuvre intematioiuue d'Aasistanoe mutueUe "La Joie de Vnrre.") 



Au Congr^ de la Tuberculose k Paris en 1905, nous avions signal^ dans 
la Section que pr^idait avant tant de science et d'autorit^ notre ami si 
r^rett^, le Professeur Grancher les m6faits graves, engendr^s chez les jeunes 
filles k leur p^riode de formation. Si les fillettes qui, n'ayant pas k gagner 
leur vie pendant cette 6tape, restent surveill6es et soign^es par des parents 
qui ne r^ussissent pas toujours^les sauver; combien est lamentable et digne 
d'int^rfit le groupe important de ces pauvres petites mal aliments, parce 
qu'elles sont les aln^ d*une trop nombreuse famille indigente. 

Examinons en raccourci leur premiere lutte pour la vie. D6j4 un peu 
an^mi^ par T^cole et le surmenage de la preparation au certificat obtenu 
ou non, Tenfant de treize ans est mise en atelier, en fabrique ou en apprentis- 



En atelieTf elle devra piquer huit heures cons6cutiv€S k la machine. Or 
la machine k coudre est ce qu'il y a de plus malsain, de plus entrmnant pour 
la chlorose, et les femmes mari^ qui veulent se livrer k des surmenages 
lib^rateurs pour restreindre leurs matemit6s emploient ce moyen comme 
excellente manoeuvre abortive. Chez la jeune fille en croissance, elle 
compromet gravement les frfiles organes g^nitaux. D serait urgent que les 
Etats k faible natality attachassent une importance capitals k ces trds 
s^rieuses constatations. 

En manufacture dans nos centres usiniers du Nord de la France, nos 
fillettes entrent en fabrique de Tdge I^gal d'apprentissage, soit treize ans 
r6volus. L^ elles sont debout toute la joum^ dans les filatures, les tissages, 
les retorderies, etc. Etant aux pifeces, et, sachant qu'elles seront mal 
recues k la maison si elles y rapportent le produit d'une quinzdne insuf- 
fisante, elles se surmSnent et bien vite les joues et les Idvres p&Iissent, les yeux 
se cement, Tan^mie s'est implants* 

Si la nourriture prise en famille ^tait rationnelle, le mal pourrwt ^tre 
enray^ avec quelques fortifiants, et quelques semmes au grand air comme 

253 



3&4 



sarm cmsscAnoVAL coxgress ox TrrBEBnTLOSis. 



je le fais ftVBe tnootm pour wi poope, bfias trop restretnt! mais en g^a^ral 
ileii de toai cd* t»'cx»ie: raEnxnUtkxi de la petite apprentk l^tuphatique 
oa BBVi i uw ! k Vexc^, eoosisle ea od loiird pUt de h&ncots ou dc pomxQeB 
dt ten« & U l^visse. Boodaai i ce plat quotii&n derant lequel son estomac 
M fenBe^dfe pstombe flurdai nwiia, oo artiebattt cm ou de la saUde. Bientot 
le tube Agortif d I*mteBti& Hsonft pris, et a bi fillette prend la moindre 
erippe^ b farofiddte ou U tobereolose iDteEdiLale m d^veloppe pour la con- 
fhttf^ au cimeiite &pcfe avoir coDtamtn^ toute la maiaomide. ''Accident 
de tnv:u]" diroot eneore ^otaine indiff^rento cyniques cruels, eomparaiit 
eeCte mort prfmatur^e, courante, mix pcries aocialcs inevitables, conime 
kur espnt maX toum^ assinula k oette iii£xne oause^ et en pleine Chambre 
pftrlementaire, te double aaaaaanal dn sorerains Portugais^ 

"Aeddent de travail," oui, Menieurs. mais ceux-la feront de terribles 
rides da&8 voe prochains cx»rps d^arm^, puisque ce sant ]es matemit^ 
vaUlantes qui soni vos pourvoyeuses. A ce grave, tr^ gra%*e facteur, qui 
fauche lea fleurs d-usine^ nous pouirions ajout^r eomme principal atout au 
fl^hisBement des moeura^ Teffet de la dangereude promiscuity de ce$ petit<3 
filles qui ooudoieot toute la joum^ le brodeur ou le tisseur. Pour peu que 
ces demiers soient alcooliques^ pr^tuberculeux ou autre chose, jupz des 
r&ultats divers de cette pronuscuit^, et des dangers enig\itabtes courus par 
la jcune enfant dont la formation morale n'est pas plus sollde que la for- 
mation physique. 

L'Apprentissage chez la couturi^re ou la repasseusej tente le plus souveat 
lea mdres s^rieuses qui veulent s^parer leurs chores petites, des filles de 
fabrique et des ateliers mixtes. Ces Midinettcs y apprennent un metier 
individuel, mais il est n^cessaire que \h, aussi, I'lnspecteur du travail se 
double parfois d'une docteur dd^gn^; car bien des enfants n'tront pas loin 
ou reiteront toute leur vie de pau\Tes souffretetises, incapables d'etre mere 
plua d'une fois pour les cona^^uencea suivantes: 

1. Parce que la fiUette qui coud courbe^ dix heures par jour ne se d6~ 
veloppe plus, lea poumons fonctionnent mal et, un examen mikUcal devrait 
etro paRs^ avont toute orientation ou commencement d'apprentissage. 

2, La petite repaaseuse qui s'est fixe^ 1^ pour gagner honorablement 
SA vie, et qui n*a point vu pr^alablement le docteur, mourra si, par exemple, 
clle a Ic« [fhila platSj infirmit6 qui s'aggrave A rester debout et que double 
enooro la vapour an^miatite qui montc du linge humects, qu'elle repasse, 
Kami oompt<T I'odeur des chlores et des produita chiniiqueSj pour cclles qui 
ont tl'iilHini procj^d^ a la lessive* Pub les dangers de contamination pour 
lofl pHUvrm fN_^t,itc8 blancliifiseuses charged du triage du linge sale, etc. 

iJjirjM c«>M profcfl«ioiis et bien d'autres des notions de pr^n'ation anti- 
tnf»*'i"<'nl'''*'*" dijvront ctrc affiehefe, ime hygifene rigoureuse obsor\'6e; et 
I'^t^ par rouloment, des M^jours au grand air eeront exigt^. 




PRESERVATION CHEZ LES JEUNES FILLES. — B^ROT-BEltGER. 255 

Conclusion: Un remMe s'impose k la conscience de ce trfis progress! 
Ck>ngrte. En raison des d^^ pr^matur^ de jeunes filles causes dans les 
centres manufacturier^, Tlnspecteur du travail (si particuli^ment z6\6 en 
France) devra, dans ses visites, ^tre accompagn6 deux fois par an d'un 
docteur. C'est pourquoi je saisis le Congrte d'un voeu que je lui demande 
de prendre en consideration, et dont je le remercie de tout coeur. 

Voeu: Dans les centres manufacturiers qui occupent sp^cialement des 
jeimes filles, Tlnspecteur du travail devra, dans ses visites, 6tre accompagn^ 
deux fois par an d'un docteur. 

The Prevention of Tuberculosis in Young Women Wage-earners. — 

(B6rot-Bekgeb.) 

It is lawful in France for girls to enter gainful occupations at the age 
of thirteen. Many become spinners and weavers, and since they are paid 
on a piece scale they are so driven that there is no time for open-air ex- 
ercise, their diet is poor and irregular, and they soon become anemic. A 
little "Grippe" allows an implantation of tuberculosis which is almost 
always fatal. Anemia and chlorosis are common also among seamstresses 
and laundry women. The indiscriminate association with male workers 
is demoralizing. Young girls in these occupations do not develop into 
childbearing women. They easily succumb to tuberculosis. 

On account of the untimely deaths of so young girls in manufacturing 
centers, the author proposes to the Congress a resolution, as follows: 

Resolved, that wherever young girls are employed in factories, the 
official inspector should be accompanied by a physician, at least twice 
a year. 



THE LFNTEACHABLE CONSUMPTIVE, 
By Ellkn N. La Motte, R,N., 

0f«dvi*> ff Ji'liiii lIupUli* UemiiuU: Tube»ul<Hds KurM of I110 laAmetriv YUtjnf Nunc 

linn of B«ltunarv, Uuryltuid. 



Thf* (^iipstinn r»f Rtamping out tuberculosis as a disease that attacks 
wnnoty in gi^iiornl luia resolved itself into the question of stamping it out in 
th« hciucH of that partirular class in which it ttoiirishea by natural ri^t. 
It Ls primarily nnd osscnlially a disease of the poor, and it is they who are 
thp sourofi from whiiih contamination comes to other classes of society. 
For Olio tnillionairt' with tu^jerculosis, there are hundreds of sbop-^rls wha 
Uiixv it wlio must kopp IxHly and soul together on five or sLx dollars a week;j 
for ti*n j>rofcii8ionnl tnen who l>ecoine infected, there are hundreds of day- 
Udxirora ttupiKirting themselves and large families on ten or twelve dollars 
h woek or l(\srt; for fifty bank-clerks who are tulx;rculous» there are thousands 
of nogrocw, foreigueTB, and others who are ekeing out an existence among the 
Inwcttt rmikH of wpkfa-eanwrB* 

Tho |»n>hl<^ni, therefore, Is one that concerns the prosperous classes only 
inciih'iitally —it w not a q\ie-stiori of teaching the well-t-o-do people how to 
ftvoiil infection ami how to cure themselves if they become infcctodj nor of 
hriviiiji; (hem provide tlipmselves with sanatoriums^ knowing that, after they 
leuvo {hru\f they will W*. taken care of in their own homes. The root of the 
whole i!mtit*r lies in dealing with tubcrculosia in that class of society in 
which it pitivailH, and to which it belongg. If adequate care be taken of the 
patiiniU tjf lluH dasa^ the prol)lftm will be sf>]ved. 

In thiH lii'.i tiie crucial point, ''Adequate care" means to put into 
pra<:tico, Hyntematically and uaflinchingly, those principles and methods 
thut have IxM.in tistablishcd m indijspen.sable to the cure of tuberculosis and 
to the prevention of its spread. This bnn^ us face to face with the question: 
Ih our prt»scnt manner of carrying on the tuijerculasis campaign attaining 
this result? If it ia not, then the whole campaign la thereby balked of ita 
luooeig, 

U't. UN nee how the niatter stands. Thus far in the campaign we have 
rr'licil u|ion t^<iucaU4>u tm the weapon for fighting tuberculosis. "Education" 
ifl the cry— <nluctttion in t!io laws of hygiene and prophylaxis for the million- 
jviro, the profcHnional man, the bank-clerk, the ahop-girl, the day-laborer, 

256 



THE UNTEACHABLE CONSUMPTIVE. — LA MOTTE. 267 

the drunken n^ro. Most of these can leam by rote as much as is essential 
to our purpose. The first three alone can be brought to apply this knowledge 
to their daily lives. Precisely at this point the efficiency of education ceases; 
precisely at this point the campaign against tuberculosis breaks down. 

The day-laborer, the shop-girl, the drunken negro belong to a class that, 
by reason of the very conditions that constitute it a class, is unable to make 
use of what it learns. That as the campaign is conducted at present tuber- 
culosis is for the poor neither curable nor preventable, is the conclusion 
arrived at by the writer as the result of three years' experience among the 
poor of Baltimore, where, as a tuberculosis nurse, she has had the most 
ample and extensive opportunity for the observation of conditions and 
results. During three years she has entered, thousands of times, the homes 
of 1160 patients. It was her mission to instruct them as to the contagious 
nature of the disease, to teach them how to make use of the sputum-cups, 
paper napkins, pockets, and disinfectant which she provided, and how to 
dispose of them afterward. The families of the patients were also shown 
how to care for them, and how to protect themselves from infection. The 
patient's living conditions were looked after. If possible, he was made to 
sleep alone in a room, or at least in a separate bed, and if he was unable to 
buy a bed, one was procured for him through one of the charitable agencies, 
which furnished a good deal of relief, including diet (milk and eggs) for 
patients below the poverty line. 

But the instruction given by the tuberculosis nurse was only one of the 
ways by which the education of these people was carried on. To begin 
with, in every one of these 1160 cases the advice and warning of a ph3rmcian 
had preceded that of the nurse. The majority of them were or had been 
dispensary cases; others had been visited by physicians in their own homes, 
so that both the patients and their families had already had a good deal of 
advice as to care and prevention. Moreover, the work of the nurse was 
constantly supplemented by the teachings of the charity agents who furn- 
ished relief, by those of church workers, clergymen, and intelligent neighbors 
who were capable of grasping the fundamental ideas of the nature and 
prevention of tuberculosis. Education through specially prepared literature, 
books, and tracts, simple and easy to understand, has been made a prominent 
feature of the campaign, and each patient visited was given books of instruc- 
tion and advice to be read by himself and his family. Moreover, the press 
of Baltimore is particularly active on the subject of tuberculosis, and these 
people read the newspapers incessantly. Finally, for the past three years 
the Maryland Association for the Prevention and Relief of Tuberculosb has 
maintained a traveling tuberculosis exhibit, which has been shown in different 
districts of the city so often that no neighborhood has been left unvisited; 
and it has been seen not only by the neighbors and families, but in many 
VOL. m— 9 



25S 



SIXTH INTEHNATIOKAL CONGRESS ON TUBERCULOSIS, 



instances by ttie patients themselves. In all these ways, and from lUl these 
sources, then, education in the treatment and prophylaxis of tuberculous 
has been brought to bear upon these people — over and above and through 
all the rest, the regular^ painataldng, never-ending work of the nurse. Now 
let ua examine the results. For convenience, these have been tabulated by 
dividing the paticnta and their families into four groups, classified according 
to the degree in which they were able to put this education into practice. 
The first group, designated ''adequately careful/* includes those who utilized 
to the full the knowledge they had received; the second group, "fairly 
careful/' were able to profit more or less by what they had learned; the 
ttiird group, "careless/* could not or would not use their instructions except 
irregularly and inconsistently; on the fourth group, "grossly careless/' 
all teaching, from whatever source, was utterly thrown away so far as their 
putting any of it to practical use was concerned. Here is the showing in 
numbers: 

Adequately careful .,,,..,.,., 9 

Fairfr careful - , . , 143 

Carefoaa 719 

Grossly careless ,,...,,...,..,....,.. , 289 

Total 1160 



So far as the suppression of tuberculosis goes, the first group alone would 
count; for even those who come under the head of "fairly careful*' are con- 
tinuing to spread infection; while, as it is, anything that might be accom- 
plished by the "adequately careful" is utterly swamped by the more than 
overwhelming majority in the other three groups. 

It now remains to consider why the educational method is a failure. 
In the opinion of the writer there are three reasons for tliis: namely, tem- 
perament, environment, and familiarity, and these we will consider in the 
order of their importance. 

First, as to temperament: People of this class are by nature weak, 
shiftless, and lacking in initiative and in perseverance. They have neither 
inherited nor acquired moral strength any more than physical strength, and 
they are often \4cious besides. It takes a high grade of moral fiber to main- 
tain the persistent and long-drawn struggle that must l^e kept up in fighting 
tuberculosis, and they have not the self-control necessary for forcing them- 
selves and their families to maintain the required standard of living, and to 
exercise the required carefulness; in other words, their moral as w^ell as 
their physical resistance is low — a fatal combiaation. No amount of educa- 
tion in the laws of hygiene can give them moral fiber, nor can they be trained 
to exercise self-control in time to do any good. The progress of tuberculoas 
is alow, but the process of making over a human being to the P<^^^^ ** 



THE UNTEACHABUB CONSUMPnVB. — LA UOTTE. 259 

which he can take up the fight against tuberculosis with some prospect of 
success is so much slower that there is no chance whatever of its winning 
agunst the disease. 

Second, as to environment: This term is used broadly to include general 
home conditions, income, and a number of other factors on which the cure 
of the patient and the protection of his family depend. The crowded 
quarters in which these people live mean inevitable contamination of the 
patient's household. As a result of small wages, the food on which they 
subast is scanty and poor, the family being forced to curt^ul expenses in that 
item in which economy can be most readily practised. Rent, fuel, clothing, 
must, to a certain point, be provided, but food can be reduced to a still 
lower minmum of quantity and quality. A pitiful fact in this connection 
is that the other members of the family often deprive themselv^ of nouiish- 
ment in order to give the patient a little more of the food that he craves, 
thus reducing their own vitality, and increasing their risk of infection, 
merely to prolong the life that, in itself, endangers them all. This is human, 
and could not well be prevented, but while we persist in using a method 
that seems letting society take care of contagious diseases in its own way and 
in its own homes, we may as well note the facts. 

Moreover, the circiunstances imder which these people live make it 
impossible to get money to carry oi^t the technic demanded. Even when 
their intentions are of the best and they are acting in the utmost confidence 
that they are doing exactly what is light, they will unconsciously do or leave 
imdone some little thing that nullifies all the care that they have taken in 
other directions. For instance, when the mother of a family is also the 
caretaker of a consumptive, we see her leave her bread-cutting to nm out 
to arrange the patient's pillows, perhaps to pick up the paper napkin that 
has fallen off the bed, and then she goes back again to prepare supper with- 
out stopping to wash her hands — a trifle in technic that she is too busy and 
too tired to think of. Most patients are fairly careful in their use of the 
sputum-cup, and it may be the object of close attention on the part of the 
rest of the family, but at the same time they may allow it to stand in the 
middle of the kitchen table, or entrust it to a child to empty or bum, or in 
other ways permit it to become a serious source of danger. The casual 
observer, seeing a patient spending his days out on the porch and using his 
sputum-cup faithfully, may readily conclude that here is a demonstration 
of the triumph of education; close inquiry, however, reveals such conditions 
as have just been described. When a household worker, whose hands are 
already full, or more than full, is pressed into service as a nurse, such mis- 
takes as those noted will always occur. In other words, the element of 
danger is constantly present in small households of thb class that shelter 
consumptives. The danger is sometimes less, sometimes more, but it is 



2ao 



SIXTH DTTERNATIOKAL COKGRESS ON TUBETlCULOaffl. 



always there, and a system of dealing with tuberculoma that does not remove 
this danger must render itself barren of result. It is these circumstances 
of environment that prevent eam^t efforts on the part of both the paUent 
and his family from rraulting at best in anything more than a lessening of 
danger — elimination of it is out of the question. The "fairly careful" 
group is made up of these people. It is only by the cooperation of patient 
and family that they get even this far; if a careful patient and an indiffcTient 
family were found under the same roof,^thought as it happens, this is never 
the case, — ^the results obtained either way would be insufficient to place this 
household above the "careless" group. 

This brings us to the third factor, familiarity. Sometimes, with a new 
case, it is possible to impress on the patient and his family the necessity for 
carrying out instructions, and to obtain for a time verj"- satisfactory results. 
But these^ unfortunately, are but short-Uved. The patient, seeing no im- 
provement ui his own condition, grows indifferent; the family, seeing no 
bad results in consequence of this relaxation, also become indifferent, and, 
moreover, are tired of doing the things that cost an effort. They cannot 
see beyond the immediate present. If tuberculosis were a little more 
sensational in its development^ education would show better results, Alb it 
is, the period that elapses between exposure and infection is so protracted 
that people of limited intelligence cannot be brought to see the connection. 
They forget what they have been told, or, what is worse, cease to believe 
it, and assume an attitude of wilful indifference from which it is impossible 
to rouse them. People who have passed into this stage generally fall into 
the class of the ''grossly careless/' 

To sum up : the conclusions inevitably reached by one who has observed 
these people in their own homes for three years are just these: that at 
present we are trying to apply to them a method that cannot in reason be 
productive of results--^ method that depends for its usefulness on the pos- 
session of certain mental and moral qualities, combined with the financial 
means of maintaining a certain standard of hving, and of commanding 
proper surroundings, so that the few who have the mental and moral qualities 
demanded are barred by circumstances of environment from reaching the 
desired end. 

There is one better method that suggests itself to replace the one that 
has failed. The homes of the poor should be regularly and competently 
inspected, and the moment the inspector seea that a tuberculosis case has 
reached the point where the family is unable to deal with it adequately, 
the State should step in and protect the community by removing from it 
the source of contagion that threatens its well-being. 



THE UNTEACHABLE CONSUMPTIVE. — LA MOTTB. 261 

£1 Taberculoso Rentiente a la Instruccion. — (La Motte.) 
Conraderando la educaci6n como una solucI6n del problema de la tubercu- 
4odB, una debe tomar en cuenta que existe una cantidad de personas que no 
pueden ser educadas. Tambi^n debe recordarse que esta clase pertenece & 
la daae mas predispuesta d la enfermedad, esto es, los muy pobres. A estos 
pacientes se les puede ensefiar algunas cosas, mas en la prevenci6n de la 
tuberculosis no es sino el uso constante de las precauciones apropriadas que 
puede restringir la diseminaci6n de la enfermedad. For lo tanto en tal clase 
de sociedad que por raz6n de las circunstancias, y limitado desarrollo mental 
y moral, son incapaces de una atenci6n y precauci6n constante, no es una 
dase de la cual la tuberculosis puede eliminarse por medio de los m^todos 
de la educaci6n solamente. La experiencia del autor en 1160 pacientes de 
esta dase, en la categoric de la pobreza 6 cerca de esta, demuestra que 
nueve famllias solamente se encontraron capaces de ser adecuadamente 
precauciosas 719 fueron descuidadas y 289 fueron en extremo descuidadas. 
Tales pacientes son ima gran amenaza para la sociedad. Esto parece, por 
lo tanto, que en una comunidad en donde tal clase existe, serd justificable 
tomar medidas mas radicales que la "educacion" como un medio para la 
prevenci6n de la diseminad6n de la tuberculosis. 



Le tuberculeuz que l*on ne saurait instruire. — (La Motte.) 
En consid^rant Tfiducation comme la solution du problSme de la tubercu- 
loee, nous devrons consid^rer qu'il y a une grande classe de personnes qu'on 
ne pent pas instruire. II faut aussi se souvenir que cette classe, c'est-^ire 
les tr^pauvres, est particuli^rement pr6dispos6e k la tuberculose. On peut 
enseigner k ces malades quelques precautions, mais pour pr^venir la tuber- 
culose, ce n'est pas I'usage occasionnel, mais Tusage continuel de pr^aution 
Bufiisante qui peut en arr^ter le d^veloppement. En cons^uence une classe 
de la soci6t6 qui, en raison de Tenvironnement, et de bas degr6s de la men- 
tality et de la morality, est incapable de prendre de la precaution continuelle 
et sans relache, n'est pas une classe d'ou la tuberculose peut 6tre extirp^e 
par les seules m^thodes d 'instruction. L'exp€rience personnelle de Tauteur 
avec environ 1160 malades de cette classe, vivant dans un etat de pauvret6 
moyenne ou extreme, montre qu'U n'y avait que neuf families capables 
de prendre des precautions suffisantes; 143 etaient assez soigneux; 719 
ettuent negligents; et 289 etaient negligcnts d'une mani^re flagrante. De 
tels malades sent un grave danger pour la society. II semblerait done que 
toute communaute, ou une telle classe existe, f(it autorisde k prendre des 
mesures plus radicales que 1'" instruction " comme ime m6thode pour arr^ter 
le progr^ de la tuberculose. 



2G2 8IXIH vrrEBSJOiasAh oongsbbb on TUBEacuuxas, 

Dcr ungdefaxige Sdnrindsfiditige. — (La Mottb.) 
In der Betraditung tqq Emelnmg als d^ Losung des Scfawindaudit- 
Pioblems mussen wir in Betracht aeben^ dasB es eine graeBe KlasBe von 
Leutcn giebt, die nidit untcniditet vcnkn kuinen. Wir muasen uds auch 
ennnem, dass dieses die EUase ist, (tie besondeis xa Tubokukne neigt, 
namlich die Annen. Man kann diese Patimt^i ein paar Sadien lehrrai, aber 
in der Veifautung d^ Sdivindsucht ist es nidit die gelegentlidie, sondem 
die fortdauefnde Vorsicht, die ihicr Weitervertneitung eine Schranke seUen 
kann. Fol^dir eine Klaase d» Gesellschaft, die auf Gnind ihrer Umge- 
bung und niedexen Grade von Intdligenz und Stten nidit immer und 
unaufhoriicb arhtsam sein kann, ist nidit eine ElasBe, aus velcfao' Sdiwind- 
sudit bei Enidiungsinethoden alkin ausgerottet werdcn kann. Des 
Verfaaseis personlidie Eif ahning mit einigm dfbuDdert seefazig Patienten 
dieser KlasEe, an oder untcr der Aimutslinie. leigt nur 9 Haushaltungen 
veidie fahig varen, geniigeDde Sorge fur arfa zu tragen: 143 varen zionlich 
sorcam: 719 waren narhlafrig und 2S9 waren koDossal nacfalaasig. Soldie 
Patienten sind eine sdiweie Gcfahr fur die GeseOsrhaft. Es scfaeint dem- 
narii, dass eine Gemeinde, in veldier solcfa eine Klaase als vorfaanden 
btkannt ist, beiechtigt ware, radikalere Massnahmen zor Ejiiehung fur die 
Metfarae der Gnsdirankung der Weitervesiseiiung der Tubertnikne zu 



INDUSTRIAL INSURANCE IN RELATION TO THE 
CONFLICT WITH TUBERCULOSIS, 

By Charlks Richmond Henderson, 

Univenity of Chicago. Department of Sociology. 



I. Social Measures and Financial Considerations. 
A modem social program that comprehends all the measures recom- 
mended by modem medical science and human experience must include at 
least the following factors:* 

1. The discovery of the communicable disease at the earliest possible 
moment. A bare enumeration of the most conspicuous factors in this 
process will indicate what this involves: the discovery of parents who are 
morally certtdn to transmit feeble constitutions to their offspring and to 
infect their infant children from the moment of birth; the discovery of in- 
fants already infected and imperiled; the regular and continuous inspection 
of children in schools of all grades, for the discovery of tuberculosis and other 
diseases and all the conditions that are likely to enfeeble the organism; the 
inspection of all workplaces, factories, mines, warehouses, mercantile es- 
tablishments, by trained medical graduates; the frequent and systematic 
examination of all public institutions, lodging-houses, hotels, street-cars, 
passenger and sleeping coaches, waiting-rooms. 

And with such inspection must go the employment of all the scientific 
tests known to specialists, as examination of sputum in laboratories, tubercu- 
lin tests, compulsory registration, medical visitation of dwellings and lodg- 
ing-places. 

2. Curative treatment, after discovery of disease, involves an immense 
and costly social organization that must include such means and measures 
as these: 

(a) Dispensary treatment, gratuitous, if necessary, in district offices or 
hospitals, not too far from the families of the poor. 

(6) Dispensary advice must be followed up with medical visits to the 
homes or boarding-places, and with the supervision and ministry of district 
nurses carefully trained for such service. And even this agency is fruitless 
if nourishing and appetizing food is not fumished in sufficient quantity. 

* "Tuberlnilose/' Arbeiten aus dem kais. Gesundheitsamte, Berlin, 1904. 

263 



264 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



(c) The program demands places of recreation for suspected cases, for 
incipient cases^ for the feeble who have been exposed to infection, for the 
isolation of those in danger; and these establiahmenta must pro\'ide a suit- 
able diet, physical comfort, and the care of physiciaJis and nurses, ^th rest, 
recreation, and freedom from exhausting worry and anxieties. 

(d) Furthermore^ our medical counselors demand of the community, as 
a condition of restoring the tuberculous to healthy that they have the help of 
great hospitals and (e) specially equipped sanatorinms — some of these in the 
forest, by the sea, or on the mountain or sunny slopes. They are helping the 
patients in a desperate struggle, and lack of equipment and service means 
defeat, and spells death. 

(/) After the patients have been restored to some measure of strength 
and the progress of the foe has been arrested, all the expenditure is wasted 
and lost unless the medical men have conval^cent homes and stations. 
Suitable employment must be found, and the convalescents trained, perhaps, 
to take up a new calling, lest return to the dusty workplace, the dark dwell- 
ing, and the exhausting toil bring on a return of the dread malady. 

(g) For a considerable number of special cases particular kinds of healing 
waters, baths, and electric apparatus are asked for by the experts, 

(A) Then com^ the after-eare of "'arrested eases" when they have re- 
turned to their homes and callings. 

3. In spite of all efforts, many cases are found incurable, and these help- 
less victims of the white plague must be provided with shelter, food, and care; 
must be kept from infecting other persons; must at last be decently buried.* 

4. The family of the wage-earner must be supported during his illnes. 
Tuberculosis, as is well known, is a pauperizing disease, for it enfeebles, dis- 
courages, lingers long^ turns the productive citizen into a dependent, and 
makes the strong man a burden and a menace to his dearest friends, his wife, 
and his children. If he Is sent to a hospital for treatment, he tosses on hb 
bed through long and sleepless nightiJ, thinking of the sufferings, the hunger, 
the need of his wife and children. The cold sweat is on his forehead, and 
anguish oppresses hk spirit at even' thought of them. He cannot take food, 
because of the belief that his family may at the moment be hungry. The 
"wage-loss^* must be made up in some way, merely aa a necessary part of 
the medical treatment. Indeed, multitudes of men have staggered on at 
their daily toil for wages until the disease was past remedy, just because they 
knew that if they stopped for cure, the income of the family would be cut off. 

5. Turn now to the demands made by the medical profession for meaoa 
to prevent tuberculosis. These are denmnds that we neglect at our 
peril: they are the voice of the final authority in this field. The authority 

* Alfred Grotjohn. " Krankcnhausweaea uod HeilslAtlenbew^utig im UchU dtt 
SoiMlcti Hygiene, Leip&ig. Vogel, 1908. 




IKDUBTRIAL INSURANCE IN TUBERCULOSIS. — HENDERSON. 265 

even of the Supreme Ck>urt must bow before the unanimous vote of the 
phy^dans. 

(a) Society in this country must provide for systematic, scientific instruc- 
tion, on a national scale, for our 80,000,000 persons, every one exposed daily 
to danger. Those who are already sick and those who are well alike need to 
be taught as to the peril, and the means of prevention and of immunity. 
Physicians, nurses, teachers must instruct persons, classes, families; the 
newspapers must be supplied with reliable and readable lessons; exact and 
intelligible warnings and directions must be posted by the millions in work- 
shops, in mines, in factories, in bakeries, in Uvery stables, in lodging-houses — 
everywhere; illustrated lectures must be given, and exhibits with microscopes 
and charts set up in suitable places; labor organizations and lodges must be 
induced and helped to diffuse the evangel of health, and sound the warnings 
of science; all schools, colleges, and universities must be centers of instruction 
on this subject; the churches must irradiate the theme with the supernal 
light of religion, and be taught the deadly effects of superstition and pseudo- 
science. 

(b) At the time of leaving school, and at other crucial moments in life, 
many, perhaps all, need professional examinations and instruction in rela- 
tion to the selection of a calling, marriage, place of residence, and other 
matters bearing on personal health. 

(c) The entire system of sanitary police measures must be set up and 
maintained by rural townships and counties, by cities, States, and federal 
administration, so that the spread of infection shall be stayed. 

Not without the utmost vigilance can the public be protected from the 
fatal bacillus in street-cars, passenger coaches, sleeping cars, omnibuses, 
carriages, workplaces, hotels, lodging-houses, theaters, churches, concert halls. 

(d) The physical conditions of dwellings have a direct and causal relation 
to tuberculosis. Darkness, dampness, dust, crowding of living beings in 
narrow space, imperfect ventilation, depressing odors, sights, and sounds, 
wasting friction by enforced contact, are all aggravating conditions in rela- 
tion to the development of the malady. Therefore an adequate and com- 
prehensive program must include all that is implied in the modem methods 
of dealing with the housing problem; the regulation of new buildings; the 
condemnation of unfit habitations; the construction of suitable houses that 
can be rented at a price not too high for wage-earners to pay. 

' (e) Concomitant with all the foregoing specific measures, means must be 
provided by community action for increasing physical vigor, and with that 
power to resist the encroachments of disease and immunity to infection. 
Under thb head may be mentioned, by way of illustration, the extension of 
parks, especially numerous small parks, public playgrounds, provision for 
outdoor sports, physical education in schools, shops, everywhere; instruc- 



266 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS- 



tion in the selection of dietaries and preparation of foods, not to dwell on the 
necessity for higher wages and increased earning capacity through technical 
education, 

6. All the proposed schemes for ma-king medical advice and prescrip- 
tions effective call for trained adjutants, eocial workers, friendly visitors, 
teachers^ and skilful nurses; and back of all tliis must be an elaborate social 
organization of training-schools, ^\'ith apparatus, teachera, buildings. 

7. Deepest of all is original, pioneer investigation, — in chemistry, bac- 
teriology, biolog>% physiology, and pathology, — clinical observation, com- 
parison of studies and experiments, publication of results^ competent and 
incessant criticism. This calls for private endowments, hospitals, subsidies 
by the State. 

8. The financial aspects of the antituberculosis movement might be con- 
sidered in relation to such questions as these: 

(1) What is the present social cost of tuberculosis in terms of money? 

(2) What would an ivdequate system of treatment and prevention cost? 

(3) What would be the net gain of a social Investment that would place 
in the hands of the medical profession sufficient meaaa to fight tuberculosis 
Buccesafully? 

(4) But even if a losa on this investment w^ere shown, still society nmst 
either provide means or perish, so that the financial balance sheet must take 
account of the entii^e future and all the wastes of disease- 
It must at once be confessed that we cannot offer satisfactory statistics 

on a national scale for such a calculation as we have suggested^ but some 
materials for a more exact conception may be furnished, useful so far as 
they go. 

In this connection we must remember that in erecting social macliinery 
for eradicating tubei-culosis we are at the same time reducing exposure to 
other diseases* Just now we ai-e aroused by the appalling discovery that this 
disea.'^ is the one most dangerous foe; but perhaps in a few years we shall 
need the same or similar militant agencies to cure or prevent other diseases 
that crowd close upon the heels of this monstrous plague. 

And, beyond all this, and by means of the same costly but necessary social 
organization, shall we be drilled and tmined to act together as a nation to 
enhance and multiply the vital force, the industrial efficiency, the capacity 
for usefulness and happiness of all coming generations. These considera- 
tions justify the movement and give to it a permanent basis. Those who 
contemplate givirjg endowments should make the conditions flexible enough 
to leave them value in the good time coming when tuberculosis will, like 
smallpox, cholera, and yellow fever, cease to be a serious menace to our 
nation. 

The figures given below for the expenditures of Germany will help one to 



INDUSTRIAL INSURANCE IN TUBERCULOSIS. — ^HENDERSON. 267 

realize the colossal cost of a complete equipment for a national war on tuber- 
culosis. The people of the United States, wickedly wasteful of forests, soil, 
and mines, are equally reckless of the cost of human life. Only our blinded 
optimism, our immense natural resources, which we foolishly imagine to be 
limitless, have kept us from keeping any sort of record of the ruin and loss 
from tuberculosis. If ever we seriously gather and confront the statistics 
of wanton and cruel waste from disease, we shall be startled into action. 
The social loss from tuberculosis is so great that it justifies, even compels, 
vast expenditures for prevention; society is struggling for its own existence; 
every man, woman, and child is in hourly peril. 

The number of deaths from tuberculosis in the United States ia estimated 
at 150,000 annually. 

The greatest mortality is in the productive years, 20-40 years: from 20-24 
years, 34.31 per cent, of all deaths; from 25-29 years, 35.34 per cent.; from 
30-34 years, 30.68 per cent.; from 35-39 years, 25.09 per cent. 

Tuberculosis is a lingering disease. In the acute diseases — pneumonia, 
diphtheria, typhoid fever — the time of disability extends from one week to 
one month; in consumption, from one to often more than five years.* 

Dr. Hermann M. Biggsf has estimated that the total annual cost to New 
York city from tuberculous disease is at least $23,000,000, and that the loss 
to the United States must be more than $330,000,000 each year. Yet New 
York city spends only about $500,000 to treat and prevent tuberculosis. 
Counting the loss of money invested in children who die of tuberculosis, loss 
of savings of those who die before the end of the producing age, and the cost 
of care of the sick, the annual loss to the State of Illinois has been estimated 
to be $36,000,000 and more each year. 

When we come to estimate the cost of treatment, we immediately con- 
front figures of vast extent, as will be indicated later for countries that fur- 
nish statistics. In America the cost of caring for patients in sanatoriums 
built to furnish good treatment for those who cannot afford to pay for shelter 
in boarding-houses has been $8 to $10 a week, and charity has frequently 
paid the difference between what patients could pay and this cost. Mr. 
Homer Folks believes that the cost of a municipal sanatorium for 500 pa- 
tients in New York would be about $450,000. The cost a patient a day at 
Rutland, Massachusetts, was in 1902, $1.42, the average number treated 
being 177. The cost at Bedford, New York, was 76.8 cents, with a different 
class of patients. The cost at Liberty, New York, was $1.21. The cost varies 
with the stage of the disease, the number of patients, and other factors. 
Dr. W. A. EvansJ says that buildings for consumptives should cost $50 to 

* From "Reasons Why lUmois Should Have a Sanatorium for the Treatment of 
TuberculoBis/' 1905. 

! "Handbook of Prevention of Tuberculosis," p. 165. 
Evans: <' JEteport of State Board of Public Charities of Illinois,". 1900, p. 178. 



268 



SIXTH INTERN ATIONAl/ CONGRESS ON TUBEBCUIiOSIS, 



S200abed; shacksand tenia can be erected for S60 to |100 a patient. Other 
figures are given by F. R. Wallace.* But bow utterly inadequate our ex- 
penditures are may be i]lustrat42d by one statement: *'In this whole great 
countiy we have beds for 80CX) patients in our sanatoriuius and hospitals for 
consumptives, anil in the city of Philatlelphia, in four months^ SOOO new 
cases of consumption are re]x>rted" (National Conference of Charities and 
Correction, 11*06, p. 501). 

II. Present Methods of Providing for the Cost in the United States, 

1. Reliance on Individual Savings of Workmen, — The first method 

of providing for the cost of curative and preventive treatment of victims of 

tuberculosis is to make a draft on the savings of wage-earners. Is this a 
reliable and adequate source of funds to support a complete policy of social 
protection against this common enemy of mankind? We may form a rather 
definite judgment on this point by studying certain facta relating to the 
income, the property, the expendituresj the surplus, and the deficits of wage- 
earners in the United States. f 

The federal government made a study of 25^40 families of wage-eamera 
of the industrial centers in 33 States, including the District of Columbia. 
The data are mainly for the year 1901. The total average income of a family 
is S420.03 in South Carolina, and S90S.6S in Colorado. In 8 States the annual 
income was over $800; in 12 States between S700 and $800; in 10 Stat^ 
between SGOO and $700; in 2 States between S500 and S600; in one State 
under $500. Of the total family income, 79.49 i>er cent, was supplied by 
the husband; 1.47 per cent, by women; 9.49 per cent, by boarders; 7,78 
per cent, by children; from other sources, L77 per cent. 

The expenditures of families annually, on an average, for 20,615 families 
in the United States in the year 1900 amounted to $699,24, and varied from 
$365,15 in South Carolina to $7S6.64 in the District of Columbia, The ex- 
penditures in the North Atlantic States were 93.21 per cent, of the family in- 
come; in the South Atlantic States, 94.12 per cent.; in the North Central 
States, 94.31 per cent.; in the South Central States, 94.82 per cent.; in the 
Western States, 84.27 per cent. The total average annual income of 25,440 
families ejtceetled the exj^enditures by $50.26; but if payments on mortgages 
are counted, only S7 was left. At the end of the year, 12,816 families, about 
half, had a surplus of $120.84 on an average; while 4117 families showed a 
deficit of 165.58 on an average each; 8507 families seem to have come out 
even. 

I These figures show that the average family of wage-eamers is always near 
♦ Wallace: "Sanatoria for Consiimptivea," p, 389, London, 1905. 
t Eigtit^jetith AnntiaJ Report of the Commissioner of I-abor, 1903^ ou Cost of Living 
and Retail Friceu of Food. 



ixdustrial msmiANCfi in tuberculosis. — hendeiisox. 



269 



I 



I 

ft 



I 



to poverty; that a few weeks of illness or unemployment reduce the average 
wage-earner's family to the need of asking outside help; and that there is 
no margin for meeting extraordinary drafts. The statistics of public and 
private relief are very imperfect, but they go far to show what happens to a 
multitude of families whose inconae is inadequate. The heavy mortality of 
infants in* quarters occupied by working-people shows the effect of a low 
standard of living and inadequate income. The brevity of life of wage-earners 
aa compared with the length of life of well-fed persons tells the same story. 

There is no savings fund to support the cost of the contest with tubercu- 
lods. Preaching the doctrine of Malthus and Poor Richard's Almanack 
makes no impression. Many ought not to save; many cannot; and of those 
who might save, few are willing. It all amounts to the same practically: 
there is no security in depending upon savings to protect the nation's life 
against the white plague. 

Dr. N. D. Bardswell* illustrates the futility of reliance on the ordinary 
income of workingmen in times of extraordinary distress. He describes the 
situation of ten patients during their illness, and he speaks of the ^'hopeless 
financial outlook that the majority of these patients had to face when over- 
taken by illness." For the maintenance of 10 men, 5 women, and 16 chil- 
dren the income was only 35 shillings a week. The total coet of restoring 
the 10 patients to health and to a working capacity, together with the cost 
of mmntaining the families of the married men, was £259, 19 s., all of which 
was subscribed by charitable f)eraons. After the cure, the men earned 
£600 a year. 

But would it be just to use up a larp part of the sa\nng3 funds of in- 
di'V'idual workmen for the war with a disease for which the individual is in 
small measure responsible, and of which he is the \ictim? The aggravating 
causes of tuberculous disease are largely in social conditions tolerated by the 
community; would it be just to employ individual savings of men already 
stricken do^Ti and helpless in order to protect the general public? Will 
the enlightened moral sense of the nation subject individual citizens to such 
a crushing burden? 

2, Private CHARrrr. — Most of the schemes for the cure and prevention 
of tuberculosis in tliis country rest financially on public or private charity; 
it is virtually acknowledged that where the white plague rages worst, the 
savings fund is soon exhausted. 

Private charity has its place, and will long have an honorable mission. 
Its function is — (1) To make experiments; and (2) to supplement in counts 
less delicate ways the rough machinery of public relief; and (3) to care for 
those who are industrially incompetent from the start. 

But there are fatal defects bx private cliarity, aa the foundation of a 

* Baxdawell: "Tbe Consumptive Working Btlon," p. 74, London, 1906. 




M 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



comprehensive, regular, and permanent system of social control of wide- 
spread and communicable diseases. (1) Private charity has no police 
powers, and, therefore, cannot exercise that firm and rigid control over the 
personal centers of infection that public security requires; (2) private 
charity reaches mainly the very poor — those who have long fought a losing 
battle and have been subdued by the lash of fate to confess defeat and beg 
for pity; (3) it comes too late to save the afHicted person and to prevent him 
from infecting his family and neighbors while reUef ling:ers; (4) it degraded 
the recipient and his family, or tends to do so; (5) it humiliates and wastes 
the time and energies of social workei3 themselves to go up and down the 
streets begging contributions from busy men who do not realise their ovm 
exposure to the disease; (6) it is totally inadequate in amoimt, and it flows 
sluggislily in fitful streams; (7) private charity is also unequal, since it asks 
a benevolent person here and there to bear the cost ofsuppressing a common 
enemy of mankindj while most refuse to help — asks liim to do what is equally 
an obligation and an interest of every citizen. 

Many charitable persona are discovering these defects of private charity. 
Thus, in a report of the Pennsylvania Society for the Prevention of Tubercu- 
losisj we read: ** Emphasis was laid upon tuberculosis fact^ and figures of 
glaring import, the need and the neglect, the meagemess and uncertainty, 
of private charity, the growing recognition of the necessity and opportunity 
and policy of governmental action and aid; that the problem is too gre-at 
and urgent to be left alone to a hesitating philantln'opy; and that, as a 
public matter, it should be provided for and supported most largely out of 
public funds. , , , It simply wished legislators to realize the tremen- 
dous needs, and the present total inadequacy of charity to coj:)© with them." 
But even tliis report indicates no sources of supply for treatment except some 
kind of public charity — apart from general measures of sanitation. 

We may take for an illustration^ and partial evidence for our argument, 
the work of one of the most effective societies in this country — the ReUef 
Committee of the Committee on the Prevention of Tuberculosis of the New 
York Charity Organization Society. (Report far twenty months, January 
8, 1906, to October 1, 1907.) This report reveals the positive necessity for 
private charity and, at the same time, its limitations. The plan of opera- 
tion was based on the principle that the Charity Organisation Society should 
make use of all agencies at hand — ordinary relief and the tuberculosis dis- 
pensaries in the city. "This decision was based upon the conviction that 
the treatment of tuberculosis is a municipal problem, and that, however 
large the relief fund at the committee's disposal, the individuals to be directly 
bene&ted through financial assistance will necessarily be but a small portion 
of the total of those requiring such aid/' " Lack of adequate funds prevcnt-ed 
the C. O. S, from providing the special treatment necessary to enable it to 



INDUSTRIAL INSURANCE IN TUBERCULOSIS. — HENDERSON. 271 

oodperate effectively with the dispensaries in the treatment of these cases; 
the suppljdng of special diet, the making good of the wage loss resulting from 
the absence of the bread-winner in a hospital or sanatorium, the paying of 
rent in lighter and better rooms — ^were all out of the question without the 
provision of special means to enable the society to meet these needs," 

A few men contributed funds for the experiment, and from various sources 
$33,496.60 were raised. It was a beautiful, humane, and wise effort; it gave 
home treatment to 127 persons, sent 87 to day camps, gave combined home 
and camp treatment to 12, cared for 47 in sanatorium, and sent 48 to the 
ooimtry — ^in all, 321 persons. The average cost was $67.26. But how few 
persons are 321 out of the 30,000 persons infected in the great city of New 
York! The report recognizes the dangers of home treatment, and yet says: 
"Home relief and home treatment are inevitable. . . • Is it a problem 
impossible of solution? Yes, in an overwhelming and appalling majority 
of cases, if by relief is meant cure, and given only the means and methods 
now available. It is time that it be realized and acknowledged that there 
are over 30,000 tuberculous persons in the New York city tenements, the 
most of whom will never see the inside of a hospital." The demonstration 
of the inadequacy of private charity is one of the most important results of 
this valuable experiment. 

Dr. Henry Baird FaviU ("Unity," December 5, 1907) says: "In 
innumerable directions we do admirable bits of work. Almost as fre- 
quently the work falls short of its full result by reason of the fact that it 
does not * hitch on ' to its immediate successor or predecessor in the sociologic 
procession. Let me illustrate: The dispensaries for the treatment of the 
sick undertake to afford a statement as to what is the matter and advice as 
to what to do about it. In the nature of things, the advice is, for the most 
part, useless, because under the existing conditions the resources which we 
need to be drawn upon for practical application of the advice do not exist. 
Inestimable time, effort, and money are to-day wasted upon that illogical 
atuation." 

There are in all our cities many physicians who, in addition to giving 
time and talent to the relief of the poor, are compelled to beg on bended 
knee for money to do what their science demands. This is imjust. The 
community should furnish the money. 

3. Public assistance might, conceivably, be made large enough to pro- 
vide curative and preventive measures, although the figures of cost already 
cited make this seem chimerical. 

But the chief difficulty is not in raising money by taxation : it is that, so 
long as relief measures have the character of public charity, they are even 
more repulsive than private benevolence. There is an immense amount of 
evidence on this point from all countries. Public relief is the last resort of 



272 



BDCTR INTERXATIONAL CONORESS DX TUBERCULOSIS. 



the ^lespairing* Only when a man has sunk down under the crushing weight 
of toil and misery will he stretch out his hand to the public for its pauper 
iiUowance. And while he refuses help, he becomes daily weaker and 
ficatters the germs of lib disease upon the common air; he carries with him 
wherever he goes the seeds of disease, and becomes daily a plague to hj£ 
family, hla neighbors, and the entire community. 

Mr* F. L. Hoffman, Htatistician of the Prudential Insurance Company, 
who is in the best possible position to know the facts, has inforo^d every 
part of my argument in the most explicit manner.* 

As to the inadequacy of wages: "The wages received by the average 
man arc insufficient, and will remain insufficient for many years to come, 
to meet all tlie requirements which a healthy and happy social life imposes 
upon them. Since sickness is always a remote contingency, the ^urpliB 
earnings will be devoted to other purposes for the time being, rather than 
put aside for a possible occurrence, which, however, may never take place" 
(p, 274), 

" It is absolutely impossible, at the present rate of wages and at the pres- 
ent cost of living, for a worldngman to save a sum sufficient to do away with 
all the eocifil and economic mLserj^ of modern life" (p. 273)* 

But Mr. Hoffman — pronounced enemy of compulsory insurance — de- 
clares that private industrial insurance companies cannot undertake the in- 
surance of consumptives. ''The average consumptive, apparently, would 
pay in premiums $2-i to meet an expense of S65: henoe the conclusion ad- 
vanced by me at London may be restated with emphaaiSj that the treatment 
of consumptive polioy-holiJers on the part of industrial companies, in sana- 
toriunis or otherwise, is financially impossible and for several reasons in- 
expodiont" 

Ho concludes that, in the absence of compulsory insurance, "a special 
fi)i7H t*f insurance for the proper treatment of consumptives would not be 
possible . . . without the very liberal aid of charitable and philaa- 
thropical agencies," This brings us back into the same vicious circle — the 
resort to charitable rehef; it is a confession of failure, not a contributionto 
Statesmanship. 

4. Public sanitary measures may very properly be supported at common 
expense and by means of taxation, since these are impersonal and not 
favors shown by pity to individual sufferers. Thus police measures prohibit- 
ing unclean practices of exi^ectoration in public places and conveyances; 
hygienic regulations of lodging-houses, hotels, and dwellings; projjer con- 
Btniction and discipline in jails, prisons, and charitable institutions; ventila- 
tion of workships, mines, and mercantile establishments; and many other 

♦ See S<>cond New York State Conference of Charities (IBOX), p. 269, He makes 
reference to hia pruvioits aiidr?aa before tho Tuberculosig CongresB in London. 




INDUSTRIAL INSURANCE IN TUBERCULOSIS. — ^HENDERSON, 273 

measures of this class are properly supported from taxation for common 
defense and welfare. There is no hint of charity here. But such measures 
fall short of the social need. More positive and constructive work is needed. 

III. The Way of Social Insurance. 

The utter inadequacy of savings and of charity has become apparent to 
many thoughtful persons, and they are casting about for some method that 
will be prompt, sufEcient, economical, reliable, and free from degrading 
associations. Men are turning to insurance schemes, for we have learned 
by long and extended experience that at comparatively slight annua! cost 
for premiums we can provide indemnity against losses by fire, burglary, hail, 
fflckness, accident, dishonesty of employees, and death itself.* The ap- 
parently chance uncertainties of life can be reduced to reliable averages, and 
met in advance by small payments into a common fund. All sagacious and 
prudent people avail themselves of this discovery of the law of probabilities, 
and the duty of insurance has been adopted into the moral code in all ranks 
of society. 

1. I have elsewhere described all types of organization of social insurance 
found in the United States, t There is not space here to repeat the analyses 
and statistics there presented. Unquestionably, even in those crude and 
imperfect forms, the wage-earners have found refuge many times from ex- 
treme misery caused by tuberculosis and other diseases. 

But in this country, at least, all schemes of voluntaty social insurance 
break down when tested by the appalling burdens of cure and prevention of 
tuberculosb. All these associations and private insurance companies, fra- 
ternal societies, and trades unions must have rigid medical examinations and 
exclude those who are most in danger and greatest need of insurance. It is 
true that those who are actually members for some time may receive for a 
few weeks, or even months, considerable aid; but the cases are rare when the 
resources of the society can carry the confirmed invalids to the end. 

We can imagine how successful the voluntary societies might become if 
only they were thoroughly organized, placed on a sound actuarial basis, and 
if all the wage-earners were willing to become members. But the serious 
fact is that the vast majority of workingmen neglect to join these associations 
or to take out insurance in sound companies. Indeed, the cost of solicita- 
tion, collection, administration, and payments of salaries and dividends in 

♦K. Pearson, "The Chances of Death." Manes, "Versicheningswesen," p. 13. 
Dr. A. C. Klebs has discussed some aspect's of this subject. "Insurance of Industrial 
Woikingmen as an Instrument of Tuberculosis Prevention," National Association 
for the Study and Prevention of Tuberculosis, second annual meeting, 1905-06, p. 141; 
published also in Amer. Jour. Sociology. 

t "Die Arbeit erversicherung in den Vereinigten Staaten von Nord-Amerika," 
Berlin, 1907, also in articles on Industrial Insurance in the Amer. Jour. Sociology, 
1907-08. 



INDUSTRIAL INSURANCE IN TUBERCULOSIS. — HENDERSON. 275 

ness and invalid insurance laws are, for our purpose, most important, we 
may ^ve some of the results of those forms.'*' 

SICKNESS INSURANCE, 1885-1904. 

Sick benefits 1,114 629,489 

Physicians 514,803,920 

Medicines, etc 402,767,651 

Care in institutions 303,061,148 

Death benefits 83,763^39 

Women in confinement 36,543,672 

Other benefits 38,414,074 

1885-1904 2,493,973,793 

1905 250,000,000 

Total, 1885-1905 2,744,000,000 

INVALID INSURANCE (SINCE 1891) IN MARKS. 

Invalid pensions 560,486,961 

Old age pensions 336,472,378 

Medical care 55,371,747 

Return of premiums: 

(a) At marriage 38,026,117 

ft) At death 13,422,508 

(c) Cases of accident 171,201 

1891-1904 1,003,949,912 

1905 162,000,000 

1,166,000,000 



Altogether, up to the. end of 1905, about 70,000,000 persons — sick, in- 
jured, invalids, and their dependents — ^had received 5,000,000,000 Marks in 
accident, sickness, and invalid insurance benefits. The workmen had con- 
tributed less than half; the employees have received 2,000,000,000 Marks 
more than they have paid out. The property owned by insurance associa- 
tions was worth in 1905 about 1,700,000,000 Marks, of which about 500,000,- 
000 marks were invested in workmen's dwellings, hospitals, sanatoriums, 
convalescent and recreative homes, and ^milar welfare works. 

What, according to Dr. Bielefeldt, are the physical, psychical and social 
effects of the compulsory insurance system? 

" If industrial insurance did not exist, the great majority of cases of sick- 
ness, invalidism, and old age would be followed by pauperism and misery, 
or at least economic ruin. For wages usually are only suflBcient for the or- 
dinary necessities of daily life, and fail in times of extraordinary strains. 
To be sure, the workman is offered private insurance; but even if the ma- 
jority of workmen did not lack the foresight and appreciation of the value of 
such insurance, the cost of premiums would be prohibitive. 

" The benefits of the German compulsory industrial insurance prevents 
lixe necessity for the workers at times when their strength is insufficient for 

* *'Leitfaden zur Arbeiterversicherung des Deutschen Reiches," Berlin, 1906. 



276 SIXTH nnXBNATIONAL COXGBEaB ox irBEBCULOSIS. 

family support to depend upon inadequate poor relief. Poverty and self- 
denial in connection with sicknesB. espedalh' tuberculofiis, are often causes 
of further illness. . . The very feeling of aecuiity vhea the stroke of fate 
is heavy sustains courage and vitality." 

Inilustrinl insurance heals the sick workman and also provides means for 
pif NTUting the spread of the disease. The insurance funds provide medical 
tn^itniontr medicines, and hospital care. ^The better sickness insurance 
iw^viadons have long since found that bo^ital and sanatorium g^ve better 
n>etult.H than family care. In these institutions the mectical treatment is 
Uhxiv n^ilnr; the means of aid provided by science and art are always at 
ha»d; tiio patient is always under watch-care. Standing contracts with 
hvv^^t^K rllnicH, sanatoriiuns, and other institutions make it possible to 
iii^t tho varied needs quickly." 

\ V. Uiolt'foUit and others have described the various institutions which are 
At tV \Hituituuul of the insurance associations, and the German government 
wv^nW ^'^ lino oxhibit of them at the St. Louis Expodtion in 1904: the recrear 
«%\v Kv^U(Hti t'ho forest schoob for feeble children, the convalescent homes. 

W luvnlul insurance funds are most important in thb connection, for, 
haHnV Vtn^ iHMiHion fund is burdened so long as the workman is unfit for labor, 
» w ^'I^^^M'r to rcHtore him to health than to support him in idleness. The 
>«vi )s^utit!t the invalid insurance authorities to take hold of a sick man early 
%.«hv i<iMV Itini under a control that gives promise of prompt arrest of the 
,^A'v^'«h'^ rht« family being supported, the patient is more contented to wait 
<v x\Hk\ uUw(HMUH>. "Experience has shown that sick men, when they see 
.V,. vVv Ctuuiru^H arc not provided for, will leave the sanatorium before the 
^vwr\vs*\^* v*f tl»o tnnitnicnt, and some lose all they have gained." 

^V v\^*»t«* HtatistirH of insurance for 1891-1895 show that 158,462 re- 
^Vv\W ^^V'^^^v^ ivuHionn; of all male workmen under thirty years invalid, 
.*>,sv. .\k^v A^ \v»' wut, wore tuberculous; of women twenty-five to twenty- 
..:^- wwH \st 5^v» \\mv\y 50 per cent. In 1899 the statistics revealed a 
^^ix% *>'. .\kvsvM» Uouw tdnce 1895 the Invalid Instu-ance has been the chief 
»Hr»'V- ^' ■'^' V^iU-^vuliwiM movement in Germany. 

1. .V vsw* t^W UHM, 75,771 men were treated 6,572,055 days; 26033 
-AW-v^* >*.v*v vi\VAKs4 .;/MU,74S days. Over 100,000 persons annually are 
-Nv»».v vv*v*i-i*».**^> ^ud ndtHiUtttcly. The total amount spent on tubercu- 
^v^^ v..m. N^^v\ M*.\VaW Mttrks, The cost per man in 1904 was 373.91 
V -v ^<^' ^^^ ViW^^; the cost per woman in 1904 was 327.28 Marks; 

U>M^ ithM> Men. Womcn. 

, ^ , 2,454 1,143 

"^V 62,916 20,297 

V ■ ■^^'•^- *^'"^^ 6,428 3,028 

^ *- ^ 117 46 



INDUSTRIAL IN8UBANCE IN TaBfiRCULOSIS. — ^HENDERSON. 277 

To the end of 1904, the invalid insurance funds had subsidized various socie- 
ties to the amount of 178,000,000 Marks, and had paid for their own treat- 
ment directly over 33,000,000 Marks. 

It woxild be impossible, of course, to define the ezact value of any particu- 
lar factor in the system, but the statistics of the reduction of tuberculosb in 
Germany, mnce the insurance laws went into effect, are very encouraging 
and significant. From 1897-1900, in 10 German states, there died of tuber- 
culosis 7566 fewer persons than in 1892-95, in spite of increase of popidation. 
In Prussia, in 1886, the mortality was 88,283; in 1902, only 66,726. In 
cities of 100,000 and over, of 10,000 m 1886, 37.36 died; in 1902, only 22. 
Dr. Bielefeldt says that "one would not go too far if he said that this 
result is due chiefly to the curative and preventive measures of the German 
industrial insurance."* 

If it be thought that German opinion may possibly be prejudiced, then 
let us hear the highest English authority speak in the person of Dr. Bui- 
strode;! although the facts given by the German author have a force 
and value quite independent of any personal opinion or patriotic bias. 

" As regards the influence of sanatoriums, whether as curative or preven- 
tive agents, it is aflirmed by the Germans that they would never have existed 
had not the insurance institutions furnished the funds and the patients, and 
this b a claim which may well be seriously considered as regards the general 
provision of sanatoria in England and Wales. To these facts may be added 
the circumstance that no less than £6,650,000 has been expended by the 
insurance agencies in Germany in the construction of wholesome dwellings 
for the working classes. Such a S3rstem must be instrumental, among other 
things, in inducing the workingman to seek medical advice at an early date, 
and thus to materially assist in the recognition and arrest of pulmonary tu- 
berculosis, and it must also, by its educational value, conduce to the preven- 
tion of disease generally. . . . If it be true, as has been suggested by 
Lord Rosebeny, that the real difference between the rich and the poor is that 
in time of illness the rich have at command all the resources of healing, while 
the poor often die the direct victims of poverty, it is easy to appreciate how 
great may have been the influence of the German insurance system in pro- 
moting the decrease in pulmonary tuberculosis which has recently taken place 
in that country. Moreover, it is well to bear in mind that the German work- 
man has a legal right to the relief and treatment that he receives. He has 
himself contributed to the funds during the years of health which he may have 
enjoyed. This fact, seeing that it enables him to retain both his self- 

*C/. Dr. Hubert Korkisch, "Der Geschaftsbericht des Deutschen Reicha-Ver- 
BicheningssyBtemes fUr das Jahr 1905/' in Zeits. f. VoIksw.^Soz.-politik. u. Ver., Bd. xv, 
1906f p. 380. "Das Deutsche Reich in gesundheitlicher und demographischer Bezie- 
hung,'' Festschrift, Berlin, Puttkammer und MUhlbrecht, 1907, pp. 120. 122. 

t Thirty-fifth Annual Report Local Government Board, 1906-06, "On Sanatoria 
for Consumption, etc." [Ckl. 3657]. 



respect and his hope, does not produce that depression which is associated 
with Poor Law infititutions, and which is such an inhibiting factor to a 
successful outcome of sanatorium treatment." 

This testimony of Dr. Bulstrode is confirmed by the eminent English 
economist, Professor W. J* Ashley, in his book, "The Progress of the German 
Working; Classes in the Last Quarter of a Century" (1904). 

A distinguished French authority confirms these estimates of the 
supreme value of the German compulsory insurance system in the treat- 
ment and prevention of disease.* 

An American medical authority expresses the same judgment.-f 

The paper of Dr* A. C. lilebs is cited elsewhere In this essay. 

IV. Brief for a Compulsory Sickness and Invaud Insurance Law 
FOR States in the United States. 

Constitutional Basis for a Compxdmry Sickness and Invalid Insurance 
LaiL\—Jj\ the decision of the United States Supreme Court in Curt Muller vs. 
State of Oregon the principle on vvliich the decision is based la that the 
measure was necessary to the public health, Rafety, and welfare, and that 
it properly came under the police power of the State legislature. 

In determining the fact that this legislation was necessary to the public 
health, safety, and welfare, the Court gave attention to the statements of 
the brief of Mr. Brandeis, in which he cited the opinions of metlical men^ fac- 
tory inspectors, and o^ier experts to the effect that the particular law was 
necessary for the purposes mentioned. These witnesses agreed that long 
hours were dangerous to the health of women, and so dangerous to their 
families, their offsprings and to the race; that shorter hours were demanded 
as the only possible protection; that shortening of the hoiu^s was of general 
benefitj that hours could be shortened without economic disadvantage; that 
uniformity of law was essential to the efhciency of the measure^ and in justice 
to individual employers; that a ten-hour day was reasonable; and tliat the 
particular trade involved, laundries, came under the conditions named in 
the argument. 

The Supreme Court said that "when a question of fact is debated and de- 
batable, and the extent to which a special constitutional limitation goes is 
affected by the truth in respect to that fact, a widespread and long-continued 
belief concerning it is worthy of consideration. We take cognizance of all 
matters of general knowledge/* 

In case of Holden vs* Hardy (Febniaiy 28, 1898), just ten years earlier, 

the Supreme Court had said that '* the police power may be lawfully resorted 

to for the purpose of preserving the public health, safety, or morals, or the 

•Emilfl DuelAUX, "L'Hygiene Soeiale," Faria* 1902, Cf. "La Propagation de 1& 
Tuberculoee/' Paris, 1900. 

t "Handbook on Prevention of Tuberculosia," 1903^ p. 232. 




INDUSTRIAL INSUKANCE IN TUBERCULOSIS. — HENDERSON. 279 

abatement of public nuisances/' and that State legislatures have full powers 
to this end. 

We have already presented part of the evidence that proves that experts, 
practically all competent persons in the civilized world who have given 
proper attention to the subject, are agreed that the only adequate means of 
combating tuberculosis is the establishment of a system of inspection, noti- 
fication, quarantine, sanatorium treatment, family treatment, etc., which is 
enormously expensive, and which requires means far beyond the resources 
of private and public charity; that even if charitable relief were sufficient 
to supply the means, the working-people would not avail themselves of those 
agencies from dread of being public dependents and socially disgraced, and 
that such refusal leaves the great public exposed to contagion. 

The evidence comes from analysis of reports of experiments in the United 
States that demonstrate the utter failure of charity to cope with the ^gantic 
forces of disease in cities, there being in New York city alone over 30,000 
personal centers of infection in tenement houses. 

The positive evidence comes from a history of the successful working of 
the German compulsory sickness and invalid insurance laws in diminishing 
tuberculosis. 

This evidence is presented by numerous German men of science, but has 
been repeated with professional and expert approval in the report of Dr. 
Bulstrode to the British Parliament, and by others of competent authority. 

We already have a compulsory education law in all the more advanced 
States, and it is only a question of a little time when all States will protect 
themselves agfdnst the evil effects of ignorance and neglected tnuning by 
compelling parents to have their children properly taught. 

We already have compulsory laws that invade the privacy of business 
and of residence to inforce modem requirements relating to sanitation. 

We already have everywhere laws that compel all citizens to pay for the 
support or relief of the dependent poor, the insane, the decrepit, the feeble- 
minded, the aged, and the invalid. 

We must, as laymen in this field, defer to the opinion of lawyers as to 
whether compulsory industrial insurance is at present constitutional. Law- 
yers and courts must express the authoritative judgment as to what law 
actually is at this hour. 

But the scientific study of nature and society tells us when a law works 
evil, as our poor law, though necessary, does work much evil; and it tells 
us what law ought to be in order to promote the public welfare. 

We compel citizens at present to spend their money on a system that at 
once humiliates the spirit and destroys the Hves of workingmen afflicted with 
tuberculosis; and we might make it compulsory to provide a fund by a 
method that is not humiUating, and is effective to reduce contagious diseases 



280 



SIXTH INTERNATIONAL CONCRESS ON TlfBERCULOSlS. 



through insurance. We admit the latter method is not yet law, but it is 
common sense; and a& common sense always succeeds in changing laws, and 
even interi^retationa of the Constitution by the Supreme Court, the issue 
cannot be doubtfuL 

With legal advice we venture to suggest the following cases in wMch 
what we contend for seems to lie germinally implicit: The following are the 
principal cases that support the exercise of the police power for the protec- 
tion of health: 

Sanitary an^ngementa in tenement houses: Health Department vs. 
Trinity Churchj 145 New York, 32; the State may compel the owner to 
make reasonable expeaiditures, 

Compultsory vaccination; Jacobson va. Massachusetts, 197 U. S.; tho 
Stat« may require the vaccination of adults. 

Regulation of marriage: Gould vs. Gould, 78 Conn., 242; the State may 
prohibit the marriage of epileptics. 

Requiring physicians to report disease: Robinson vs. Hamilton, 60 
Iowa, 134; State va. Woodin, 56 Conn., 216. 

Labor of women (ten-hour day); Muller vs. Oregon, 208 U. S., 412. 

Underground labor of adult men (eight-hour day) : Holden va. Hardy, 
169 U* S., 366. 

Principle of compulsory insurance (only with regard to loss of sheep* 
Idlled by doga through a tax on the keeping of dogs) ; Van Horn vs. People, 
46 Mich., 183; Hoist vs. Roe^ Oh. St, 340. 

Legal authority can he cited for the belief that the measures here proposed 
come under the police power of the State and would be constitutional. A 
leading tejtt declares: 

** In a large sense the community is certainly interested in averting sud- 
den and unexpected losses, as well as the destitution following from sickness 
and disease^ and the distribution of these losses over large numbers through 
insurance is a legitimate end of governmental policy. There is no warrant 
for the denying the State the power to adopt compulsory measures for the 
purpose, , . , It may, however, be safely asserted that compulsory 
insurance requires that either the State itself becomes the insurer, or that it 
exen*ises an efficient control over private or semipublic associations which 
the individual is compelled to join; for this alone eUminat^s from the prob- 
lem the difficulty that the State would force the individual to enter into con- 
tract relations with other private parties without substantially guaranteeing 
performance to the individual who b required to part with his money,"t 

Professor Monroe Smith, of Columbia University, a distiiiguished legal 

authority, says; "That any nine Americans, upon whom should be thrown 

* It ivoutU be straage, indeed, if it ware coaatitution&l to ineure Bheep^ but not to 
iBBure men. 

t E. I'reund, Police Power, pp. 463-164. 



INBIT8TRIAL INSUBANCE IN TUBERCULOSIS. — HENDilRSON. 281 

the duty of detennining in any degree the policy of the nation, should desiie 
or should be able to set themselves permanently against the general senti- 
ment of the nation is unthinkable. The Supreme Court of the United States 
has never shown any such desire. . . Statutes which embody new poUcies 
and which are in conflict with the spirit of the Constitution as previously 
interpreted, are, on first impression, pronounced unconstitutional; but 
when it becomes evident that the new policies do not represent a passing 
whim or fancy, but a settled popular conviction, a way is found to give effect 
to the popular will." The most direct and certain way to secure a favorable 
opinion from the Supreme Court on a measure that vitally concerns the wel- 
fare of the people is to convince the people that they should persistently 
demand it. 



Aseguros Industriales en Relaci6n con la Lucha contra la Tuberculosis. — 

(Henderson.) 

Este artfculo tiene por objeto establecer, la necesidad de un costoso, 
fflstema de prevencion: la instrucci6n de una poblacion de 80,000,000 de 
habitantes, examen de las personas expuestas d la infecci6n, medidas sani- 
tarias, provisi6n de residencias saludables, un sistema de educaci6n fisica, 
provisi6n de lugares de recreo, de trabaj adores adiestrados 6 investigaciones 
originales sobre el aspecto cientifico del problema. El desembolso para llevar 
i cabo todo esto, si bien adecuado, tendr4 que ser imensamente mayor 
i los gastos del presente. Las p6rdidas de la ciudad de New York, consecuen- 
tes d la tuberculosis, son de $23,000,000 anualmente y en los Estados Unidos 
son de $320,000,000 ; y sinembargo, la ciudad de New York gasta solamente 
de medio million en el tratamiento y prevencion de la tuberculosis. Las p6r- 
didas en el Estado de Illinois, se dicen ser $36,000,000 al afio, y sinembargo 
los gastos son relativamente pequenos. 

Los metodos presentes para llevar d cabo estos gastos, en los Estados 
Unidos, son enteramente inadecuados. Nosotros hemos confiado sobre las 
economias de los trabajadores, mas el gobiemo federal ha demonstrado, que 
los salarios del pueblo no dan suficientes fondos para hacer frente d los gastos 
extraordinarios que demanda la campana contra la tuberculosis; y dado el caso 
de que de los salarios pudieran sacarse los gastos seria injusto 6 inhumano. El 
peligro es nacional, el peso de la carga corresponde d la nacion. Volviendo la 
vista hacia las caridades privadas, uno descubre: que 6stis son inadecuadas 
para llevar i cabo tan enormes gastos, segundo, si 6stas fueran capaces de suplir 
suficientes fondos, los trabajadores son demasiado orguUosos para aceptar 
esta ayuda. En vista de esto no queda sino um metodo para proveer tales 
gastos y este es el aseguro social. En los Estados Unidos, el metodo de ase- 
guros industnales, carece de bases fundamentales. Algunas de las formas mas 




282 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS* 



i 



popularea no proveen aseguros en caso de enfemiedad, I^s eociedadea de 
beneficiencia mutua, son incapacea de cuidar por loa invalidos sine por pocaa 
semanas. En vista todoa estos sistemas iiiadecuadoa, no quena sitio algiina 
forma de aseguro obligatorio en caso de enfermedad ^ invalidee. Los metodos 
en Alemamii son completes y adecuados^ el trabjador tiene un aseguro en 
caso de enfermedad 6 invalidez, mientras ^1 esta sano contribuye A los fondos 
de la agociaci6n y cuando enfermo gosa del beneficio, no por caridad sino por 
derecho legal que le corresponde : por lo tanto tan luego como las priineraa 
indicflcioties de tuberculosis aparecen, ea puesto bajo la atencidn de un medico 
y tiene las mejores probabiHdades de recuperar cuanto antes la aalud y mien- 
tras tanto no es un centro de infeccidn para los otros. Durante el curso de la 
eufermedadj bu familia es proveida de lo necesario^evitando aa Wgravamenes 
de la enfermedad que ocacionan las penas morales y la ansiedad. No sola- 
mente AJemania> sino que tambien Francia, Inglaterra y las autoridades de 
America, pueden citarse como favorecedores de eate principio como el iinico 
m^todo efeetivo para proveer fondos suficientes en la lucha contra la tuber- 
culosis. En Aleniania, con mas rapidez que en ninguna olra nacion, la 
tuberculosis ha disminuido. Si el aseguros industrial es necesario para d 
bienestar y salud publica, entonces este debe constiiuir una parte de la le^s- 
lacion y de la naci6n. Laa mas alias autoridades legales declaran que la 
Corte Suprema nunca estarS. en contra del scntimiento general de la nacion 
para asegurar el unico metodo adecuado, comprensivo y prospero eu la lucba 
contra la tuberculosis, Se necesita solaniente ponvencer al pueblo, y t^u 
petici6n sera oida en cada vestibulo de la legislatura lo mismo que ante ea 
cuerpo judicial de la naci6n. 



Assurance industrielle dans sod rapport avec la lutte coatre la 
tuberculose. — (Henderson,) 
Cette 6tude cherche k d^montror la n^cessitd d'un systems de preven- 
tion, cher, n eat vrai, maas pourtant n^cessaire; instniire une population de 
80,000,000, examiner les personnes sujettes h la contagion, prendre des mes- 
ures de police sanitaires^ voir que les habitations soicnt salubres, arranger 
un syat^me d'4ducation physique, des pares de r6cr6ation3 pour les enfanta; 
obtenir les services de travailleurs habiles et faire des investigations ori^- 
naleu des c6t^ scientifiques du probl^me. Pour suffire les d^penses pour 
ces diff^rents buta devraient fitre beaucoup plus grandes qu'elles ne sent k 
present. La perte r^ultant de la tubereulose dans la ville de New York est 
dfi 123,000,000 par an, et aux Etats-Uois de plus de $320,000,000; et pour- 
tant New York ne d^pense qu'un demi million de dollars environ pour 
trailer et pr^venir la tubereulose. On dit que la perte dans I'lllinois est de 
S36,55],000 par ao^ et cependant la somme d^pens^ est une bagatelle en 
comparaisoa. 



INDUSTRIAL INSURANCE IN TUBERCULOSIS. — HENDERSON. 283 

Toutes les m^thodes actuelles pour empdcber cette perte aux Etats- 
Unis sont enti^rement insuffisantes. Nous avons compt^ sur les Econo- 
mies des ouvriers, mais le gouvemement f^^ral a montrE par un examen de 
25,440 families dans 33 Etats que rouvrier n'a pas assez de fonds k sa dis- 
position pour subvenir aux frtds caus^ par la lutte contre la tuberculose; 
et m^me si les ouvriers Etaient en Etat de payer ces frais, il serait injuste et 
inhumain de Texiger d'eux. La danger est national, le fardeau devrait 
aussi 6tre national. Si nous faisons appel k la charity priv^, nous d6eouv- 
rons qu'elle est entiSrement insuffisante pour payer cette d^pense 6norme, 
et que, m^me si elle pouvait foumir des fonds suffisants, les ouvriers sont 
trop fiers pour accepter cette aide. II ne reste qu'ime m^thode pour sub- 
venir k cette d^pense 6norme et c'est la m^tbode d'assurance sociale. Maia 
les m^tbodes d'assurance industrielle aux Etats-Unis ne sont pas sur une 
fondation convenable. Quelques-unes des formes d'assurance les plus popu- 
lures ne possftdent pas d'assurence contre la maladie. Les soci^t^s mutuelles 
de b^n^fices ne peuvent supporter leurs invalides plus de quelques semaines. 
II ne reste done plus qu'une forme quelconque d'assurance obligatoire contre 
la maladie et I'incapacitE de travail. Si nous consid^rons les m^tbodes alle- 
mandes, nous trouvons qu'elles sont completes et sufBsantes. En Allemagne 
cbaque ouvrier a une assurance contre la maladie et TinvaliditE; 11 contribue 
k cette assurance quand il est en bonne sant6 et il a un droit lEgal, sans cbaritE, 
k ces fonds quand il est malade. Pendant qu'il ne peut travailler, sa famille 
est pourvue d'argent et sa maladie n*est pas aggrav^e par son anxi6t6 pour 
sa famille. On dit que les meitleures autorit^ non seulement allemandes, 
mus aussi fran^aises, anglaises et am^ricaines sont en faveur de cette m^tbode 
comme 4tant la seule m^tbode effective pour procurer des fonds dans la 
lutte contre "la peste blancbe." On a r^uit la tuberculose en Allemagne 
plus rapidement que dans tout autre pays. La cour a plus d'une fois afiirm6 
que tout ce qui est n^cessaire pour la sant6 publique, la surety et le bien- 
etre est une mati^re qui est du ressort de la legislation nationale ou de la 
legislation de TEtat. Si Tassurance industrielle est n^cessaire k la sant6 et 
au bien-^tre publics, alors on peut faire de cette assurance une loi nationale 
ou une loi d'Etat. Les plus bautes autorit^s legates d^clarent que la Cour 
Supreme ne s'opposera jamais au sentiment g6n6ral de la nation pour in- 
troduire les seules m^tbodes suffisantes, g^nerales et sures pour combattre 
la tuberculose. Nous n' avons qn*k convaincre le peuple. 



HISTOIRE D'UN DISPENSAIRE DE FAUBOURG. 
Par Mlle. L. Chaptal, 

Fuifl. 



Farmi tous les faubourgs cle Parb, il en est un plus tristement c^lfebre dans 
les annales de la tuberculose, c'est celui de Plaisance. DEs longterai^s il 
^tait d^nonc^ dans les ouvrages sp^ciaux (notamrnent "Hygiene Social e *' du 
Professeur Duclaux) et dans toutes les statistiques officielles de mortality, 
comme l^ plus contamin^ par la tuberculose. Cette mortality significative 
qui atteignait parfois 104 pour 10,000 habitants, — alors que d'autres quartiera 
de Pans, mieux favorisds, ne d^passaient pas 17 pour 10,000 habitants — fut 
la raison dterniitiante do la fondation de Toeuvre anti-tuberculeuse que nous 
avons A d^crire devant oe Congr^- 

"Mieux vaut pr^venir que gu<5rir" (prevention is better than cure). 
Jamais cet a?dom ne fut plua applicable qu'en mati^re de tuberculose* On 
peut classer cette maladie parmi celles que Touvrier contracte le plus aisfiment 
et dont i! gu4rit avec le plus de difficult^* C*est done principalement vers 
la prevention que voulait lutter, dfe I'origine, I'oeuvre des tuberculeux 
adultes. 

Au moiB de Novembre 1900, un dispensaire gratuit pour lea indigents 
fut ouvert dans ce coin desh4rit^ de Paris, 63 rue Vercing^torix, dans un 
modeste local ayant servi jusque^l^ de boutique k un marchand de vina 
(saloon). Le mot terrible de tuberculose n'dtait pas, k cc moment, prononc^, 
afiji de ne paa heurter de frant le prejug6 popuhiire, tr^s fort parmi la claaae 
ouvridre d'alors. En effet, la tuberculose 6tait universellement c.onsid<Sr§e 
dana le peuple comme un mal h^r^ditaire et incurable. De \h. une grande 
difficult^ pour atteindre les cas et les surveiller au d^but. On inscrivit done 
sur la boutique t^tte enseigne plus encourageante: "Dispensaire pour les 
maladies des voies respiratoires" (Dispensary for diseases of the chest). 
On ne se defend pas de ce qu^on croit fatal, il s'agissait done de parvenir 
graduellement h instnure le peuple de ces v<*ritfe scientifiques: contagion 
et curabaiit^. 

Ive nouveau dispensaire fut ouvert troi foia par semaine, de 5 heures h 
7 heures du soir, heures accessibles k rouvrier, ausai biea qu'^ sa femme et 
k ses enfanta En efifet^ il importe que lea malades trouvent un m^ecln A 

284 



HISTOraB d'uN DISPENSAIRE DB faubourg. — CHAPTAU 285 

kur disposition apr^ leur journ6e de travail, afin que la tentation ne leur 
vienne pas de remettre de jour en jour k plus tard la consultation que peut 
les soigner k temps. Cast tout au d^but du mal, c'est-^-dire quand il n'a 
pas encore renonc6 k travailler, que Thomme doit ^tre instruit des precau- 
tions qu'il aura k prendre pour ne pas tomber. J'en citerai pour exemple 
cet employ^ de chemin de fer qui nous arrivait au dispensaire, en 1901, 
tou de perdre ses forces au point qu'il ne pouvait plus, nous dit-il, " courir 
plus d'une lieue (quatre kilometres) sans transpirer." A Tauscultation, on 
dfe)uvrit des riles au eommet du poumon, et, grdce aux soins donnas et k 
hygiene observe, cet homme, qui est le p6re de quatre enfants, n'a jamais 
cess^ son travail. II revient avec perseverance, depuis plus de six ans au 
dispensaire oii toute sa famille recoit egalement nos instructions. 

Ce dispensaire de Flaisance dont je pris la direction administrative, en 
m^me temps que la responsabilit6 morale et sociale, 6tait dirige m^dicalement 
par le Docteur Saunal, remplace depuis par deux autres medecins devours 
aussi k la cause anti-tuberculeuse. Seule, k I'origine, pour les seconder 
pendant les consultations, je me fis aider au bout de peu de temps par une 
ou deux auxiliaires benevoies, amies de pauvres. L'une de nous prenait les 
inscriptions des nouveaux malades, pr^parait les fiches m^dicales (obser- 
vations detainees) causait avec les nombreux clients qui remplissait rapide- 
ment la salle d'attente. Une autre faisait, sur Tindication du docteur, les 
injections hypodermiques conseiliees, et distribuait les bons (cards) de 
viande ou de lait devolus aux plus malheureux. Certes, la t&che n'etait pas 
petite, si on consid^re que les entrees atteignirent bientdt soixante par 
seance, d^s I'annee 1901. Peu k peu les malades s'amenaient les uns les 
autres, trop souvent parvenus k un degre de tuberculose impossible k guerir. 
C'est alors que les instructions d'hygifine avaient leur plus grande utilite, 
ainsi que les conseils pratiques accompagnes de Taide materielle necessaire. 

Les premiers succds remportes sur la maladie nous permirent au bout 
de quelques mois de prononcer ouvertement le mot tant redoute de tubercu- 
lose. "Je sais bien que je sub poitrinaire" (consumptive) nous disait au 
debut une malade, " mais si on me disait que je suis tuberculeuse j'en mour- 
nus de chagrin." Ces notions erronees disparaissaient peu k peu, devant nos 
efforts, et lorsque, en 1902, le dispensaire changea de local pour s'agrandir 
et s'installer dans une rue voisine, 25 rue Guilleminot, oCl il est encore, et 
que je fis inscrire au fronton de la maison son veritable titre: "Oeuvre des 
Tuberculeux Adultes," cette declaration de guerre ne provoqua aucun 
etonnement parmi nos gens. Le M&xi etait demasque, la lutte allait devenir 
plus active encore. 

C'est en cette m^me annee 1902 que M. le Docteur Calmette, dont le nom 
est ceiebre en tuberculose, inaugurait k Lille son dispensaire de prophylaxie 
anti-tuberculeuse, appeie depuis par lui du nom, si explicite, de " preventor- 



SIXTH iNTEHNATIONAli CONGRESS ON TUBERCULOSIS, 



ium." I] y avait install^ d'embfe une buanderie k vapeur pour le diao- 
fectloQ et la blanchUsage du linge contamm^. Je me rendis k Lille et. grdce 
k aes cooseils, avec Taidc efficace de M. le Docteur Roux et de M. Martm^ 
architect© de rH6pItal Pasteur, je pus organiser en 1903 une annexe aoar 
logue, rue Guilleminot 23. Les fends nScessaires me fureiit accorddeapar 
le gouveniement, sur les recettes du Pari-mutuel, en raeme tenipa que 
ToeuvrG des tuberculeux adultea recevait du Gonseil d'Etat la reconnaissance 
ofRcielle d'" Etablissement d'utiiit^ publique." L'oeuvre n*avait- 6i^ 
Boutenue jusque-!^ que par des dons et contributions priv^, le plus souvent 
anonymes» 

Le service de blanchisserie 6tait — et est encore — organist de la fa^D 
auivaiite: Lorequ'un malade indigent^ iiiscrit au dispensaire, est reconnu 
contagieujc (soit par I'analyse de sea crachata, soit par tout autre Indice), 
U lui eat remis un sac num^rot^ de toile impermeable, h fermeture herm^ 
tique, dans lequel doit Otre plac<^ au fur et k niesure de I'usage, le Hnge qui 
lui a servi et qui a ^t^ prdalableuient tiinbr^ au m^me numfiro d'ordre que le 
sac. Cbaque semaine, le sac rempli est porte k la buanderie, oil, upr^s one 
premi&re desinfectiori, faite k froid par les antiaeptiques, et saos manipulation 
d'aucune sort«, le linge est soumit k une lessive 6nergique h I'eau bouUIante 
,inuaie de natronite, aveo barbot^ge in^raiiique. Deiia femmea sont pr6^ 
■poshes h ce lavage et, la machine k barboter munie de deux ouverturea ^tanl 
plac^e en travers de la Balle ou se fait de ce travail, I'une de ces femmes a 
pour tache d'y introduire le linge sale, dans TouveHure plac6e du c6t^ 
eeptique^ tandis que Tautre, rest<kj du c6t§ aseptique, le retire propre par la 
deuxieme ouverture et le place dans reasoreiise m^eamque, puis dans la 
cshambre chaude oii il s^che en respaca d'une heure. La chaufferie est 
'desservie par un m^canicien pay^ k Tann^- Le cout annuel de cetto organ- 
isation annexe, qui pent d^sinfecter et blanchir 300 Kilograniraes de Unge 
par joum6e> est de environ 6(X)0 francs par an. On y pent r&iliaer quelques 
recettes, qui att^nuent les frais g^n^raux, en blanchissant moyennant 
paiement le linge de la "Maison — Ecole dlnfirmi^rea privfies/' dont il eera 
paHd plus bas. 

Ce service annexe a certainement contiibud ainsi que lea disinfections 
op^rtSs chez les tuberculeux par nos soins, soit qu'ils meurent, soit qu'ils 
changent de logis, et de la distribution gratuite de crachoirs de poche faite 
aux indigents inscrits, k diminucr les chances de contagion et k restreindre 
par 1^ le nombre des cas de tuberculose k Plaisance. Mais je dois parler 
ici de Taction personnelle k domicile, dans la famiJle ouvri^re, par les visites 
r^it4r6es chez les clients du dispensairo. C^est 1^ on n'en dout^ra pas, Tun 
dee facteurs lea plus actifs de la lutte antituberculeuse, parce que c'est un 
des moyens les plus pratiques dlnstruetion hygierdque et de prophylaxie. 

D&3 longtemps I'ouverture du dis|>ensairc— eo fait k partir de Taruido 



mSTOIRB D'UN DISPENSAraE DE FAUBOURG. — CHAPTAL. 287 

1894 — ^je m'6tai8 rendu compte, dans des visites fr^uentes faites aux 
pauvres gens du XIV' arrondissement, que la plupart des maux dont ils 
souffraient 6taient dtia au d6faut d'hygi^ne, hygiene personnelle, hygiene 
de logement et des conditions de vie. Contre ce mal comment lutter? 
De deux mani^res, Tune, Tinstruction personnelle par la conversation, 
Fautre, I'am^lioration mat^rielle de conditions du logement. 

La visite k domicile, pour 6tre effiace, doit Hre faite par quelqu'un ayant, 
d'une part des notions suffisantes d'hygi^ne pratique, d'autre part, et cela 
est essentiel, poss^dant assez d^autorit^ morale et de s3riDpathie directe 
pour §tre 6cout^ par le pauvre. Get ascendant, il m'^tait ais6 personnelle- 
ment de I'exercer, gr&ce aux rapports de constante cordiality que ma fr^ 
quentation du quartier avait ^tablis entre un grand nombre de families 
ouvri^res et moi. Quand une fois on a appris k connaitre et k aimer le peuple, 
on sait lui parler — et on en obtient line docilit6 d 'enfant — sans pour cela 
lui rien retirer de sa personnalit^ et de sa spontaneity, pour peu qu'on ait 
le respect de ce qui fait la dignity humaine. 

G'est en faisant ces visites k domicile que m'^tait venue la premiere id6e 
de fonder une oeuvre de prophylaxie, sous forme d'un dispensaire. Cast 
encore par de visites r^it^r^es que put s'^tendre et se consolider Toeuvre 
entreprise. Peu k peu furent attir6 k ce quartier d'autre visiteurs on visiteu- 
ses, et un service d'enqulte r^guli^re sur chaque famille dont un membre 
est inscrit au Dispensaire n'a cess6 de fonctionner depuit Torigine. II 
s'est 6tendu cette anne6 par une investigation plus d^taill^ des conditions 
hygi^nique du logement, dans le but d'6clairer sur ce point le bureau central 
de statistique de la Ville de Paris, au point de vue special du easier sanitaire 
des maisons. Et ce m§me service se compldtera encore incessamment d'une 
annexe nouvelle qu'i Texemple d'Edinburgh, et surtout des Etats-Unis, nous 
organisons actuellement k Plaisanee. C'est ici qu'il convient de parler de 
la fondation de la Maison — Ecole d'lnfirmi^re priv^s. 

En effet, depuis Tann^e 1905, le service du Dispensaire a 6t6 enti^rement 
fait, sous ma direction, par les el^ves-Infirmi^res de cette Maison-Ecole. 
Les inscriptions et les fiches medicates, la verification de feuille d'enqu^te, 
les divers soins aux malades-pes^es, temperature prise, injections, r^vulsifs, 
etc., la distribution des erachoirs, des bons de nourriture, des brochures de 
propagande anti-tuberculeuse et antialcoolique, bref, tout ce qui n'est pas 
la fonction propre du m^dicin — a 6t6 accompli par ces Infirmidres qu'une 
instruction toute sp^ciale y prepare Tune aprfes Tautre. Et c*est encore 
parmi ces Infirmiferes de la Maison-Ecole que se recruteront les visiteuses 
(district-nurses) qui porteront k domicile le secours de leurs soins et de leurs 
Gonseils. 

Quant a I'ameiioration materielle des conditions de Thabitation, dans un 
but d'hygi^ne, c'est ime question qui n'a cesse de me pr6occuper depuis 



SIXTH INTERNATIONAL CONGR&BS ON TUBEHCDIX>SI9, 



plumetirs ann^. Car, enfin, qu'est-ce que lea cooaeila r^pandus, qu*est>-ce 
que le secours h plus gdndreiix, qu'est-ce m^me que le placement temporaire 
k la campagne (que nous pratiquona aussi fr^uemment qull est possible) 
si la demeure de Touvrier est malsaine en elle^mSme? Et quelle t4che 
d^courageante si, en sacbant de pr^vemr I'effet, on ne travaille poa en m6nie 
temps k Buppriiner la cause^ 

Or, la cause, c'est Pinsalubrit^ du logement par le manque Vmr, de lumi^re, 
d'e-au^ — les trois 41^ments essentieb de la vie humaine — comment, malgr£ 
touts les pi-^cautions, C'vjter que des ^tres huraains s'^tiolent et ae contami- 
nent, sHls respirent dans des tatidis oii Tair ne se renouvelle pas, oil le solell ne 
p^n&tre jamais ou rarement, et oi\ Teau est uue denr^ trop rare pour n*^tre 

pas tn^nag^e Oui, la question de la tuberculose est trop 

souvent une question de logement, et comment la r^udre si Ton attend 
pour commencer que des terrains soient libres dans les villes, alora que, de 
plus en plus, et fatalement, se resserrent les maisons dans lea faubourgs, 
B'agglora^m la population, et qu'alnai diminuent en apparence les chances 
d'offrir un espace auffisant k r^panouissement de la vie populaire, 

C'est, en consequence, dans !e but de tenter un essai d*am4Iiora:tion des 
immeubles existants que je pria en location en 1902, pour en faire ['experience, 
une maison loufe jusqu'alors h destination d*h6tel meubld et ausii insalubre 
que raal habits. Cong^ fut donn^ aux locataires de passage et, des chambres 
lou^e pr<5c4demraent s^par^e, je fis composer deg logements de tioU pieces, 
puis, avec le concours du m^me architecte d^vou^ qui construisit la buandarie 
antituberculeuse, M, Martin, nous proc^damea k un assainissement gdn^ral 
de rimmeuble. La peinture a I'huile remplaga sur les murs le papier, les 
plafonds furent peints ^galement^ le sol rdpar6, Teau amenee aux ^tage par 
des conduits, les W, C. hygi6niques h chasse d*cau automatique et le systSme 
du " tout k I'egout" instalMa, bref toutes les modifications possibles k apporter 
dans un vieil immeuble furent cffoctu^es \k. Ce n'6tait pas un assai financier, 
mais un essai hygi^nique, jeme hate de la dire. 

PuiSf les logements furent unis en location et attribu^s i des families 
charges d'enfanta et dont plusieurs pr^sentaient des debuts de tuberculose, 
car ce sont 1^ celles qui trouvent le plus difficilement une habitation conven- 
able. Au point de vue de Thygi^ne, eette tentative r^ussit pleinement* 
A rheure ou j'^cris, la maison est habit^^e par sept families comprenant 
ensemble 28 enfanta,— Trola de ces families composent de veuves dont les 
maris sont morts de tuberculose, avant leur venue dans la maison, deux 
parmi les quatre autres ont eu leup chef atteint de tuberculose et gu^ri par 
les soins de notre dispensaire. Pas un seul cas de contagion quelconque 
ne s'est pmduit sous ce toil, malgr^ Tagglom^ration d'enfants qu'il poss^de, 

Devant ccs r^sultats d'exp6rienee, on pourrait consid^rer Tessai comme 
probant. C'est alors que, ayant acquis un des rares terrains rest^ Ubree 



RIBTOIRE D*UN DISPENSAIRB DB ^ATTBOirRG. — CHaPTAU 



289 



dans le quartier, je contstittm, avec le concouis de quelques amis, la " Soci^t4 
aDon3ane des Logements de Plaisanoe/' destin6e k constniire des habitations 
ouvriferes hygi^niques et k am^liorer des immeubles dans le m^me but. 
Cette soci^t^ est actuellement au capital de 200,000 francs* et donne cette 
annte un dividende de 3% k ses actionnaires. Elle a d^but^ en 1901 par 
la construction d'une maison sanitaire type, oil tout est lavable, de la cave 
au grenier, avec, dans la cuisine de chaque logement, un 6couIement direct 
des eaux de lavage ^ ras du sol. Divers avantages sont offerts aux locataires 
tela que lavoir et s^choir gratuits k la disposition des m^res de famille. 
Deux autres immeubles acquis par la Soci^tS ont ^t^ am^iior^s et am^nag^ 
k I'exemple du premier essai d^crit plus haut. 

En dehors de ces demi^res organisations, le quartier de Plaisance poss^e 
depuis 1901 une oeuvre assez importante d'assistance matemelle et infantile, 
destin^ aux enfants au-dessous de trois ans, et qu'il serait trop long de 
d^iire ici, plusieurs caisses d'^pargne pour loyers, pour les dots des jeunes 
gens, une Soci^itd Cooperative de Consommation destin6e k lutter contre 
I'alcoolisme, d'autres organisations populaires, oeuvres de conference, etc. 
fondles ^galement sur notre initiative. Tout cet ensemble constitue un 
armement un peu complexe, mais dirig^ dans une vue unique, et sans doute 
n'a pas peu contribu^ a modifier la mortality tuberculeuse et la mortality 
infantile dans la mesure oiX les chiffres suivants le r^v&lent. 



TABLEAU DE STATISTIQUE DE 1900 A 1907. (MORTALIXfe TUBERCULEUSE 

DANS LE XIV*-ARRONDISSEMENT) t (TAUX CAL- 

CULfe PAR 10,000 HABITANTS). 



AmtiiMB. 



1900 
1901 
1902 
1903 
1904 
1905 
1906 
1907 



Dans la XIVb-Abbon- 
disbkment. 



885d€cds 

787 " 

683 " 

712 " 

648 " 

711 " 

741 " 

620 " 



= 64,9% 

- 56,3% 
" 48,3% 
= 48,6% 
= 43,1% 

- 47,0% 

- 48,4% 

- 40,1% 



Danb lb QiTABTna db 
Plauiamcb. 



579 d€c^ - 90,9% 

475 '* - 72,6% 

373 " - 55,6% 

384 " - 55,9% 

348 " - 49,8% 

396 " - 56,4% 

402 " - 56,9% 

362 '* » 50,2% 



Dans lbs 3 Aurass 

QCABTIKaS. 



306d£cds 

312 

310 

328 

300 

315 

339 

258 



» 42,1% 

- 41.9% 

- 40,6% 

- 42,0% 

- 37,5% 

- 39,3% 
= 42,3% 
" 32,2% 



On le voit, tandis que le quartier de Plaisance, si fortement contamin^ 
avant 1900, voyait sa mortality baisser graduellement, malgr6 de courtes 
recrudescences, k une moyenne inferieure de 40 points (50,2 au lieu de 90,9, 
soit 40% environ) les trois autres quartiers, moins atteints ^videment, ne 
baissaient que dans la proportion obtenue par les autres quartiers de Pans 

♦ Par actions de 500 frances. 

t Le XIV^-arroDdifisement de Paris, ouest de la ville, se compose de quatre quartiers, 
dont Pun est Plaisance. 
VOL. Ill— 10 



290 SIXTH INTERNATIONAL CONGRESS ON TDBERCUL08IS. 

dans les dix demi^res anuses, soit 10% environ, on est done en droit de le 
dire, la lutte antituberculeuse possMe, dans le Dlspensaire et ses oeuvres 
annexes, un moyen puissant d'action et, si ee genre special de travail, plus 
social encore que purement medical, demande une somme d'efforts con- 
^d^rable, il n'exige que des d^penses minimes, en proportion des r6sultats 
notoires qu'il obtient. 

En effet, Toeuvre des tuberculeux adultes, qui ne s'en est pas tenue au seul 
quartier de Plaisance, mais qui posskle actuellement et fait fonctionner 
dans Paris deux autres dispensaires de faubourg, ne dispose que d'un budget 
annuel de 23,000 francs, lequel suffit k defrayer Tentretien de ses trois 
Dispensaires et de sa buanderie m^anique 4 disinfection. Et cependant 
elle donne plumeurs milliers de consultations par an, elle distribue 15,000 
bons d'alimentation, elle rayonne sur plus de 2000 families chaque annfe- 
gr^ce surtout, je dois le dire en terminant, k la collaboration g^n6reuse de 
tons les savantes; m^decins, sociologues, philantropes et to)nomistes, 
lesquels n'ont cess6 d'aider les humbles efforts d'une initiative, qui n'avait 
pour moyens d'action que sa simple bonne volenti. Et ma conclusion sera 
celle par laquelle le Professeur Landouzy terminait r^mment son discours 
k Tune de nos assemblies g^n^rales: "Si le coeur doit 6tre le moteur des 
institutions de pr^voyance, c'est la science qiu doit en tenir le gouvemail." 



LA LUTTE ANTITUBERCULEUSE SUR UN NOUVEAU 

PLAN A ANVERS PAR L'OEUVRE DES DISPEN- 

SAIRES ANTITUBERCULEUX ANVERSOIS. 

Par Dr. L. Van Boqaert, 

Antwerp. 



L'oeuvre des dispensaires antituberculeux anversois Mt fondle en 
Avril 1902. Son dispensaire central situ6 k Anvers, rue de TEmpereur 6, idt 
ouvert en 1903, et son type ou organisation un peu sp^ciale merite d'etre 
connu par les lutteurs antituberculeux. 

n a son service m^cal et bact^riologique, son enqu^te domiciliaire 
et mMicale, ses repas au dispensaire m^me, son traitement m^dicamentaux, 
symptomatique ou sp^ifique, son vestiaire, la disinfection p^riodique 
des vdtements et habitats, son comit€ de surveillance ou de changement 
n^cessaire d'habitations des malades atteints ou predisposes, sa colonic 
marine et campinoise ou oeuvre de "Grancher." L'oeuvre elle m^me est 
dirig^e par un comity g^n^ral superieur, compos6 d'un bureau, de 20 con- 
seillers et de 150 membres fondateurs, appartenant tous aux personaiit^s 
les plus en evidence de Taristocratie, du commerce et de la finance de notre 
grande cite. Hemarquez ici I'abstention complete de mise en sc^ne m^di- 
cale aux yeux du grand public. II est certain que dans beaucoup de ces 
oeuvres similaires la mise en avant de certaines personalites m^dicales a 
fini par choquer beaucoup de personnes. Aussi avons nous dans notre 
oeuvre voulu k tout prix eviter ce reproche. Jamais le nom d'un m^dicin 
qu'il appartienne au comite technique, au comite Grancher, au corps medical 
de service au dispensaire, n'arrive aux oreilles du grand public, Le comitc 
central superieur seul est r^presentatif, figure aux joumaux, rapports et 
autres publications du domaine general. Le comit6 central ne peut avoir, 
d'aprfes les statutes m^mes de l'oeuvre, dans son sein aucun m^decin, ni 
pharmacien. Or ce comite seul figure officiellement. C'est lui qui donne les 
ceremonies publiques et y preside. C'est lui seul qui visite la presse, se met 
en rapport avec les gouvemements et les pouvoirs publics, en un mot, c'est 
lui seul qu'on connait, c'est lui seul qui represente l'oeuvre en public. C'est 
lui ansa done qui se charge avec les comites annexes des dame, des fetes 
et de recolter les fonds necessaires k l'oeuvre. C'est done lui aussi, k juste 
titre, qui est aux honneurs. C'est enfin lui aussi qui donne mandat au 

291 



292 



SIXTH INTERNATIONAL CONGREBS ON T0BERCUU)SIS. 



comitd technique pour la rnarche vdrit^ible de son dispensalre avec ses servioee 
siibalternes: m^5dical, adminbtratif, di^tfitique, th6rapeutique, de d^nfectioa 
dc vestiaire et de visite k domicile. Comme voua le voyez, si les piemiere 
ctiniit^s forment k eux seuls I'^tat^major brilliant, officiel, remarqu^ de 
notre oeuvre, le comiti? technique avec ses accoljits obligfe, forme \e 
comitd de travail, lea artisans, lea ^oldats des gros rangs, cach^^ embusqu^ 
demure rincognlto n^ce^isaire pour r^usslr d'autant mieux dans aa campagne. 
En effet do cctte fagon ce petJt conilt^ m^diciil technique heureusement 
a i'abri de tout oeil indiscrete jouiasant comme tous les sous-comity du 
reste cfune autoiiomie presque absolue, peut travailler sans bruits et sana 
entravf^ h la rduKsite do Toeuvre. Ce comity technique se compoae d'un 
bureau et de 9 conseiilers, entout douze menibres: 8 m^decins, 3 pbarma- 
ciens et un v^t^rinaire. Un des membrea du bureau est regent du dispeu- 
saire et r^gle dans sa visite joumali^re la marche de celui^ci, I^e bureau se 
remit chaque semaine, et le comity dans son ensemble tous les mois. 

Jc ti^entrerai pas dans les details d^organisation de nos divers comity 
cela nous entrainerait trop loin, Je me contenterai d'un tableau de ceux-d 
publid k la 6n en r<^uni6, et m'arreterai seulemeiit & vous d^crire quelquea 
c6t63 sp<5cifique8 de notre organisation type. Je vous parlexai d^abord de 
nos repas- L'oeuvre des repas au dispensaire m^rae comporte deux phases: 
la premiere comprenenant tous nos maladea et consistant dans la distribution 
au local m^me de lait homogen^isd k discretion avec deux biscottes, Pouf 
les enfants on y incorpore souvent de Tovo-maltine, ou autre cerealose de 
m^me genre- Cett-e distribution est joumali6re et appliqufe h tous le^ raar- 
lades, mais la consommatiou doit rigoureusement se faire au refectoire m§me 
du lopaJ. La seconde phase comporte les diners* Ici encore cela se passe 
au refectoire da dispensaire, ct le mdme comprend du potage, souvent 
purfea varices, une bonne viande grille ou braiss^ (altemativement 
boeuff pore ou mouton) avec pomnies de terre et legumes, tout a discretion, 
pain et excellente bidre, ainai qu'un dessert consistant en pates et sucreries. 
Tout est pr^par6 d'une fa<;on jd<5ale h la cuimne du local mtoe, avec des ma- 
tiers premiere de toute bonne qualit6, tr^s soigneusement et trfea s^v^rement 
control^ par le regent. A chaque festivity nos malades y participent 
par un extra au diner du local ou h. la gdn^romt^ de Tun ou Tautre fervent de 
Toeuvre, A ces repas toutca fois ne participent pas tous nos malades; 
les places sont surtout reservto aux moins atteinta, carj en r^gle g^n^rale, 
c*est aux moins frappds que nos seeours en vue d'un effet curatif, s'^tendent 
le plus, alors que notre attention prophylactique va surtout aux plus atteints 
par une surveillance plus serr<5e, par des instructions plus sev&res etc. Nous 
faiaons aussi du traiteraent au dispensalre: traitement symptomatique ou 
pp^cifique, Au ddbut nous avions accept^ les id^s th^oriques ^mises 
un peu partout, grdce k Tinexp^rience du moment, de Tinutilit^ de I'inter- 



: 




DISPENBAIBEB ANTITUBERCUliEUSES ANVERSOXSES. — VAN BOGAERT. 293 

vention th^rapeutique, mais la practique nous apprit bientdt deux choses 
tr^ importantes : la premiere et la priucipale que cette mesure s'imposait 
dans Fint^r^t du malade et de Toeuvre. La seconde, c'est que de sol disant 
fervents apdtres de Tabstention n'^taient pas du m^me avis dans leur 6tablis- 
sements et faisaient bel et bien du traitement. La seconde partie de notre 
argumentation ^tait certes de peu d'importance, mais j*ai tenu a rappeler 
ces faits, car dans cette voie comme dans tout d'autres, la sincerity souvent 
fait d^faut. Mais en sommes c'est I'int^ret de notre oeuvre, et surtout 
de no6 malheureux qui nous dicta cette ligne de conduite. Un but moral : ob- 
tenir la confiance de notre clientele de dispensaire et principalement la 
perseverance, qualit^s maitresses dans cette terrible lutte antibacillaire. Un 
but humanitaire, soulager la symptomatologie si triste des affections tuber- 
culeuses par une th^rapeutique s^rieuse. Quel est en effet le m^decin 
praticien honn^te qui oserait pr^tendre que la tuberculose est une maladie 
qu'on pent soigner en clientele sans donner quelque drogue. Enfin pour- 
quoi priver le pauvre de cette th6rapeutique nouvelle plus ou moins s^rieuse- 
ment sp^cifique que nous batons d'appliquer avec plus ou moins de confiance 
et plus ou moins de succ^ dans la clientele riche, et dont certes le mal- 
heureux aura entendu vanter par des tiers le m^rite. Qui de nous n'a pas 
entendu dans son cabinet de consultation priv^ des malheureux s'adresser 
k nous pour obtenir ce medicament pr^cieux, eutopique je le veux bien, mais 
Buggestif pour lui, que la polyclinique, I'hdpital, le dispensaire refusait de 
Ixii donner parcequ'il est pauvre et le remMe trop couteux, Aussi le comit6 
technique et m^decins du dispensaire sommes nous convaincus que cette 
mesure th^rapeutique sHmpose moralement et humainement, et nous crions 
k tous nos contradicteiu^ de cette innovation qu'ils en fassent Tessai sincere: 
pendant un an avec traitement et pendant un an sans, tant au dispensaire 
que dans la clientele privde et ils verront k quels r^sultats ils arriveront. 

La visite au domicile des malades du dispensaires est faite d'abord par 
notre pisteur et nos m^dicins chefs de service, mais aussi par les membres 
du comite technique eux m^mes. Chacun de ces demiers a, dans ses attri- 
butions, les malades d'une ou de deux sections de police que le pisteur a 
ordre de lui signaler avec adresse exacte au fur et k mesure de leur admission 
au dispensaire. Avant chaque reunion du comite technique chaque membre 
a visiter ces malades k lui, s'est rendu un compte exact sur les desiderata 
et a controls I'observation des instructions regues par le malade au dispen- 
saire de faQon done k ce que chaque membre du comity technique arrive 
k la stance avec son bagage tout pr^t k etre r^uni au proces verbal, 
expedie de suite au comity g^n^ral et au comity des dames, au comity de 
rhabitation, de disinfection, ou au comity Grancher qui se chargeront im- 
m^diatement de I'execution de ce qu'il y & k faire au domicile. De cette 



BIXTH TNTEHNATTONAL CONGRESS ON TUBERCULOSIS, 

facon aucuD retard n'est possible, et noua voyons en quclques heur^ se 
produire eeqiii, (rune anlit; fagon, metterait des semaines i se fain?; qui, itne 
il(5.siiLfoction du local halait^ pour laquelle il recoitj en outre, one prime de cinq 
francs (ceci a. 6t£ f^t h cause de la difficult^ que nous rencontrlona en 
gdn^ral aupri^H de nos malades pour obtenir la faveur, d*une dfein- 
fecticm des locaux).; qui, un blanchissage ou nettoysge k fond de Thabitat; 
qui, des secours de toute esp^cc: literiea, hahillements etc. ; qui, un changement 
de domicile phis salubre, plus spacieux etc.; qui, uiie recommendation pour 
un patronj pour uiie oeuvre de bicnfaisance speciale, pour un hopitalj pour 
un sanatorium, pour une colonie scolaire etc. ; qui , une reprimande de ra^decin 
traitant pour non-observation de mesures de prophylaade ou d'hygiene 
gdiK^rale ou priv6e etc. 

Cette division de travail, marchant de pair avec une autonomie k peu prfe 
complete, nous a du reste admirabtement second^s; tous nous maJades 
nous sorit counus jusque dans leur intimity, et de cette fagon rioteret qui 
se rattache au travail mSme est beaucoup plus engageant. La question d'a- 
mour propre ^tant ainsi rnise en avant, chacun en quelque sorts defend sa 
categoric de inalades, aes enfants d'adoption philantTOpique. 

Nous disions que nous avons aussi comrae annexe k notre oeuvre, une 
oeuvre tlite de Grancher, visant surtout la preservation de Tenfance, Com- 
menc6e il y a deux ana, elle est en ce moment en plelne prosperitd. Nous 
choiamsons nos enfanta destines h nos colonies de la campine ou 
de la mer, parmi les enfants fr^quentant notre dist)eiisaire comme pr^ 
tuloerculeux ou retrouvt^s dans les families contagionnantes de nos 
malades, mais non encore contagieux euxmSmes. Trois arguments 
dictent notre choix; un milieu oil Tenfatit va se contaminer s'il y reste; 
un enfant mcnac^, par mis&re physiologique, de (levenir une victinie du 
baciile de Koch, sans notre intervention; et enfin un enfant pr6dispos6 par 
tare h^^r^ditaire. Une fois le choix fait, I'enfant eat trfe soigneusement 
examjn6 par nos m^dicins et a'il n'est pas tlangereux au point de vue de 
contagion, on Tcnvoie, avee le consentement 6crit de ses parents k la campine 
ou k la mer. II a*agit d'un veritable exode, car nous visons surtout le sejour 
prolong^ k la campagne. II varie entre 1 et 14 ans; c'est k dire, qu'A partir 
de 4 ana jusqu'it J'Age de 17 ans nous les acceptons 1^ avec un minimum de 
sejour supports d'un an. II est alora confix k des nourrisseurs h I'abri de 
tout repi-oche, dans un centre des plus sains de nos foists de sapins ou de 
la cote marine. lA on a'occupei'a de tous les besoiua de Teiifant — habille- 
ment, nourriture, logement, Education religieuse, morale et iutellectuelle, 
grice k un comity local de dames, sous la pi-6aidence du ]uge de paix de 
Tendroit. Le regime alimentaire et di^t^tique des enfant-s est du teste 
dict^ aux nourriciei's par nos m^decins du dispensaire et du comity techniquej 
et contrald de plus par un mddecin de la locality m6me joumellement. Ce 



DKPBNSAIRES ANTTTOBERCULEUSES ANVERSOISES. — ^VAN BOGAERT. 295 

i^me comporte cinq repas: trois principaux, et deux intercalaires lait, 
oeufy pain, beurre. Le logement et Tentretien des v^tements sont surveill^s 
avec une minutie extreme, et les parents des enfants en visitant cenx-ci, 
sont r^llement enchant^s des soins que prodiguent k leurs petits les parents 
adoptifs. Je dois k la v6rit^ de declarer que le d^voument de ces campagn- 
ards pour ces petits malheureux est admirable. Pour ceux un peu plus 
avanc^s en dge, nous tachons de leur inculquer des gouts champdtres, leur 
procureur un m6tier agricole: jardinier, agriculteur, etc., enfin de les fixer 
d^finitivement plus tard dans cette region oil ils ont reconquis la sant6, et 
nous sommes convaincus de plus en plus que ces difi&cult^s sont loin d'etre 
aussi insurmontables que cela nous avait sembM au d6but. Nous avons 
aussi d^ le d^but tenu k payer assez largement nos nourriciers; de cette fagon 
outre leur dfivouement qui est Evident, nous avons tenu k nous les attaches 
aussi encore mieux par la question p^cuniaire, notre r^sultat final n'en pent 
que b^n^ficier. II est certain que I'importance tr^ grande de cette oeuvre 
de Grancher avait exig^ de notre comity g6n6ral ses sacrifices materiels 
6normes: nous avons assez facilement r^ussis, par un systdme un peu parti- 
culier dont je veux vous dire un mot, et qui nous a du reste admirablement 
r^ussi. Nous recevons k la section Grancher outre nos z^latrices habituelles 
des grandes favorites. Qui sont les m^res adoptives et les marraines de ce 
comity? Les mdres adoptives sont les dames riches qui veulent blen prendre 
k leur frais un enfant en colonie depuis le jour de son entree jusqu'au jour 
de sa sortie, prenant absolument tout k sa charge, pendant les ann^ que 
Tenfant sejoumera k la colonie. Les marraines sont les dames qui veulent 
bien prendre k leur d^pense personelle le cout du s6jour d'un enfant k la 
colonie pendant un an. Je puis vous certifier que ces ^mes charitables, tant 
dem^res adoptives que de marraines jusqu'& present ne nous ont gu^re fait 
d6faut. 

Notre service de disinfection au local et au domicile ne m^rite aucune 
mention sp6ciale. Cela se fait par les soins du Service Communal d'hygi^ne 
ou par les soins de notre service personnel de laboratoire du dispensaire 
m3me. 

Le service du vestiaire est le m6me que partout ailleurs, mais fait avec 
minutie typique k cause tou jours de son autonomie et surtout grdce k ce 
beau principe de la division du travail, qui caract^rise notre grande oeuvre, 
et a aussi pu lui donner son cachet un peu sp6ciale et particuli^rement riche 
en r^sultats. 

Aussi le considerons nous jusqu'^ present comme un protot3rpe dans la 
lutte contre la tuberculose. Si on veut arriver k des r^sultats r^ls et dui^ 
ables et ne plus pi^tiner sur place en gaspillant en pure perte des sommes 
6nonnes recolt6es au prix de si grands sacrifices. Venez vous et vous serez 
convaincus. 



THE RELATIVE VALUE OF CLIMATE IN THE CAM- 
PAIGN AGAINST TUBERCULOSIS. 

By Sherman G. Bonnet, M.D., 

Denver, Colomdo. 



A literal interpretation of this subject naturally suggests an effort to 
tleiiiiej with approximute accuracy, the merits t>f cUninte as an agent of 
prophylaxis in comparison with other necognized means of defense- 
It is not tl&signed to minimize the vital importance of compulsor}'^ noti- 
fication, with a systematic supervision of the consumptive, the practical 
scope of State sanatoriutns and tuberculosis dispensariea, nor the need of an 
organized campaign directed toward the enlightenment of the masses by 
means of antituberculosis societies, publications, lectures, and exhibitions. 
Neither is it intended to accord faint support to the advocacy of other 
dominating considerations, relative to tho matter of administrative control, 
namely, the supprc^ion of promiscuous expectoration in public places, the 
regulation of schools, the inspection of food-supply, the hygienic constructioa 
and sanitary supervision of public buildings, conveyances, factories, and 
tenement-houses. 

In the midst of the vigorous educational propaganda already inaugu- 
rated, and the aggressive efforts toward municipal supervision, it is hoped 
merely to present such authentic data as will establish the considerable 
importance of climate in the organized movement of prevention. 

Any concentrated effort toward the restriction of a social disease should 
be directed to the limitation of exposurej the prevention of infection in 
apite of exposure, and the restoration of health, through the arrest of the 
tuberculous process, after infection has taken place. It is proposed to show 
that the most complete fulfilment of each of these rauch-to-be-desired ends 
is made conspicuously simple as a result of favorable climatic infliiences. 

A broadly conceived movement toward the uttiraate efTncement of tuber- 
culosis must take cognizance of each factor capable of rewtricting the spread 
of the disease. In an endeavor to preserve the public health it is no less 
desirable to secure an arrest of the tuberculous process in infected individuals 
than to institute? a comprehensive system ten<ling to prevent exposure to 
the micro(>rganism or to lc?sscn the opportunities for infection. A war of 
;terminatioii against the offending bacillus, unless supplemented by rational 

290 



THE RELATIVE VALUE OF CUMATE,— BONNEY, 297 

measures known to increase the powers of individual resistance^ will scarcely 
suffice to obliterate the scourge. 

That recourse to properly selected climates, in conjunction with the 
enforcement of a strict, hygienic r^g^e, represents a therapeutic measure 
of the greatest value, has been recognized from the earliest days of medicine. 
Despite an unfortunate delusion, somewhat prevalent in recent years, 
concerning its non-utility, the beneficence of climate in the management of 
pulmonary tuberculosis is fully attested by the known physiological effects 
produced by the combined atmospheric attributes characteristic of localities, 
and by the convincing logic of impartial clinical observation. 

It is not contended that any single climate is appropriate for all classes 
of consumptives. Among pulmonary invalids essential differences exist 
in the indications for climatic selection, in accordance with temperamental 
idio63nicrasies, varying combinations of physical signs, and the associated 
disturbances of circulation, digestion, and elimination. Many consumptives 
present marked peculiarities in their constitutional vigor and the character 
of complicating conditions. Some patients derive exhilaration and stimu- 
lation in localities that induce irritability or depression in others. Ag^, 
invalids with a disturbed nervous equilibrium may experience a pronoimced 
soothing effect in certmn regions characterized by their usual enervating or 
relaxing influence. It is thus apparent that the efficacy of climate, in 
selected cases, is primarily contingent upon a knowledge of the physiological 
effects likely to be produced, the constitutional requirements of the in- 
dividuxd, and the degree of functional adaptation to the atmospheric 
conditions. 

It b impossible at this time to review the physiological action of the 
several climatic attributes upon the organism, but it is well known that a 
profound influence may be exerted in the promotion of tissue change. As 
has been shown by Huggard, the animal functions are stimulated or imp^red, 
with a resulting effect upon metabolism, largely in accordance with the 
demand for heat-production and the degree of heat-abstraction. The at- 
tainment of maximum nutrition for the pulmonary invalid b commensurate, 
to some extent, with the heat-abstractLag powers of the climate, provided 
the individual b able to respond to the unusual demands for its production. 
In thb connection the influence of temperature, humidity, wind-movement, 
and variability upon the vigor of the oxidizing processes b of exceeding 
interest and value. Considerable importance attaches to the direct effect 
of diminbhed atmospheric pressure upon tissue change, the increase In the 
number of red-corpuscles, the rate and depth of the respirations, and the 
invigoration of the nervous system. 

In addition to the combined scientific and clinical observations, which 
establbh the rdle of climate in the management of pulmonary invalids. 



ons 



MVra IKTEBNATIONAL CONORESS ON TimcaCULOSIS, 



il Txa lacking to eu&tmn the belief that by the same means valuable 
di\ •* T«»**M^^ '<^ '''*' cause of prevention. 

If CI <4fAr Ihnt, by virtue of the arrest of the tuberculous process in 
^tt>if^\ mlMduoHB, exposure to othcis becomes greatly limited, Wth 
'■■•' \o health, in favorable climates, innumerable centers of 
; niinncnily eradicated from local communities. An economic 
, ^4 <Miwidcrftble importance b the fact that the source of danger is 
^fWMkW^t fn«ni households in densely crowded districts and from unhygienic 
^ff/^M/it9 and work^fihops freqtiently occupied by individuals posseting 
JliiOii.tiitT^n' ix>wpi« of resistance* Climate thus becomes indirectly a valuable 
)n Uw rnmpaign against tuberculous. 
Il ttwyc \^ ur>?'d by some, ho^'ever, that the transplantation of consump- 
|o t«UitT localities, while admittedly lessening the possible sources of 
al homOj ia, nevertheless, instrumental in a further dissctnination 
^^ilbVMO elfewhere. In this connection it is pertinent to r!ail attention 
IHk |lw ii^<^t that in health resorts, and particularly iji modem institutions, 
^ tetVoK^t b \iflunlly bmught to a realization of the importance of sanitary 
MjMklkUont Ah a n^Hult of the educational influences imparted in popular 
)^^4^lk« U^ oonsumptivps, the possibilities of exposure are greatly mini- 
■lij^t AuoihtT factor of still greater importance is the materially lessened 
M^;^b4Mhl>' \4 iiiftvtion in favorable climates, even though exposure is quite 
^^wikW<**^« ^y virtue of the greatly increased poweis of resistance often 
•MH^myi )lh «uoK nv«4>rtfl infection y comparatively rare. 

^flflilll^ H cmuiot ho asserted that any single climate grants complete 
tlMWMViii^V H< tul»orpulosia, irrespective of predisposition, occupation, or 
d|^\Jfts4^^)M4\l« Ihe mfrequency of consumption in certain large centers of 
^^»liV*iUm\ U iHirt*e«*tHl of great significance* Wherever the conditions other 
k)^ ^K* t*lTitr a Buitable basis for comparison, the evidence is quite 

\^ , '■ I*; the relative degree of immunity conferred through 
Ll.(Kuuu^ . I tide cHHubincd with dryness and sunshine. 

n^a luitnMHiary tuberculosis has been shown to be on the decrease 

: V of tall buildings, large mercantile establishments, departs 

( (iwtt»riect» comprising a population of 200^000 inhabitants, 

Ai* iui|H\rt^ consumptives. Tuberculosis is undoubtedly 

VIA v\4w*^h^ ^ **^*"^^ extent as a natural result of the massing 



tt* **— m^i^^tt* *^ UwAwtrial pursiiitSp the special predisposition of a con 
SkMAWvuriiou oi fcl*^ youii|;vr population, t>orn of tuberculous parents 






•rr 



sviuiT, That the disease is not more prevalent 

.. iissuU of those factors, is particularly illuminat- 

i,y wUh which tuberculosis has developed in Colorado 

I... riilly a marked inherited taint, and often 

_. - 1 tvtion, is particularly instructive. I have 



THE RELATIVE VALUE OF CLIMATE. — BONNET. 299 

been privileged to observe a large number of children who have thrived to a 
surprising extent, although both parents were tuberculous. 

According to a recent annual report of the Denver Health Department, 
39 cases of pulmonary tuberculosis were stated to have developed during 
the year, in comparison with a total tuberculous mortality of 661; the 
proportion is thus established of 5.9 per cent., which is much less than any 
previous year since such statistics were first compiled, in 1893, despite an 
annual increase in the population. During a* period of seventeen years I 
have observed personally but 35 cases of indigenous tuberculosis in Colorado, 
in nearly all instances the development of the disease being explained by 
virtue of special predisposition or wanton exposure. This is strictly in 
accordance with the experience of other observers. 

Inasmuch as tuberculosis for many generations has been rarely indigenous 
in certain localities, notwithstanding the existence of conditions strongly 
conducive to the development of native cases, it must be assumed that the 
lessened opportunities for infection in such regions are referable, at least in 
part, to climatic influences. By this token the value of climate as an agent 
of prophylaxis, in addition to its therapeutic utility, is readily demonstrable. 



LE DISPENSAIRE ANTITUBERCULEUX DE LYON. 
Par mm. S. Arloenq et J, Courmont, 



Notre Dispensaire Antit-uberculeux n'eet qu'une nouvelle section de 
I'Institut Bacteriologique de Lyon, que nous sivona fond<?^ en 1S99, 

Llnstitiit bact^riologique do Lyon est ime association dirigrde par un 
Conseil d adminiatration absoiument indSpendant, et qui a pour but de 
favorieer, dans ia rtj^on lyonnaise, le d^veloppement de la bact^iiologie dans 
ses rupporta avec la m^decine, Thygiene, rindiistrie et 1 'agriculture. Get 
Institut se conipose d'ltn certain nombre de sections* Existent d6j^: U 
Section S^rothSrapique (s^mm antidipht^rique et anlit6tanique) et la 
Section Antirabique, Cette dcmiere fonctionne pour 14 d^partements et 
traite chaque annte 700 3. SOO mordug; elle est surtout aliment^ par des 
subventions d6partementaleB et communales. Le Dispensaire Antituber- 
culeux est une troisi^me section que nous avons ouverte le ler F<5vrier 1905, 
9, rue ChevreuJ, k c6t^ de la Faculty de M^decine, 

II occupe un b&timent special repr^ntd, dans son ensemble, par la fig, 1* 

Ce bdtiment a 6t^ constmit grdce i des resources de deux provemLUces 
difF^renfea: lea dons de plusieura merobres du Conseil d'administmtion et 
une somrae de 50,000 francs vot^ par le Consei! municipal, sur la proposition 
de Victor Augagneur, qui 6tait president de droit de notre Conseil d 'admin- 
istration^ comme malre de la ville de L3^on. 

IjG diKpensaire est vaste, a^r<5 et cnsoleiUfi, lavable dans toutes ses parties, 
absolument modemCr 

Les figures 2 et 3 montrent les plans du rez-de-chauss^ et du premier 
^ta^; au deuxiOme ^tage est le iogement du personnel subalterne. 

Au rez-de-cbauaa^ sont install^s: une buanderie moddle^ chauffage 
central, un petit chenll, un ^tabli^sement hydroth^rnpique complet Grains 
ordinaires et suifureux, douches gSnfirales et locales, pulverisations Iaryng6es, 
etc.). 

Au premier §tage so trouvent: une vaste salle d'attente avec large bale 
vitrde, des lavabos, des cracboirs, queiques plantes vertes, des affichea 
antialcooliques^ dm brochures sur rhygidne; deux vestiaires avec lavabo 
et craehoire; une aalle de consultation; un cabinet pour les mddecins; dea 
labonitoirea; deux pieces destin6es k Tenqu&teur et au concierge. 

300 



LB DISPENSAIRE DE LTON. — ^ARLOING ST COURMONT. 301 

Les murs sont en faience, en Josz, ou peints au ripolin; les, angles sont 
anondis; les planeheis sont en faience ou en parquets hygi^niques; lea 
tablettes en lame ^maillde. 

Le personnel est compost de: deux m^decins, un ouvrier enqu^teur, un 
concierge et sa femme s'occupant surtout de la buaaderie et de Thydroth^r- 
^ie. 

Pour I'instant, nous recevons uniquement les tuberculeux indigents que 
nous envoie le Biueau de bienfaisance; notre action ne s'^tend mSme qu'^ 
la partie de la ville qui occupe la rive gauche du Rhdne (Brotteaux et Guillo- 
ti^re, c'est la plus populeuse, il est vrai) ; nous sommes en pourparlers pour 
faire profiler les mutualistes de Lyon de notre installation. 

Lorsqu'un m^ecin du Bureau de bienfaisance se trouve en pr6sence d'un 
tuberculeux, il nous I'envoie au dispensaire. Nous avons k notre disposition 
des cahiers d'ordonnance du Bureau de bienfaisance, et nos malades vont 
chercber leurs rem^es dans les diff^rents h6pitaux ou ^tablissements qui 
leur sont indiqu^s, comme ils le faisaient auparavant; ainm, nous n'avons 
pas & nous occuper de la d^livrance des medicaments; la consultation 
m^dicale du Bureau de bienfaisance est, de ce fait, d^harg^ de tous les 
tuberculeux, sans augmentation de frais pharmaceutiques, plut6t aveo 
diminution sur les anciennes ordonnances, I'hygi^ne remplacant, pour nous, 
un assez grand nombre de m6dicaments. 

Ces tuberculeux sont recus, k leur arriv^, avant la consultation, par 
I'enqu^teur qui leur demande tous les renseignements utiles et leur annonce 
sa visite k domicile; il n'a done pas k d6pister les tuberculeux, comme k 
Lille. II n'y a pas non plus d'inscription, puisque nous acceptons tous les 
tuberculeux envoy^s par le Bureau de bienfaisance et nous ne recevons 
qu'eux; nous ne faisons done concurrence k aucun m^decin praticien. De 
m^me, lorsque nous aurons dtabli une entente avec les mutualistes, nous ne 
nous occuperons, pour ces demiers, que de I'hygifene et nullement des soins 
purement m^caux. 

L'ouvrier enqu^teur va k domicile et remplit la feuille d'enqu^te ouvridre 
destin6e k completer Tenqu^te m6dicale. 

Dfe Tadmission du tuberculeux, ses crachats sont examines; d'oCl le 
classement en contagieux et non contagieux. 

Munis de tous ces renseignements, on decide Tassistance, presque unique- 
ment en bons de viande, le Bureau de bienfaisance accordant les secours 
en charbon, pain, pommes de terre; on donne un crachoir; on lave le linge 
contamin^ apport^ du dispensaire dans des sacs semblables k ceux de Lille; 
on fait profiter le tuberculeux et toute sa famille de Tinstallation hydroth6rar 
pique et autres mesures hygi^ques. 

Pour la d^infection du logement, nous d^clarons au Bureau d'hy^^ne 
les logements oil les tuberculeux sont morts ou ceux quitt^ par oeux-d; 



3(12 



SIXTH INTERHATIOHAL CONQRESS ON TUBERCULOSIS. 



lu dfisLnfection m fait alors complOte. Pour le tuberculeux k bacilles, lum 
habitant eneorD son appurtement, le Bureau d^hygiSne nous fournit une ^uipe 
(lui va Bans attiror Tattenlion des voisins, sana appareils bruyanta ou volum- 
ineux, sous la direction de Tenqu^teur^ laver soigneuaement le plancher et 
batligi&oaner lea murs k la chaux; c'est une op^ation de propret6 autant 
que de d^Ssinfection, 

Nous nooa occupons de placer lea enfanta k la montagne ou implement k 
la campagne, quand cela eat n^ceasmre. 

La Municipality nous a pr^t<5 quelquos lita que nous mettons k la disj 
tion iles families qui en ont beaoin pour isoler les tuberculeux, 

Notre bu<tgct annuel a troia sources de revenus; 1** une importjinle sub- 
vention de ]a ville de Lyon; 2° une subvention du Bureau de bienfaisance;^ 
3° \es revenus propres de I'lnstitut dont toutes lea disponibilitds seront at- 
tribu^s an diHpeusaire, 

Telle est notre organisation k Lyon. Gr&oe ^ notre Conaeil d*acLiumis-J 
tration qui conipte la plus grande partie des plulanthropea <le la ville et novas 
soutient nioraleraent et niat^riellement; grAve au Conseil Municipal de Lyon 
et k son Maire, dont T^loge n'est plus k faire; gr&ce au Bureau de bienfaia-l 
ance; gt'at« au Bureau municipal d'hygiene; grac?e i la confrat-emelle en- 
tente avec lea nn§decin9 du Bureau de bienfaisance; grdc^ au d^vouenaent 
de nos miklecins et de notre enqu^teur, nous avonis pu doter Lyon d'un dia- 
pensaire *nype Calraette'^ adapts aux conditions locales, sang avoir, pour le 
moment, fait aucun appel soil aux fonds d'Etat, soit k une souscription pub- 
lique. Nou3 aurons recours k ces moyens quand nous aurona fail nos 
preuves* 

Danstoutea lea villesoft les pouvoirs publics, les philanthropes et leamddo- 
cins uniront leurs efforts, la lutte sociale contre la tuberculose pourra s'or^l 
ganiser sur les mtoea bases, Dans la pkipart des caa, cctte alliance sera 
n<5cessaire, peu de regions pouvant, en France, compter but tes donateurs 
aussi g^n^reux que ceux de noa d^parteraents du Nord, qui ont aid^ puiaaam- 
ment Calmette dana la creation de sou dispensaire. 

Situation hygi€nique du logement. 



Be <x>mbicn de pieces se compoee le loge- 

meot du manage? , * 

A quel 6tage se trouve*t-il 7 , . . 



3 pfeoee. 
Kea-de-chau8&fe, 



Quelles dimensionfl a la chambre du mnlade? 

Coin bien de personnes rouchent dans la 
chambfe du maiade? Lesquelles? ....... 

Combj^n y a-t-il de lita pour toute la famillet 

Le malade occupe-t-il un lit &euir , 

Etttt de la lilerie 



40 metres cubes. 

Seul. 
4 lita, 
Oui. 
M6diocre. 



liE DI8PEN8AIBB DB I*YON,— ABLOINQ ET COUBHONT. 

^tuation hygi^nique du logement. — (Continue,) 



303 



Combien de manages habitent la 
mawon , , , 


m6me 


5 m&iages. 
Mauvaise, humidity 

Une cour. 
Une fenStre. 


Situation hygi^nique g6n4rale de la maison. 
La chambre du malade donne-t-elle 8ur la 

rue, BUT une cour ou sur un jardin? 

Combien de fendtres-a^t-elle? 


Peut-on les ouvrir facilement? 


Oui. 


D'ou provient Teau d'alimentation? 
ou eau de la ville? 


Puits 


Eau de la ville. 






Ou et comment se fait la lessive? 


Au lavoir. 


Ou et comment sdche-t-on le linge? 








Propret4 de la chambre du malade 


M^ocre. 


Y t^tr-H lieu de faire nettoyer et blanchir 
la chamhrfl du malftd<^7 


Oui. 






Est-il n^cessaire de le faire changer de 
logement? 


Oui. 


Obeerrations 


Tr& n^ceesiteux, 1 fr. 26 pour 10 per- 
sonnes, ne travaillant pas. 



Visites ult^rieures. 



DATS8. 


BEMABQUKS. 


DESINVBCnON DU LooEiairr. 


20 IV 

26 IV 


Enqudte ouvriere. 


P^rinfection et hlanchlment. 


10 V 

• 


Visite de Tenqu^teur. 





Annexe N<> 2. — Feuille d'enqudta m^cala. 



DiSPENSAiRE AnTITXJBERCULEUX. 
DE LYON 

9, rue Chevreul, 9 
Telephone 30-39 



I. ENQU^TE M^DICALE. 



Localiaation de la tuberculose: 
£tai de la maladie: ler degr6, 



Diagnostic. 

2e degr^, 



No A 87 
Date: 19 avrii 1905 



3edegr£, 



304 



SIXTH INTERNATIONAL CONQRESS ON TUBBRCOLOBI3. 

Diagnostic, — {Conlintii. ) 



Nom ftt- Pf^nnniia , , , 


Marie E 


Age . . ^ . . . * * . . . 


37 aofl. 


'SUA^ (e) ou cdlibatflire 

Domicile »».... ,,....,.. 

Prafeodon . , 


Mari^. 

Rue..... 11 .. 
Tapissier. 


Aiit^ciSdeutH indivjduels 


Q 

+ 2 


Alcoolismc AIcttoIipitig 


+ 2 


1 Al>Hmthiiiiiie». . ,.,..._.,.»... 

Cauaes ^rMispoBantee 

Contagion .,.*.,.,,*..,. ,.._,. 


+ 5 
? 



SantS du p^re ,,..,,.. 

— d<j la m^rc , . , . 

— de la fprnmc ou du maH 

— dee enfanta ......,...,, 

— doa colUtt^raux ..»,...., 



Date du d6but , ■ . 

Ph^nomones de d^btit ,,.,........ 

H^moptyBies ,........«..> 

Fiivre , .»,.,., 

Etat g^n^ral .,,**♦... ....... 

Toux 

f MuqueusG 

Expettorat ion \ Purulente , , 

[rm^c 

Larynx... 

Autrca localisatfoiui,,, , . . . 

Appareil circuiatoire 

— digeatif 



ApparcO r^nal , 

PomIs ,..,*,,...,, 

Radioscopie 

Diaso-r^action ............. 

s*'»?-diagnoetjc tuberculeux. 
arqiiea diveraes 



niQite cardiaque. 

+ 

+8| — I m€nlngit« (*). 




Amaigmsement: 13 kiL 



+R siimifie qu'il ^ a encore 7 enfanta rivanta; — 1 ro^ingite signifie qu^un 
n:iorl de tn^amgke. 



Schema de la l^on pulmonaire. 



ATAMT, 




Wf 



'Rouge, 2« degr^ (induration). — Bteu, 3« degrd (cavemea). 



LE DISPKNBAIRE DE LTOK. — ABLOING ET COUBUONT. 305 

Consultations. 



Dftta. 


ExHsUnique. 


Poids. 


BmUIm 
AawGiatiotis. 


8ero- 
diagnoBtio. 


Tnat«m«nt. 

(♦) 


Aasbtuoe. 


19 IV 




62 






457 




26 IV 






+ 5 




479 


Sac no. 28.* Crachoir. 


3V 










498 


Viande. 


10 V 


Accds febrile. 








515 


id. 


17 V 










562 


id. 


24V 










603 


id.+ Ut. 


31V 










686 


id. 


7 VI 










716 


id. 


14 VI 










763 


id. 


21 VI 


- 








798 


id. 


28 VI 










851 


id. 



(*) Lee num^roa correspondent aux num^ros des ordonnances du cahier confix par 
le Bureau de bienfaisance. 



Annexe N*' 3. — Feuille d'enqudte ouvri^. 



DiSPENSAIRE AnTITUBEECULEXJX. 
DB LTON 

9, rue Chevretd, 9 
Telephoki: 30-39 



Date: 20 avril 1905 
No d'ordre: A 87 



II. ENQUETE OUVRlfeRE. 



Nom et prtfnoms 


Bfarie E 


Age 

Domicile 

Prof easion 

Nom et adresse du patron 


37ans. 

Rue...., No .... 

Tapissier. 

7(Ne travaille plus depuis longtemps). 




Le malade vit-il seuli en manage, ou chez 

see parents? 

Le malade a-t-il des enfants? Combien? . . . 
Quel Age ont les enfants? 


En manage. 

7 enfants. 

12. 10. 8. 6. 5. 4. ans. 23 mois 4. 


A-t-ii perdu des enfants? 


Un. 


Dequeiles maladies et& quel Age? 


M^ningite. 


Salaire et heuree de travail du malade 

de travail 


4 francs, 10 heures. 
Blanchisseuse. 


Profession des enfants; salaire et heurea 
de travail 


Un apprentL 


Profession des parents; salarie et heures 
de travail 


N^ant. 







306 



SIXTH INTERNATIONAL CONGRSSS ON TDBERCULOSIS. 



Depuis combien de temps le malade est-il 
obljg^ de ch6mer7 



6 mois. 



Travaille-t-a a ratelier ou a domicileT 

La famille du malade tient-elle un commerce? 


A Tat^lter. 
N^ant. 


Lequel? Rapport approximatif 




Le malade a-t-il des parents a entretenir? . . 


Pas de parente. 


Montant du loyer 


17 fr. par mois. 




Le manage recoit-3 des secours de TAssis- 
tance publique? Lesqueb? 

Le manage recoit-il des secours des ceuvres 
privfiesT Lesquels? 


Oui, 20 kil. de pain 
Non. 



Le chef de famille est-il affiH4 a une Soci^t6 
de secours mutuela? Laquelle et quels 
secours? 


Neant. 


Le chef de famille est-il affili6 a une oeuvre 
donnant des secours en cas de maladie? 
Laquelle et quels secours? , 


Neant. 






Le malade reste-t-ii chez lui ou se pro- 
m6ne-t-il? 


Se promene. 






La mftre place-t-elle des jeunes enfants aux 
creches ou chez des gardeuses? 


Non. 






Le malade a-t-il une alimentation suffisante? 
— des vet^ments chauds? 


Tout i fait insuffisante. 


■^ draps et des couvertures? 


Mauvais etat 






Od le malade crache-t-il? 


Pas de crachoir 


Comprend-il la n^cessit^ de ne pas cra- 
cher par terre et de d^truire ses era- 
chats dans I'mt^ret de sa tant4? 


Oui. 


L'exercice de sa profession est-il p^nible? . . . 

Quelle est, de I'avis du malaoe, la situa^ 
tion bygi^nique de Tusine ou de I'ate- 
Uer ou iltravaiUe? 


Assez penible 

Malsanie, poussiere (cardage de crin). 


Existe-t-il des antecedents alcooliques 
personnels? 

Boisson pref^r^e; quantity absorb^e par 
jour 

Existe-t-il des antecedents alcooliques 
patemels ou matemels? 


Oui, ties nets. 
Pas d'alcoolisme. 



LB DISPBNSAIRE DE LTON. — ARLOING ET COURMONT. 307 

Die antituberkulSse FUisorgestelle in Lyoii.~-(ARLoiNG und Courmont.) 

Diese Anstalt, welche nach dem Princip von Calmette eingerichtet ist, 
ist hauptsachlich der Hygiene und Prophylaxis gewidmet. Sie bildet 
einen Teil des Bacteriologischen Institutes in Lyon und wurde unter der 
Aufsicht von den Herren S. Arloing und J. Courmont in 1904 gebaut und 
organisirt. Die Anstalt hat ihre eigene Verwaltung und verdankt ihre Exis- 
tenz speciellen Geschenken \md einer Unterstiitzung der Stadtverwaltung im 
Betrage von 59,000 Francs. 

Das Gebaude ist dreist6ckig. Im zweiten Stock befindet sich ein grosses 
Wartezimmer, wo an der Wand Notizen iiber den schadlichen Einfluss des 
Alcoholismus angeschlagen sind. Es befinden sich da auch zwei Ankleide- 
zimmer mit Waschtischen und Spucknapfen; ein grosses Consultations- 
zimmer mit einem kleinen Arzeneischrank; ein bakteriologisches Labora- 
torium, ein Zimmer fiir X-Strahlen, Raume fiir den Inspektor und filr den 
Verwalter. Im ersten Stock befindet sich eine Muster-Waschanstalt und 
eine vollstfindige Wasserkur-Einrichtung mit Badewannen, Brausen und 
Spiitzen. Die Bekleidung der Wande in diesem Zimmer ist aus glasirten 
oder waschbaren Ziegelplatten hergestellt und uberall sind Spucknapfe 
hingestellt, u. s. w. 

Die Kranken werden von den Arzten nach dem Bureau de Bienfaisance 
hingeschickt imd dasselbe ist somit in der Lage, uber die tuberkulosen 
Kranken zu verfiigen, und kann demgemass auch der Fiirsorgestelle, nach 
dem Verhaltniss zu der Zahl der Kranken, Unterstiitzung zukommen lassen. 

Jeder Kranke wird untersucht xmd wird, wie es in Lille der Fall ist, 
von einem speziellen Inspektor in seiner Hauslichkeit besucht. Gemass 
dem Berichte des Inspektors, dessen Function die allerwichtigste in der 
Organisation ist, werden die Kranken von den Arzten imtersucht, es wird 
fiir die Desinfektion der Wohnung gesorgt, etc. 

Der arztliche Dienst wird von drei Arzten, unter Aufsicht des Directors, 
versehen. Die Arzte erteilen den Rat, aber die Arzenei wird von dem 
Bureau de Bienfaisance verabfolgt. In der Fiirsorgestelle wird auch, auf 
Anordnung des Arztes, Fleisch, Milch, Brot und Kohlen verabreicht. 

Jeder Kranke wird einer arztlichen Untersuchung unterworfen: es wird 
sein Auswurf \mtersucht imd seine Wohnung besichtigt. Verlockend 
wirken auf den Kranken die Bequemlichkeiten der Anstalt in Bezug auf 
Behandlung, und wo ihm auch ausserdem noch Unterstiitzung angeboten 
wird. Die Prophylaxis, welche die Hauptsache am Untemehmen ist, wird 
ausgefiihrt — erstens, durch Versehen des Kranken mit einem Spucknapf und 
Erteilimg von Anweisung in Bezug auf Hygiene. Zweitens, durch Desin- 
fektion der Wohnimg unter Aufsicht der Inspektoren. Drittens, durch 
Desinfektion der Familienw&sche in der Waschanstalt, die ebenso einge- 
richtet ist wie im Calmette Dispensary, Viertens, durch Anbieten von aUen 



308 



BDCTH INTERNATIONAli CONORESS ON TUBERCULOSIS. 



mdglichen Bequemlichkeiten fiir Reiiilichkeit m der Wasaerkur-Einrichtiing, 
Seit 1906 mrd eine atmliche Zweigeimichtung, mit einem anderen Inspektor 
und zwei anderea Araten, in einem anderen Telle der Stadt, unterhalten. 



Los Dispensaries Antituberculosos en Lyon, — (Arloinq r CouKMO>rT.) 

Esta institucida oonetruida segdn el tipo recomendado por Calmette, 
estA dedicada cspecialmente d la higiena y la profilaxia. 

Esta inHtituci6n forma parte del Institute de Bacteriologlft de Lyon 
y fue construidfl y organizada en 1904 bajo la direcci6n de los Drs. S. 
Arloing y J. Courmont. Esta debe su existencia a las donacionea especiates 
y al subsidio de 59,000 francos del Consejo Municipal, 

El edificio es do tres pisos* En el Begundo piso ae encuentra ua saldo 
de espera, en las paredea del cual cuelgan avisos sobre la acci6n daflosa 
del aJcohoIismo, el cuarto tambien est^ provisto de literatura para recreo 
de las visitas; Dos cuartos para vestirse con lavatorio y escupideras; un 
cuarto grande para consiiltaa con un pequefio gabinete medico; labora- 
torio de Bacteriologia; cuarto para los rayos X y apart^meutos para el 
inspector y la portera. El piso de abajo contiene una lavanderia modcio 
y un establecimiento completo de hidroterapia, con baiios^ duchas y re- 
gaderas. Las paredes de estcs cuartos est4n ctibiertaa de latninas de vidrio 
6 de otra siistancia lavable. 

Lo3 enfennos son enviadoa por los doctores del Bureau de Bienfaisance, 
por medio de lo cual eate dispone de los pacientes tuberculosos, y por lo 
tanto subside los dispensarios en proporcidn al nilnriero de pacientes que 
envfa. Aai como en Lille, cada paciente es examinado y recilje las visitas 
de un inspector especial en su casa. De acuerdo con el infomie dado por el 
inspector, cuya funcion es mas iniportante en la organiaacifin, el paciente es 
examinado por el m6dico, y tambien se atiende d la desiufecci6n de laa habi- 
taciones, etc. El serv'icio ea adminialrado por tres medicos bajo la super- 
vision del director. El medico da la consulta, pero las drogjis son supUdas 
por el Bureau de Bicnfaisance. El tUspensario tambien suple dc carnes^ leche, 
pan y carb6n de acuerdo con las ordenes del m^tiico. El paciente es 
atraido par loa aspectos terap6uticos de la inatitueionj en donde obtiene no 
solamente el trataraiento sino tambien asistencia; la profilaxis, que es el 
verdadero objeto del problema, se lleva a calxt del modo siguiente: Primero, 
proveer de escupideras y darle al paciente la instrucci6n en higiena; segundo, 
la defiinfecci6n de las habitaciones bajo la eupervisi6n de los inspectores; 
tercero, la desinfecci6n de la ropa en la lavanderfa, la cual esta organlzada 
de acuerdo con el dispensario de Calmotte; cuarto, darle d los pacientee 
toda las facilidades posibles para la limpiczfi en los establecimientos hidro- 
terupicos. Desde Enero de 190S, un anexo se ha organissado en otra parte 
de la ciudad* 



LE DISPENSAIRE DB LYON. — ^ARLOING ET COUBMONT. 309 

The Antitnbercnloas Dispensary in Lyons. — (Arloiko and Coitrmont.) 

This institution, which was modeled on the Galmette type, is devoted 
chiefly to hygiene and prophylaxis. 

It forms part of the Bacteriological Institute of Lyons and was con- 
structed and organized in 1904 under the direction of Messrs. S. Arloing 
and J. Cburmont. It is under its own management, and owes its existence 
to special donations and a subsidy of 59,000 francs by the Municipal 
Council. 

The building is of three stories. The second floor contains a large 
waiting-room, where notices setting forth the evib of alcoholism are 
tacked to the walls, and other literature is provided; two dressing- 
rooms with washstands and cuspidors; a large consxilting room with a 
small medical cabinet; bacteriolo^cal laboratories; an :c-ray room; and 
quarters for the inspector and concierge. The ground floor contains 
a model laundry and a complete hydro-therapeutic establishment, with 
baths, douches, and sprays. The walls of this room are covered with 
glazed or washable tiles. 

The patients are sent by the doctors to the Bureau de Bienf usance, 
which is in that way enabled to dispose of its tuberculous patients and 
can subeddize the dispensary in proportion to the number of patients sent. 
Each patient is examined and visited at his home by a special inspector, 
as in Lille. According to the report furnished by this inspector, whose 
function is most important in the organization, the patients are examined 
by the physidans, and the disinfection of dwelling houses is attended 
to, etc. The medical service is rendered by three physicians under the 
supervision of the director. The physicians give advice, but drugs are 
furnished by the Bureau de Bienfaisance. The Dispensary also distributes 
meat, milk, bread, and coal on the physicians' order. 

The patient is attracted by the therapeutic feature of the institution, 
where he receives both treatment and assistance; while prophylaxis, which 
is the real object of the undertaking, is carried out first, by providing the 
patient with a spit-cup, and giving him instruction in hygiene; second, 
by disinfecting the dwelling houses imder the supervision of the inspec- 
tors; third, by disinfecting the family's washing in the laimdry, which is 
organized like that in the Calmette dispensary; and fourth, by giving the 
patient all possible facilities for cleanliness in the hydrotherapeutic estab- 
lishment. Since January, 1906, an annex has been carried on in another 
part of the city. 



THE INSTITUTION «HALSAN" (HEALTH) AND ITS 

WORK, 



Bt C, Neanuer, M-D. 

It FhyHCiAO ftt the Social Hygienic SIaUdd. Lower LuleA. Sweden. 



Until a long wiahed-for specific has been found, £J1 that we know 
about the cure of tuberciilosis must be summarized in the phrasDi better 
hygienic conditions; while the attainment of satisfactory hy^enic conditions 
for every member of the community must possibly be considered as a social- 
economic problem (in the opinion of many people a purely Utopian one) 
whose final solution is yet far distant. 

Knovring, on the other hand» with what magnificent generosity the strugg:Ie 
in Sweden had been supported, it seemed possible to find an opportunity 
of carrying out a plan which had been proposed at a very early date by the 
Swedish National Association^ i. e., to bring about extensive hygienic im- 
provements within a comparatively small and limited area, cliiefly for 
experimental purposes, to the end that the knowledge thus acquired should 
be to the ultimate benefit of all the national antituberculosis associations 
in their struggle agiunst the diseiise. It waa clear that such a social-hygienic 
experiment carried out in a large town would tliffer in essential features from 
one dealing with the conditions existing in a country district. The Sweclish 
association has had an opportunity of arran^ng the experiments in question 
in both town and country, but it is of the work in the latter only that the 
following detailed account is now ^ven. 

The financial support necessary was presented by the Grangeaberg- 
Oxeloaund Mining Company, which generously placed an annual sum of 
12,000 kronor (about S3200) at the disposition of the Swedish National 
Association for a period of eight years. As the population of the experi- 
mental district is about 2000 per&ona, the annual sum given amounts in 
round numbers to 6 kronor (about SI. 60) per head, from wluch it follows 
that, should the same work be ext-ended so as to embrace the entire populfw 
tioD of Sweden, no leas than 30 million kronor (about $8,0(X),000) yeaj^ly 
would he required for the purpose* 

Search waa made for a country district suitable for the experiment. It 
had to be a tract where, within wellndefined limits, there lived a fijted popu- 
lation wilh high frequency of tuberculosis and plainly bad hy^enic condl- 

310 



THE INSTITUTION "HAISAN" (HEALTH) AND ITS WORK. — ^NEANDBR, 311 

tions. Such a place was found in the north of Sweden, and the work was 
commenced in April, 1906. The district consists of four villages, Antnas, 
Ersn^, Langnas, and Alvik, in the parish of Lower Lule& and the govern- 
ment-district of Norrbotten. The villages are situated in about 65.5° north 
latitude, on a narrow firth of the gulf of Bothnia. The soil consists to a 
great extent of old sea bottom, which in parts is low and marshy; and the 
whole tract is very open and windy. The inhabitants, in number about 
2000 souls, support themselves chiefly by agriculture and, to some small 
extent, by fishery. The people are, as a rule, small farmers whose unceasing 
labors gain them but a scanty livelihood. No great degree of economic 
well-being can be found, but, on the other hand, there is no great amount 
of actual want. Some of the yoimger members of the population add to 
their incomes by temporary employment at adjacent industrial centers. 

The people are industrious and honest in the highest degree, and the 
abuse of alcohol is almost unknown in the district. But, as a rule, they look 
upon every innovation with the greatest suspicion, and it is only after much 
deliberation that they will relinquish traditional manners and habits. 

The plan of the experiment was this: In an establishment, to which 
was attached a residence for a doctor and sick-nurses specially trained in the 
treatment of patients suffering from tuberculosis, there were to be received 
hospital cases, and some specially suitable patients, for whom sanatorium 
treatment should be provided. Besides this, room was to be found in the 
institution for about ten healthy children from homes infected with tuber- 
culosiSf while another feature of the plan was that dispensary work should 
also form part of the program of the establishment. 

Other important details were that the population of the district should 
be enlightened as to the character and dangers of the disease as actively as 
possible, and to exercise direct personal supervision over hygienic conditions 
in the dwellings. Numerous lectures on tuberculosis, and other hy^enic 
questions, have been given in the four villages, and opportunities have been 
afforded, after the lectures, for conversation with the doctor. As a rule, 
these lectures have been well attended and have interested the population. 

Supervision of the hygienic condition of the dwellings has been carried 
out in the following way: Before a family was medically examined for the 
first time, the home was visited by the doctor or a nurse, who drew a plan of 
the house and gave as full details as possible concerning the sleeping-place 
of every inmate, the occurrence of so-called cupboard-beds and of rag- 
carpets, the possibility of opening the windows, the general conditions of 
cleanliness in the house, etc. Then, when the family came to be examined, 
the doctor was able, by the ^d of this plan and the memoranda, to give ad- 
vice concerning changes of sleeping-places, and other alterations in the house. 
Later on, the dwelling-houses were visited now and then by the doctor and 
the nurses, and on these occasions special attention was, of course, paid to 



312 



SIXTH INTERNATIONAI* CONGRESS ON TUBERClTLOaiS. 



the homes where there were persona suffering from tuberculosis, wlule 
greater care was devoted to families where there were babies living with 
people suffering from consumption in its Infectious stages. 

It is quite clear that great prudence has been necessary in carrying out 
this work, and that too energetic interference with personaJ liberty had to be 
avoided. It has been necessary to content ourselves %vith small results, 
slowly attained. The peasant in these districts is very suspicioua of innova- 
tions, while, at the same time, he is very independent in character* As a 
rule, he is open to reason, and is not unthankful for good advice, and when, 
after many useless visits and much arguing* he at length determines to make 
the alterations suggested, he eeema in general satisfied and even proud 
over the matter. It has sometimes happened that the doctor or the nurses 
have been called in by a peasant or his vnie who, with triumpliant mien, 
has exclaimed: "Come in and look; we have taken away the cupboard- 
bed," or "We have put in a hinge<l window since you were here last." 

The following facts respecting the conditions of living in the district may 
be of interest. As a rule, the dwelling-houses are large and corajnodious and 
contain several rooms, of which but one^ the kitchen (the largest room of all), 
is inhabited during the long winter, and that by all the members of the 
family. The kitchen is heated either by an open fireplace or by the cooking- 
range; tlie last method seemingly enjoys a growing popularity- There is 
seldom any possibility of opening a window during the winter. The sleep- 
ing-placea are either beds and aofaa of ordinary construction ^ or "cupboard" 
or ''shutter-keds," as they are called, which are perhaps typical for these 
districts. The cupboard-beds consist of close cupboards, fastened to the 
wall and having a lower and an upper sleeping-berth, admission to which 
la gained tln'ough the front long-side, which is then closed by shutters. 
The "shutter-beds," which admit very little sunlight, and which are some- 
what difficult to keep clean, must be considered very unhealthful, and much 
trouble has been taken to convince the inhabitants of their unsuitabiUty. 
It would seem, however, that they are now passing into disuse, and new 
beds of thia kind are no longer constructed in the district. A great numl>er 
have been removed since the experiment began ; in some places these shut ter- 
beds have been transformed into real cupboards and used for other purposes. 
In many of the homes where such beds are still to be found, they are employed 
only by old people, who will not give up a habit to which they have been 
accustomed since childhood. In several homes, where space is limited and 
the family numerous^ they have been declared to l>e indispensable, but it 
would seem that in these cases greater care is now paid to cleaning the beds 
and airing the bed-clothes. 

The sense of cleanliness and neatness does not appear to be less developed 
in this district than in other parts of Sweden. The floors are in g&neral color- 



THE INfimTDnOX "HALftAX" (HIALIH) aXD TTS TORK. — XK&XtkEK. 313 

washed. On fine dajs the bed-dothes are aired outfide the houses, Unh in 
winter and in sommer. A custom especiAlly worthy of praise is that the 
Idtchoiy which b often t|ie over^pulated dvefling-room during the winter, 
is scarcely anywhere in use during the summer. About midsummer the 
kitchen undergoes a most thorough deaning, both floor and ceiling being 
rqwinted and the open fireplace freshly whitew^bed. The family mo>^es 
out into a smaller so-called summer-room, or endeavors to find cooler 
sleeping-fdaoes in the attics or elsewhere, not returning to the old dwdling- 
room before the begjnning <^ autumn. 

The personal hygiene among the population here, as among the inhabi- 
tants in the other country districts of Sweden, leaves much to be ilesired. 
Baths are seldom taken during the long winter, though it would seem to 
be no very difficult matter to create a desire for bathing if only suitable 
means could be offered. At the establishment ** Halsan " there was starteii, 
during the autumn of 1906, a so-called Finnish bath-house, which since that 
date has been open twice a week, free for the people lix-ing within the ex- 
perimental district, who have availed themselves of the opportunity to the 
extent of more than 4000 baths. 

The necessity of caution with regard to the expectorated matter b not 
grasped with clearness, by the older members of the population at least. 
The habit of spitting on the floor b not unknown. Ver>' much has been said 
on the subject, and sputum-cups for the night-stand or for attachment to 
the wan have been distributed, usually gratb, in many homes where there 
were tuberculous patients. In addition to thb, a little pamphlet issueil by 
the Swedish National Association, and entitled *' Advice to Consumpti^'es," 
etc., has been left at every bouse. Thb pamphlet b usually found fasteneii 
up on the kitchen wall. 

The food of the people of the district offers little variation, and its prepara- 
tion b very primitive. Its chief constituents are: potatoes, breail, milk, 
and coffee; fish (salt or dried) rarely, and meat. 

The following b a typical bill of fare for one day: 

5 A. M.: Coffee, usually without any bread. 
7 A. M.: Breakfast, consbting of bread, milk and potatoes, 
or salt fish. 
11 to 11.30 A. M.: Dinner, consbting of potatoes, bread and butter, 
gruel, and sometimes fresh meat or bacon. 
3 p. M.: Bread and milk (sour milk), 
6 to 7 p. M. : Supper, consbting of porridge and milk. 

Coffee b taken three or four times daily, usually without any bread, 
several cups being drunk on nearly every occasion. 

Since nearly the same meals are repeated day after day, they become 
very monotonous, and it may be said with certainty that the population 
b insufficiently nourished, a condition predbposing to tuberculoeb. Of 



^V 314 BOCTH INTERNATIONAL CONGRESS ON TUBERCU1X>f%IS. ^^^H 


^M course, the experimental estabiishment has tried to bring about some im- H 


^H provement in thia matter. A teacber of cookery has b^n appointed super- ^M 


^M intendent of the kitchen at the Institute, and young women have been taken ^ 


^H as pupils and have received three months' training in cookery, in atldition 


^M to free board and lodging at "Halsan," In this way It is hoped that a 


^H knowledge of cookeiy will spread, which, although plain, will be more 


^M rational and offer more variety than that hitherto in use. In consequence . 


^M of want of room, only three pupils can be received at a time, so that one of ■ 


^B the hoped-for designs is to establish a large school of cookery, ^M 


^^ The institution has been making gpeclal efforts to introduce a rational ^M 


^H method of bringing up babies* As a rule, children are nourished during the 


^m first year by the mothera' milk, but in those cases where this is not ptw^sible, ^ 


^B the plan of artificial nourishment is usually very unsatisfactory. In a<Idi- ^M 


^H tion to this, the babies are anxiously kept indoors, they are too warmly ^M 


^H ela(J, and they often look pale and weak. Neither is sufficient care taken to ^M 


^M protect babies from infection by members of the family who may be suffer- ^M 


^H ing from tuberculosis. Not infrequently these okler people, with violent 


^H coughfij ' * in order that they may be of some use/^ are entrusted with the care ^J 


^H of infants. In some cases, such old persons suffering from tuberculosis have ^M 


^M been received for a time at the Institute in order that they may, if poaaible, H 


^H learn to be careful with respect to expectorated matter. ^H 




AlVTHAB. 


EuK£fl. 


LanohXb, 
Altik. 


Tqtai» ^H 


^H Numljer of inhabitants ..... ^ , , .....,,. 


3S1 


SS5 


1027 


2293 H 


^H Number examined . 


336 


573 


589 


1498 ■ 


^^M Of which number adultj , , , , ,..,,,. , 


210 
126 


335 

2rw 


376 
213 


921 H 
577 H 


^H Of which children midet lifteea 


^^M Among the adults: 










^^^^^H^ Tuberculosa ,,,,,.,, «.....,,, 


41 
23 


52 
36 


45 
29 


138 H 
88 H 


^^^^H Doubtful CAaea ............................ 


^^^^F Tuberculoeis in gloDda 


' 24 


43 


28 


■ 


^V , Among the chUdren; 








■ 


^^H 'ruberculoais ..,,,> , . ^ 


8 
7Q 


S 
102 


7 
119 


23 ■ 
357 ■ 


^H TulK?rru[o^ls in inlands 


^H Total number of ca»ea: 










^^^1 l^uberculoaJB ,,*«»._..»... ^. ...<.... ....*<■ 


49 
23 

100 


60 
36 

205 


52 

29 

147 


161 ^^1 
452 ^^H 


^^H Doubtful cases , , 


^^V Tuberculosis in gWds , 


^H Qivu«a A Pebc£ntaoe of: ^H 


^M AiJulU: 








^H 


^^^1 T ubercuJosis ,» •... 


19.5 

10.95 

11.4 


15.5 
lOJ 

12.8 


11.97 
7J0 

7-44 


14.98 H 

9,55 ■ 

10.31 ^M 


^^^^^_ 1 )oubtf ul cases - 


^^^^^H Tubeft'uloidiii In etimds . . . * . ■ 


^^^H Children: 


^^^f TubercuJoBLEi ..,.., .>,,., 


6,3 
60.3 


3.3 
68,06 


3.:^ 

55.86 


3.38^^1 

6].87^^^H 


^^H TubcrettlnKiH in glunds 


^H Of the total number e^Eamined: 








^^^^H 


^^H TuLHTCiilosia. 


U,5S 
6.d 


10.4 

6.2 


8.82 
4.92 


^1 


^^M Doubtful cases ............................ 


^H Tuberculosis in glands 


29.7 


36.7 


24.95 


30.2 H 





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I ^fi/tifytary t»t/>rrrulr»t»- 



THE INSTITUTION " HAINAN " (HEALTH) AND ITS WORK. — NEANDKB. 315 

During the year 1906, Dr. E. Danielsson, who was then the leader of the 
work, made a medical examination of the population in as complete and ex- 
tensive a manner as possible. Of the 2293 registered inhabitants, 1498 were 
examined. The result of the examination will be seen by glancing at the 
table on page 314. 

From these figures it will be seen that tuberculosis is enormously spread 
within the district chosen for the experiments. 

In April, 1908, another examination of the inhabitants was commenced, 
which was concluded in the village of Antnas at the time of writing. The 
result of this examination is given here and, for the sake of comparison, we 
reprint the figures from that made in 1906. 



Antnab. 



Number of inhabitants 

Number examined 

Of which number adults 

Of which number children under fifteen 
AdulU: 

Tuberculosis 

Doubtful cases 

Tuberculosis in glands 

Children: 

Tuberculosis 

Doubtful cases 

Tuberculosis in glands 

Total number of cases: 

Tuberciilosis 

Doubtful cases 

Tuberculosis in glands 



1908. 



GiviNO A Percentaoe op: 



Adults: 

Tuberculosis 

Doubtful cases 

Tuberculosis in glands 

Children: 

Tuberculosis 

Doubtful cases 

Tuberculosis in glands 

Percentage of total number examined: 

Tuberculosis 

Doubtful cases 

Tuberculosis in glands 



1006. 



393 
359 
208 
151 


381 
336 
210 
126 


45 
16 
12 


41 

23 
24 


9 

1 

76 


8 
76 


54 

17 
87 


49 
23 

100 


21.1 

7.7 
5.8 


19.5 

10.95 

11.4 


5.9 
0.66 
49.7 


6.3 
60.3 


15.0 

4.7 

24.0 


14.58 
6.9 

29.7 



The greatest difference shown by these two examinations may be noticed 
under the heading of "Tuberculosis in glands among children," where the 
figure seems to have dropped from 60.3 per cent, in the year 1906, to 49.7 
per cent, in 1908. Possibly this difference may partly be explained by the 
fact that the two examinations were carried out by different doctors, although 
the latter endeavored as far as possible to follow the same views as his pred- 
ecessor. The decrease, however, may be regarded as the visible effect of 



316 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 

efforts made chiefly during the last two years to teach the parents how to 
treat their children rationally, by seeing that they obtain fresh air, sun, and 
more nourishing food. 

As regards the 49 persons who were re^stered under the heading " Tuber^ 
culosis" (that is to say, were slightly infected) at the examination of 1906, 
the last examination has shown: 

Tuberculosis 39 

Dead 6 

Doubtful cases 2 

Not examined (away from home) 2 

49 

The 23 persons who were roistered in 1906 as "Doubtful Cases" were 
noted in the examination of 1908 as follows: 

Doubtful cases 12 

Tuberculosis 7 

Without symptoms 3 

Dead 1 

23 

The examination of 1906 found 100 persons in Antnas suffering from 
tuberculosis in the glands (24 adults and 76 children). In 190S they were 
registered as follows: 





Al>ULTS. 


CHXU>mBH. 


Tuberculosis in glands 


10 

*i 

8 
2 
3 


56 


Tuberculosis 


1 


Doubtful cases 




Without symptoms 


19 


Dead 




Not examined 








Sum 


24 


76 







The frequency of consumption is made clear by the diagram on page 317, 
which gives the percentage of consumptives among those examined and 
arranged in groups, each group being a ten-year-age-period. A glance at 
this will show the comparatively high percentage of elderly persons suffering 
from tuberculosis. These aged victims of chronic consumption have, as a 
rule, a cough accompanied with abundant expectoration, and feel "a heavi- 
ness on the chest/' but are otherwise fairly active and fit for work. They are 
of great importance, partly because it is so difficult to make them adopt mod- 
em ideas of cleanliness and precaution in dealing with their expectoration, 
and on account of the opposition they generally offer to reforms in the home; 
above all, to the removal of the so-called cupboard-beds and, partly, because 



THE INSnTUnON "HALBAN" (HEAWH) and its work. — NEANDER. 317 

the other members of the family do the heavy work, leaving them to look 
after the youngest children, with whom they often share their beds. 

The frequency of tuberculosis in the glands is shown by the diagram on 
page 318. 





r- 




r 








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The frequency of tuberculosis of the lungs in Antnfis, according to investi^ions 
made 1908, expressed in percentage of the number of persons examined withm each 
age-class of ten years. 



The population of Antnas b divided into 76 households (families), 
of the households will be seen from the following figures: 



The 



12 members , 

11 

10 

9 

8 

7 

6 

6 

4 

3 

2 

1 member 





1 family 


2famibes 


3 


t 


5 


t 


10 


t 


10 


t 


9 


f 


12 


t 


9 


€ 


8 


t 


5 " 


76 fan 


ilies 



318 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 

The number of young children (under fifteen) in the different families: 

8 children m 1 familjr 

7 " in 3 famibeB 

6 " in 2 " 

5 " in 4 " 

4 " in 8 " 

3 " in 9 " 

2 " in 9 " 

1 child in 15 " 

" in 25 " 

76 families 



























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The frequency of tuberculosis of the glands in Antnfts, according to investigations 
made in 1908, expressed in percentage of numb^ of persons examined within each 
age-class of two yeais. 

Seventy-five of these families have been examined as carefully as posable. 
Only one family has been prevented from appearing for examination. 

Tuberculosis in some form or other has been found in 61 families out of 
the 75, gi^•ing a percentage of 81.33 per cent. 

Out of the 14 families in which no tuberculosis has been found, only 9. 
however, have imdergone a thorough examination, one or more members 
of the remaining five families having be^i unable to appear for examination. 
Thu^ only the aforementioned 9 households can with certainty be r^arded 
as free from tuberculous. 

The examination showed that the size of these 9 families was as follows. 



7 members in I family 

5 " in 1 

4 " in 1 

3 ■ in 1 

2 in 2 familMWi 

1 member in 3 " 



THB INSTITDTION "HAMAN" (HBALTH) AND ITS WORK. — NEANDBR. 319 

The remaining 61 families have thus shown signs of tuberculosis in some 
form or other among their members. There were: 

Tuberculoeis in lungs (or doubtful cases) in 19 families 

Tuberculosis in dands in 16 " 

Tuberculosis in both glands and lungs. 27 " 

61 families 

It is, of course, clear that, outside of the purely practical social-hygienic 
work of the Institute, it is possible to contribute something to the solution of 
the many theoretical problems involved in the tuberculosis question. Thus, 
for example, interesting observations concerning the connection between 
human and bovine tuberculosis could, a priori, be expected from this dis- 
tricty where human tuberculosis exists in a most unusual degree and where 
the people are brought into close daily contact with cattle. The matter 
will probably form the subject of a detailed report on some other occasion. 
It will here be sufficient to mention that, during the year 1907, examinations 
for tuberculosis were carried out on 263 cattle, on 42 farms, and that the 
examinations gave the unexpected result that not a single animal showed 
any reaction. It would thus seem that within this district, where human 
tuberculosis is spread enormously, and where for many generations back 
both the full-grown cattle and the calves have been looked after by tubercu- 
lous persons who have never been careful about their expectoration, there 
appears to be a total absence of bovine tuberculosis. 

Another observation made during the examination of the district is that 
certain forms of tuberculosis are rare. It would seem as if the cases locaUzed 
in the lymphatic glands of the throat and in the lungs are almost the only 
ones existing. The examination last held at Antnas dealt with about 400 
persons, among whom there were found 150 certain or suspected cases of 
tuberculosis of the lungs or of the Ijonphatic glands of the throat, but there 
was discovered only one gonitis. In the village of Ersnas, where pulmonary 
and glandular tuberculosis seem to be of the same frequency as at Antnas, 
there has been found of other forms only one spina ventosa. 

Such, in brief, is the story of that part of the work of the Swedish National 
Association which is called "the social-hygienic experiment in the parish 
of Lower Lulea." Even if the hope is excluded of our ever being able to 
carry on a struggle against tuberculosis in the nation as a whole with the 
same intensity as in that far-off northern district, still it may be expected 
that from such an experiment, some hints may be gained of the proper meth- 
ods for attaining that end which at present seems to be the primary one, 
viz., the possibility for those who now are in their tenderest infancy to be 
better protected, even in their earliest years, than their fathers were, from 
an enemy which has already deprived their country of far too much working- 
power and has laid all too many of their forefathers in untimely graves. 



RELATION OF TUBERCULOSIS TO CRIME AND THE 
INCARCERATED CRIMINAL, 



By Julhts B. RansoMp M.D., 

Fhyudon. dlBtoD FtiaoD, New York. 



Chime and Its Relation to Tubehculosis. 

I approach this subject of the relation of tuberculosis to crime with a 
great deal of misgiving, betause I believe there are no well-authenlicat^l 
data upon which we may base a convincing statement as to just what part 
tuberculosis plays in the causation of crime. That the psychic disturbances 
wrought, and the enervating effects of the presence of the toxins of tul^rcu- 
loais, may distuH) the mental equilibrium and throw the balance to perhaps 
an inherent tendency toward crime, is undoubtedly true in a measure and 
more especially so when the higher elements of character are lacking and 
when there is an absence of well-developed inhibitory power. 

That there ia some relation between tuberculosis and crime has come to 
be well accepted by those who have made a study of the environment txom 
which criminala largely come. But just what significance it may have as 
a factor is as yet, I believe, undetermined. That so large a percentage of 
the criminal population is infected in some degree with tuberculosis means 
more than the mere effect of prison environment. It means that tubercu- 
losis is rife among the criminal classes. It means, therefore, that the classes 
from which criminals largely come are especially exposed to the influences 
that make for the development of the disease. 

Tuberculosis is a disease of the life complicated, and is primariJy not a 
disease of the upper stratum of society^ but essentially of tiie substratum. 
It develops and extends not from above downward, but from below upward. 
It finds its richest sustenance in the lowest wjilks of life, in dark tenemetits, 
in the damp, narrow streets of large cities, and in the unsanitary habitations 
of the poor* VVbile no age, race, or class is exempt from the disejise, it would 
be short-lived, Indeed, if these conditions of ill living were eliminated* We 
believe, therefore, that the child reared in the unsanitary home where tuber- 
culosis is present comes to the full stature of adult life with his perceptions 
more or less dulled, and his mental vision more or less obscured, from the 
effects of the disease. More than that r this incapacity is transiiuttetl to his 
offspring, and if the parent with age and experience finds himself unable 

320 



I 



TUBERCULOSIS AND CRIME. — RANSOM. 321 

to cope with the world because of the yoke this disease has placed upon him, 
bow much less able is the child to sustain the conflict? With a certain 
inherited susceptibility to infection, surrounded by the demoralizing in- 
fluences that disease brings into the home, it is not strange that he grows up 
with criminal impulses, and becomes impotent to withstand the flood of evil 
that flows in on him. It is not, therefore, surprising to find the child of a tu- 
berculous parent at an early age committed to some reformatory institution. 

While we wish to make it perfectly clear that we do not believe that 
tuberculosis necessarily implies criminality, we repeat that the enervating 
effects due to its presence upon a person who has already been subjected to 
the retarding and blasting influence of an unsanitary and immoral environ- 
ment, will render him less able to combat those naturally destructive ten- 
dencies to which man is heir, and which often lead to criminal acts. 

The part that the work of preventing and arresting tuberculosis is playing 
in the problem of lessening crime and the number of criminals is a most 
important one. We know that a considerable number of criminals owe 
their downfall to moral weakness consequent upon mental or physical 
disability caused by disapation or disease. It is estimated that there are 
in Greater New York from 20,000 to 30,000 cases of tuberculosis, or 7 per 
cent, of the population. These facts become significant of the importance 
of tuberculosis as a factor in the production of crime, when it is admitted 
that 15 to 16 per cent, of the populations of the prisons of the State of New 
York are infected with the disease. 

This wide disproportion between the percentage of tuberculous cases in 
the population of the city of New York and the percentage in the prison 
population of the State cannot be explained by the mere effects of prison 
environment, but is undoubtedly largely due to the fact of their coming, 
as they do, from those areas of population in which tuberculosis is most 
rife. This is also reinforced by the fact that the large majority of the tuber- 
culoias population of the prisons of the State of New York comes from 
Greater New York. 

We believe, therefore, that tuberculosis may be a cause of crime, and in 
many instances is a determining factor in the causation of crime. 

Relation of Tuberculosis to the Incarcerated Criminal. 
Of the relation of tuberculosis to the incarcerated criminal much more 
can be said, based upon conclusive data; and while the fact of confinement 
cannot account entirely for the large number of cases in the prison population, 
yet there is ample evidence that there is a decided relation between such 
environment and the development of tuberculosis. Statistics go to show 
that a very large percentage of penal populations is infected with the disease, 
and that 50 to 60 per cent, of all deaths in prison are due to it. 

VOL. Ill — 11 



322 



SIXTH IHTEBN.ATIONAI, CONGRESS ON TUBERCULOSIS. 



The average ages of commitment to penal institutions predispose some- 
what to tuberculous; the abridgement of liberty, the mental strain conse- 
quent upon protracted cionfinemcDt, and the neceasaiy restrictiona as to 
the amount of outKloor living, the lack of fresh air and sunshine^ the moral 
degradaljon, seLf-cx)nsciousness, and monotony — all th^e tend to render 
the Incarcerated criminal susceptible to infection. It needs no lengthy 
di^ertatlon to convince any one that tuberculosis is essentially the one 
disease that criminal populations have to fear, both from health and economic 
standpoints. 

As great as is the need, and broad as is the field, t-hat penal institutions 
ofiTer for the work of extermination, comparatively few elfective measures 
have as yet been instituted. 

la making my report to the BSgbth International Prison Congre® in 
1905, based upon the reports of 77 institutions of the United States, em- 
bracing 38 States and 2 territories, with a total prison population of 44,285, 
1 found that but few States had done any effective work in the special 
treatment of tuberculosis in penal institutions. Referring, however^ to 
the most recent director)" of the National Association for the Study and 
Prevention of Tuberculosis, I find that 21 institutitjns have in some degree 
taken steps properly to meet the situation. There is an awakening to the 
fact that aggresd^ve, determioed, and per^stent work is nece^aiy if the 
p^ial institutions are to be rid of this scourge. 

To illustrate the possibilities in this direction I csmnot do better, it 
seems to me, than pve you a short fcdstory of the work that is going on at 
Ointon Prison, New York. 

History op Clinton Prison* 

Clinton Prison is located on the southern slope of a northeastern spur 
of the Adirondack Mount^uns, and has an elevation of 1500 feet above the 
Bea-leveL The institution is located in the midst of a large tract of State 
land, several acres of which are under cultivation for the purpoae of nusing 
v^etables for the institution. The water-supply is obtained from mountain 
springs, and the institution has a modem sewerage system. 

In my annual report of 1S90 I reported 75 per cent, of the deaths of that 
year to be due to tuberculous. The conditions were even worae in the other 
prisons of the State. In one prison alone 44 deaths were reported in one 
3rear as due to tuberculosis; and during the period of five years from 1S91 
to 1895 inclusive, there were reported 253 deaths from tuberculosis ill the 
three prisons : viz.. Sing Sing, S6; Auburn, 133 j Clinton, 34. 

At this time began the more or less irr^ular transfer of the more ad- 
V'anced cases to Clinton Prison^ and a special line of treatment was adopted 
that resulted in a great reduction of the death-rate &om tuberculosb. The 



I 




TUBERCULOSIS AND CRIME. — RANSOM. 323 

five years from 1896 to 1901 inclusive showed a total death-rate of but 72 
in the three prisons, as against 253 in the previous period of five years — a 
gun of 71 per cent. 

In 1893 a special ward was set aside for the treatment of tuberculous 
patients; this ward accommodated only 11 patients, and not until 1901, 
under the present superintendent, was anything in the way of systematic 
work in this direction begun. Through his efforts that year an appropriation 
of $2500 was obtained, and a special ward, accommodating 43 patients, was 
built and went into operation July 8, 1902, giving a total capacity of 54 
patients receiving special treatment for tuberculosis at that time. The 
results were so favorable that in 1906 a ward was completed that accommo- 
dated 105 patients, giving a total bed capacity of 159. This now constitutes 
what is known as the Clinton Prison Tuberculosis Hospital Annex. The 
support and income of the hospital are obtained entirely by State appro- 
priation. 

The Tuberculosis Hospital Annex consists of three extensions to the main 
hospital, radiating from a central court, and occup3diig a floor space of 
20,000 square feet. The south extension, 75 by 65 feet, is devoted to the 
treatment of far-advanced cases, and accommodates over 50 patients. The 
eastern extension, 20 by 55 feet, forms the special diet-kitchen and labora- 
tory, while the northeastern extension, 70 by 150 feet, is devoted to the 
treatment of cases in the early and somewhat advanced stages. 

The main ward in constructed with a high, vaulted-roof ceiling, extended 
upward by a clearstory to a distance of 55 feet, thus affording a large air 
and light space. The building is windowed on all sides as closely as safe 
architecture permits, the clearstory being entirely set with windows opening 
and closing by a mechanical device. In connection with this ward are 
modem lavatories, toilet facilities for spray and tub baths, rooms equipped 
for the treatment of patients by the incandescent and arc lights, and a 
difflnfecting room. 

The ward has a hard-wood floor, waxed and polished, and is heated by 
steam and lighted by electricity. Adjoining this ward is a dining-room 
that will seat 120 persons, the food for whom is supplied from the special 
diet-kitchen. The ward is cheerful, light, and airy, and admirably meets 
the purpose for which it was designed. Each patient in this ward has a 
white enameled-iron bed furnished with woven wire springs, fiber mattress, 
feather pillow, sheets, woolen blankets, and a counterpane. At the head of 
each bed is a white enameled-steel bedside table, with glass top and steel 
shelf, while at the foot is a comfortable arm-chair. The patients are also 
supplied with a porcelain-lined drinking-cup and a different form of sputum- 
cup. The ward devoted to the treatment of the fai^advanced cases is 
similar in most respects. 



92i axTB imrnxMSKm^M. 



TV <S«(-4citdben. an inqwftam £a«tor in dne vmIl is eqapped with s 
tasstd4f3fA Freocfa steel nn^, a br^ porDebm-fined ifffiigfiah ir, and all 

tfa» rtfwajT aynMir r^tfiMwg fnr p w^i>ying fnriH m^w^ ml iiig trt mntfam iwfthnrfw- 

Patietzu are admittod to thb hoqiital br <firect conmntment faom court 
to the prison, bat br far the larger number ai« tranrferTed on older of the 
guyerimeojent of State prisoDS from other penal insthotkios of the State. 

On leoeipt of a tubermloos subject be is giTen a ipedal cxandnatian, 
zoiefudini^ the ophthalmo-tubereulin Cafanette) test, and a m ici aa c opical 
<?yaiT«nation is made of the sputum, blood, and mine; a careful Fceocd cf 
\m or>{K!itkm is made and kept. He is placed in the tobercnlosis hoepital, 
ajvl isolated from the general prison population. When the <fi9eaae is 
arrested or apparently cured, he is placed at fi^t labor untfl be is diachargBd 
from prison. 

The number of patients transferred to Clinton Prison for special treat- 
ment anoe the b^inning of this woric to Juhr 31, 1906, was 1459. From 
October 31, 1907, to Juh' 31, 1908, 412 cases have been treated. Of these, 
2^ were treated in the tubercukisis hospital and 82 in invafid company 
celLf, Of the 412 cases, 83 have been discharged from prison and treatment* 

The condition on admittance of the 83 discharged patients was: 

EmiiftUmt 34 

Adv»neea 56 

FsTHulvaiiced 13 

Toul ua 

The condition of the 83 patients wbrai discharged was: 

Apparcntljr cond 18 

Vmrntu urvmUd 22 

Imprr/v«d 30 

N«SEaiv« 4 

Died from tubertuloni tt 

TnuMf«rred to 8uUe hospital 3 

ToUl 83 

The percentage of deaths from tuberculosis on the tuberculous pt^ulaticm 
wais 0.014 plus. 

On July 31, 1908, there were 329 cases oi tuberculosis in the institution. 
Of these, 144 are under special treatment in the tuberculosis ho^italy ^nd 
185 are engaged in suitable employment about the institution. 

The condition of the 329 patients under treatment was: 

Eftriy rtage 127 

Advftnoed 125 

Far-«dvaneed 3g 

Quicsoent '..'.'.'..'.'.'..'....'...[.'. 30 

To« ^ 



TUBERCULOSIS AND CRIME. — RANSOM. 325 

The condition of the 6 patients dying from tuberculosis on admittance 
was: 

Early st^e 2 

Advanced. 1 

Far-advanced 3 

Total 6 

So far as possible modem outdoor treatment is applied, the hospital 
patients spending the whole of the prison day outdoors. 

Special clothing (such as overcoats, etc.) is provided for these men in 
the cold weather. They are fed a generous mixed diet, in which proteids, 
such as fresh meats, eggs, etc., predominate. All patients receive milk 
daily, and, on order of the physician, special or additional diet is provided. 

A library, containing over 1000 volumes, is given over for the exclusive 
use of the tuberculous population of the hospital. 

Results. 

The work in the prisons of the State of New York has progressed to a 
point where highly satisfactory results are being obtained. These results 
are being shown in the reduction of the death-rate from tuberculosis in the 
several prisons of the State to a minimum, as compared with former times. 
Furthermore, the personnel of the men, in habits and physique, has been 
improved, so that on their discharge they are in a condition to earn a living. 
If no measures for their relief had been adopted, these men would either 
have died in prison or have gone out in ill health, only to become paupers 
or dependents and carriers of infection. 

Though the work has thus been placed upon a substantial footing, it 
is still in its infancy. It is hoped to extend it and increase its capacity to a 
point that will admit of the transfer of all cases of tuberculosis in all the 
penal institutions of the State, including the jails; for it is during the jail 
life of the prisoner that infection is most likely to take place. 

Recommendations. 
The first step in the intelligent and effective treatment of the tuberculous 
prisoner b to introduce into all institutions systematic methods of examina- 
tion that will make not only possible, but render as certain as may be, the 
early diagnosis of the disease. In my judgment, a compulsory law should 
be enacted in every State that will make mandatory upon the physician of 
every juvenile penal institution, jail, penitentiary, or prison the examination 
of every person admitted to the institution of which he is in charge, with a 
view to the detection of the disease at the earliest moment, as well as at 
any stage in which it may at the time exist. 



326 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



Properly printed blanks should be furnished, indicating how such ex- 
aminations are to be conducted. If, on examination, a jail physician shall 
find an inmate to be suffering from tuberculosis, he shall at once fill out this 
blank and file a copy with the district-attorney, with a view to hast-ening 
the trial of the infected person and effecting his transfer to the institution 
wliere he may receive the benefits of special provisions made for him by the 
State. In cases of conviction, a copy of this certificate should accompany 
the commitment in every case. The recognition of the disease is the key 
to the situation, and upon it must rest all subsequent effort looking to lis 
prevention and the proper treatment of those already infected. 

The means that I believe most likely to secure the best possible results 
may he briefly summariaed as follows: 

L Improved construction, housing, and working environment. 

2. The recognition of the prisoner's receptivity to infection. 

3. The absolute separation from the prison population proper of all 
tuberculous subjects. 

4. Special wards for the treatment of all active cases. 

5. A compulsory law, enforcing the examination of every criminal ad- 
mitted to every penal institution, for the purpose of facilitating an early 
detection of the disease. 

6. The construction, in every State^ of a special hospital or sanatorium, 
and the transfer thereto of all tuberculous cases from all the penal insti- 
tutions. 

7. Provisiona for outdoor employment, such as gardening, light fann- 
ing, etc. 

There is one phase of the work that is not restricted, I believCp to penal 
institutions, but it is a generally felt want; this is the providing of employ- 
ment for such cases as are so far improved, arrested, or cured as to be able 
to do light work. My personal observation of those whom I have been able 
to put at properly graduated work, after the disease is in a state of arrest, 
has been that they have always done much better than those who remain 
in idleness. 

There comes a time in the treatment of tuberculosis when employment 
for mind and body is as important as outdoor life is in the earlier phase of 
the treatmeat. I believe that there is no feature of the tuberculosis work 
tliat demands more careful consideration than this of providing work for 
the tuberculous patient. 

It is coming to be recognized, by nearly all those engaged in prison work, 
that not only are these things neceasary to the prevention and cure of a 
special disease, but they are essential to a sound and satisfactory penal 
administration, for it cannot be said that tlie presence, in an institution, of 
a population afflicted in any degree with a communicable disease, which 



TUBERCULOSIS AND CRIME. — RANSOM. 327 

impairs the usefulness of so many inmates, is compatible with a prosperous 
and economic administration. 

Possibilities for Research. 

One feature of the relation of tuberculosis to the incarcerated criminal 
that, I believe, has never received proper consideration is the possibilities 
for extended experimental work in connection with the tuberculosis hospitals 
of penal institutions. I mean by this the establishment, in connection 
with institutions having a large enough number of tuberculous subjects to 
make it practicable, of laboratories for the study of tuberculosis in the 
classi5ed human as well as in a comparative way in the lower animals. 

Just at this point in the study and prevention of tuberculosis it would 
seem that a much more thorough and exhaustive study in the human than 
has yet been done is imperative. The difficulty all along has been, as I 
understand it — 

1. To obtain control of sufficiently large numbers to make possible 
intelligent comparative work. 

2. The difficulty of obtaining groups of subjects permitting a comparative 
study extending over a number of months and years. 

3. The difficulty in controlling the habits, food, clotlung, hours of rest. 

4. The difficulty of getting subjects who are willing to imdergo this 
form of observation. 

In populations of tuberculosis sanatoriums connected with penal insti- 
tutions all these requirements exist. These populations are mostly of the ages 
most vulnerable to the disease, represent many different nationalities, and 
come from all sorts of social environments. There is a sufficient number 
of men to establish classification; their food, hours of labor, and of rest, 
their clothing, and nearly everything pertaining to their personnel is under 
the control of the management of the institution. 

Now, this control is a very important factor in the study of tuberculosis; 
and, in addition to this, I have always found that the tuberculous prisoner 
in nearly all cases is willing to submit himself to any line of experiment or 
treatment. It possesses a novelty for him, and gives him an opportunity 
for change; and these men often become enthusiastic over the study of the 
disease itself. 

Opportunities Afforded. 
I beUeve that the tuberculosis problem has reached a degree of solution 
where there remains much of hard work to be done. Much of the brush- 
wood has been cleared away, but we know that there is much more to deter- 
mine. There are great questions to be settled, theories to be controverted, 
and theories to be established. What better opportunity to study the num- 



jt3$ SIXTH INTERNATIONAL CONGBESS ON TUBERCITLOSIS. 

^^v;2:ji phases tlus disease presents, in its relation to the normal and abnonoal 
functions of the body to organic integrity and organic disint^ration; the 
rcTtvts of feeding and of fasting; the study of these complex features of the 
1>Iixk1, such as the opsonic index, the reaction of serums, and the whole questicHi 
of sorum-therapy and immunity; all the numerous physiological experiments 
th»t belong to the province of phyaolo^cal chemistry; and, in the realm 
of phj'sics, the effects of Ught, of pneumatic pressure, of vacuum, the x-ray, 
the various forms of light* and, lastly, the effects of climatological changes 
ut>on the blood-pressure, temperature, ptilse-rate, and many oth^ physiolog- 
ical processes? Here is the affonted opportunity for the study of different 
grou]>s of men separately and then compearing the results of the study to 
determine the bearing of isolated data upon a general result; and, in fact, 
the great opportunity is afforded for the testing of the value of therapeutic 
measures too numerous to mention. Not only this, but, what is well known 
to be fully as important as the investigations and studies themselves, namdy, 
the making of minute and exact records of the facts observed and thdr 
deduction into intelligent data. In institutions of this kind we have an 
abimdance of free labor capable of making accurate and minute records in 
relation to these experiments. 

Not only could we have this opportunity for the study of tuberculosis 
in (he human, but, in connection with such an institution, could be easily 
luaitiUiinoil, ivlso with free labor, an animal farm for the rearing of such 
AuimiUs as are found useful for experimental purposes. 

\\\Y scNTral >Tars I have been laboring to bring about the establishment 
y\| >^\ioh ;> l:OH>rntory in connection with the Tuberculosis Hospital of Clinton 
t>sAM>. whioh. so far jvs I know, is the largest tuberculosis hospital connected 
\\u:\ ;*»v> l^M^td insiUution in the coimtry. 

Un vnoN OK Tuberculosis to General Society, 

U ilv Oui m tvstnblished that tuberculosis is a factor of grave importance 

!u ivlau^yi Is* oHiuo mul the incarcerated criminal, we must then consider 

xUv" ij^uitujituv this Innirs to the general social order. Of what moment is 

i\ ' vM what intouvst is it to the general social body? Why should we 

^v' ; Mvi II v'uiMvlo prison walls? Is it really of so much importance to the 

V . . .;! ; uU ividv^^is work that it shoultl have the attention of a deliberative 

'..'.Iv Uko l^i^.* What matters it whether a penal population is scourged 

'\ ..:^•:s■u^v.^u^'* What matters it how many criminals meet death from 

' \ -. i.uu' v^iivn siud that the quicker a criminal dies, the better for 

^ V' vs ;(.;> i.-* v^H^u roUcved of the exjxinse of his maintenance. In 

• x.au '.li^^tiX and social ethics I should be wasting time should 

.■ s 1 .\- A' ^*^\^cuU*v^8 a statement as to the right of the prisoner 

, ..^\ is^iiuv^ x\( tht> lH)8sibilitie3 of his future usefulness. A 



TUBERCULOSIS AND CRIME. — RANSOM. 329 

little reflection, a little examination into the subject, will quickly convince 
any one with ordinary reasoning powers that it is of incalculable importance 
to the general social order, what the conditions of our criminal populations 
are with reference to the development and presence of tuberculosis. 

There are annually discharged from the penal institutions of the United 
States over 100,000 prisoners. Of this number, we find by reports and care- 
ful inquiry, that 25 per cent, are in some degree infected. These, upon 
leaving their respective institutions, become scattered throughout the coimty, 
many of them wandering from one place to another, living under unsanitary 
conditions, regardless of their personal needs, and often harboring a feeling 
of hostility to society. This annual host of infected individuab has in it the 
power to propagate and spread the disease to an incalculable degree; hiding, 
as they often do, from the officers of the law, living in sections of large cities 
where health conditions are favorable to the development of tuberculosis, 
they constitute a menace to the social order unequaled by any other class. 

We cannot estimate the possibility of infection that this vast army of 
discharged prisoners may possess; we cannot estimate just what share they 
may have had, and to just what degree they are responsible for the prevalence 
of this disease in our large cities and towns. It is not, therefore, alone for 
the sake of the healthy prison population that we make our plea, imperative 
though that is; nor is it for the economic advantage to our prison adminis- 
tration; but it is for the whole population — for all classes and conditions of 
men. And if this campaign against tuberculosis and its development is 
to succeed; if we are to annihilate this menace to human prosperity and 
happiness, every department of the social order must be well rid of the disease. 
A chain is no stronger than its weakest link, and ultimate success in this 
cause means not only the purging of the slums of large cities and the sani- 
tation of our homes, but it also means the reduction of the disease in our 
institutional life, especially in penal institutions. In pleading for the pris- 
oner I am pleading for the citizen; in pleading for the citizen I am pleading 
for the homes; in pleading for the eradication of tuberculosis in penal 
institutions I am pleading for its universal extermination. 



Relaci6n de la Tuberculosis con los Encarcelados. — (Ransom.) 
La significancia de la tuberculosis como un factor del crimen no estd bien 
determinada; la gran proporci6n de tuberculosos en las prisiones, y el hecho 
de que la mayor parte de estos casos provienen de los distritos infectados de 
la enfermedad, pudiera tomarse como ima indicaci6n de la relaci6n de la 
tuberculosis con el crimen. 

Los prisioneros tuberculosos representan una de las grandes amenazas 
al orden social en general. El convencimiento de este hecho, y el empren- 



330 



SIXTH INTERNATIOKAL COXGRES8 ON" TUBERCUDOSI8. 



dimiento de trabajos hacia este fin, son esenciales al bienestar de la comimidatl 
entira. La necesidad de una ley que haga obligatorio el exaroen de los pri- 
sioneros que se admiten en las cdrceles^ es abanlutamente necesaria* 

La historia del trabajo sobre la tuberculosis^ hecho en Clinto prison^demu- 
estra loa resultadoa ventajosoa obteDidos del tratamiento especial de Ins 
crimmalea enearcelados; las estadisticaa demuestran la diBminucidn de un 
71% en la mortalidatl de los tuberculosoe en las clircetes de New York. 

Muchas ventajas pueden aacarse del e^tudio 6 investigacioD^ sobre la 
tuberculosis en las prisioaes. Los tubereulosos en las carceles ofrecen una 
oportunidad exepcional para los estudios ^ investigacion*^ prolougados y 
posee ventajas dificiles de eneontrarse en otras partes. 



Relation de la tuberculose avec le cnminel incarc^^. — (Raksom.) 

Le r6le de la tuberculose comme facteur dana les aetes criminels n*est pas 
enti^rement d^^termin^, bien que la grande proportion dea caa tubereuleux 
dans les prisons et le fait quo la plupart de ces caa viennent des centres Ln- 
fectea de la population semblaagent indiquer que la tuberculose ^t plus ou 
moins intimement ali^e au crime, 

Le prisonnier tuberculeux est une des plus grandcs menaceg physiques 
pour I'order social g^n^ral, 11 est esaentiel pour le bien-^tre de la cotumU' 
nautd en gindral de r^aliser ce fait et de fairs des efforts sp^iaux dans cettc 
direction. II est d'absolue n6cessitd de passer une loi rendant obligatoire 
Ve^camen de tous les prisormiers admis dans les prisons. 

L*histoire de la lutte contre la tuberculose dans la prison de Clinton 
foumit un excellent exemple des rfeultats avantageux que Ton peut obtenir 
par un traitement sp6}ial des criminels tuberculeux bcarc<5r&, I.es atatis- 
tiques des quinze demidre^ annfe montrent une reduction de 71 pour cent 
dans les caa de mort par tuberculose dans les prisons de New York, 

L'^tude de la tuberculose dans les prisons prfisente de nombreux avan- 
tflLges pour les recherches. La population tuberctdeuse des p^tenciers 
offre une opportunity exceHente pour des experiences et des etudes prolong6es 
et pr&ente des avantages que Ton ne saurait trouver £ulleurs. 



Beziehung der Tuberoilose zu Yerbieehen. — (Hansom,) 
Die Bedeutung der Tuberculose bei Verbreehen ist nicht gauz klargestellt, 
Der groase Procentsatz der Tuberculosen in Gefangnissen, und die Thatsachc, 
dass die meisten derartigen Falle aua inficirten Distrieten der Bevolkerung 
Bich recrutiren, konnte als An:zeige dienen, daas die Tuberculose in mehr oder 
weniger enger Beziehung zu Verbreehen steht. 

Die tuberculosen Verbrecher bilden sine grosse Gesuadheita-Bedrohung 



TUBERCOLOaiS AND CRIME. — TRANSOM. 331 

fur das Yolkswohl. Die Erkentniss dieser Thatsache und eine specielle 
Thati^eit nach dieser Richtung hin ist sehr wichtig fiir das Wohl des Volkes 
im allgemeinen. Cresetzlicher Zwang fiir Untersuchung eines jeden, der in 
eine Strafanstalt eiBgeliefeit wird, ist eine absolute Nothwendigkeit. 

Die Geschichte der Thatigkeit im Clinton Gefangniss, in Bezug auf Tuber- 
culoee, zeigt die vortheilhaften Resultate, welche durch eine specielle Behand- 
lung eingekerkerter tuberculoser Yerbrecher zu erreichen sind. Die Statistik 
der letzten 15 Jahre weist eine Herabsetzung der Sterblichkeitszahl der Tuber- 
culose in den Gefangnissen von New York von 71% auf. 

Das Studium der Tuberculose in Gefangnissen kann in mehrerer Bezie- 
hung von Vortheil sein. Die tuberculose Bevolkerung in Strafanstalten 
pebt die beste Gelegenheit fiir langerdauemde Experimente und Studien und 
bietet Vortheile in dieser Beziehung, die man nirgend anders vorfinden kann. 



STUDY OF THE RELATION OF PROSTITUTION TO 
TUBERCULOSIS. 

By Dr. J. Willoughby Ihwik, 

Philadelphia, Pd. 



I 



In making this iitvestigatian it waa our intention to find out the number 
of cases of tuberculosis in a given number of prostittites, and at the same 
time to find out as many facts as possible from a sociological atandpomt. 
While the work was extremely distasteful^ yet we feel that the few facts that 
we bring before you have a bearing upon this crusade. If it does nothing 
ebe but call the attention of the authorities to the amount of the disease 
among the prostitutes, we shall be well repaid. The majority of the ex- 
aminations were made in Philadelphia and Atlantic City, and the number 
under consideration is 218. In Philadelphia the majority were born and 
raised in that city; the gathering in Atlantic City was cosmopolitan, many 
having come from cities all over the United Stat^: for instanc^^ New York, 
Buffalo, Chicago, St. Louis, San Francisco^ Harrisburg, Pottstown, Reading. 

The question of race must naturally be considered in a paper of this 
character. The investigation showa the following distribution: Celt, 94; 
Hebrew, 22; Teuton, 83; Latin, 12; Slav, 3; Negro, 1; Mulatto,!; Chinese, 
1; American IndiaOj 1. With the exception of ten, all were bom in this 
eountiy. 

The Celtic race, of which the number is the greatest, gave historiea from 
all walks in life; from the rich families to the poor. In but one case out of 
the whole 218 under consideration was I able to get a history of true seduc- 
tion. This young woman, under the promise of marriage, became pregnant. 
Fearing the wrath of her parents, and being unable to find employraent, 
she drifted to the "Tenderloin.'^ 

Of the 218 cases examined, the age at the time of examination was as 
follows; From fifteen to twenty, 3; from twenty to twenty-five, 115; from 
twenty-five to thirty, 53; from thirty to thirty-five, 21; more than thirty- 
five, 2e. 

Age at Starting. — This life began, in 5 instances, between the ages thirteen 
and fifteen; in 95 instances, between fifteen and twenty; in 90 instances 
between twenty and twenty-five; in 21 instances, between twenty-five and 

332 



THE RELATION OF PROSTITUTION TO TUBERCULOSIS. — IRWIN. . 333 

thirty; in 5 instances, above the age of thirty. One woman began at 
forty-two. 

Years in Prostitution. — Thirty-two had been in the budness one year 
or less; 100 from one to five years; 48 from five to ten years; 27 from 
ten to fifteen years; 11 from fifteen to fifty years, one woman professing to 
have followed this vocation for half a century. 

The police officials state that the average length of time for a prostitute 
in the "Tenderloin" is between seven and eight years. That means one of 
four different things: she gives up practising, moves from the "Tenderloin" 
and is kept elsewhere, marries, or dies. Few return after five years. 

Social Condition, — Among these women there were, married, 45; single, 
©5; widows, 17; separated, 59. 

Remarkable b the number of married women. Upon inquiry we find 
that in over 90 per cent, of the cases it is with a full understanding on the 
part of the husband. To the moral person this no doubt is a shock, but the 
reason for it is that the men are mmnly pickpockets, gamblers, burglars, 
thugs, and drunkards. The other 10 per cent, were married in name only, 
lovers having ^ven their names to the prostitutes either in religious or dvil 
marriage so that they could more easily control their earnings. 

The majority of those separated had been prostitutes before marriage, 
and, finding married life more or less irksome, deserted their husbands or 
were deserted. 

Previous Occupation of Prostitutes, — ^Artist, 1; book-keeper, 4; cigar- 
maker, 11; clerk, 13; cloak model, 1; cook, 3; detective, 1; glove-maker, 
1; housework, 43; lady's maid, 1; laundress, 6; manicurists, 2; machine 
operator, 3; mill hands, 24; milliners, 3; nurse, 1; paper-box maker, 1; 
school-girl, 1; school-teacher, 1; seamstress, 17; stenographers, 2; tele- 
phone operator, 1; wwtress, 20; wire winder, 1; without any occupar 
tion, 56. 

Housework includes servants and those running a house; clerk includes 
salesgirls in department stores, etc. ; miU hands include weavers and finishers 
in mills of various descriptions. It will be noticed in the number of previous 
occupations that much of the work was laborious and of such character as 
to cause frequent mingling of the sexes, bringing the girls in more or less 
contact with men. On inquiry as to how they happened to enter this life, 
when they had occupations of honest labor which supported them, the an- 
swers most frequently given were "easy money"; "to acquire more dress 
and jewelry"; "the want of excitement"; and "to have a general good 
time." These answers also apply to those without previous occupation. 
Many came from homes of poor but honest people, the parents being perfectly 
willing to keep their daughters in idleness, but unable to dress them well. In 
several cases the girls came from families well off and well able to supply 



STl 



of C.i ■ 
time !^ 
VViiil.- 

wo li 
else ' 

aiiio' 
aniiii. 

Uiuli-l' 

hiLviti. 
BulT;,: 
t: 

char: I 

Hebn 

1; Ai; 

count r 
Thc 

al! walk 

the who: 

tion. Ti 
Fearing \ 
she drifts 
Of the 
follows: lY 
twenty-five 
five, 26. 

Age at Sta 
and f if toon; i 
between twenl 



^ . .\u3iSe ON TUBERCrU>3IS. 

-— , ut -iS prostitutes, 10 gave an un- 

urw,, 146: street-walkers, 48; secretly 

^w-uraikers speak for themselves; just a 

1 \vete employed during the day, 20 out 

o&'.ment stores and the rest at housework, 

„« tf K»urs of 8 and 12 in the evening, all 

.^ .^iiii hey were out ^isiting, at the theatre, 

_.c .. cnm^ing their earnings so as to supply 

. .. * *^-eral put it, to "sport on" during 

!v strvet-walkers and those in houses, 
^tus. '«tch two exceptions) to Chinamen 

^ a.^a*ur*lly acquired other ba^i habits, the 
. * A.*.. The following is the list, diviiled 

> .aw!* XT reference further on: 

^ .,.. .vw.^v and alcohol, 27; alcohol, 15: 

..,^1. * :%<vicco and opium, 4; tobacco, 

. ^.v. u^vi^.Ti. and cocain, 2; tobacco and 

.viiiTn. 1: total, 72. 

..,Mk.», V fc'.v>hol. 29; tobacco, 12; tobacco 
. , yiM*ix. •; lolvacco, alcohol, opium, and 
X ^.-caI. U12. 
_^. .1 J»»f— 10 tuberculous, 34 nontu- 

,, ^- •twsr ATWstedonce; 16, twice: 14. 

^^^ . 5a w* :wenty times. The object 

_^ . «««.«c w*5 to see if from the im- 

^ »*** -**wvl for the average earning 
ti .»c.tc *tme. The answer was as 

V!. »k -*a average, $10 a week; 22 

,^j^ *j*; :Seir maxima ranged from 

.^ *; uimmum wage, and for the.se 

^ . -^in..^: ^ gave $12.00 to $15.00 

^^^^. .'*»** wn $20.00 and $80.00; 16 

.*-*, ^ ui awrage income of $25.00 

. ,lj:i^ -iud for these the maxima 

-<..i,».k' .'^ Hvek; 40 clmmeil to re- 

« ii« :u.vuma in thLs group ran 



THE RELATION OF PROSTITUTION TO TUBERCULOSIS. — ^IRWIN. 335 

The prostitutes examined were from the highest to the lowest priced 
houses, from the large dwelling to the poor hovel ; hence the var3dng amounts 
given by them as earnings per week. Among those examined are included 
the proprietors, and the largest amoxmts quoted represent their proceeds for 
one week. Half from each patron goes to the "madam"; and, in those 
houses where wine is sold, the girls receive a percentage upon all wines which 
they induce their patrons to buy. Out of the prostitute's half she pays 
laundry and board and any other incidentals. Under the old *' check system *' 
in one house in Philadelphia, the lowest order of houses (50 cents), the 
earnings of the prostitutes after board, laundry, and half to ''madam" was 
^ven, were 17J cents per patron. 

Number of Patrons in Twenty-four Hours, — Concerning the number of 
patrons in twenty-four hours, the least numbers reported ranged from 1 to 20; 
the greatest numbers from 1 to 45. The tuberculous reported, in gei^eral, 
less numbers than the non-tuberculous, the maximum in this class being 25. 

In making the examinations to determine if the cases had tuberculosis, it 
was necessary for us to rely upon the ph3rsical examination, the history of 
conta^on, and the associated symptoms. In but five cases were we able to 
make an examination of the sputum, all of which were positive. Six reported 
that the physician in charge had had the sputum examined by the Board of 
Health and it had been pronounced positive. 

The examination of the chest to determine the stage of the disease is here 
put down according to Turban's scheme, which was as follows: First 
stage, 63; second, 18; third, 2; making 82 tuberculous out of 218 examina- 
tions. Of these, 4 cases in the first stage gave the hbtory of the disease 
and the physical examination showed disease arrested. All four women 
were practising secretly. Of the 218 examinations, all but 5 gave a fine 
family history. 

Family History of Contagion; Prostitutes Tuberculous, — Married: Four 
out of 20 gave family history of contagion, one possible house infection, and 
two would not give family history. Two consorts had tuberculosis, 
leaving 14 without either family history of contagion or contagion from con- 
sort. Sepamted: Eight out of 15 gave family history of contagion, one 
consort had tuberculosis, leaving 6 without either family history of contagion 
or contagion from consort. Widows: Four out of 7 gave family history of 
contagion, one consort had tuberculosis, leaving two without either family 
history of contagion or contagion from consort. Single: Sixteen out of 40 
gave family history of contagion, leaving 24, without family history of con- 
tagion, who had the disease; leaving 46 who are tuberculous who did not 
have history of contagion either in the family, consort, or house. 

Prevums Diseases that Greatly Predispose^ were reported as follows: 



.-. 111:1. 4 : ::uimTu. - . Vl'^'- -• pleurisy, and pneu- 

.*. ..." muli.-*!. ! f-imtiiL jpiiriinonia. and malaria. 

. 'yj^hv:! :ii*iiiri*7 . niLii.'r^. anil pneumonia^ 1; 

.;.\::;g 44 :.:«i.-iviilnit vrit^irr-zei without history 

.^- '^\<ti:\iUi r'*."»frri4iY»w.. iC'-Piriing to patient: 3, 
' io!V of weigh.".; t»4. p.L»aC±- According to his- 
■I'urisy; 2, hemorrtii^; 3-3, loss of weight; 64, 

"'r.w Haring Tuberculosis: Dght had hemor- 

N h.^.l oinijrh; 64 had expectoration in van-ing 

X '>iu- "i* tw^xvtoration; 23 had dyspnea; 28 had 

^ . ^;u: yvvit:*: 44 had leukorrhea; 16 had pain- 

v-r.:!vvsi5, 3S had leukorrhea; 7 had painful 

. . . ..^ \*v: :ho following miscarriages and pregnan- 

. .. .^y : hAd 2; 5 had 3; 2 had 5. Twenty-sLx 

. '.^ .^ I had 4; IhadS. 

\.«- .\is. .'W had I miscarriage; 12 had 2; 10 

^ - . Xid 9. Thirty-six had 1 full pregnancy; 

■I. iMsjiiatt* was tjikon into consideration — the 

wu. .::r, snd lartTO, The small room contained 

v^ ■, -JtV cubic fool, the medium from 1200 

. w :«^';rp more than 1500 cubic feet. The 

. .v^ -.' --'• - 'fiU>M\ are in the tables following. 

. __ ..*, • i.-vV* 8 

.. , ... • .NV» 2 

. _ ,;», * v*vv« 3 

,^ > wnV** 13 

' .^ <> iixi'ws 3 

I . ,; .. .:«.i.>«s 2 

ir- ., .„ » iAV« '^ 6 

i;, ' * -. -. •'^■■^'« 2 

^ ^ *^ • ;*xx*w* 15 

\\\.- ' !' ...s, • :»*^*«* 7 

^ -,. v-v* 3 

"^ ' : . ^^"^'i 8 

iv|»' ■ ,, . . .«,-;j«»v*'^ 1 

. jx-v*^ '"5 

awi ■■•■ ' ■ .^^ 3 

wen- ■'.,. -ajC*'* 1 

cciv(^ ' g2 

from > 



THE RELATION OF PROSTTrUTION TO TUBERCULOSIS. — IRWIN. 337 

NON-TUBERCULOUS. 

Small room, clean, well yentOated, one window 21 

clean poorlv ventilated, one window 2 

dirty, poorly ventilated, one window 3 

clean, poorly ventilated, one window 2 

clean, poorly ventilated, two windows 3 

dean, well ventilated, two windows 33 

clean, well ventilated, three windows 16 

Medium room, clean, well ventilated, one window 3 

" " clean, well ventilated, two windows 18 

" " clean, well ventilated, three windows 7 

" " dirty, poorly ventilated, three windows 1 

" " clean, well ventilated, four windows 2 

Large room, clean, well ventilated, one window 1 

" *' clean, well ventilated, two windows 16 

" " clean, well ventilated, three windows 8 

" " clean, well ventilated, four windows 1 

Total 137 

Of those arrested, 2 had hemorrhage from the excitement, and while in 
prison; 1 contracted pleurisy, and 6 after imprisonment from three to six 
months returned to their old haunts with a cough which they did not have 
preceding their arrest and imprisonment. Those that had hemorrhage, and 
the one that contracted pleurisy, had the disease before being arrested ; those 
who came out of prison with a cough probably contracted the disease there, 
as there was no history of family contagion, house infection, or of having 
acquired the disease from a lover. 

In one case arrest and imprisonment had a decidedly good effect, as the 
prostitute was addicted to smoking opium, and while in prison was tempo-^ 
rarily cured, returning to the old habit a few months after she returned 
to the "Tenderloin." 

We have seen that 46 of the tuberculous prostitutes did not have a history 
of contagion, either in the family, consort, or the house; that 44 were without 
previous history of diseases that greatly predispose them to tuberculosis. 
The question naturally arises, Whence came the contagion? It is not 
beyond the range of possibility that they acquired, or at least some of them 
acquired, the disease from their male associates. 

Many of them are kept in a poor condition from frequent abortions. The 
percentage of miscarriages or abortions in the tuberculous and non-tuber- 
culous are about the same; the percentage of full pregnancies are also about 
the same. We cannot lay the disease to the rooms, as it will be seen that but 
two occupied by the tuberculous were dirty and poorly ventilated and that 
but three clean rooms were poorly ventilated. In the non-tuberculous, three 
were dirty and poorly ventilated, and two which were clean were poorly 
ventilated. 

All, with the exception of two, claim to eat three meals a day, and the 
record of food was good throughout. 



338 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOBIS. 

When the subject of venereal diseases was touched upon, we always found 
difficulties, and it was only by the most careful and perastent questioning 
that we were able to get the admission from five that they had had gonorrhea; 
four had one attack before tuberculosis, one had two, one had one after 
acquiring tuberculosis. Those who had the disease before having tubercu- 
losis maintained that they had not seen good health since, and went so far 
as to declare that it was responiuble for the condition of their lungs. The 
one that had the attack after acquiring tuberculo^ was perfectly satisfied, 
and from the history I am, too, that the tuberculosis increased very rapidly 
from the onset of the gonorrhea. 

Five gave the history of chancroid without evidence of its having any- 
thing to do with the increase of tuberculosis. 

Two cases acquired syphilis after tuberculosa, and the history of each b 
one of rapid decline. 

A word about the Clunese prostitutes. Of 22, 12 were tuberculous. The 
surprise to me is that they all did not have the disease, consorting with the 
Chinamen in the living-rooms of the Chinamen, some of which were filthy and 
the majority poorly ventilated, all smoking opium and cigarettes, some with 
the cocain habit, and all drinking alcohol. The 12 who had the disease were 
the most deplorable looking wrecks I have ever seen. The non-tuberculous 
gave evidence of inhalation of opium smoke by the peculiar sonorous and 
sibilant r&les heard over the entire chest, from the apex of the lungs to the 
base. 



Das Verh&ltniss der Prostitution zur Tuberkulose. — (Irwin.) 

Bc! Vornahme dieser Untersuchungen lag die Absicht vor, die Zahl der 
Tul>crkul6son in einer gegebcnen Anzahl von Prostituirenden auszufinden, 
und zu^lcich sovicl als m6glich, vom soziologischen Standpimkte aus, 
iiit<!ras.sant« Thatsachcn zu sammeln. Die Zahl der Untersuchten betrug 
21S uiul (lie Untersuchungen wurden ausgefuhrt in Atlantic Qty und in 
riiiliidclphia. Die in Atlantic City Untersuchten gaben als ihre Heimath 
voiHcliiodorm Stadte in alien Theilen der Union an. Das Alter zur Zeit 
dor Unlorsuchung schwankto von 15 Jahren bis iiber 35; das Alter, in wel- 
choni (Ho Prostitution angefangen, wurde 13 bis 42 ang^eben; die in 
rrostitiitioii zuKobrachte Zeit wurde von 2 Monaten bis 50 Jahre angegeben. 
Die j^rosste Zahl gab als Alter zur Zeit der Untersuchung von IS bis 25 
J:ilin\ iin pmzoii 118. 192 fiuRcn dieses Leben im Alter von 13 bis 25 an; 
I.io iiii Altor von 20 Jahren. Die I^nge der Zeit, welche eine Prostituirte im 
*''P(Mul('il<nn" zubrinj^t, bctriigt im Mittel 7 bis 8 Jahre. 

I") \v:iro!i vorlioinithot; 95 waren ledig; 17 waren Wttwen; 59 waren 
f;r.s(iru'il(ii. iK)% der vorheiratheten Frauen haben das Leben gefuhrt 



TRK tuELAfuas oT nucwTTTrnox TO 7VBtMct:uMm,--imwtx, 339 



■B voOem EuivenUindiiuM ihrer EhefnAniMr, Die«eUjen wann 
TMrlwmfabe» SpMnr, Einbrecfaerr Mj&rd«r uod Biufer, Die aadena 
Ui% wwco mtr 4em Kaomr nairh voiMirathet, cLuntl <iM MituMcr ihren 
Vcnfiemt tcicfater erintroOimi iMonten. Von dm ipoichkviaien halmi die 
■MteD McfaMi ror der VerfaeinUbung pro«tituirt. 

Von den 2L8 Pro«lituirten bfttjen 10 unzweifelhafte Nymphomaiiie 
ccDgMtAoden. 

V<ia dm 218 F&llen haljen 174 Tuliak, Aloob^ Ofjium, ond Coeain, 
asftwoder jaJe» aliesn oder mefarere xui^ch, gebrMicht, Voo den 174 
wen 72 tul^erkulQft, 

Die Untenfturhuni^ der Psttenten xur Fe«tffteUuni^ deif 8udiun» der 
Knokfwit ijift OAch dem Turban Vhen Hcbema tttAlrt, und du l:>|pebnifli 
lit Col|eend«t: 63 im enten Hudium, 1:^ ini zweiten, I im dritten, — 
sanumnen ^2 F&lle von Tu^jerkuluNe sua 21H Untersucbteru V^/d <iieMen 
hfeljen 4 mm <km enrten fjUklium die Knuikbeit angecpefjen, und die pbyxi- 
lttJli«elje Untervucbunf^ icMrte, 'iw» 'lie Knuikbeit ziim HiiUsUaid iptrkonunen 
war, 32 icaljen Tu^^erkukwe in der Familie an; rj8 balten Krankbeitea 
durefaiEeaiacbt, weiche zur Tuberkulfjme veranL^en, wie Typhus, Pleu- 
ihk, FneunyjnM und Malaria. 

Die eriften Hym[fUtwe der Tu^^erkulone M den PrvMrtituirten waren, 
naeb ibren eiiEenen An^Ealjen suiroU alu nacb den Untennicbunipenf Pleuritia 
In 3 Fillen; I5lutun<c in 2; Gewicbtoverlufft in 13; Husten in 61—8 jpiben 
Bhttuniora an; 9, Uutticeff Hputum; 78, lluxten; 54, Aunrurf; 4, keinen 
Httrten; iH, keinen Au^nrurf; 2% Athemnrnh; 2H, Heuierkeit; 16, Frdvtein; 
34, HcbwiwM*; 44, wetMsen Fluw. In liexii% auf Febljpeburten und auflipo- 
traieerie HrbwanfrenfchAfum wunJen et^enfalbf I'ntennicbuniEen anipBrtellt und 
e* enc;^/ »^<r:h, 'Jj^kijK 'k'F IVxicfiUatz unUr Tu^^erkulOflen und Nicbttuljerku- 
Umsn un^atrfj&hr 'k'ng^.-l^jt; war 

Von fkriefi die arrftirt wurden, baljen 2, w&brend »e tm (jetAnfjum 
waren, vf>rt Aufr^irunf^ Blutunipen Ijekonunen, 1 zt% sicb eine Pleuritic 
su, und 6 kibhrteri rijihcb ibrer Kntlattflini^ auH dem CiefAnpUMi (wo me vrm 
3 biji M<>riateri zu«E(rt>racbt luktten) zu ibrer Ik^Krliaftij^ng zuruck, brachUm 
aber «r» Hu.>tler»l<ft'ien mil, wfrlcJiew we vor ilinrr ^jefaro^emtcbaft nicbt batten* 

iVi 4Q von (km (ynAtituirrmfJen TufjerkulOnen Iconnte in deren Kranken- 
gKaehicbten \uiiftit lfiriw«^)turM( auf Arufteckuni^muf^cbkcit wc«ier von 
ibren Familieri, suj*:U von ihren OefaJirten o'ler von den Ifausem ain^rtatirt 
wer'km. iV-i 44 %tinn auch k/rine KrankJjeiten, weiclie zur Tufjerkulo«e 
reranlaieen, voraas^trfcariK^fi. h'ji v^ durcbaUH riicbt unnvWdicb, dsum 
di«MrllATi, 'f^ifif inn 'Ilrffil von ihnen werajpiterw, uicb <lie Tubcrkul«*e durcb 
den Verkirbr r/iit trifjc'rkiil'>teri Minnem zufffU'tfem ba(ien, Wenn wir <ia« 
Lel^rfi, m-l'.^rf-- 'Ir'-wflf^rri Mtnm, in IVnracbt ziet^m, und die G«fwobnlietten, 
wdclie m: iticb, aki{^<.-M.4Mrn vom pMiNtituiren, ancfifpaen* no wird e» unscbwer 



340 



SIXTB INTERNATIONAL CONGB&BS ON TT;BEBCUU)SIS. 



au verstehen, wanim so viele von ihnen tuberkulos werden. Vide von 
ihnen koramen hemnter dureh die Abortionen, welche sie selbst an aich oder 
andere an ihnen vornehmen* Aus den Tabellen iiber die Wohnverhaltnisse 
mit Bezugnahme auf Ranlichkeit uad Ventilation, ist eraichtlich, dass nur 
zwei von Tuberkulosen bewohnte Zimmcr schmutzig und schlecht ventilirt 
waren; von den Zimmem welche von Nichttuberkulosen bewohnt wurden, 
waren drei schmutzig und sclilecht ventilirt, 

Mit Ausnahme von Zweien, gaben alle an, dass sie drei Mahl^eiten im 
Tag batten^ und dass, fur gewohnlioh, die Nahrung durchaus gut war. 

In Bezug auf venerische Krankheiten konnte dureh vorsichtiges und 
beharrliclies Ausfragen nur von 5 das Zugestandfiisa eriangt werden, dass 
sie Gonorrhoe hatten, Vier von ihnen batten die Krankheit je einmal 
vor der Tuberkulose; eine hatte die Krankheit 2 mal; eine hatte die Krank- 
heit, nachdem sie J^reits tuberkulos war» Diejenigen, welche Gonorrhoe 
hatt^n, bevor me tuberkuloa wurden, behauptebcn, dass sie nicht mehr 
wohl waren seit der Zeit, und die eine, welche Gonorrhoe hatte, nach- 
dem sie bereita tuberkulos war, hehauptete^ dass ihr Lungenleiden ach 
seit der Zeit schnell verschlimmerte. 

Filiif gaben an, dass sie Chancroid hatten^ ea warindess kein Anzeichen, 
dass diese Erkrankung etwas mit Verschlimmerung der Tuberkulose zu 
thun hatte. Zwei bekamen Syphilis nach der Tuberkulose^ und in jedem 
Falle fand ein schnelles Verfallen statt. 

Von den 21S Fallen waren 22 chinesische Proetituirende und 12 von 
diesen waren tuberkulos. Alle rauchten Opiura und Cigaretten; einige 
varen dem Cocaingebrauch ergeben; alle tranken AleohoL 




BEST USE OF A LARGE BEQUEST IN THE ERECTION 

OF A SANATORIUM FOR THE BENEFIT OF 

CONSUMPTIVES. 

Bt William Frederick Slocum, 

Preaidattt of Colorado College. 



Before the first step can be wisely taken in the erection of a sanatorium 
for tuberculosis patients, it should be definitely decided what is to be the 
permanent purpose in the creation of such a foundation. A well-regulated 
"home," where sick people are well housed and where their last days are 
made- as comfortable as possible, is worthy of generous recognition, but its 
ultimate contribution to the welfare of the race must be comparatively 
small. Such an institution is distinctly a contribution to the problem that 
confronts this Congress, and under all conditions must be recognized as such. 

There is, however, a much larger and better thing to be done than the 
establishment and maintenance of such a home for consumptives. There 
is something to be achieved in the establishment of a sanatorium such as 
this paper discusses, which ought to contribute vastly more than a plant 
that simply alleviates suffering for a comparatively few who can be housed 
within it. The ultimate end to be kept in view is the eradication of tuber- 
culosis from the race; and such a foundation as is advocated in the present 
discussion has for its purposes this far-reaching achievement. There is no 
need to mention that the old attitude toward the disease has changed, and 
that we have come not only to realize that this disease is killing one-seventh 
of the people bom under civilization, and crippling as many more, but that 
it is the business of science to destroy the causes of what Dr. Oliver Wendell 
Holmes called ''the great white plague of the North." We are, in other 
words, at last discovering, with all its fullness of meaning, that prevention 
is better than cure. To this enormous task the scientific world is setting 
itself with persistent devotion and with the hope of ultimate success. If, 
however, the contention of the German experts is true, that "Jeder Mann 
ist am Ende ein bischen tuberkulose" ("every man is in reality somewhat 
tuberculous")* then the mighty battle that is being waged is fought with 
numerous difficulties, and is one that will command the skill and persistent 
energy of the world's best men. The time has arrived when this great task 
must be taken up with larger devotion and greater faith, for if it is true that 

341 



M2 



eiXTB INTEHNATIONAL CONORESS ON TUBEfiCULOSIS- 



the disease cannot be destroyed, then it is also true that the comparatively 
few sanatoriums, hospitals, and "homes" for those stricken with ihifi 
terrible malady play a very small part in mitigating the 8ufi[erings of thou-^ 
sands of imfortunate persons* ^M 

In other wordsj the world Is finding that the one purpose that Bhoidd 
dominate all others should be the study, examination, and treatment of 
consumption^ with the definite end in view of its extermination. It la 
certainly time that the civilized world accept the war-cry of the German M 
carapaignj namely, '*No more tuberculosis after 1930.'' V 

With this as the fundamental working principle which is to be recognized, 
we are prepared to discuss the erection and equipment of a sanatorium 
for the treatment, and we may add the extermination, of tuberculosis. In 
view of this fundamental principle, it will be recognized at the outset that it fl 
is little short of crime to expend any considerable sum of money for such a 
foundation as that to which reference has been made, without correct 
scientific examination of all conditions involved. It is comparatively an ■ 
easy task to copy the plana of the beneficent '* homes'' to which reference 
has been made, but it is vastly more difficult to establish a scientific plant 
where everything should contribute to the extermination of the curse that 
is playing such sad havoc with the fives and health of men, women, and 
children throughout the whole world* It is true, however, that sufhcient 
data have now been accumulated, from experience and experiments that 
have resulted in failure or success, to make the expenditure of a large sum of 
money wise and effective- The discovery of the definite and fiving cause of 
the disease — the Bacillus tuberculosis — of itself throws very definite fight 
upon what should exist in the construction of such a sanatorium, and the 
creation of conditions necessary to produce the desired result. 

In seeking for the fundamental principles that should be recognized m 
the erection of such a building, every one agrees that only those are to be 
consulted who are best equipped for the solution of the problem and what is 
involved in this solution. Having found such persons, they must always 
be left free and untrammeled to carry out the task to which they are asked 
to set themselves. It must be borne in mind also that the most generous 
gift for this purpose is one made without conditions other than that the 
expenditure of the fund should be controlled by men of experience and 
scientific equipment for a definite and specific end. In this connection it 
may be added that there should be a fund large enough to command the 
services of the best proved experts that the world to-day affords. 

Its erection must also be considered from a much broader standpoint 
than that of the arbitrary claims and contributions of any special locality. 
In other words, no one should have the right to demand the creatioUj in a 
particular place, of such a sanatorium simply because the people in that 
locality ask for it. The disease with which such an institution propoaea to* 



I 




ERECTION OP SANATORIUM FOR CONSUMPTIVES. — SLOCUM. 343 

deal is, unfortunately, of world-wide existence, and can be studied and 
treated in the best way only by men free from local or professional prejudices. 

Adequate time must be taken to consider all conclusions bearing upon the 
scheme of architecture, location, equipment, and general plan of the whole 
foundation. The matter is too serious, too far reaching, too important, to 
be treated otherwise than in this profound and careful manner. It is only 
fair to say in this connection that the examination and study of this 
problem have led to the conclusion that the sum of $10,000,000 is necessary 
to accomplish the great ends that such a sanatorium can work out for the 
world. Its creation has much more in view than the care and possible cure 
of a certain number of patients. It should have ever in view, as has been 
said, the study of the causes of tuberculosis, its prevention, and its ultimate 
elimination. It should contribute definitely and constantly to this great 
end. In other words, it must be planned, equipped, and erected from the 
beginning with the definite idea of doing its full share in making such a 
sanatorium for the cure of tuberculosis ultimately unnecessary, by helping 
to destroy the causes of the disease and by working for its universal eradi- 
cation. It should become such a center of experiment, study, and patho- 
lo^cal practice that, from time to time, there should pass out into the world 
&om it those contributions to human knowledge that are necessary to effect 
the same results in the treatment of this disease as are being brought about 
in the treatment of yellow fever. 

What has already been emphasized so strongly makes unnecessary an 
apology for the statement that the creation of such a sanatorium, first of 
all, necessitates the erection and preparation of such laboratories, with their 
modem scientific equipment, as are required for the most careful biological 
and bacteriological experimentation that bears in any way upon the causes 
and cure of consumption. 

It should be recognized, at the outset, that this scientific equipment is 
absolutely essential for the high purpose to which reference has been made. 
It is hardly necessary to add that such an equipment includes the very best 
microscopes that have as yet been produced for bacteriological investigation; 
in fact, that it necessitates not only the purchase of whatever apparatus has 
already been perfected, but such other equipment as expert instrument- 
makers may produce from time to time, and that can be of any service. 
Nothing whatever that the best thought and training can reasonably ask 
for should be omitted from these laboratories, which are to be created for 
research and the gathering together of such information as the world needs 
in the movement that has called this Congress together. 

Everything bearing upon the light and the isolation of the individual 
worker should be keenly kept in mind. It is hardly necessary to add that the 
creation of such laboratories and the procuring of equipment must be 
undertaken by men who best know what is essential. 



Ui 



t;mscSArt0stfkL 



TCBEBCXXO^lS. 



FrhMoo iDiilt be made Ate to eociiinatid the aerrieeiy in ft |0e^^ 
wmf, d men of the faigimt frinilifift tnining and afaifity, 
ftie mmytd oofy by the ftecntate reeolU of thar icseftxch an 
dmirn ffom them, and ako from their larger and thofoo^ 
with the oontr&utioDs made bj other men In whatever part of the worid 
ipx)d work ia being daim^ 

Id thia e oune c t ion it may be added that the management and adminia- 
tration of such a plant must be In the hands d as good a man as can be 
fotind anywhere in the woHd; a man of bieadth of view, without piejodioe* 
with accurate acientitie traimng, with ran devotion to the great taak set 
Mam liim, with the bigbeat ideals of work find service, and a man of eEecu- 
tfve ability and commanding infttence. Thste must be placed in bis banda 
[rffi authority, anrJ he ahould have entire freedom b gatbenng aboot him 
other men of the l^etrt training and of the same large ^irit of devotion and 
hard work tliiit he hiimielf poeaeaaea. In other words, tbe woHc has now 
rcachd a point where a group of such men can render a service to tbe worid 
beyomi all evtimate. 

Another matter bearing upon tbe success of the movement is its geo- 
KrAphical location. Hera only most advanced scientific conclusionaj drawn 
{r<mi actual atuily antl experimentation, should influence the men bavixig in 
charjce the decision of the location. All meteorological and climatic factors 
arrr U> Ije conmdered. The neeessary part that sunshine plays in destrojiing 
(hi-! gcnrw of ttil>prculo«i8 is eeiHential in this decision. Conditions of soil, 
dva'innf^i, and the relation of all the^ to ventilation will naturally come 
umUrr roiiHitlf^raiton. It \h certainly essentia] also to study tbe influence 
of (invironmMit up<jn the spirits of patients who come not only for their 
own [leramnent cure^ butj for what ia more important, to furnish examples 
of what can fio accomplL^he^^l in the elimination of the disease. It is well 
to aay, in thm connection, that the whole matter of the influence of mental 
conditioiu^ and their reaction upon phthisis patients plays even larger part 
than haa probably an yet been realised in the study of the problem. Just 
aurh prhirifjlcrt Tkti arc depicted in the book by Dr. Du Bois,of Berne, should 
l>c conrtidnrrMl in thirt matl/er. 

HnvinK ^tt^ttJed upon (be location, the next problem to consider is that 
of the builriinfca tliomselves. Offices of administration and laboratory 
bitil(linK« >ihonlfl occupy a position by themselves. Satisfactory arrange- 
nu^nlH fthoulcJ alno lie made for housing those who are in charge, in order that 
(hey all may live ft life indqx^ndent, as far as possible, of the daily routine 
of thrir workf m that the most wholesome intellectual and moral conditions 
may be sccuroil. The health and intellectual life of those in charge are even 
niorp inipoi-tnnl than that of the patients themselves, if these larger results 
arc to be secured. 




ERECnON OF SANATORIUM FOR CONSXIMFTITES. — BLOCUM. 345 

As to the housing of the patients, everything must be done to prevent 
any excessive association of sick people, both for physical and for mental 
reasons. The individual life of the patient is decidedly an essential matter, 
and such wholesome environment as will bear upon each patient is most 
important. All open wards and, as far as possible, adjacent rooms for 
individuals sick with consumption are to be avoided. The ideal — and I 
am discussing, as far as possible, the ideal situations — ^is individual cottages 
for each patient, with such conditiofis as most make for a wholesome home 
life. Each of these should possess an outrof-door and an indoor sleeping 
room, a sitting room with a fireplace, a veranda opening to the sun, a small 
dining-room where meals can be served, with adequate bath-room faciUties. 
All these cottages, which need not be very extensive, should be made to 
face away, as far as possible, from the general plant, and should not suggest 
hospital conditions. 

Nothing, perhaps, is of more importance than the question of food — ^its 
purchase, preparation, and its service to the patients. Every fact bearing 
upon wholesome foods must be kept constantly in view. Every form of 
adulteration should be made impossible in the preparation and purchase of 
these foods. The scientific laboratories, to which reference has been made, 
should have constant facilities for examination and analysis of all food- 
supplies. The preparation and cooking of food should be done in a way 
that will render it free from all possible bacteria and dirt pollution; in fact, 
each person dealing with the food-supply, its preparation and service, should 
not only be well trained, but should be made to feel that a disregard of 
hygienic requirement is cause for dismissal. Such results can be secured 
only by constant watching, care, and insistence. Fortunately, the modem 
study of food-supplies, their chemical constituents, their adulteration, their 
preparation for passage into the human system, have now been so thoroughly 
and accurately investigated that the best results can be secured. The best 
manner of serving food is in the small dining-rooms of the individual cot- 
tages. To do this, careful arrangement can be made, so that, with modem 
cooking apparatus, the meals can be carried to each patient hot, savor>% 
and in the best condition. It seems hardly necessary to add that the cleans- 
ing of all dishes and of table linen must be so thoroughly done that these 
can be no source of contamination. 

It may be added here that it will be almost impossible to exaggerate the 
importance of perfect sanitary conditions, especially as they bear upon the 
problem of sewerage. Experiments performed in France show that all 
sewage can be either cremated or converted into fertilizers that will not 
be a source of danger even after a term of years. 

Of course, special attention must be paid to milk-supplies, not only in 
their constant analysis and the study of dairies from which these supplies 



346 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSA. 



oome, but also in their enrichment by the presence of butter-fats. The 
same care must be constantly taken in regard to the water-supply^ both for 
drinking and for bathing purposes. Those who are in charge must be 
wilLing to give adequate time and paina to all these mattetBr 

A special income should be set aside every year for the purchase of all 
books, pamphlets^, and magazines bearing upon everything that has been 
done throughout the world in the study, treatment, and eradication of the 
disease. It should also be expected that those who are employed in connec- 
tion ftith the sanatorium and who, by their training and research; are able 
to make contributions, should do so, not only for the advantage of the local 
plant, but for whatever is being done in the treatment of the disease in all 
countries. In fact^ the publication of results secured is perhaps a matter 
of the most importance in connection with thii3 whole movement. 

It may be said that the conditions here suggested are merely theoretical, 
and not practical. It is most essential that somewhere there should be 
some great foundation, unhampered by the lack of necessary funds, estab- 
Ushed for the purpose of making valuable contributions to the world for the 
extermination of tuberculosis. That it is feasible under the administration 
of such men as have gathered here at this time catmot be intelligently denietl. 

Such a plan as outlined offers an opportunity for some large-minded 
and wealthy pei-son to render an unequaled service to humanity in a move* 
ment that should command the thought and serious conjsidenition of those 
possessed of funds adequate to the accomplishment of this great work. 



DISCUSSION. 

Dr* Robert Hessler (Logansport., Indiana) : We have not yet reached 
a stage where we make sharp distinctions between "pure air" and "fresh 
air*" Many use these terms ayaonomously. Air may, of course, become 
impure in various ways. 

The chief factor which accountiS for most of the ill health and disease 
in the small city in which I am studying dust uifluences {population about 
20j[KX)) ia dust — dust due to pulverized ex|jectoration. When one critically 
stuilies the causation of the symptoms of ill health and of disease^ it is 
remarkable to what extent this dust plays a part. 

The pictures which I herewith present revea! remarkable conditions, and 
show how the air becomes polluted and how infection is taken into the 
hornet of the people, even of the country' people who come to town to shop 
and stand about the street-comers, and by the women who trail their dresses 
over the filthy sidewalks, not to mention the floors of stores and public 
buildings^ Europeans see nothing like it in their own countries. I am 
led to believe that if this spilnlust factor were eliminated, there would be 
comparatively Lttle sickness among us — and sickness is the cause of most of 



I 



hose I 

I 

I 

I 




ERECTION OF SANATORIUM FOR CONSUMPTIVES. — SLOCUM. 347 

our poverty, and that, in turn, is the chief cause of ignorance and of crime. 
A community that allows conditions like those here pictured to exist is 
not civilized. [The speaker then showed a number of "spit pictures," 
photographs illustrating sidewalk conditions in the heart of hb city and 
about the doorways and air inlets, with comments on each — ^verified by 
clippings from local newspapers.] One can readily understand how the 
air-supply of a building may be polluted when it passes through an iron 
grating in the sidewalk alongside a building, literally used for a cuspidor, and 
which also collects the already pulverized spit-dust of the sidewalk and 
carries it into the different rooms. The air coming in may be fresh air, but 
it certainly is not pure air. A general filthiness of the streets, with many 
streets unpaved and deep in either dust or mud, and the absence of an anti- 
loitering ordinance are factors that add to the prevalence of the spitting 
habit. Filth breeds filth, and dust-clouds carry disease. Some of our 
newspapers are more and more calling attention to these spitters, at times 
characterizing them as "spit ho^." These words are not elegant — neither 
is the spitting habit. Our worst spitters are not "foreigners," but "natives," 
whose ancestry usually goes back to the "poor white" stock of the southern 
mountains; they demand the right to spit on the sidewalk, as in time past 
they demanded the right to allow their stock to graze along the public 
highways and their hogs to roam the village and town streets. 

The relationship of spit-dust conditions to advertisements of patent 
medicines was referred to: when an eighth of the total space of a newspaper 
is occupied by patent medicine advertisements whose existence rests mainly 
on the condition of the streets and the sidewalks, we may well pause and 
inquire if there is not something wrong with the municipality. 

Country people are presumed to live in fresh air. How does the other 
half live? I have here a picture illustrating how many farmers spend the 
long winter days about the stove of the village store, with spittle all over 
the floor. We hear much about the large city. What of town and village 
conditions? This is a neglected field. 

Dr. R. W, Corwin (Pueblo, Colorado): In regard to the relation of 
employer and employee to each other and to the State, and what they 
should do to improve conditions, I submit: 

1. No employer has the right to neglect or impose upon an employee. 
He has no right to overwork his men, to furnish poor ventilation, permit 
dust or poisonous gases where it is under his control. 

2. No employee has the moral right to abuse his family, his employer 
or his country, by drinking, smoking, or gambling to an extent that unfits 
him for duty. 

3. No company has the right to overwork a laborer. No laborer has the 
right to work when overworked. It is as criminal to go to work when one 



318 8IXIB IXTEEXATIOXAl, COXGSEB6 OX TTBXBCCUIBIB. 

has DOC lud rest and is tired, as it is to vork a petaon after he is tired or 

4, Ho^ihals should be built in the eoantzv. So longer should we build 
any but emer^gency hoepitals and retaining statknis in the citieB. It is 
cheaper for both patient and State to treat the sick in the eountiy. It not 
only cuts short the disease, saving pain and suffering, but it lets a patient 
^ back to work and to family earlier, furnishing the family with 
means of support, and supporting State by supplying labor. Hie countiy 
hospital has not only the advantage over dty hospital in air, but as well 
in food. Pure and sweet food can be obtained with ease fnmi the farm 
for the country hosfntal. The dty hospital must ba\ie aD food shij^Kd 
to it, which means that the food is not improved by tranqsortation or storage. 
There is no good reascm why hospitals should not be moved from the dty 
to the country, except that the public does iK>t yet und»stand it, and the 
doctor, on account of being obliged to go so far to attend his patients, 
objects; and also it is inconvraiient for the doctors ecMmected with educa- 
tional ii^itutions to take tbdr students to the country hospital fw denxm- 
stratiicm- This, however, shoidd not be an excuse, when it is at the expose 
of the patient's health. 

5. Education ci the public must be our chief woik; how this can best 
be accomplished b a question. Probably by lectures, scboob, and pi^>eTS. 
Women as well as men must be tau^t. Men must learn ^y they should 
take rest — and not dismpate; women, how to cook and keep house. There 
b much to teach and there is much to learn. Let all who can, teach; let 
all the rest learn. 

Dr. Watkins, Mr. A. £. Kefrford, and Dr. E. F. Kiser, also took port 
in the discussion. 

The following resolution was introduced by Miss Sadie American: 

Resohed, — That this Section indorse and recommend the ^despread 
establishment of playgroimds as a powerful means of prevention of tubercu- 
losis through their influence upon health on account of exercise, fresh air, 
and moral uplift, and therefore the raising of general vitality and the re- 
sistance to disease, or the creation of immunity. 



SECTION V. 



Hygienic, Social, Industrial, and Economic Aspects 
of Tuberculosis (Continued), 



FOURTH SESSION. 
Wednesday afternoon, September 30, 1908. 
EARLY RECOGNITION ; AFTER-CARE. 



Importance of Discovering the Persons who have Tuberculosis before the Disease 
has Passed the Incipient Stage; Examination of Persons Known to 
have been Exposed or Presumably Predisposed; Systematic Examination 
of School Children during their Course and on Leaving School to go to 
Work; Professional Advice as to Choice of Occupation in Cases where 
there is Apparent Predisposition to Disease. 

Instruction in HealthftU Trades in the Sanatorium; Farm Colonies; Con- 
valescent Homes or Cottages; Aid in Securing Suitable Employment 
on Leaving the Sanatorium; the Return to Unfavorable Home Conditions, 



The fourth session of Section V was called to order by the President, 
Mr. Edward T. Devine, on Wednesday afternoon, September 30th, at half 
past two o'clock. 



THE IMPORTANCE OF EARLY RECOGNITION, 

PROMPT RELIEF, AND PREVENTION FROM 

AN ECONOMIC STANDPOINT. 

By John H. Pryor, M.D., 

BuCfklo. N. Y. 



The vast majority of consumptives belong to the wage-earning class with 
small means. Many are afflicted and succumb during the period of greatest 
productivity. Some explanation of these facts can be offered by the student 

349 



SIXTH I>fTERNATlONAL CONORESS OS TUBEHCULOSlft, 

of hygiene or sociology, but the truth to emphasize is this : a large percentage 
of the victims of tuberculosis develop the disease and die unnecessarily simply 
because their linuted meaixs will not secure protection and the unusual relief 
required. Perhaps an appeal for sympathy and fair play may acoomplish 
more than startling statements and statistics, which have failed to help that 
great army of the dependent sick. 

If the public is to be aroused to radical action, an educational crusade 
should include frank explanation why the disgraceful death-rate and the 
ravages of tuberculosis continue almost unabated, There are three domi- 
nant reasons: (1) Failure on the part of the medical profea^on to recognise 
early manifestations of diaeftse* (2) Inadequate protection from infection. 
(3) Lack uf provision for proper care. 

The demand for special education of the phj'siciaa hm received some 
attention, and improvement is noticeable. This is shown by the recent greAt 
increaso in the applications for the relief of incipient cases. There has been 
and will be little gained by an early [jiagnoas if opportunity for scientific 
care is not obtainable. Much of the blame for the awful death-rate from 
tubercolosia must fall upon the timid, incompetent, unprogressive health 
officer. So-called prevention is usually a grot^que delusion and a snare. 
The disease is not studied, att-acked, or controlled as an infectious malady. 
It is essentially the manifest duty of that offidal to lead in the combat against 
the scourge which contributes so largely to the ghastly loss by illness and 
death. The public must insist upon special qualifications and greater re- 
sponsibility in our health departments^ even in this country, where ideas of 
public health are quite crude and somewhat barbaric, Oertsun strange 
contlitions noake the lot of the poor consumptive unique* He is the only 
sufferer from disease who is denied necessary relief. Our knowledge of 
miQB&t ti^eatment, and prevention beae&t very few. Not more than 1 per 
cent, of the do-caUed industrial class receive proper aid at the right time and 
at least 60 per oeoU of those afflicted die unnecessarily. We offer make- 
eiufts and apologies. Results are attacked, not causes. The conmimptive, 
as a rxile. Is simply tbe neglecte^i \icrim of tuberculosis. We must find him 
earij to remedy 30]Bd:>ody's blunder* Much money must be spent to pro- 
vide institutioiud care, education, and pre\*entioii wben the sufferer can be 
saved and belore be becomes a source of danger* No cnsade at thU time 
ttn be suoeeaaful unless hnspit^ are provided. Tbe Appalling loes of Me 
and wiealth constitutes a cocifes^oo of inaptitude^ apathy, and nc^eett and 
a teimble arraigDiDeat of social and govenuaental eonditiODa. 

The wFU'to-<lo have a j^ood ehaoce to escape or meaner from tuberculo- 
flift. Those with ^AoMfar means are mono esipoeed, and the posdMlity of 
rabcmal help ia pathetically and cnaelly afight. There are many reaaoos 
vhy the poor cooESumplive is the inddsst Uu^g in tfas wovld. I w>oi>der if 



SARLT diagnosis: PROBCFT REUEF. — PRTOR. 351 

Uiis epoch-making meeting will lessen his woe by arousing definite humane 
action and stimulating practical efforts, so imperatively necessary to make 
our vaunted knowledge effective? 



Diagnostic pr^cocei Secotirs imm6diat et la Prevention au Point de Vue 

Economique. — (Pryor.) 

Una croisade d'^ucation devrait comprendre dans son programme une 
explication franche des raisons pour lesquelles la honteuse mortality de 
la tuberculose et sea ravages continuent presque sans lutte. H y a trois 
r^sons dominantes; premidrement les m^decins ne savent pas reconnattre 
les premieres manifestations de la maladie; deuxiSmement, la protection 
contre Tinfection est insuffisante; troisi^mement, on n'a pas fait de prepara- 
tions pour donner les soins convenables aux malades. 

La demande d'une Education speciale pour le mddecin a fini par Hre 
prise en consideration et on peut noter quelque amelioration. On le con- 
state surtout par la grande augmentation qui a eu lieu r^cemment dans le 
nombre des applications pour le soulagement des cas naissants. H y a eu et il 
y aura tr§s peu d'avantage k diagnoser les cas de bonne heure, si Ton n'offre 
pas au malade Topportunite d'obtenir un traitement scientifique. Une 
grande partie du bl4me pour la terrible mortality de la tuberculose doit 
retomber sur Tinspecteur de sante, timide, incompetent, sans idee de progr^, 
Oe que I'on appelle prevention est habituellement wne deception grotesque 
et un pi^ grossier. Le public doit exiger que les fonctionnaires de nos 
bureaux de sante aient des qualifications speciales et ime responsabilite plus 
grande. Certaines conditions etranges rendent le sort du poitrinaire unique, 
n est le seul malade auquel on refuse assistance. Pas plus d'un poiu* cent, 
de la classe appdee industrielle ne revolt une assistance convenable au 
moment convenable, et au moins 60 pour cent, de ceux qui sont atteints 
meurent inutilement. Le poitrinaire, d'une faQon generale, est simplement 
une victime de la tuberculose que Ton n'a pas aide. II faut le decouvrir de 
bonne heure pour corriger la faute de quelqu'im. H faut depenser beaucoup 
d'argent pour procurer des soins, pour Teducation et la prevention, alors 
que le malade peut encore etre sauve et avant qu'il ne devienne une source 
de danger. La perte terrible de vie et d'argent constitue une terrible con- 
damnation des conditions sociales et gouvemementales. 

Les personnes k Taise ont toute chance d'echapper k la tuberculose ou 
d'en guerir. Celles qui ont des moyens plus restreints sont plus exposees 
et la possibilite qu'elles ont de recevoir des soins intelligents est cruellement 
minime. II y a beaucoup de raisons qui font du poitrinaire pauvre le spec- 
tacle le plus triste du monde. 



352 



BIXTH INTEHNATIONAL CONGEESS ON TUBERCULOSIS. 



Die Wichtigkeit der friihen ErkeimuDg^ schnellen Erleicbterung imd 
Verhinderungf von eiaem okcnomischen Standpunkte aus.— (Phvor.) 

Ein Erziehungskreuzgang sollt^ eine ofTene Erklarung dcr fast uriauf- 
horlichea Fortckuer dea Bch^ndlichen Absterbens und der Verwiistungen 
der Tuln^rkulose gebea, wetin man diis Publikum zu grundlichen Tat-en 
aufwecken will. Dafijr sind drei Haupturstichen vorlianden: 1. Mangel 
seitens des arztlichen Standea, friihe Krankheitszeicben zm erkennen; 2. 
unsuiaaglichen Schutz gegen Infektion; 3. Mangel an Provision fiir passende 
Pflego. 

Das Verlangen einer besonderen Erziehung des Arztes hat einige Auf- 
merksanikeit erweckt und Verbcssarung folgt, Diese zeigt sich durch die 
neuliche \'ergro9serung in der Zabl der Bewerbungen fiir die Erleichterung 
anfangender Schwindsuchtsf^e. MsE gewinnt wenig durch eine friihe 
Diagnose wenn Gelegenheit zur wissenschaftlichen Pflege iiicht zu bckom- 
men ist. Der furchtsAme, unfiiliige, conj9er\^ative Gesundheilsbearate muss 
die Schuld des furchtbaren Tuberkulosenabsterbena tragen. Als ansteckend 
wird die Krankheit wetler sluiUrt, noch angegriffen, noch beherrscht. Das 
Publikum muss auf besonder^ Fiiliigkeiten und grossere Verantwortlich- 
keit in unseren Gesundheitsbureaux bestehen. Gewisse merkwiirdige 
Zustande machen das Loa d^ schwindsiichtigen Armen ganz eigentiimlich, 
Er ist der einzige an Krankheit Leidende, dem notige HQSfe ver^'eigert wird. 
Nicht mehr ab ein Prozent der eogenannten Arl^eiterklsksse empfangt 
passende Hulfe zur rechten Zeit und wenigstena sechzig Prozent dor Ange- 
griffenen sterben unnotigerweise, DerSchmndsiichtigeist gewohnUchgan* 
einfach das vernaclilassigte Opfer der Tuberkulose. Wir mussen ihn 
friib finden um irgend jemandes Fehlen zu corrigiren. Viel Geld muss 
ausgegeben werdeu um anstaltsmassige Pflege, Erziehung und Verhinderung 
2u verschaffen, ehe der Leidende gefiihrlich wird oder noch heilbar ist. Kein 
Kreuzzug kann zu dieser Zeit gelingen wenn keine Spitaler vorhanden sind. 
Der furchtbare Lebens- und \'erniogensverlust ist ein furchtexliches Vor- 
gerichlstellcQ der Social- und Regierungszustande* 

Die Wohlhabenden entgehcn Ideht der Tuberkulose oder genesen davon. 
Die Arnicren dnd der Krankheit mehr ausgestellt und die Mogliclikeit der 
veraiiaftigeu Hiilfe ist grausam klein. 



THE EARLY RECOGNITION OF TUBERCULOSIS: 

SOME OF THE DIFFICULTIES, PROFESSIONAL AND SOCIAL, 
AND SOME SUGGESTIONS AS TO THE REMEDY. 

By Edward O. Otis, M.D., 

Tnhmor oi Pulmonary Diaeuea and Climatology in the Tufta College Uedioal Bebool, Boston. 



The importance to the community of an early recognition of pulmonary 
tuberculosis cannot be better expressed than in the following words of the 
illustrious Grancher: ''Ce diagnostic pr^coce, si important pour le malade, 
est au moins aussi important pour la soci^t^ tout enti^re; car, au cours de 
la premiere et de la seconde 6tape, le malade tousse tr^ peu ou ne tousse pas, 
et est inoffensif pour son entourage. Trait6e et gu6rie a cette ^poque la 
tuberculose cesse d'etre contagieuse."* 

If, as Philip, of Edinburgh,! after a thorough study of the subject, has 
estimated, the ascertained mortality from consumption in any city can safely 
be multipUed by ten in order to represent approximately the number of 
persons living, already seriously affected, — and even twice that figure, he 
thinks, would be still below the mark, — then it is apparent that a very con- 
siderable number of cases remain undiscovered. Furthermore, a large pro- 
portion of the cases of tuberculosis which come under the observation of the 
phyracian, or apply for entrance into a sanatorium, are in a more or less 
advanced stage of the disease; for example, the proportion of rejected appli- 
cants at the Boston examining office of the Massachusetts State Sanatorium 
is about two-thirds of all those who apply. It is evident, then, that a very 
large number of these undiscovered cases must be in the early or incipient 
stage of the disease, and the problem is how to discover these hidden, early 



In the consummation of this desired end, certain obvious difHcuIties are 
encountered. 

First: Failure or inability on the part of the physician to make an early 
diagnosis. 

Second: Failure on the part of the public to appreciate the importance 
of an early diagnosis. 

♦ Gongr^ International de la Tuberculose, Paris, 1906. 
t British Medical Journal, Dec. 1, 1906. 
VOL. m— 12 363 



354 



BVCTE INTERNATIONAI> CONGRESS ON TUBERCTTLOSlS. 



Third; Inadequate facilities for obtaimng an authoritative examiaatioa 
of adults and children by means of free dispensaries and other agencies. 

Fourth: Fear that tuberculosis may be discovered and, in consequence, 
one's occupation and, hence, livelihood may be sacrificed. 

Fifth; Failure on the part of the nation, State, or municipality to recog- 
nise its duty in the prevention and control of tuberculosis. 

In the first place, the physician must be capable of making an early 
diagnoeb, and so great is the prevalence of tuberculosis, and such the supreme 
importance of detecting it at the earliest possible moment, that I am con- 
vinced that special clinical training should be devoted to the subject in the 
medical schools, and personal experience in teaching this subject for some 
years has only strengthened this con\'iction. Even with such special in- 
struction in the medical schools^ the practitioner will not become an expert 
without constant and continued experience, but he will, at least, be on the 
alert to suspect tuberculosis, from such symptoms as are easily diseo^'erable 
from a painstaking inquiry, and if, after such physical examination as he is 
able to snake, he is still in doubt as to his diagnosis, he can refer the case to 
the expert. 

The recent simplification of the tuberculin test by the cutaneous method 
of von Pirquet, or the ophthalmic method of Wolff-Eisner and CalmettCj has 
now placed in the hantls of the general practitioner an easy and apparently 
safe aid to the early recognition of tuberculosis, to be used, of course, only 
when the ordinary methods of examination fail. In raany cases, I believe, 
the failure of the general practitioner to make an early diagnosis is due quite 
as much to a neglect of the means which he has at hand and knows how to 
use as to lack of skill in making a physical examination. When it is remem- 
bered that, in so mjmy instances, the |M}saibIe case of tuberculosis first con- 
sults his family physician, then the possession of reasonable skill in the early 
diagnoeb of the disease and a keen appreciation of suggestive symptoms b not 
too much to require of any general physician. 

The second difficulty is on the part of the public to appreciate the im- 
portance of an early diagnosis. How is any person who happens to feel 
indisiK>aed, perhaps not enough so to seek medical adWeCj to suspect that 
his condition may be that of early tuberculosis, and seek an examination of 
his lungs? Or, again, if he has a suspicion that such may be the case, how 
can he be made to realize the supreme importance of early diagnosis and 
treatment both to himself nnd to the public? 

The general dissemination of knowledge by all the various methods now 
employed, such as exhtbitioa^, lectures, literature, the public press, the in- 
fluence of sanatorium graduates, the work of the visiting and school nutses, 
anil the instruction of school children upon the subject now required by 
law in the public schools of Massachusetts^ are all aiding in the solution of 



THE EARLY RECOGNITION OF TUBERCULOSIS. — OTIS. 



355 



thia problem, Indeedj it would seem that every individual, from all this re- 
iterated teaching, might leam, or already has learned, the few simple symp- 
toms which are indicative or suggestive of pulmonary tuberculosis, and the 
importance of early treatment. Such, however, we know is not the case. 

I Consider the submerged tenth of the tenement-house districts; the newly 
arrived and ignorant emigrant in this coimtry, the thougancls of laborers 
and operatives who are so oppressed with their daily struggle for existence 
that they are oblivious of everything except their daily routine of work, and 
sleep of exhaustion; so many of whom patiently toil on in spite of increasing 
weakness until the disease is past arrest. To such we must go, and carry 
instruction, and seek an examination. This, to a certain extent, the dis- 
trict visiting nurse already does, whenever she has occasion to enter the 
hora^ of the poor, where a case of tuberculosis exists, by ur^ng all the 

■ inmates to go to the dispensaiy for an examination. Very much could also 
be accomplished If a periodic examination of all mill or factory operatives 
was required, and provision in sanatoriums or elsewhere was provided by 
the management for those discovered to be tuberculous, as is already done, 
I believe, in some establishments in this country and abroad. 

The more perfect way, and one which we may find necessary if we are 
ever to absolutely control tuberculosis, is a house-to-house inspection in the 
^ment-house districts, and an examination of every inmate- An experi- 
it of this kind has recently been made in one of the streets of Boston in a 
congested locality. Each household was visited by a phj^ician and each 
member of the family was examined as regards tulierculosis. By tact, 
patience, and kindly atldress, the goo<l-will of the mmates was gained and 
the opportunity obtained for making the investigation. 

The third difficulty I have mentioned is lack of adequate facilities for 
free examinations. More free dispensaries are needed, particularly in the 
smaller cities and towns; and they must be so ixjpularized and advertised 
that they will be eagerly resorted X^ by the working people. The trained 
vifliting nurse, or investigator, is now recognized as an essential part of the 
equipment of such dispensaries, and it is ob\'ious that the number of early 
cases discovered is greatly increaseil by this instrumentality, for the nurse, 
as I have before said, advises all the members of the families she visits to 
seek an examination; she Is, indeed, the advertising agent and promoter of 
the dispensary. 

By holding some of the climes in the evening, a very important class of 
patients^ as regards early diagnosis, is obtained, namely, those who do not 
feel ill enough to sacrifice a day's work or even part of a day in order to \isit 
the dispensary. In the evening the workingman will feel more inclined to 
visit the clinic, even for what seems to him only a suspicion of disease, 




356 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



knowing it will entail no loss of time from hia work, and that the visit wiU 
be less conspicuoua. 

The fear that tubereulogis may be discovered and, in consequence, one's 

employment may be lost, undoubtedly tteters many from seeking an examinar 
tion, even though they may suspect that something Is wrong with their lungs. 
This fact presents two serious and important social problems, the solution 
of which will materially aid us In obtaining larger opportunities for making 
an early diagnosis. 

First: The public must be disabused of the idea that a eonaimiptive ia 
necessarily dangerous to those about him. On the contrary, it must be im- 
pressed upon the pubUc again and again that a consumptive without sputum, 
as frequently occurs in the early cases, and one who properly disposes of his 
sputum, are both innocuous and are not to be shunned. 

Second: The provision of proper occupation for such oonsumptivea as 
are able to do some work for this support- Already this problem is in process 
of solution by means of farm colonies, etc., but until a more general realizar 
tion of this need exists, and greater opportunities are afforded to meet it^ 
many early cases will remain undiscovered, because the discovery now 
means, in so many cases, Joss of one's occupation, and hence loss of support 
for one's self and family. 

Another field, wlxich offers fruitful results in the endeavor to make an early 
diagnosis, is the examination of children — school children, for, in fact, in 
most civilized countries, all children, with comparatively few exceptions, are 
school children. Furthermore, I would esrtend such examination not only 
to school children but to all students, for it is comparatively easy to deal with 
an organized body, as a school, academy, or college. There is nothing more 
pathetic than to be confronted with a case of advanced tuberculosis in a 
young student, where hfe might have been saved if the disease had been 
detected in its inception. 

I would have a yearly examination of all school children and students, 
and, finally, an examination at the close of their school or college career, when 
ad\ice as to the choice of an occupation would be of inestimable value to 
those who show evidence of a tuberculous tendency. If^ as is now required 
by law in Massachusetts, for example, all school chiklren are examined once 
at least in every school year, to ascertain whether or not they are suffering 
from tlefectivo sight or hearing, it would seem to be equally important to 
require a yearly examination of their lungs, when one considers the preval- 
ence of tubercnlosia. Moreover, the machinery for doing this is already at 
hand in the medical inspection of schools, now quite universal. 

Much is already being accomplished in the examination of children 
through various agencies. Notably is this the case in France, and no other 
country, to my knowledge, has so clearly recognized the importance of this 



4 

4 



THE EARLY RECOCmTION OF TDBEXtCULOSlS. — OTIS. 



357 



I 



I 



I 



I 



ph^se of the tuberculosis problem, or so comprehensively set about its solu- 
tion. In my own city (Boston) we are working out the problem in the 
following way: The dispensary of the Municipal Consumptive Hospital de- 
votes one clinic a week, on Saturday, which is a school hoUday, solely to 
children. The visiting nurse urgps the family in which a case of tuberculosis 
exists to send all the children to the dispensary for an examination. By 
means of circulars sent to clergymen, teachers, and agenU of children's 
societies, an urgent appeal is made to have all children under their super- 
vision sent to the dispenaaries for an examination. Thus we expect; and 
experience is already verifying our expectation, to secure the early recogni- 
tion of many cases of tuberculosis in children wliich would otherwise remain 
undiswvered until more active symptoms developed in later life. 

Finally, the nation, State, or municipality can, officially, lx>th directly 
and indirectly, promote the early recognition of tuberculosis, and in most 
countries much is being done in tins direction, dependent upon an int-elligent 
and lively appreciation of the nation's duty in the prevention and control of 
disease. 

The State or municipaUty can establish free dispensaries, and ia already 
doing so. It has lis laboratories fur the free examination of sputum, It 
indirectly adds in the early detection of the disease by providing sanatoriuniB 
for incipient cases, and thus encourages the individual who fears he may be 
suffering from tuberculosis to apply for an examination, knowing that if he 
is found to be tuberculous an opportunity is afforded him for treatment. 
The nation can require that all its employees in the army, navy, or civil 
service shall be periodically examined. The State can go further, and insist 
upon the examination of all operatives in workshops and factories before 
referred to, Massachusetts^ for example, now requires that all factories 
shall be well lighted, well ventilated, and kept clean; that cuspidors shall be 
provided; that there shall be proper sanitary arrangements; that medical 
and surgical appliances shall be kept in all factories; and that proper egresses, 
fire^-escapes, and fii'e-extinguishera shall Ije provided. Why not extend 
this paternal care of its working people, and require a periodic examination 
of the lun^ of each operative, perhaps of equal value with these other require- 
ments, when one considers the frequency of tuberculosis among workers? 
Moreover, euch a requirement might, with equal reason, be extended to 
large department stores, where many young women are employed. 

Again, the State, by exhibitions and the dissemination of literature upon 
tuberculosis and other educative measures, can impre^ upon the public the 
importance of the early recognition of tuberculoslSj ^ith especial reference 
to the favorable results of treatment in the early stages of the disease. Thus 
it will be Been that official action can, and in many countries does, accom- 
plish very much toward securing to its citisens an examination as regards 




358 



BlXm INTERNATIONAL CONGRESS OS 



tubercutoms, and can, by these various measures, cause H, in matsy eaees, to 
be disruvered in its incipicQcy, when cure is eaay and the i nfect ion of oU«3 

impossible. 



" Aigunaa 4e Las Dificultades (Profesionales y Sociales) «a tl Recoood* 

mieato Prenmturo de la Tuberculosis^ y Algunss Soges- 

tiones Como Remediarlas.**— {Otis.) 

Be bftcalculmio tine In inortatidad de la iisis, en ima dudad cuakiakn, 
BB flC^aniente uiux tt^tiinti dv\ rmmerc real afectodos seriamente de U 
dad, por lo tanto un ni'tniom ixmsiderable de ellce no son recoDoddas^ y 
gran [)»rte do wtw riwiw* oniMinw deben eer aqueilo€ que est^ en el primer 
estado tie la ciifrruie*ilnd. 

Difirultadw* que* «* oniHicntran en e! reoonadmiento pretnaturo de U 
enfermodftilr 

IViincro: IVwuido en la parte de! mddico en hacer un diagndstlco 
pront^T, "Si Kf tirno pivi^utita i\m las mas veces en que el padente soep&ch^ 
la onfcrnioiiad jhu* lo ppmilnr i>nmcramf*nte consuJta el mMloo de la familla, 
III pososion (Ic unw nwmukble habilidad en el diagn6etico de la enfenoedad, 
y un perspicaz iveonuiMiniento do k>8 Kfntomas no es demasiado pedir al 
practicante en genend/* 

Sogundo: Falta en la parte del pilblioo en apreciar la import^mcia del 
diagn68tico prematuro. Esta dificultivd piiode evitarse por noedio de U 
0(Uu*ari6n sobre tuberculosis en las e&cuelas, por medio de conferendas, 
o\liilnt ioncs, etc, por medio do visitas de la enfermera, examen de tas casas 
Y K« individuosj loa talleres y factorfas en general, 

'IVnwi: I'^aita de medios adecuados para el exainen gratis. Falta de 
ihtttcitwio lu'tnioro dc dispensarios, priniipalmente en las ciudades pe quefiaa. 
'^ i\>r ttW\l'w del cstablecimiento de clfnicaa nocturniis, una clase muy im- 
l^^^i^tiUi do pririrnti's, fns que eston en el primer estado de la enfermedad, 
l^^tU^ >tt*l«^THMvr. r [«!-. Si.n, aquellos que no se sicnten suficientemente en- 
I^^Mi l^ra an^Ttfu'iir un dia de trabajo 6 una parte del dla, a Bn de eonsultar 
\ ' tk^h/" Cada uno de estos dispensarioa deberd tener una enfer- 

. ujil la muvl visitard las casaa en donde se encuentre un caso de 

r nv^v ih quo el carficter de b enfermedad sea descubierto y 

■ . •: M. i,i do cllo, la ocupaci6n del individuo y los raedbs de soa- 

uv mms\ \w^r%\i\.Uvti. Kn este becho doa problemaa, serios e impor- 

, rK\u onvuolloe: Primero^ la creencia de que el tlaico es 

. igt\w« para los otros; ^te no lo es si se toman las pre- 

^« v^^n v\ wputo, 6 en el prininr estado dc la enfermedad 

VAWiUV- ^iK^ t^^ |**^mhnvv1nvia:segundo: el problema de proveer ocupa- 



I 



I 



I 



THE EARLY RECOGNlTIOTf OF TUBERCULOSIS. — OTIS. 359 

clones apropiadas para tales enfermos capaces de hacer algunos trabajos 
para su sostenimiento. Este problema esti en vffts de resolverse por medio 
de laa colomas rurales para tuberctilosos, etc^, ''mas para este fio, sUiem- 
bargo, una realizacion mas general sobre este punto existe, y mayores opor- 
tunidadea debieran ofrecerse; en muchos casoa la enferiuedad queda oscura 
por que el reconociniiento de ella, al presente, significa, la p^rdida de una 
ocupacion y la falta de medios de sustento para el individuo y la fomilia/' 

Todos lo9 nines de as eseuelag deberiin ser examinadog periodiramente. 
Todos los niiios de la fanulia en donde un caso de taljercabsis existe, deljev^n 
ser examinadoa, 

Ftnalmente: La naindn, el estado y la cindad pueden oficialmente, por 
medios directoa 6 indirectos, promover el roconocimicnto premature de la 
tuberculosis por medio de organizacidn de dispensarios gratis; el examen 
gratia del eaputo; provisi6n de sanatorios para los casos en el primer estado 
de la enfermedad; el requerimiento de que todos los empleados de armada, 
de la marina y del sevicio civil, sean periodicamente examinados; las raedi- 
das educativas; el estado ''puede imprimir en la mente del pueblo la im- 
portancia del reconocimiento prematura de la tul>erculosis, con referencia 
especial sobre los resultados favorables del tratamiento en el primer perfodo 
de la enfermedad." 



De quelques dlfficuJt^s rencontr^es dans la reconnaissance pricoce de la 
lubercnlose, et de quelques suggestions pour y remSdier. — (Otis.) 

II a^t^estira^ que la mortality provenant de la tuberculosa dans une ville 
est seulement le dixi^me du nombre de personnes siSneusement atteintes par 
la maladie; il a'en suit qu'un grand nombre de malade.^ restent inconuus ct 
que parrai eux bien souvent la tuberculosa est dana un Stat recent. 

Difficnlt^s rencontr^es dan^ ta reconnaissance pr^coce de la tuberculosa: 

1. Fawte du docteur qui ne reconnait pas la maladie k son d^but. *'Si 
Ton remarque que dan3 un grand nombre de cas le malade consults le docteur 
de la famille, ce n'est pas tr6p demander k un praticien que d'avoir I'habilit^ 
n^cessaire pour rendre un diagnostic pr^coce ou la sagacity pour reconnaltre 
Ie8^mpt6mes," 

2. Le manque de la part du public d*appr4cier I'importance d'un diag- 
aostic pr^coce. 

L'on peut rem^dier k cela par des conferences et des expositions faites 
dans les ^coles, par garde-malade (visiting nui^), par Tinspection des mai- 
fions ouvrifejiea et de leurs habitants, des usines et de leurs ouvriers. 

3. Le manque de facilit^s pour dea examen gratuits. De plus nombreux 
dispensaires aont n^cessaires, particuli^rement dans les petites ville5, *' En 
ouvrant quelques dispensaires^ durant la solr^, en ea qui concerne un 




300 



SIXTH INTERNATIONAL CONCHESS ON TUBERCULOSIS* 



diagnostic prficoce, I'on rGncontrerait une classe de malades tr^int^rressante; 
les personnes qui ne se sentent pas assez malades pour perdre lour jounife 
de travaU en visitant un tUspensaire, par exemple. 

Chacun de ces dispensaires aurait une garde-malade dipl6irn5e qui irait 
visiter les families oil un cas de tuberculose a ^t^ decouvert. 

4. La crainte de la part de eartaines personnes qu*en 6tant reconnues 
atteintes de tuberculose elles soient dana rimpossibilitS de soutenir leur 
famille ou elles^m^mes. Deux graves et iraportanta probl^mes aociaiix 
sont impliqu^a par ce fait: 1. La croyance commune qu'un consumptif 
est dangeureux pour son entourage — il ne Test pas loraque les crachats sont 
soigneusement recueillis ou aa d^but de la maladie lorsqu'il n*y a pas de 
crachats, 2, La difficult^ de procurer pour ces malades une occupation en 
rapport avec leur dtat, quelques uns ^tant en ^tat de travailler, Cette 
demi&re difficulty est en voie d'etre toum^ par r^tablissement de colonies 
fermi^res, etc. Mais cependant jiisqu'^ ce que ce projet soit plus gi^n^ralis6, 
de nombreux eas oCl la maladie est d son dSbut resteront inconnus, car sa 
reconnaissance implique pour beaucoup la perte dos moyens de vivre. 

Tous les enfanta h T^cole devraient fitre periodiquement examines et 
aussi lorsqulls quittent r^cole. Les enfant3 dans les families oil des cas de 
tuberculose existent devraient ^tre examinfe. 

Enfin la nation, T^tat ou la ville devraient encourager d*une mani§re 
officielle la reconnaissance pr^coce de la tuberculose; et cela: en ^tablia- 
ant des dispensaires gratuits; par I'exainen gratuit des crachats; en ouv- 
rant des sanatoriuma pour cas pr^coces; en forcjant lout-s leurs employ^ 
dans I'ana^, la marine, et Tad ministration ^ ^tre examin^ p<5riodique- 
ment. Auasi T^tat par mesures 6iucatives *-peut imprimcr sur le public 
I'importance d'une reconnaissance prt?coce de la tuberculose, en faisant 
ressortir les heureux r&ultatsobteuus en attaquant la maladie i son d^but." 



I 



INSTITUTIONAL CARE FOR EARLY OR FOR AD- 
VANCED CONSUMPTIVES ? 

By Jacob H. Schiff, 

FncAdent Hontofiore Home for Chronic Invalids of New York. 



Montefiore Home for Chronic Invalids, a hospital for incurables and 
CDimtry sanatoriiun for consumptives, started in the year 1884 with but 
thirty beds. The institution grew rapidly, until it now houses, in its build- 
ings in New York City, about 270 patients, while about 170 are provided 
for in its Country Sanatorium at Bedford Station, Westchester Coimty, 
some forty miles distant from New York. The City Institution admits 
patients suffering from almost every kind of incurable disease, including 
consumptives in the advanced stage, for whom separate rooms and wards 
are set aside in which, however, only about fifty can be accommodated. 
None of these beds are at any time imoccupied. A large waiting list always 
exists, from which admissions can be made only as patients pass away. 
A better state of affairs exists in the Coimtry Sanatorium, where only con- 
sumptives in the earlier stage of the disease are taken in. The Country 
Sanatorium has room for 170, and generally accepts a few beyond this 
number. The stay of patients at the Country Sanatorium is Umited to 
one year, it being assumed that those who cannot be substantially improved 
in that time are beyond hope of permanent recovery or lasting improvement. 
Quite a number leave of their own accord before the expiration of the time 
limit; a few leave soon after their admission, because they cannot adapt 
themselves to institutional life; others have to be discharged for disciplinary 
reasons; some feel sufficiently improved, after a short stay, to return to 
their homes; while a considerable number become cured, their disease 
is arrested, before the year limit is reached. Thus it becomes possible to 
assure fairly quick consideration for those who apply for admission into the 
Country Sanatorium. 

Practically all who are cared for in Montefiore Home belong to the 
tenement house population of the City of New York. This population being 
somewhat migratory in its habits, it has been found difficult to obtain 
reliable information as to the permanent benefit which discharged Sanator- 

361 



382 SIXTH vsmssjososAis otocgbebb ox twoktvoss^ 

inm panente hare reoeiTed; but as most of tlnose who, alter their <fi9diai]ge, 
cured or i mprw ed, votild liidy api^y for readmisaon upon a more setioas 
lelapge, aod as sacfa applications are reiatzrciv fev in nmnber, it is reasoo- 
aUe to asRune that the curative resuhs obtained at the Coantiy SaDatoiiam 
are OD the whole sati^actory, 

Xotwittoanding all the good that has been accomplishwi throog}! the 
tubercukss woric of )£oatefir>re Home Countrr Sanatorium, it cannot be said 
that the effect of the work, when compared with the amount of tuberculosis 
existing in the city of New York, has been far-reaching or has made much 
of an impreasicm upon the state of health of the community. 

I <k» not for a moment wish to be und»?tood to imply that sanatoriums, 
such as Montefiore Home Giuntry Sanatorium and similar institutions, are 
not needed. Just to the contrary: in a large coam^wlitan ocHnmunity, 
which receives constantly numerous accessions from other countries, often 
imderfed, of weakened constitutions, and generally tmaccustomed to the 
rigr/r of the new climate, considerable ntunbers are liable to become attacked 
by tuberculoses who, unless they are promptly and prt^wrly provided for, 
will succimib to the disease, from the advancing effect of which they migbt 
possibly be saved by prompt adequate treatment, such as a sanatorium 
alone can provide. I am, however, by careful observation, led to the belief 
that while the sufferer &om consumption in its incipi^it or earlier stage re- 
ceives, as a rule, preferential attention — perhaps properly so, for we should 
aave life at any cost where this can be done — too little is being done for those 
who have become afflicted with consumption in its more advanced stage. 
The conviction must gradually force itself upon any one under whose more 
careful consideration the effect and ravages of this terrible scoiu^ are 
brou^t, that every case of tuberculosb, as soon as it enters upon an advanced 
stage, should be isolated, and that it should be made the duty of healtii 
boards and kindred public authorities to enforce isolation in a reasonable and 
humane manner whether the patient belongs to the dependent or to the 
well-to-do class of the community. The consumptive in the earlier stage of 
the disease, throu^ the desire for self-preservation, is likely to follow very 
minutely any treatment prescribed for him, and generally observes att^i- 
tively the methods he is advised to follow to prevent the spreading of his 
diaeaae in his surroundings. The advanced phthims patient, to the 
eontrary, is likely to be more indifferent, and in almost every instance be- 
oomes, to some extent at least, a danger to his family and a center of con- 
tagion for his surroundings. If, therefore, the greatest good to the greatest 
rnunber is to be accomplished, if a more visible decrease in the dreadful 
floourge is to be effected, it appears to be high time to apply mxxe rigid 
measures to the disease in its advanced stage. 



INSTITUTIONS FOB ADVANCED CASES. — BCHIFF. 



363 



I 



Whether under the name of sanatoriums or hospitals, every possible pro- 
vkion should be made, particularly by the State, for taking care of every 
case of advanced consumption. The unfortunate sufferer, when his illness 
has progressed beyond a certain stage, should no longer be left free to 
choose whether or not he will leave his home, but should be made to enter a 
hospital or sanatorium. This may perhaps seom a harsh proposition, but it 
appears not likely that except by auch meana and methods any perceptible 
inroad can be made upon the extent of the scourge. 

It muBt, moreover, be quite clear to the careful observer that the pri- 
vat« hospital can at best take care of only a very limited number of con- 
sumptives in the advanced sta^e, and that such hospitals are under the 
necessity of housing their tuberculosis patients in more or less close proximity 
to patients suffering from other kinds of disease* It follows that the duty 
of making sufficient provision for the great number of advanced consump- 
tives, particularly in large communities, should fall upon the State, and it 
were well if the private hospital withdrew entirely from the care of the 
advan(%d consumptive. 

On the other hand, the State and municipality are not so advantageously 
situated for looking after the phthisis patient in the early stage, who needs 
very careful and scientific treatment if he is to have a reasonable chance for 
a cure. Private philanthropy should interest itself to a larger extent than 
is already the case in making provision for the incipient and early sufferer 
from consumption. Each and every human being afflicted by tuberculosis, 
whose infection is discovered in time, ought to be able to find sufficient 
provision, through which a reasonable expectation of the arrest of the dis- 
ease may be assured, if that be possible. It is, therefore, greatly to be 
hoped that possessors of wealth will be most liberal to sanatoriums and other 
institutions which have undertaken the care and treatment of sufferers from 
phthisis in the early stage. No more far-reaching altruism can be thought 
of than that which seeks out and helps to restore the health of the countless 
numbers of men and women who, afflicted with consumption in its early 
stage, often perish, but could be saved, if adequate provision existed for 
their proper treatment. 

It is, however, not alone the disease m its early or its last hopeless stage 
with which we should deal in order to protect the human family against the 
terrible suffering which its spreatling brings forth. As in almost every other 
instance, here too prevention is better than cure; indeed, prevention, if it 
can be obtained, will hardly in any other instance prove aa far-reschiug as in 
the case of tuberculosis; for ever^' human being who is made immune against 
consumption may mean the saving of generations from the scourge. This 
can readily be understood when the fact is taken into consideration that 




364 



Sixth intebnatioxal coNOHEsa on tuberctjlosis. 



persons affected by phthisia have the .tendency to propagate to a consider- 
able extent. 

What I have reference to is the provision for the care of underfed chH- 
dren and anemic young people, such as are now being looked after to some 
extent in convalescent homes and kindred institutions. This should in 
particular be done in cases in which parents or other members of a family 
have been or are sufferers from tuberculosia. I believe it is disputed that 
tuberculosis in itaelf ia inheritable. But it will be conceded that the off- 
spring of consumptives have very often, through weakened constitutions, 
the predisposition to the disease. Many a life could no doubt be saved and 
the spreading of consumption coultl, to some extent at least, be avoided, if 
particular measures were taken to guard the anemic child and to strengthen 
its reaisting power. 

In New York city, and probably elsewhere, the system of the school- 
tnirse is a] move in this directioui but more far-reaching provision can no 
doubt be made in this respect, which thus far has been mostly left to private 
philanthropic effort. The State has not troubled itself to any too great 
extent to look after the child whose physical condition declines to a level 
where its body becomes liable to almost any disease, consumption in par- 
ticular, which may be prevalent in its surroundings. It is a well-known 
fact that anemic children and young persons are especially liable to infec- 
tion from tuberculosis, even if otherwise not predisposed toward the 
disease, which finds its most ready victims among the tenements and in 
other quarters where great congestion prevails under unsatisfactory coadi- 
tiona of sustenance and nourishment. It is urged that not alone the philan- 
thropist, but^ to a larger extent, the State, should seek methods through 
which to get hold of anemic children and young people of weakened phy- 
Biqui;^^, with a view to building up their pJiysical condition in a systematic 
and efficient manner. This may be a difficult problem, but a solution can 
without doubt be found, and may justify the expectation that by better 
methods large numbers may be immunized against infection, and further, by 
removing the centers of contagion which the consumptive in an advanced 
stage forms, results could be obtained which would be far-reaching and of 
lasting benefit to mankind. 

To summarize the observations of a layman, who for many years has been 
the chief executive officer of a large philanthropic private institution, dealing 
with consumption in evety stage of the disease, it is submitted; 

That the private hospital should exclude advanced and incurable con- 
sumptive patients* 

That the State should make adequate provision for the care of advanced 
and incurable consumption^ and that the isolation of phthisis sufferers in 



I 
I 

I 
I 



DltfWTUTlONS FOR ADVANCED CA8B8. — SCHIFF. 365 

an advanced stage be made compulsory by law, though in a manner most 
considerate of the sensitiveness of the patient. 

That ample provision should be made in sanatoriums and otherwise for 
the scientific treatment of the consumptive in the early and curable stage of 
the disease, both through private philanthropy and by the State. 

That a thorough system should be organized through which to discover 
casee of weakened constitution and anemic conditions in children and 
young persons, especially in families afflicted with consumption, and that 
provision should be made for curing such conditions, wherever they may be 
found. 



Le Soin dans tine Institution des Phtisiques pr^coces ou avanc^» lequel est 
le plus important des deux. — (Schiff.) 

Apr^ une experience de presque vingt-cinq ans, comme administrateur- 
en-chef d'une grande institution philantropique privte, qui traite des cas 
de tuberculose dans tous les degr^, parmi les classes indigentes de la popu- 
lation des quartiers populeux de New York, je suis devenu conv^cu que 
a. I'on doit combattre le fl^au effectivement, nos plans doivent 6tre plus 
vastes et beaucoup plus hardis qu'ils n'ont 6t6 jusqu'ici. 

Mes observations et mes reflexions sur le sujet m'ont amend k formuler 
quelques principes g6n6raux pour agir sur une dchelle plus large, k savoir. 

Que les hdpitaux et les sanatoria pnvds refusent d'admettre les poi- 
trinaires avancds et incurables. 

Que r£tat pourvoie amplement et suflisamment aux traitemcnt des 
malades dans un 6tat de tuberculose avancd ou incurable, et que I'isolation 
des phtisiques dans un dtat avancd soit rendu obligatoire par la loi. 

Que Ton offre, dans les sanatoria ou autrement, un traitement scien- 
tifique pour les poitrinaires qui sont encore dans le ddbut de la maladie 
ou qui peuvent 4tre gudris, les fonds doivent etre foumis ou par la philan- 
tropie privde ou par TEtat. 

Que Ton organise un syst^me complet pour ddcouvrir Texistence de cas 
de constitutions aflaiblies et d'etat anemique chez des enfants ou de jeunes 
personnes, et que Ton fasse les arrangements ndcesstdres pour traiter et 
gu6rir ces conditions, quand on les decouvre. 



Anstaltssorge fiir den friihen oder fUr den vorgeriickten Tuberkuldsen; 

welche ist wichtiger? Erfahrungen und BeschlUsse 

eines Laien. — (Schiff.) 

Als Resultat einer beinahe ein Vierteljahrhundert dauemden Erfahrung 
als Prasident einer grossen menschenf reundlichen Privatanstalt, welche die 



9G6 SIXTH INTKBXATIOXAL CONGRESS OX TUBQtCUUlSra. 

Sdbwindsucht in jed»n Grade unter d^i abfaangigen Klaangt der annsten 
Ber^ening New Yorks behandelt, Ihd ich uberzengt vorden, daas -wvsm 
wir die Plage mit Effekt behandeln voDen, wir graesere und kuhnoe Flaiie 
mach^i mussm. 

Meine Bemeikmigai und Bed^ikoi d^ Sache haboi midi zum Ab- 
f aasm ^niger auf die Wirkung tiinlSngiirhAn allgMnpinwn Gnindsatze 
gefuhrt: 

DasB die PrivatsiHtaler und Sanatorien den vorgeschrittaien und un- 
heflbaren Schwindsuchtigen die Aufnahme vra^reigeni. 

DasB der Staat roUe und genugende Provision fur die paasende Soige 
der an vorgeschrittoier und unheilbarer Schwindsucht Leidaidai macht 
und dasB die Abeondening der vorgeschrittoiai Pbthiaka' Zwan^oidnung 
verde. 

DasB Yt^ Provision in daa Sanatorien und scHistwo fur die wissen- 
sdiaftliche Behandlung des Sdiwindsuchtigen im fruhoi und heilbaren 
Grade der Krankheit dureh private MaischKtfreundlichkdt und audi vom 
Staat gemacht sei. 

DasB ein grundliches Syst^n organisiert wande, wodurdi das Dasetn 
gescbwachter Constitutionen und anamiscben Zustandes bei Elndoii 
und jungen Leutoi veroffenbart wird und daas pamende Provision gunadit 
vird, urn scdcbe Zustande xu andem. 



THE EXAMINATION OF PATIENTS EXPOSED TO 

TUBERCULOSIS AND PATIENTS SUSPECTED 

OF HAVING TUBERCULOSIS. 

THE RESULTS OF A PLAN OF ADMINISTERING RELIEF TO TU- 
BERCULOSIS PATIENTS BY THE NEW YORK ASSOCIATION 
FOR IMPROVING THE CONDITION -OF THE POOR. 

By Linsly R. Williams, A.M., M.D., 

New York. 



For many years relief had- been ^ven to tuberculosis patients after 
investigation by a visitor of the Association. It was a novel idea when, 
a few yeaiB ago, it was ordered in the Relief Department that no tuberculosis 
cases should receive relief until an examination had been made by a physician. 
These examinations by a physician resulled in many complications, as is 
shown in the first of the few typical cases reported. For example: W. F. 
was examined on December 4, 1904,. by a private physician, who informed 
him that he had dry pleurisy, possibly tuberculosis; a year and a half later 
another private phj^cian stated that the man had pleurisy, possibly kidney 
trouble; on May 26, 1906, he was told at a dispensary that he had tubercu- 
losis; on June 18, 1906, the Board of Health inspector reported that the 
man did not have tuberculosis; and on December 11, 1906, another dis- 
pensary physician diagnosed his case as acute bronchitis and indigestion. 

Such reports as these were so confusing that it seemed wise to adopt 
another plan of administering relief, and the following plan was adopted. 
This plan consisted in the employment of a physician who was to visit every 
family under the care of the Relief Department in which a member was 
known to have tuberculosis, or was suspected of having tuberculosis, or in 
which a member had recently died of tuberculosis. As each case was re- 
ferred to the physician he was asked to examine at his early convenience 
each and every person in the family and to make verbal and written reports. 
He was expected to keep the family under observation and to give them 
instructions, and to secure, with the assistance of the relief visitor, proper 
care for them. Proper care meant regular medical care, an adequate 
amount of material relief, the supply of extra nourishment, provision of 
sanitary surroundings, and the sending away of one or more members of 
the family to the country. With the physician's medical knowledge of the 

867 



368 



SIXTH INTEIRNATIONAL CONGRESS ON TXJBEKCULOSlfi. 



case, and with his pergonal observation of the social conditiooB at the 
patient's home, and ^vith his confitant eooperation with the relief \Tsitor^ 
it was possible to insure for every expenditure of money the greatest amount 
of benefit. 

Advantages ofthk Medicai. Examination, — Employing an exjDerienced 
physician whose judgment and skill in diagnosis coidd be relied upon, many 
cases of previou-s erroneous diagnosis were discovered. Six hundred and 
sixty-nine indivitluals in 290 families were examined and 110 families were 
found to have no tuberculosb. In some of these 110 families, however^ 
no previous diagnosis of tuberculosis bad been made, but some member 
of the family had died of tuberculosis, or was suspected of having the disease 
by the relief visitor. Many of the patients ejcamined suffered from anemia, 
bronchitis, pulmonary emphysema, chronic pharyngitis, and other condi- 
tions far removed from tul^erculosis. One hundred and forty-one cases of 
pulmonary tuberculotda were found, 8 incipient^ 51 advanced, and 82 far 
advanced. Twenty cases of bone and gland tubereulosis were found, 49 
doubtful casGvS, and in 459 cases no tuberculosis. In 7 families 2 members 
were found to be suffering from the disease, and in one family, 3 members. 

Advantages to the Pali-ent, — ^The medical diagnosis indicated the proper 
nioiUca! treatment, sensible care at home or in an institution, instruction in 
personal habits, anil material relief, 

Adi^atitagcs to the Family, — These advantages were not readily recognized 
by the members of the family outside of the patient, Opposition t-o the 
exjuuination was often encountered, with the protest "I am perfectly well." 
Tlxis opposition was generally found among the working members of the 
families and the young girls. Repeated efforts were made to overcome the 
objections, involving numerous revis^Its and evening calls, but the total of 
669 individuals examined numbered only 53 per cent, of the individuals 
in the families. But an interest was aroused even tlu-ough the opposition, 
and discussion offered a good opportunity for instruction in the necessity 
of care and watchfulness in all cases predisposed to tuberculosis. Special 
attention wt\s given to the children of tubercular parente, aud surviving 
parents were instructed in the best preventive measures, In the 49 exam- 
ined cases classified as "doubtful/' prompt preventive measurea were used, 
extra nourishment, lighter work, better rooms^ more fresh air and sunUght. 
They were kept under observation, and if any positive signs of the diaeASe 
appearetl, were placed under proper treatment. 

Adi'antagcs to the Relk} Visitor included the removal of doubt as to 
whether tuberculosis existed or not; the written record, to which reference 
might be made at any time; the frequent conferences with the physician, 
and liis advice as he made regular observations of the family and noted 

ilta of treatment or relief; the establishment of the principles that no 



I 



EXAMINATION OF THE EXPOSED AND SUSPECTED. — WILLIAMS. 



369 



permanent relief should be planned without the physician's approval, after 
seeing the members of the family, ayid that all relief should be withhold 
where the family persistently opposed the advice of the physician; the better 
knowledge of the kind and quantity of relief advisable in homes where 
consumption is present or threatened. 

The following five cases show the type of case that was daily met: 

W* F., aged forty-two, Italian. In United States seventeen years; he 
has a wife and seven children. Wife^s mother hves with them. Patient 
being out of work, February, 1904, Mrs, F* applied for relief at the A, I, C. P. 
Fattuly in reduced circumstances, needed relief during 1905 and 1906* 
Case closed when W, F, wtis able to get work, and reopened several times when 
thrown out of work* December 4. ID04, saw physician, who informed him 
that he had dry pleurisy, possibly tuberculosis- February 18, 1906^ a 
private physician states man la suffering from pleurisy and possibly kidney 
trouble. May 26, 1906, at dispensary was told that he had tuberculosis. 
June IS, 1906, Board of Health inspector reports man. not suffering from 
tuberculosis- December 11, 1906^ physician at another dispensary made 
diagnosis of acute bronchitis, but that his present indisposition is due to 
indigestion, December 15, 1906, examined by A, L C. P, physician. States 
that he was well up to a year ago, when he de\'eloped a severe cough and had a 
hemorrhage, and has had several hemorrhages since; still coughs a great de-al 
at times. July 11, 1908, medica! report Believue Dispensary, man in first 
stages of disease; able to work; general condition excellent; improved; 
prognosis good; no nourishment. 

December 14, 1906, wife and four children examined for tuberculosis, 
December 15th, husband and two children examined. Husband tubercu- 
lous. The woman was working; husband unable and unmlling to supijort 
entire family. Wife has con^nt^d to have three cliiUlren committed, on 
ad\ice of physicitui, who wanted them removed from their tulwrculous 
environment. 

During three years, relief was given in food to the amount of $90.40, in 
rent $19* in coal SI 7.84, in medicines $7*27, and e-xtra nourishment, milk 
and eggs, was given to the amount of $21.24. Clothing was also given them. 

J. N., tlurty-six years old. He has a wife and five children. Wife 
applied for relief on account of baby's illn^s. Man in the hospital, February, 
1905» with pleurisy and pneumonia. Case was closed when the man was 
again aljle to work, but reopened again. On Deceml>er 8, 1905, he was 
examined by a private physician, who stated that one lung wag affected* 
January 2, 1906, having had a number of hemorrhages and feeling very 
much worse, application was made to Riverside Hospital* January 9th 
the Board of Health reportetl: *'Case of J* N. is a true one* Patient has 
been U! for the p:ist year, considerable expectoration, present condition ia 
good, is under the care of a private physician. Will be kept under obser- 
vation by this Department." On March Sth he was taken to Riverside 
Hospital, where he stayed three months. October 29, 1906, he was operated 
on at the New York Hospital, for cancer of the stomach. Report received 
from the hospital that J, N, had a growth in the throat, the exact nature 
of which oould not be determined. It made necessary tlie operation of 




370 



SIXTH INTERNATIONAL CONGRESS ON TUB£KCULOSlfi. 



g&stroiomy. Prognosis unfavorable, especially if, as is posdble, the growth 
is malignant. 

November 30, 1906. Examined by A. I. C* P* physician. Stated that 
he had an attack of pleurisy three years ago, but otherwise was well up to 
last filarch, when he contracted pulmonary tuberculosis and went to North 
Brothers Island, where he remained until May; he was so much improved 
at that time that he returned and went to work again. In Aug\»st he began 
to get weak and lose his appetite; was treated by a private physician, who 
told him that he had a tumor. Went to New York Hospital and had tumor 
removed. Has been home two weeks, Telephoned to New York Hospital, 
and found that man had a carcinoma of esophagus, which was removed. 
The man grew weaker every day and died on January 11, 1907. 

On March 17, 1906, M. N., his daughter, was examined at the Vanderbilt 
Clinic for tnljerculosis, but the physician was unable to give a positive 
diagnosis until after another examination. The girl was sent to the Roose- 
velt Hospit^al for three weeks, and afterward to Morristown, N. J., for a 
months where she improved steadily. 

On Maruh 13, I9D6, E. N-, his wife, was examined by a Department of 
Health physician for tuberculosis, but was not told what her trouble was. 
On December 22, 1906, she and three children, M. N. and two others, were 
examined by the A, I, C. P. phydcian. E. N. states that she was always 
well up to last spring* ance then she has been sick most of the time with 
dyspepsia; has a dr}% painful cough, does not raise an3-thing, lost some 
flesh, but has no other signs of tuberculosis, except tlmt she is rather sen^tive 
over both lungs, especially the left. M. N., aged thirteen, has had a cough 
since birth^ her mother stated. Exanoination of the lungs reveals a rather 
weak condition, and child will have to be looked aft«r rather c^mefully. 

The woman and her daughter of thirteen were at work. The two older 
boys were put in a home, as they were unm&oagieable during father's illness. 

Case dosed. 

During two years and three months rdief was given in food to the 
amount of $U5,59; in coal, to |12,o0; m bedding, $13.96. Extra nourish- 
ment was also given; milk, $2.57; and medicine^ 13.53; nursing for the 
man three weeks. $21. 

F. Z., aged thirty-five, Swiss. She has a husband and five childreo, 
Man not very strong and unable to find lighter work, so on March 14, 1901, 
Mrs. Z. applied at the A, I. C* P, for relief, C^^se cloaed when man was able 
to get work, and reopened several times when he had no work, and on account 
of illness. On I>ecember 27^ 1906, Mrs. Z. was ^camined at the Northw*estem 
Dispensarv', where she was told she had tuberculous^ On January 5, 1907^ 
A^ 1. C. P. physician examined Mrs. Z. and her three younger childicn. 
Children anemic, but heart and luo^ not involved, Mrs, Z, stated that she 
bad EM>t been well for se^-eral y^rs; is being attended by doctor at North- 
western Dti^?ensan\ She is having eonslant hemorrhages. Case b far 
advanced atui little imptovemenl can be expected. Advised special nour- 
ishment and hospital eai^. February' 16, 1907, report from Department 
of Health stating that Mrs. Z, had been visited. It is a true case d tuber- 
ciiVwM, evklentfy in the first sta^ having a few iik& m the Bpia» of boih 
Fatieot has k»i eoosiderabie vea^t ; «c^ct(»mtes a giCAt deal; k 
treated at Narthnwitnm Diyensar^'. On M^ 8^ 1907^ ebe vvoi to 



I 

I 



I 
I 




EXAMINATION OP THE EXPOSED AND SUSPECTED. — WlLUAMS. 



371 



Seton Hospital, where, after a year and a half, she has improved, and expects 
to come home this fall. 

January 27, 1907^ F- Z., oldest daughter^ aged fifteen, examined for 
tiiberculoaa at A. I, C. P. office. Apparently ao involvement of hmgs. 
Teeth are bad. 

May 7, 1907, H. Z., aged fourteen^ examined for tuberculosis by private 
physician- Sent to the country, where he stayed only three weeks. Im- 
proved. August 31, 1IM7, went to country for one week. 

The woman's husband worked off and on, but being unwilling to support 
the children, the three younger ones wei^ in an institution, and the two 
older ones, a boy and girl of fourteen and ftfteen, were supporting themselves. 

During six yeara, relief was given in food to the amount of $71,79; in 
coal, S23; in bedding, $6.39; carfare, $1; and extra nourishment, milk and 
eggs, to the amotint of S1L13. Clothing was also given, 

J. v., aged thirty-eight, Bohemian, who haa been in this country for 
si^cteen years, has a wife and eight children. On December 14, 1901, Mrs, 
V. applied to the A, I. C. P* J. V, ill with heavy cold, December 20th, 
applied to Bellevue Dispensary for treatment. December 28, 1904, De- 
partment of Health inspector examined man and reported that he has been 
111 for three months and is suffei-ing from pulmonary tuberculosis in an 
advanced stage. Inspector learned that man is receiving treatment at the 
Bellevue Dispensary and that prognosis is fair, but consitlered it necessary 
to keep the case under observation. January 3^ 1905, nurse at Bellevue 
Dispensary stated that man had gained two pounds within the last week, 
but that she thought hospital cai-e the best thing for him, as the family 
were in such close quarters* January 6, 1905^ physician at Bellevue Dis- 
pensary states: "Although without confirmation of a positive sputum teat, 
man undoubtedly has pulmonary tulaerculosis. He is gaining and seems 
to be taking the precautions we advise. Hospital treatment is not essential 
for him at present/* February 4, 1905, he was sent to City Hospital with 
pleurisy. On April 2S, 1905, after losing weight and having several hemor- 
rhages, he was sent to Seton Hospital, where, after a few months* improve- 
ment, he failed rapidly, and on January 22, 1906, he died. 

August 9, 1905, Mrs. V. and seven children sent to country. 

August 17, 1906, physician at Vanderbilt Clinic reports that no member 
of the family, examined there, has tuberculosis, 

M. v., aged seventeen, examined at Department of Health clinic for 
tuberculosis. Sent to Seton Hospital September 15, 1906, where she 
stayed for thi'ee months. Returned home improved* On application to 
Department of Health clinic, on November 13, 1907, Department of Health 
stated that the girl had pulmonary tuberculosis at a fairly early stage, and 
that she wouhl undoubteitly be better off in a sanatorium; and that she had 
been transferred to the Presbyterian Dispenaarj'. On December 3, 1907, 
she entered Seton Hospital, where she stayed until February 21, 1^K)8, 
and returned to w*ork. 

Mrs. V. was working and also M. V. and the second daughter. 

On October 10, 1906, five children were sent to Presbvierian Hospital 
Dispensary for examination for tuberculosis. Report-, no tuberculosis. 
October 31, 1906, A. L C, P, physician examined J, V,, aged thirteen, for 



sa 



rATIOXAL CONQRESa ON TUBERCULOSIS. 




of limgs; run down, however, and she ^as 

on NoTwnher 14th for two weeks. 

TMM« and sa months relief w^ given the family in food, 

fliS; temK fl9.56; bedding. $5.75; glasses. M. V.. $1.75; 

9t4Si tnftBspoctAtioQ, $0.42; clot hlng amounting to $12.83, and 

fMlaiC VM iJnreiL ^>eet&] nourishment nniounting to $3.33 

Mil MMI ««S paid duiing M. V.'s absence at the Seton Hospital. 

QL» agffd tkirtr^wOk Americaix, i^ married and hm three children. 

Siv IS»v htr hasAiaod being out of work and being very much 

jAm B^^iM U.y the A. I. C. P* for lud. The case was closed a month 

hM Ite IQAB found work. On October 15, 19Q6, Mra. G. again 

iH Ih* A. h i\ P., slAtiikg that her hu^and had been insane for four 

Ml Mi • bard sinigzle to support herself and three children. 

^*"*^**^ at Bdierue Dkpen^ary for tuberculosts. No- 

Q. and threa children ex&nuned by A. I. C. P. physician 

MaL G. ralbar frail and both lungs are slightly involved; 

lif b« ife ^%iwnt ata^ and probably could be entireiy cured if she 

Ij^ 1)^ MaA a«^. la Januaiy, 1907, had an atta(;k of branchitis. In 

IW7, ^m ktti an attack of grip. Ihlarch 20« 1006, was examined 

al Dvpartmeut of lieJkHb chnic; Rtill coughing and has 

^ m^itm bipod. Ra|ioct fiom Department of Health states that M. G. 

mJwSvi» aaxohraoMiit of both lungs and is therefore unsuitable for 

^Hfeaakk h anna d a ci dad to move the woman and her children to better 

tD inimiitartn SBDeral support. Two of the boys are to be sent 

tvkUrtiy m a piavaetive measure. 

.^m >aar aod mm months relief ha^ l:ieen given to family, in 
»^i»Hiui of $75.09; in rent, $63; in coal, $16.12; in medicine, 
^ - tet*th, $0*95; transportation, $5.45; new clothing 

.-JtJir:^ XV- ^-. vsIm?!* clotliing was also given. Special nourishment 
' aittotml of $1.90, and milk tickets were also ^ven. 



of this plan for a large city have already 

VW o*«aa livfd at wide distances from one another, and 

^ QMUHWld in tAveling. This expense of time, coupled 

^uc^ |l)C a wnp^^W^ physician must not be low^ entailed a 

iMV^ Tba plan was discontinued at the end of seven 

^^w^ lte# a number of tuberculosis dispensaries were 

•A zo tic Ml^l "f *^ *^'*y' ^^^ ^* became possible to refer 

^^m^ ctinics for examination and treatment, and 

from the physicians at the clinics, 

physician is suggested for small towns 

v-^all^ liodT those places which have ^me or- 

" ..; a*> tuberculosis clinics* In such places 

jwwMit and advice with the plan of relief 

>^ % aaoat effective form of cooperation. 





EXAMINATIOK OP THE EXPOSED AND BUSPECTED. — WILLIAMS. 373 

Un Plan Para Administrar Socorro d los Tuberculo&os. — (Wiluams.) 
Los casos fueron referidoa i los m6dico® empleados en las asociaciones de 
Boeorro. Las familias en laa cuales alguno habfa failecido de tuberculosis, 6 
que un miembro de ella se sabfa tener la enfennedad, 6 era sospechoso en 
cuanto d la afecei6n, fueron referidosal medico, yel examen hecho encada uno 
de los miembroB de la familia. El medico hlzo comunicacionea verbales 
y por escrito del caao. EI plan del socorro forraulado de acuerdo con la vi^ta 
y conferencia del inMico, El plan prob6 ser de grands ventajas para el 
paciente, para la familia y para el visitadon Desventaja en cuanto a los 
gastos. The Associated Tuberculosis Clinic de New York hizo una aubstitu- 
ci6n mejor. El plan fu^ descontinuado. El plan ea recomendable para 
di^tritos pequenos en donda faltaa dUpeosarioe. 



Un Plan Pour Secourir ies MaLades Tuberculcux. — (Williams.) 
Lea caa furent reniia au mddecin employ<$ par la soci4t4» Lorsque dans 
une famille nn membre ^tait r^cemment mort de tulierculose, ou qu'on savait 
ou soupQoonait un membre d'etre poitriniure, ehaquc membre de la famille 
fut renvoyd au m^decia pour un examen physique, dont il fit un rapport 
verbal et ^crit. Le plan de secours fut formula par Tinspeeteur apr^s une 
consultation avec le m^decin. R^uJtat: grand avantagc au malade, k la 
famille et k rinspecteur. Inconvfinient de la d^pense. On trouva que Ies 
CHniques Assocides pour la Tuljerculo^e dans la ville de New York olTraient 
une meiUeure organisation, et le plan fut abandonn^. II est recommand^ 
pour Ies petitea viiles, oCj iln'ya paa de dispensairea. 



Ein Plan f ilr Htilfeleistung an tubercidtsse Kranke.— (Willuks.) 
Die Fillle warden an die Arzte der betreffenden Gesellschaft verwjesen. 
Familien, in denen irgeud ein Mitglied kurzlich an Tubereulose starb, oder 
BB bekannt war, dass eines ihrer Mitglieder bestimmt oder vermuthlich an 
Tubereulose litt^ wurden an den Arzt verwiesen, um jedes eiaxelne Mitglied 
derselben einer physikalischen Untersuchun^ zu unterziehen. Der Arzt 
machte eineu tniindlichen und schriftlichen Bericht. Nach Berathung mit 
dem Arzte wurde von dera besuchenden Mitgliede der Gesellschaft ein Plan 
zur Hiilfeleistung forraulirt. Der Plan hat sich bestimmt von Vortheil fiir 
den Patienten^ fiir die Familie und fiir das besuchende Mitglie<l en^'-iesen, 
Nachtbeil der Ausgaben. Die Vereinigung der Ivliniken fiir Tubereulose 
in der Stadt New York bildet einen beaseren Ersatz. Der Plan ist deshalb 
fallen gelassen. Derselbe kann indess fiir kleinere Ortschaften, wo kein 
i^bulaiorium fiir Tuberculdee vorbanden ist^ empfohlen werdeo. 



FIVE YEARS' INQUIRY INTO THE HOME CONDITIONS 
OF POOR CONSUMPTIVES IN THE WEST OF LONDON. 

By J, Edward Squire, C.B., M.D,, 

Phyaicuui Mt> VnmoD CooaunptioD Hoapital; 

AND E. B, HULBEKT, M.D., 
ReatiJent MedlcaJ Offiwr, St. Uaryloboae QcDeral Dispeuuy 



Antituberculosis dispensaries, such as that of Prof. Calmette in Lille, 
that of Dr. Fliilips in Edinburgh, and — perhaps most complete of all — the 
Phipps Institute in Philadelpliia, seek not only to treat the poor constimp- 
tives who apply for advice and help, but to safeguard others who raiglit be 
endangered by want of knowledge and want of care on the part of those 
suffering from the disease. With tliia object the patient must be visited at 
home, so that liia immediate surroundings may be studied and, where neces^ 
sary and possible, improved for his own sake and for the safety of those in 
close communication with him. 

In London special tuberculosis dispensaries have not been established, 
but there are many general dispensaries, which include consumptives among 
their patients, and several special hospitals for chest diseases with hirgeouV 
patient departments. The dispensaries are organized for the treatment of 
severe cases of illness in the patients' homes as well as for the treatment of 
out-patients at the institution, but have no beds for in-patients. The hos- 
pitals have beds for the admission of suitable cases, but have no pro\ision 
for visiting patients in their own homes. In connection with one of the pub- 
lic dispensaries (the St. Marylehone General Dispensary), where one of us 
(J. E. S.) was visiting physician, and the other (E. B, H.) resident medical 
officer, we endeavored for some years to carry out, as far as possible, the 
work of an antituberculosis dispensary in respect to those patients who came 
to the out-patient's department suffering from consumption. This entailed 
a very large amount of extra work, especially on the resident medical officer, 
but was useful in leading to the discovery, araong the relatives or close friends 
*" the patients, of some unsuspected cases of early tuberculosis, who were at 

2e placed under our treatment* 

Thia record of work in connection with the patients attending the Bt, 

374 



'SOME CONDITIONB IN THE WEST OF LONDON* — SQUIRE AND HULBERT. 375 



Marj'lebone General Dispensary on account of pvUmonaiy tuberculosia 
shows how the general dispensary may carry out to some extent the work 
for which specinl antituberculous cliapensarics are advocated and have been 
instititted. The detection of early cases, by encouraging the attendance 
for examination of those who have been exposed to infection, and the advice 
on prophylactic measures which is given to patients and their near relatives^ 
are of value from the public health standpoint. These notes put on record 
what we believe is the earliest systematic attempt in England to follow the 
consumptive to his home, and advise him on the prophylactic requirements 
specially atlapt-ed to his home surroundings and his family circle. Such vis- 
itations have since been instituted and earned out by the Brompton Hos- 
pital for Consumption and by the various health societies in London. It is 
interesting to note, bs is exemplified in several of the cases included in this 
reportp that cases not only of early phthisis, but also of more advanced lung 
tuberculosis, may be able to continue at work during the many months — or 
possibly years— during wliich treatment may be required if they can be 
under almost constant medical supervision* 

The inquir)' owed its origin, in great measure, to an interesting example 
of the probable influence of house infection in the causation of tuberculosis 
which came under the notice of one of us (E. B, H.) about the year IS93. 
The house in question was a rambling, picturesque, old building situated on 
the top of a considerable hill in a healthy village, some 20 miles from Ix)ndon, 
It was quite detached, and, the neighboring country being quite open, has a 
pleasing aspect. The rooms were, however, distinctly dark, owing to a ring 
of trees encircling the house rather closely. The drains were believed to 
be in good condition; the water- and milk-supplies excelletit. During the 
preceding ten years this house had been successively occupied by thrras 
families in no way related to one another; there was no known predisposition 
to tuberculosis in any of them, but during the above period five of the occu- 
pants developed consumption and three of these died. Six specimens of 
dust were collected from various parts of the house and doublestained in 
the usual manner. Owing to the different sizes of the particles of dust, five 
of the specimens showed only a confused dark mass, but the sixth, taken from 
the top of the dining-room door, was covered with tubercle bacilli. The 
subsequent history of the house is unknown to us. 

In investigating the cases of tuberculosis attending the St. Marylebone 
General Dispensary, our first idea was to pursue this question of house- 
infection, but we had to abandon it, — at least from the bacteriological stand- 
points—because of the time and labor involved, as well as from the frequent 
changes of address of a large proportion of our patients, the great majority 
of whom belonged to the poorer class* 



BDCTH INTERNATIONAL CONGRESS ON TUBEBCUIjOBIS. 



^\^lile endeavoring to trace the relative influence of the various factors 
kua^n to be concerned in the etiology of consumption— such as overcrowding 
want of ventilation^ of proper food, and of sunlight; the presence of dust in 
the home or workshop; the influence of alcoholic excess in the patient or in 
those responaiblo for his well-being — we paid special attention to the in- 
ve^stigation of the present as well as the past family history of our patients. 
We hoped thus to give the inquiry a practical value by the discovery of any 
other cases of the disease wliich might be present in the family, with a view 
to their early treatment and the prevention of the spread of the trouble. 
Similar inquiries were made in the case of the patient's intimate friends, 
feJlow* workers, and fellow*lodgera. We also endeavored in almost every case 
to determine the source of infection in the individual. Although in this way 
the health of some thousands of individuals has been carefully inquired into, 
wc are not a little surprised to find how small is the record of "suspects" 
examined, and of these, how few have been found to be affected with con- 
sumption. It must, however, be borne in mind that our patients were for 
the most part very poor working-class people, who can only with difiBculty 
absent themselves from their business for an hour or two, and that distance 
from the dispensary was an obstacle in many cases. In some cases it was 
found impos^ble to arrange a day and time for examination which was con- 
venient to tlie doctor and patients Only the positive results were filed^ and 
thus the records of many scores of n^ative residts ha\'e not been kept; thus 
the figures do not afford any adequate indication of the full ext^it of our 
investigatiQiisL 

Another point to which our attention has been particularly directed b 
in respect of the permanency of the patient's occupation, and it is oonaoliiig to 
find how many have been enabled to keep steadily on with tb^ work, some^ 
times over a period of several yeats^ with only occa^ooal attendance for advice 
and tnalmeot. This fact has been asootained as the rQsult of repeated coi^ 
suilfttKioa cither at the ^pessaiy or at their own homes. On the oth^ hand, 
the rate of mOTtality is undoubtedly depnaiBg* tbou^h the deaih^«te b, 
perhaps, not unusiuJI j higb, aeeiii^ thai many o£ tboae vbo have mm died 

wpn* qui ti* hnpAwi mmbr whim Owj firs^ e^iwfe mvly niif ittniiem mnH j^mMtWu 

ing abo the imfavorable enviroazuent of the majority ol our palimti. Great 
care was given to the foUowing up of the cases; socne leported tiK oacl » tt 
gpontaneoosiy; those wbo dkt not do ao vm loofcod up at least tvioe a ycftr. 
The 300 cases form practically an unbrolm acnos eoUected at the SL Marf- 
kboDe Diagaaauy during the five years from 1903 to 1907; no aetectjon has 
baea CMub^ excepi titat a Cov cases have bosn emitted oq aeoooBft of ikm 
dolaila being too r ncagei to be of service. Maaj ol then haTS been 
the carv of otiter meflobers of the staff, past aad praseat^ of the 




BOftfE CONDITIONS IN THE WEST OF LONDON.^ — BQUIRE AND HtlOlEHT. 377 



and we wish to acknowledge our iiidebt€dnes8 to these gentlemen for allowing 
m to make use of their not^, but all have been seen personally by us (the 
physical examination of all being made by Dr. Squire, and the inquiries by 
Dr. Hulbert), Tubercle bacilli have been sought for, as a rule, only in the 
sputum of doubtful cases. No case has been included in these tables in 
which the evidence of tuberculosis was not fairly convincing, and scores of 
cases, suspected to Ije, have been rejected after physical examination, l^ecause 
the evidence of tuberculosis was inconclusive. That the search for tubercle 
bacilli in the doubtful cases was for the great part negative, suggests that 
we have not been unduly eager to diagnose tuberculosis; the hea^y mortality 
rate leads also to this conclusion. Many patients also have been in-patients 
or out-patients, either at the Brompton, Mount Vernon, or City Road Hos- 
pitals, or at one of the general hospitals, before or after their attendance at 
the dispensary. Patients have l?een at some time or another admitted to the 
St. Mar^debone Infirmarj'j and, thanks to the kindness of Dr. J. R. Lunn; the 
Medical Superintendent, we have been able to make use of the notes of their 
progress while at this institution. The percentage of cases in whom there is a 
history of a previous attack of pleurisy is 39 for both sexes; previous pleurisy 
is, however, much more frequent in the male cases (nearly 48 per cent.) 
than among the females (35 per cent.)* Pneumonia wag an antecedent in 
about IS per cent, of the cases (20 per cent, of the males and 10 per cent, of 
the females). In the sex difference shown above we see the influence of the 
grenter exposure of the men, who have to go out to work. The Hst of occu- 
pations suggests, however,, that the influence of the home life is more power- 
ful as a cause of consumption than occupation per se, even though this latter 
may entail exposure or be carried out in a dusty atmosphere. Those occu- 
pations which are dangerous or unhealthy in themselves, L c*, which have 
special dangers inherent to the work, are now in greater measure safeguarded 
by the regulations of work by factory legislation* We are convinced that 
more dangers to health are to be found in the conditions of the home, and in 
the mode of life of the individual, than in the circumstances of his work. The 
dangerous occupation, from the pointof viewof the causation of consumption, 
is that occupation which does not bring in a living wage. 

In nearly all of our cases notification has been made to the medical officer 
of health for the district* Changes of address of patients have also been 
notified; altogether, SOO notifications were made. We have distribute<l some 
few hundreds of leaflets on ''Consumption/' and others on "Fresh Air and 
Ventilation, " to the patients as well as to their frien<l3 and relatives or other 
Buspects, This branch of the work, we are glad to think, has now become 
BuperfluouB, at least as regards the parish of St, Marylebone, owing to the 
recent formation of the "Borough of St. Marylebone Health Society," the 



378 



SIXTH INTERNATIONAL CX>NGIIES6 ON TUBERCULOSISL 



energies of which are for the present concentrated on the two subjects 
of tuberculosis and the care of infants* 

General TkdxaAimts. — The treatment of consumptives is rendered more 
satisfactory and more complete if the home conditions can be ascertmned 
by personal inspection. This is especially useful if the patient is being 
treated as an out-patient, since conditions inimical to his recovery and 
dangerous to others U\ing with him can be noted and possibly removed, 
or at least improved- It is also useful, when the patient is removed to a 
sanatorium or hospital, for the sake of the other inliabitants of the dwelling 
and also for the sake of the patient when he returns. Our experience tends 
strongly to the conclusion that among the poor the source of the disease must 
generally be sought in the home rather than in the work-room or street* 
The various excellent regulations of the public health authorities minimize 
risks in the streets and work-places, and, in fact, the diminutinn in the 
prevalence of tuberculosis, which has been marked in the past thirty years, 
appears to be due almost entirely to improvement in those health condi- 
tions which are to some extent under control of the public authorities. It 
would appear that the health conditions of the poorer classes of the com- 
munity have improved only so far as they have been compelled to take 
proper care; the condition of the home — where the sanitary official is unable 
to enter and exercise control — remains dangerously unhealtbful. Home in- 
spection in the case of consumptive patient-s may be carried outj as we have 
shown, by the institution staiT in the case of those applying for treatment 
to the general disfjensaries, but some special organization is necessary to 
effect this in the case of hospital patients. The question of expense prevents 
the hospital carrying out this work by a special staff. The voluntary workers 
of the health societies which have h&^n organized in A^arious parts of London 
could — and as a matter of fact do — undertake much of the work of home 
visiting of poor consumptives, and instructing the patient and his friends as 
to precautionary requirements. As these societies are usually in close 
touch with the local health authority and the medical officer of health, grosa 
defects in the dwelling can be reported and disinfection of rooms can be 
obtained. There are, however, inherent difficulties and disadvantages in 
such voluntary efTorta. Tliey may be remediable, but they require, first of 
all, to Ije recognized. In the first place, there is the difficulty of getting and 
keeping touch between the institution where treatment is sought and the 
organization which supplies visitors. The visiting organization requires 
to know of the existence of the cases, and the hospital or dispensary should 
be able to get reports from the visitors. Attempts to overcome this diffi- 
culty have been made by asking the hospitals to notify the local health 
society of all cases of consumption applying for treatment who reside in the 



HOUE CONDITIONS m THE WEST OF LO^^IJON.^SQUIRE AND HULBERT, 379 

society's district. This necessitates additional clerical work, and possible 
additional clerical assistance on the part of the hospital; and without com- 
pulsory notification by Uw, the notification can only be carried out Avith the 
consent of the patient. It must be borne in mind, also, that jaatients visit a 
hospital from distant parts of London^ and that in-patients are draviu from 
all parts of the country. Even in our cases — visiting a local dispensary^ — we 
had patients from such distant parts of Ixfndon as Islington and Hackney on 
the north; Chelsea, Clapham, and Dandsworth on the south; Walthamston 
on the east; and Tumhan Green on the west. Thus, obtMning the patients' 
permission to notify, and classifying patients according to their districts, 
entails a good deal of work, and, In one chest hospital at least, the attempt 
had to be gi%'en up* In smaller towns this difficulty may not occur. It 
seems evident that compulsory notification of tuberculosis throughout the 
country is first essential. As a result of compulsory notification to the 
me<lical ofEcer of health, this official would become the center with which 
all the organizations (hospitals on the one hand, and \isitors on tlie other) 
would be connected, and through which they could be placed in connection 
with one another and with various relief associations. Without such coor- 
dination it must frequently happen that, while there is overlapping in some 
instances, many csfies are altogether passed over. There must also be power 
to enforce the removal of advanced cases of " open *' tuberculosis from unsuit- 
able homes to some institutiou, such as the Poor-law Infirmar)', and to re- 
tain them there so long as may be necessary. Many of our cases were ad- 
vised to go into the Infirmary, but often they came out again, after a short 
stay, becoming a source of danger to their relatives and a drag on their 
resources. If notification were universal and compulsory, it would soon 
become evitlent that some provision b needed for the support, while the 
bread-dinner is away, of the families of those who require treatment in a 
sanatorium. Without this, many early cases will endeavor to keep their 
illness secret, for fear that they will be notified and compelled to give up 
work and go into a sanatorium. In view of the importance of early treat- 
ment, this would be a misfortune. We foimd that several of our out-patients 
were obliged to keep at work, and could not give up the time to come regu- 
larly for examination. 

Through the public health authority of the district many rooms which 
had been occupied by consumptives have been disinfected after the death 
or removal of the patient. In the majority of these cases the medical officer 
of health would have had no intimation that disinfection was desirable, ex- 
cept for the notification sent to him by us, and the rooms would havebeen 
quickly occupied by other tenants, who would hhve had no knowledge that 
they had recently been vacated by a consumptive. 



380 SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 

Condicionas del Hogar de los Tistcos en el Oeste de Londres. — (Squire, 

HULBERT.) 

Los resultadoB del trabajo en cone^6n con los pacientes que atienden 
el "St, Maiylebone Dispensary," d causa de estar estos afectados de tubercu- 
losis pulmonar, da lugar i las conclusiones siguientes: 

EI tratamiento de los tuberculosos es mas satisfactorio y mas completo, 
cuando las condiciones del hogar son estudiadas por medio de una inspecdon 
personal: 

Entre los pobres el origen de la enfermedad debera buscarse mas buen 
en los hogares que en ios talleres 6 en las calles. 

La inspeccion de las casas en e! caso de los tiaicos puede hacerse por 
medio de los empleados de la Institucion, 6 bien por trabaj adores volim- 
tarios conectados con las Sociedades de Salud recientemente organizadas, 
mas existen dificultades en depender enteramente de tales ofertas volun- 
tarias. 

Parece evidente que la notificacion obligatoria de los Oficiales Medicos 
de Salud es esencial, d fin de que 6sta sea el centro de comtmicacion para 
el hospital, los visitantes de la Sociedad de Salud, la Asociacion de Socorro 
y las otras organizaciones. 



HOW TO DEAL WITH THE DANGER TO PATIENTS 
OF RETURN TO UNFAVORABLE CONDITIONS. 

By Walter E. Kruesi, 

SecnUry of the Boeton Sodety for the Rdief and Contrd of TuberculoaiB. 



Another great atep toward making our facilities for advanced cases more 
nearly equal to our needs would be taken if a plan were devised to prevent 
the return of sanatorium patients to unfavorable conditions which cause 
them to relapse rapidly. A return to unfavorable home conditions cannot 
be prevented until the medical and social agents for the relief of the poor 
consumptive move up closer to each other and occupy together the vacant 
territory where the ex-patient now moves about under such heavy handicaps 
that he soon becomes eligible to relief institutions. But organized relief, so 
far as it is adapted to the consumptive's uses, is no more than a salvage opera- 
tion. After a patient leaves the sanatorium he can find neither an institution 
which creates good conditions for him, nor one which controls adverse con- 
ditions. There are certain devices to rescue, but none to protect or con- 
serve him. He is a victim of the confusion that exists between the old practice 
of individualism, personal initiative, self-help, freedom of contract, and the 
new practices that would give to each according to his needs. 

The laissez faire doctrine is going in regard to property; it is being at- 
tacked in industry; but it prevails undisputed in that field of health where 
the convalescent and the half-disabled are. There, at present, he is neither 
generously saved nor completely destroyed, for he is caught in the gap be- 
tween the old "do-it-yourself" morality of Herbert Spencer, and the new 
morality that will soon extend social control over all matters affecting health. 

Seventy-five poor patients were recently discharged, " arrested" or " much 
improved," from a certain sanatorium. Within from one to six months, 
32 of them were admitted in advanced stages to another sanatorium. The 
history of the interval was one of confusion, beginning abruptly on the day 
of departure, punctuated with spasmodic moments of temporary aid by 
grudging charities, and ending in a flat loss of 50 per cent, on the investment. 
What were these ignored, sick, distrusted people doing in the interval be- 
tween the closing of the door of one sanatorium behind them, and the open- 
ing of another for them? There is no record; the sad facts about a few of 
them were picked up, by hard work, and were used as the sole argument for 

381 



382 



SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS. 



the establishment of an after-care department in tbe sanatorium nearest to 
the scene of these flagrant incidents* We have, in thia instance^ a Stat€ 
sanatorium for 350 patients. The average stay is twenty-four weeks; the 
average direct cost, S250; the average income of the patient's family is 
under S900 per year. 

The after-care depaiiraent would best be worked out and established by 
a special appointive body with an adequate appropriation. To save time, 
it will be started by the volunteer society wliich has advocated it, with 
the cooperation of the sanatorium authorities. The society is searching 
for a special employee, trained and experienced in giv^ing counsel to and 
obtaining relief for individuals, acquainted with the methods and results of 
Himilar experiments, the ability to construct thia work, and the tact required 
to maintain the delicate relation of a lay volunteer guest-adjunct^officer to 
a public institution- 

The first step in introducing after-care work into any sanatorium should 
be a long informal talk^ and several shorter talks^ with patients about to be 
discharged. I would gather every available fact about home, occupation, 
personal resources, family, and condition for and limitations upon work 
activity (giving the patient plenty of opportunity for .self-expression). 

I would explain the liability to and causes of relapse, and urge full co- 
operation in making the cure complete and permanent, entirely reversing the 
usual medical custom of reticence, myater>\ and exaction of blind obedience. 
It should be possible to get a statement from each patient as to what he can, 
will, or might do; to win his active cooperation in preparing, in advance of 
discharge^ for a kindly reception, and a job for which his endurance has been 
tested. 

Physical treatment is an important element m the regime of cure and 
reestablishment. It should be arranged in graduated Etages, so that a 
patient, thoroughly tested and inuretl to one stage, can be advanced without 
danger to the next, until a discharge certificate of safety and capacity, if not 
of efficiency, could be given. The nature, speed, and amount of activity 
should ])e as definitely prescribed as are other elements of hygiene, or as 
drug treatment. The dose should be increased or diminished as the indi- 
cations demand. Some such plan as the following has been put into use at 
the Royal Victoria Hospital, OtLsville Sanatorium, and other places with 
great success. 



L Resting Slage. — Physical inactivity (a) without, (fc) with mental ac- 
tivity. On admission to the hospital all patients are given complete rest, 
which will last from a few days to several weeks, according to the individual 
case; (a) in isolated bed, (b) in ward l?ed, (c) in reclining chair — (a) with- 
out, (b) with individual pastime or entertainment 

U. Stage of Regulated Exercises, — (1) While reclining — one limb at a 



AFTEB-CARE OF PATIENTS. — KHUESI. 3S3 

time, kneading, rubbing, bathing, and massaging one's self. (2) Sitting up 
for increasing periods. Walking aroimd room and house. (3) Walking 
prescribed distances, from \ mile to 5 miles: (a) on level ground, (&) on slop- 
ing ground. Exercise to improve respiration and circulation once or twice 
a day. (4) Calisthenics. Other movements to improve carriage of shoulders, 
head, and chest. 

in. Stage of Regidaied Work. — The work is chosen with a view to util- 
ity, and with due regard to the patient's individual case, and to the past, the 
probable, and the durable future occupation. 

Grade A: Picking up papers, leaves, and other light rubbish in the grounds, 
Knitting, sewing, drawing, copying, writing, carving. 

Grade B: Carrying light baskets; weeding and other easy garden work 
done with small-sized tools; hunting eggs; feeding poultry; picking fruit; 
gathering seeds; pruning; emptying waste boxes, and assisting to carry 
away rubbish; cleaning cutlery; washing and drying dishes; painting toy 
furniture, gates, fences, etc.; decorating; playing musical instruments. 

Grade C: Raking, hoeing, digging, mowing, with medium-sized imple- 
ments; sweeping leaves; drawing two-wheeled barrow with assistance; 
other garden jobs, requiring the same amount of exertion; sweeping; 
mopping floor; cleaning brasses; brushing clothes and shoes; assisting in 
laundry, sorting and counting clothes. 

Greule D: Digging; sawing; chopping; road-making and cleaning; carry- 
ing heavy basket in the garden; wheeling and drawing full wheel-barrow, 
and other heavy garden work; pushing wheel-chair; bathing and assisting 
other patients; mangling, window-cleaning; scrubbing; polishing floors; 
sweeping and cleaning without raising dust; carpentering; joining; attend- 
ing boiler, engineering. 

In grades B, C, and D patients make their own beds and do errands. 
Short daily periods of play, involving physical activity equal to the work, 
are arranged for each grade. 

I should expect to correspond freely about patients and to have the 
home environment well mapped, by a visiting nurse or a qualified agent of 
organized charity, before the patient is discharged. I would furnish this 
person with a copy of Form 1 filled out to line 14. The lower part of this 
form must obviously be filled out as the care of the case proceeds. 

My purp>ose would be to