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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
Ifanihall 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:*
0 148 143 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 + 0 = 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 0 100 -100
6to 9 0 150 -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 0 300 -300
85 to 89 0 300 -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-
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■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 Mifthigag.
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.— mortality table 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.
0
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
0
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
0
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
0
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
0
0
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
0
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.
0
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
^jTV^ »\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 — 0
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. 0 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
foaniioveisy; 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
ytfacwd 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 connectiop b tltt pbce of
■cfOHBee of mttem is the efaief HHwiihiiitiiBi^ aid ifc k Cu-
te cboov » vvant Aopaooatoi the buanea rtrecte of ft
dHj thiB note ioipoMg quartera in sosne pubGc boldbig, viwrfa emnoflai
tmlf obUBOed. It is leco^abcd that tin ecfancatioDa] icaolts am
proportloMte 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 mcDtaoned, 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 cfiective 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^lftff 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 inconaiateaey.
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 groaicQ 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 BBViiuw! 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
a
o
"m
^
a* ^
- ~g
^^. @) ® «i
J^«l ^
■#/,
H .^ Is! ^ A
V
^
|o|
:^^^^^
^
^
Is)
lAncnas-
1906-
gg- flamtMlary tm^Ptuitit.m.
ALViK-
° ^
,
•a
' ^
i
o
'J
^^
Ol • «* tunmtln— tharam
a
o a
^1 > flmt^utaf tuMT-fCiiw-
— -—
0 :1 -'^-^ ./-O ■%„_
m m umtt f«i# r/'/Hi/»K*td>y
AiAi'vWo.fls-
• • au^rtttd rmr r//>,a-^
D
0 ii'
Q
□ - ml itn-n.ntU
'\
._„.
""■■-i
.ci ^^
•O o
us^ antnAs-
'■^^ .g. D 1©08.
cultmtM- y / \
'^^^S
□ -<««( tmamiMa- S !
\ K
^
x^ .t *«\ m i V
Qa^.
.. Bi^" '^ aigai^^ j_j-a =f»i_ *'. -=tr= _«=l — ' \i
--'''--y/^^^
' pulmonary Iti^frnlrv*'
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
n
r
r
-
r
(T
^
i7
*e
(a
^(^
rt
It
n
?(^
r7
tr
^
p^
(7
\e
S)%
frr
ff
if
.^
■V
w
P-
JT
J/'
6^
#/
/i'
7J-
f^.
m
—
v^
^
-^
V
t
*JvJS
i
-^
r^
\
/
\
f
V
m
/
\
f
y
/
\
/
\
m
J
f—
y
/
/
f
0,
_L
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 "
0 " in 25 "
76 families
1} _
n
^
{H
\f
n
>f
fT
Y'
fX
ff
tn
rrf!^
J*£-
fit
'(*■
ft
if
fi
y
ill
¥"
fH
W
n
if
f?'
;^ .
ifh
^.
«A
C
t
^
^
,i
f,
Y
t
-^
r
{Q
//
^
Wi
A
/^
V
/f
4
^
9f
^
-M
-^
H
5f
-^
^
sSf
?&l
ivt
,r
L
m
/
\
J
^
-»
^
^
^
V
/
^
m**
/
\
y
^
\
^
f
1
\
ftf4
J
V
If^
f
A
-*a
L
l^rT"
\
d^i
^
Jti
J
\
rf*
\
/
\
a
J
J
/
\
_
^
K
'S
Ni
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 ifffiigfiahir, and all
tfa» rtfwajT aynMirr^tfiMwg fnr pw^i>ying fnriH m^w^ mliiig 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 miciaacopical
<?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<niss 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 0 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 eounection 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 infection 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 imprwed, 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 dacidad 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 $1.90, and milk tickets were also ^ven.
of this plan for a large city have already
VW o*«aa livfd at wide distances from one another, and
^ QMUHWld in tAveling. This expense of time, coupled
^uc^ |l)C a wnp^^W^ physician must not be low^ entailed a
iMV^ Tba plan was discontinued at the end of seven
^^w^ lte# a number of tuberculosis dispensaries were
•Azotic Ml^l "f *^ *^'*y' ^^^ ^* became possible to refer
^^m^ ctinics for examination and treatment, and
from the physicians at the clinics,
physician is suggested for small towns
v-^all^ liodT those places which have ^me or-
" ..; a*> tuberculosis clinics* In such places
jwwMit and advice with the plan of relief
>^ % aaoat effective form of cooperation.
EXAMINATIOK OP THE EXPOSED AND BUSPECTED. — WILLIAMS. 373
Un Plan Para Administrar Socorro d los Tuberculo&os. — (Wiluams.)
Los casos fueron referidoa i los m6dico® empleados en las asociaciones de
Boeorro. Las familias en laa cuales alguno habfa failecido de tuberculosis, 6
que un miembro de ella se sabfa tener la enfennedad, 6 era sospechoso en
cuanto d la afecei6n, fueron referidosal medico, yel examen hecho encada uno
de los miembroB de la familia. El medico hlzo comunicacionea verbales
y por escrito del caao. EI plan del socorro forraulado de acuerdo con la vi^ta
y conferencia del inMico, El plan prob6 ser de grands ventajas para el
paciente, para la familia y para el visitadon Desventaja en cuanto a los
gastos. The Associated Tuberculosis Clinic de New York hizo una aubstitu-
ci6n mejor. El plan fu^ descontinuado. El plan ea recomendable para
di^tritos pequenos en donda faltaa dUpeosarioe.
Un Plan Pour Secourir ies MaLades Tuberculcux. — (Williams.)
Lea caa furent reniia au mddecin employ<$ 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 tiKoacl»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 rncagei 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 fix a rigorous and adequate standard of living
and regime of life. I would reject any inadequate aid offered by charities
in the way of odd jobs, relief at home, or a few grocery orders, and would
press the sanatorium to keep the patient until the right thing is found.
Money relief should be used to pay board at the sanatorium longer than the
"average term" if the physicians believe further institution treatment is
necessary. If any one objects to this, fix the responsibility upon him as
on one who would put a man overboard in mid-ocean.
8M
SIXTH INTEBN'aTIONAL COKGBBS& GS
Wken the employmeiit or iB&f aendes bave f oood a poatkm, <
home eooditioiM are promimg, the patient aboitki he <t*MJmy<1
aereeoKQt to i^Niit at short interrab to the age&t, who fliioiald be . ._, .
able m probation officers are. If the patiesit faile to lepoft, be ahoidd be ■
TistecL If the leports are uDsatirfactaix, the conditicpe efaoaid be iiKTali'
gated and improved. So kmg as the «ork is in an ezperimcstal stage, the
after-care worker's aodal diagnosis should be veiy thonxi^ I would hold
the padenta bade as long as possible, training and testing them in the 8aii»-
torixim; and then direct Ukem into the least dangerous channels of indostml
fi£e. A paUeDt's home is as important an index to his ca^e as the conditioD ■
el bis throat. A dbgram of what his economic state is to be after <&ebai|^ ■
m no leas important than the final dia^am of bis hings. The deieiiuuia* m
tkm of his endurance has no significance until we know what occupation ■
m going to test it, I
Oocupation without relapse^ before and after dischargep is the test of 1
endurance — not the stethoecope. But the stethoeoope at the examining
clinic should be handy to the factory bench, as the factory bench should be .
handy for delicate experiments in the sanatorium. The record must be
marie coatinuoua and the medical and social data must be charted t^^tber; ■
then will be overcome the pesaimLam of the medical 8a>'ing that a con-
gumpttve in poverty may be cured, but he cannot be saved. The circle
of medical care and of social after-care, which complete themaelves now ■
without touching^ must be brought together. They ought to be super-
tmpoeed, but the greatest risks can be avoided if they touch at one point,
making thus at least a coherent diagram of care. The medical circle must ■
not be closed until the facts of the patient's housing, occupation, and family
re»our<^a are filed in the doctor^a desk. A patient should not be cyschar^ged
according to his physical symptoms; they have Uttie Ijearing on his case
before we know what his income will be.
Problems like the following must be solved together by medical and
social care-takers:
If A — J with a dependent family and a possible $700 a year, is nearer
recovery than B — , uith $1200, umnarried; and if C — is pressing for one of
their beds, shall A — or B — be discharged?
The $700 man must be diagnosed in one way, the $1200 producer in an-
other; the differentiation must begin before the special manipulation of
home conditions Is undertaken. The $700 and $1200 organisms react to
their after-care environment in unlike ways, although they react alike in
the sanatorium, where nutrition, air, and sleep are not dispensed to the well-
to-do and the poor according to their deserts, but according to their needs.
The after-care agent will prepare the patient for his return to his com-
munity, and prepare his community for him; he will keep a friendly hand
I
I
I
I
AmiR-CARE OF PATIENTS. — KRtTSSI. 3iB5
upon the patient's shoulder until it is plun that there is adjustment to a
fair economic and hygienic plane.
I. After-care History of Sanatorium Patient.
Date Name Age
Natioiudity Present Address I^vious address
Family Phthisis in family
Occupation before admission to Sanatorium? Income?
Other means of support Sick benefit
Support of family while patient at Sanatoriimi
Cost of patient's board while at Sanatorium
Paid by
Direct cost to State's treasury
Date of admission Condition
Occupation at Sanatorium
Date of discharge Condition
Adviser on discnar^
Patient's report of mstniction received
Referred for after-care to
When did patient go to work?
At what?.... Employer
Hours Wage
Hygienic conditions at work
Hygienic conditions at home Sunlight
How many windows? Room alone? Sleep alone?. . .
Diet ample?
Use of bquor, tobacco, or drugs
Last examination of teeth Tooth brush used?
<^««^(^Siy:;:;;;::::::::::::;:::::::::::::::;:::::::::::::::
Relapse, reinfection, or serious illness since leaving Sanatorium
Probable cause
Present condition
ix>s8 or gain in weight Cough Expectoration
Kigfat-sweats Sleep Appetite
R^rds of other cases in house
Disinfection
Circumstances of death or removal
Investigator's impression of patient
Improvements suggested
Rcxnarks
Date of visit Other visits.
Investigator's name
II. Cases Illustrating Need of After-care Department to Prevent
Relapse.
Case No. 201. D. K., twenty-six years old. Admitted to Rutland,
March 9, 1907; discharged "arrested," July 27th. He was obliged to
return at once to his old occupation as tailor, apparently without advice.
Worked hard because he was out of money, and shortly relapsed. Had
been earning $12.50 a week and had saved enough to keep him at Rutland
for six weeks. Entered Day Sanatorium October 22, 1907. January 20,
1908, discharged "arrested." January 28th, Association's nurse found
vou ni — 13
3S6
SIXTH INTERNAnONAL CONGRESS ON TUBERCULOSIS,
patient is attending Mt. Sinai Hospital Class. Is getting two quarts of
milk daily and ia buying his own eggs. AVorkeci in tailor shop a few houtB
daily wliere it was clean and airy. April 6, 1908, patient working at Som-
ner'fl factory, 5 Tremont Street, past month. Buys 1 quart of milk, Mt.
Sinai ja:ives 1 quart, June I5th, Associated Charities has been paying
$12.00 rent. Hebrew Benevolent gives S3.00. July 20th, Mrs. K. has been
unsuccessful in obtaining work. Home much cleaner. Mrs. K. looks thin
and pale, says she also sleeps in tent with husband. Examined and has
loHt 10 pounds. Has a good tent on roof, in which he sleeps. July 20^ 1908,
patient is attending City Day Camp. July 7, 1908, reentered Municipal
Day Camp Sanatorium. August, 1908, discharged from Day Camp for
smoking and impertinence. Heferred back to out-patient department,
Boston Consumptive's Hospital, for supervision in his home and clinical
treatment. Wife Is attending Boston Consumptive's Hospital Clinic.
Case No, 126* Mrs. C, H., thirty-eight years old. Admitted to Rutland,
February 16, 1W7, and discharged July 27, 1907, "arrested," according to
Rutland report. The patient^ however, said the doctor told her that she
was only improved, that there was a bad spot on the right limg which would
be '* easily broken open if she worked/* Says the Rutland doctors told
her that nobody could stay well in Boston. She did little work at home
and was very careful. The nurse's history ^vea a picture of wretched
conditions, inadequate food, and an unkind husband. She would have
left Boston if she had been urged, she said, b«t did not think of that, and
stayed because her friends were here. She said she was t«o discouraged to
try to get well. Admitted to Day Camp Sanatorium August 2, 1907, Six
weeks after discharge from Rutland, stage 3. Husband in Deer Island
Penitentiary and cliildren are in homes. Mrs, D,, of S. E. Industrial School,
pays rent and provides food. January 14, 1908, patient was dischar|:ed
fi-om Cump for non-attendance. Referred to Boston C^onaumptive's Hospital
for home visits, February 25, 1908, Board of Health reports gone to
hospital or moved* March 6, 1908, Board of Health reports disinfection.
SeptemWr 17th, baby three weeks old. Patient expectorates less, is careful,
and m better. Boston Consumptive's Hospital nurse is supervising case.
Case No. 12, Joshua R., forty-six years old. Admitted to Rutland
October, 1906; discharged May 11, 1907, "arrested." May 21st he com-
plained of ''tightness across chest'* and asked to go to Day Camp, He
was, however, without funds for carfare* The Associated Charities refused
to pay carfares, because he is reticent about his second mamage, and having
Ijeen dischargeid from Rutland, ''arrested," should be able to work. On
examination for admission to the Day Camp Sanatorium he was found to
be in the third stage active, and was admitted to the Day Camp Sanatorium
three and a half weeks after discharge from Rutland, on June 5th, Dia-
charged from Day Camp December 13th for non-attendance. December
15th was readmitted. Pays own carfares from wife^a earnings, January
28, 1908, patient was offered a small place in Rutland, Mass., but declined
it, as he feared he could not make a living there. Reported stage 3 at
close of Camp, February 1st. July 4th admitted to new Municipal Day
Sanatorium, Discharged September 1 1th, No funds to pay carfares. No
active signs of disease. Will return to work in oyster shop, Boston Con-
sumptive's Hospital nurse reports wife dirty and unreliable.
■
I!
4
THE CARE OF PATIENTS AFTER DISCHARGE FROM
SANATORIUMS: THE QUESTION OF FARM COL-
ONIES AND INDUSTRIAL SETTLEMENTS.
By Elizabeth W. Newcomb,
Preoident Stony Woid Sanatorium.
One of the great problems of to-day is how to care for patients who have
been discharged from sanatoriums as arrested cases. The question of
einplo3rment is one about which the physician in charge of a tuberculosis
sanatorium is asked to advise the patient. Will she be able to return to the
crowded tenements and take up the work to which she was accustomed
before entering the sanatorium? How long will it be before she wilt apply
for readmission?
In the four short years of Stony Wold's existence, those in charge of the
Sanatorium have kept as closely in touch with the 470 discharged patients
as is possible with such a large number. Some are scattered in various
parts of the country. The majority, however, reside in New York city.
Some one hundred and sixty have been heard from and are holding their
own. One hundred and one have been lost track of, while ninety-seven
have died.
The question now confronts us, How many of those who have broken
down or died might have been saved? Would it not have been wise to have
expended a few more dollars upon them at the time of their discharge?
Could not suitable employment have been provided for them under proper
climatic conditions? For the purpose of trying to solve this problem, and
if possible to answer the above questions, the Stony Wold Sanatorium
decided to make the experiment of starting an industrial settlement or
farm colony.
This settlement will consist of patients who have been at the Sanatorium
and have become well enough to do some light work, but who cannot with
safety return to the city. The patient can carry on flower culture, raise
chickens, and do light vegetable gardening, etc., while the well members of
the family can find employment at the Sanatorium. The fathers, mothers,
and husbands of such patients should give good service, as they will have a
twofold interest in so doing.
This plan also places the responsibility of the care of ex-patients where
387
388
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
it beloogB — upon their own families* The latter are assisted in securing
work in a climate suitable for the patient, who, in turn^ can be given a more
protracted stay in the mountains under the proper care and supervision of
experienced physicians and nurses, Thia seems more practical than to have
them remain In the Sanatorium, on account of the lack of space and means
at hand for so large a number for so long a time.
The Industrial Settlement Comnattee realises the importance of the
question of work for the individual patients who have been entirely or
partially restored to health. The inability of the discharged patient to
secure employment adapted to her phyKical needs often drives her to accept
work which can have but one ending — relapse — and many lives are sacri-
ficed in this way. TMs oommittee has decided to start small industries^
under competent teachers, which can be carried on by the settlements In
tame it is hoped to give employment to many of the class above mentioned.
The committee realizes only too well the many difficulties in an under-
taking of this kind, but acts on the old saying, "Nothing ventured, nothing
won/'
Forestry will be taught. A small nursery has been started, and it is
hoped in time to have an extenMve one. Pine, spruce, luid balsam seedlings
bring good prices, as the demand is much greater than the supply. It is
posdble that a willow holt can be started, and that the experiments now
being made will prove that the soil at Lake Kushaqua is adapted to this
purpose. This industry has become a most profitable one in other parts
of the SUte.«
Last fall land was cleared. The first house of the settlement is now
being built. It mil contain a living- and dining-room, kitchen, four bed-
rooms and bath, a sleeping porch and day porch. It is the de^re of the
oommittee to make these homes and the work so pleasant as to create in
the hearts and minds of the inhabitants the love of country life. E^ch
family will be gjven one acre of land for garden purposes. It is hoped that
this one acre will be equally as productive as the five planted with potatoes
last year, which >nelded some 1400 bushels, or 280 bushels to the acre. At
the lowest market price of 50 cents per bushel^ one acne of land would in an
ordinary Adirondack season produce an income of |140 if potatoes alone
were raised. Should other vr^tables be planted on the same amount of
land, it would increase the income. One and seven-tenths acres of land
last year produced SIOOO worth of vegetables, the value bdng estiinated at
the lowest market price. This was the result of the labor of one experienced
aad hard-working man.
Ordinar)' laborers receive from SI to $1 .50 per day. Carpenters, peters,
* See the New York SULe Forest. Fish, and Gunc Commiwion^B buUetm on Willow
Ctdiure, by Mr. £. Seymour Woodruff,
aftbr-cabe: farm colonies. — newcomb. 389
and more skilled mechanics recdve from $2 to 13 per day. If the men
board themselves, they are allowed $17 a month for this item. The lowest
income which will be received by a man for the year, provided he is able
to work every day, will be $568, and he will have no rent to pay. This
amomit could be used simply for food and clothing, and should be ample
for the support of a small family. The amoimt of money secured from
the sale of v^etables could be laid aside for a rainy day. The women
employed at the Sanatorium earn from $17 to $35 per month, according to
the work.
A number of ex-patients have been and are still in the employ of the
Sanatorium. One of the eldest of a family of five children, two of whom
died of the disease, came to Stony Wold after having spent one year in the
Adirondacks. The physicians pronounced hers an advanced case, both
limgs being affected. In a very short time she was able to take entire charge
of the p06tK}ffice, and has since established a store, both of which she has
conducted successfully. For the past four years she has worked early and
late, and with it all is in splendid condition as long as she remains in the
Adirondacks. She cannot, however, go to the city, for even two weeks,
without feeling the effects of the change — usually b^ins to cough and is
quite miserable. She has two sisters who showed the beginning signs of
the disease. The younger one recovered, married an employee of the
S&natorimn, and has two healthy children. The other, by spending a few
months of each year in the Adirondacks, is able not only to support herself
in the city, but also to assist in the support of her mother.
Another young woman whose throat bore the brunt of her attack, and
who was not able to speak aloud for seven years, serves as seamstress. She
has made two attempts to resume her work as milliner in the city, but each
time has broken down. Many more cases could be cited who have been
and are now employed at the Sanatorium who have kept perfectly well
while working in the Adirondacks, but who could not maintain their health
in the city.
Colonias Rurales de Tuberctilosos.— (Newcobcb.)
De los pacientes que han dejado el sanatorio, desde el tiempo que este
ha estado en operaci6n hasta el presente, han fallecido 97. Este hecho
ha sugerido las preguntas siguientes: — Cudntos de ellos hubieran podido
salvarse? No hubiera sido mas cuerdo haber gastado mia moderada suma de
dinero en ellos al tiempo que dejaban el sanatorio? Fudiera haberse en-
contrado empleoe apropiados y bajo condiciones cllmatologicas mas favor-
ables? A fin dar una contestacion & estas preguntas nosotros decidimos
establecer una Colonia Industrial 6 Ck)lonia Rural. La Colonia consistir&
390
6IXTH INTERNATIONAL CONGRESS ON TUBERCOLOSIS.
de enfermos que ban dejado el sanatorio en condiciones tales que les peruiita
dedicarse d trabajos ligeroa, tales corao el cultivo de (lores, la crianza de aves
caserfis y otros trabajos ligeros. Mienibros de la faiuilia del eaferino podran
encontrar empleos en el Sanatorio. Este plan pone la responsabilidad del
cuidado de los enfermos donde este corresponde, esto es en su misma
familxa. Pacientes que ban sido descartados del sanatorio se ven obligados,
muchas veces, A tomar ocupaciones inadecuadas y como consecuencia un
relapso de la en fermedad es el resultado* Nitcstra Corporaci6n pretende
ensenar la parte prictica del cultivo de los bosques. Un pequeno prinoipio
estd ya en pi^. El cultivo de las semillaa de pinoa, bdlsamo, etc,» puede es-
cablecerae y la deinanda es mayor que el abaatecimiento, Nosotros tambien
pensamos establecer el cultivo del sauce para la industria de canastoa.
La primer casa de la Coloiua contiene un sal6n, un cometlor, una cocina,
cuatro cuartos de dormir, cuarto de baflo, un vestfbulo de dia y otro da
noche para dormir, Gada familia en la Colonia tendrd un jardin de una
acre de terreno en extension* La tierra puede producir como 280 fanegas
de patatas por acre de terreno. Otros granos pucden cultivarse con raayones
ventaja. En nuestra localidad im operario reclbe de fl 4 SI. 50 por dfa,
carpinteros, pintores y otros mec^cos mas iblles $2 d S3 al dia. Si ellos
cuidan de su mantencion se les reconoce $17 al mes- El salario mas pequeno
de una persona es de tS^S al ano sb tener que pagar rentas, Esto dara
para los gastos de mantenci6n y vestido y los protluctos del terreno pueden
tontarse como ahorros. Las raujeres empleadaa en el Sanatorio reciben de
S17 ^ S35 al mes.
4
4
Land-Kolonien. — (Newcomb.)
Von den Patienten, die unsere Anstalt, das Stony Wold Sanatorium,
verlassen haben, sind seit der Gritndang derselbea bis jet;fit ungefahr 97
gestorben. Wir stellten una die Frage: Wie viele batten gerettet werden
k5nnen7 Ware ea nicht geacheit gewesenj zur Zeit ihrer Entlaasung von
der Anstalt, fiir diese Patienten noch einige Dollars zu spenden? Hatten
wir fiir diesetben eine passende Beschaftigung uiiter geeigneten klimati-
schen Bedingiingen finden konnen? Um auf diese Frage antworten zu
konnen, beschlossen vdr, eine industrielle Anstalt (Industrial Settlement)
Oder eine Land-Kolonie (Farm Colony) zu grtlnden. Die Anstalt soUte
aus entlassenea Patienten bestehen, die im Stande waren, eine leicbte
Arbeit, wie Blumen-Kultur, Gefliigel-Versorgung, leichte Gartenbau-Arbeit
etc. auszuiiben. Die Mitglieder der Familie des Patienten wiirden im
Sanatorium Beschaftigung finden. Dieser Plan legt die Verantwortlicb-
keit fiir die Versorgung der ge^^esenen Patienten auf diejenigen Leute herauf,
denen sie gehdrt, namlich auf deren eigenen Familien. Oftmals milssen
A]?TER-CAR£: FARM COLONIES. — ^NEWCOMB. 391
die entlassenen Patienten eine unpassende Arbeit ausiiben und haben
dadurch Riickfalle. Wir hoffen, praktische Forstwirtschaft unterrichten
zu kdnnen. Ein kleiner Anfang wurde schon gemacht. In den Adirondack-
Crebirgen kdnnen Fichtenbaume gepflegt und verschiedene Wald-PFodukte
erzeugt werden, fiir welche die Nachfrage viel grosser wie das Angebot ist.
Wir wollen auch eine Weidenkultur griinden, die uns das Material fur die
Korbflechterei liefem wiirde.
Das erste Haus enth< ein Aufenthalts-, ein Speisezimmer, eine Kiiche,
vier Schlafzimmer, ein Badeadmmer, ein Tages-Vorhof und eine offene
Halle zum Schlafen. Jede Familie der Anstalt wird einen Acker Land
fiir den Gartenbau kriegen. Der Adirondack-Boden kann 280 Scheffel
Kartoffel pro Acker produziren. Andere Anpflanzungen wiirden sogar
noch vorteilhafter sein. In unserer Gregend verdient ein Tagelohner einen
bis anderthalb Dollars taglich, Tischler, Maler und Mechaniker zwischen
2 und 3 Dollars pro Tag. Wenn die Patienten ihre Lebensmittel selbst
besorgen wollen, wird ihnen 17 Dollars monatlich ausgezablt. Das kleinste
Einkommen, das ein Mann erhalten wird, der jeden Tag arbeitet, wiirde
568 Dollars j&hrlich sein, ohne da von Mietzins zu zahlen. Diese Summe
wiirde ihn mit Nahrung und lOeidung versorgen, und das vom Verkaufe
der Garten-Produkte erhaltene Geld kann gespart werden. Frauen, welche
im Sanatorium angestellt sind, kriegen von 17 bis 35 Dollars monatlich.
A FARM COLONY EXPERIMENT.
By H^NTir Bahton" Jacobs, SLD.,
What I shall say to-day is in the nature of a preliminary report upoa
an experiment which i^ being made at the Eudowood Sanatorium near
BaUiniore, Md, It is too soon to record definile results, but I have
felt that the circumstancea which led to the idea, and the early arraoge-
mentfl for its trial, might be of interest to those actively engaged in
nanatorium management.
The first point to notice is the situation of Eudowood in reference to
its HUpply of patients. In this respect it is particulariy favored. The Sana-
torium owns and occupies a farm of about 100 acres of excellent soil, at an
altitude of nearly 700 feeti eight miles from the center of the city of Balti-
more, from which it is reached by an electric car in forty minutes. The
proximity to the city makea it easy to induce patients to attempt treatment,
as they are to be still so near home and friends, and the facilities for the
latter to get to them are so good that there is little difficulty in prevailing
upon them to stay at the Sanatorium, there to recdve the weekly or semi-
weekly visits of those most interested in them.
Moreover, by means of the intimate connection which the Sanatorium
enjoys with the Phipps Tuberculosis Dispensary of the Johns Hopkins
Hospital, it is possible to make that dispensary the source of supply of
patients, and as the attendance upon this dispensary now numbers some
2000 patients annually, the oppDrtunity for the selection of cases most suit-
able for treatment in the Sanatorium is very great* The result is that, in
the past two years, the patients admitted have been, almost without excep-
tion, in the ver>^ earliest stag© of the disease. Indeed, a considerable num-
ber were received before active ph3^sical signs could be perceived, the diagno-
sis being made upon rational lagns, the history, and in a number of instances
by the use of tuberculin.
The Eudowood Sanatorium m not endowed, and its expenses are met by
State and city appropriations, Ernd by voluntary contributions. Almost aU
the patients are unable to pay anj'thing toward their maintenance, so that
the fees from patients are inconsiderable. These facts, and others to be
392
A FARM COLONY EXPERIMENT. — ^JACOBS. 393
Spoken of, early determined the resident physician to introduce the system
of work into the management of the Sanatorium. As the money to meet
expenses wholly was always wanting, it became necessary to economize in
every particular; and so the rule was made that every patient should par-
ticipate in the work of the Sanatorium as far as he was able without imperil-
ing in the slightest his chances of recovery. Not only was it deemed
advisable that patients should assist in carrying on the institution from eco-
nomic reasons, but because Dr. Forster, the resident physician, was convinced
that recovery was more rapid and more secure if the patients liad certain
definite tasks to perform, depending upon their physical condition, which
should tend to keep their minds occupied and interested and would prevent
them from falling into the idle, indolent sanatorium habit, often so dele-
terious to the morale of the patient.
So it is that the waiting at the tables has been done largely by patients,
the dishes have been washed by them, the beds made, the paths kept in
order, the wood cut, the hot-beds cared for, and much of the planting, cril-
tivating, and harvesting done.
No rigid courses of work have been laid out, as by Dr. Patterson at
the Brompton Sanatorium at Frimley, but rather each individual patient
has been assigned duty, and carefully guarded that he should not over-
tax his strength or do anything likely to be detrimental to the progress of
his cure.
The experience, gained in watching the progress of patients under this
r^me, logically led to the conclusion that there were a certain number of
patients who would benefit by a more prolonged course of work than could
rightly be given in the Sanatorium; a class of patients, men especially,
suited to outdoor work upon the land, with an aptitude and a liking for it,
who, unable to compete in the farm labor market with more able-bodied
men, must go back to their old city surroundings and to their old trade in
order to make their livelihood, unless something could be provided whereby
they could be assisted for a time to work only in accordance with their
strength, at the same time being paid such wages that they might feel they
were Again self-supporting individuals.
Before this audience it would be folly for me even to refer to the danger
of such cases relapsing, if compelled to return to old surroundings and to
fight the battle for self and family support. It has already been well said
that, given a suitable case in an early stage, the arr^t of tuberculosis is an
easy thing; but in the prevention of a relapse there lies the difficulty. The
subject of after-care of convalescent patients has occupied the thoughts of
all sanatorium managers for years, and various suggestions, particularly in
England, have been made as to the best methods of providing it.
304
SIXTH INTERNATIONA!* CONGRESS ON TUBERCULOSIS.
The opportunity of reBting an adjoining farm, equipped with fann-
house and large barn and cow stables, determined the directors of the Eudo-
wood Sanatorium to make the experiment of undertaking a "farm colony"
of cixred or convalescent patienta* Dr, Forster entered enthusiastically into
the movement, and through his willingness to undertake an ever-increaang
amount of work and responsibility, we have been able to proceed with the
experiment. It was not thought possible to meet expenses immediately, nor
was it thought desirable that the financial responsibility of the undertaking
should fall upon the resources of the Sanatorium, so a number of gentlemen,
among them the oi^Tier of the farm, agreed to contribute toward the rent
for the first year. The resident physician has assumed general over^ght
of the undertakings and he selects the patients whom he considers worthy
and fitted for work, and, with the approval of the executive committee of
the directors, determine the amount of wages each shall receive.
A head farmer has been secured, a team of horses and a team of mules
have been hired, and farming operations upon rather an extensive scale have
been undertaken. At present there are at work upon the farm eight mea
and boys, who have been under treatment at the Sanatorium and have so
far recovered that they are able to do a fair day's work without undue fatigue
or any detriment to their phjrsical condition.
One of these has been working steadily for the past six months taking
care of the cow stable. He is receiving wages of S15 a month. While in his
case there still remain slight physical signs, his disease seems to be in an
arrested stagej there is no sputum, and the general condition has improved
under the farm work. Formerly this man was an iron-molder and received
good wages, but he seems to be thoroughly content with his present position,
and appears to realize it would not be well for him to return to his former
trade. Another, a very intelligent and industrious man, who was a potter,
is being paid S12 a month. He devotes his entire time to the garden. He
is far more intelligent and capable than any farm-hand who would have to be
paid $20 a month. The other six who are upon the farm have not been paid
anjlhing, but are glad of the opportunity which is thus given them of
maintaining themselves by their work in surroundings likely to prolong
their Uvea.
A number of other patients have asked to be sent to the farm, but the
resident physician has not felt justified in accepting them until the financial
results of the experiment were better understood- The farm foreman is
paid 840 a month and his board provided. He is an intelligent, practical
farmer, but not capable of organizing and managing the colony without the
assistance of the re^dent physician* His wife has general supervision of
the farm-house and a negro woman is employed as the cook. In order to
4
I
I
— sr-^ I • —fci
A FABM COLONY EXPERIMENT. — ^JACOBS. 395
Spare the patients, the heaviest work upon the fann is done by three able-
bodied men, who are employed at wages of $25 and $20.
Dr. Forster writes me: "Even though we have had so little experience, I
feel we have taken up a most important work. The class of patients we
receive are not paupers in any sense of the word. They have all earned a
livelihood prior to their illness and are willing and anxious to do so again as
soon as they are able. By means of this farm we are furnishing them with
an opportunity of doing so in an intermediate period, during which they are
still becoming stronger, and when if they were compelled to return to th^
former trades, they would run the risk of again breaking down."
Of the crops expected in this first year I can say that, despite the very
severe drought of June and July, we have gathered 65 tons of hay, valued at
$20 per ton. We have 25 acres of com planted, several acres of potatoes,
and have transplanted 5000 tomato vines, besides putting in sufficient garden
v^etables to supply the Sanatorium throughout the year. The city of
Bfdtimore furnishes a favorable market for such produce as is not needed
by the Sanatorium.
No attempt has yet been made to introduce any of the modem refine-
ments of farming, which tend to lessen labor and increase the yield per acre.
This species of scientific development must come gradually as the experiment
proceeds. The main purpose has been to introduce some form of "after-
care," in the nature of healthful occupation, where patients might feel them-
selves again self-supporting and allow them time for making permanent the
result for which they and the Sanatorium had been striving. The desirabil-
ity of such efforts is imquestioned, and the justification of this early report
is found in the fact that here is the first attempt made in this country to
provide for those leaving a sanatorium with work in a field where they may
be able either partially or completely to support themselves, imder such
guidance and in such favorable surroundings that the ciure they have made
is likely to become permanent.
It is hoped this experiment, begun carefully and in a small way, may
grow in usefulness and prove itself worthy of being followed by other sana-
toriums.
Bin Experiment einer Farm-Eolonie.— (Jacobs.)
Dieser Vortrag ist seiner Natur nach ein vorbereitender Bericht iiber
eine versuchsweise Farm-Kolonie, welche von dem Hospital f iir Schwindsiich-
tige von Maryland bei seinem Eudowood-Sanatorium bd Towson, Md.,
angelegt wird. Die Klasse von Patienten, welche in jenem Sanatorium
aufgenommen werden ist eine solche, dass einige Vorkehrungen fiir eine spa-
tere Fiirsorge ausserordentlich anstrebenswert sind. Dies sind mit wenigen
SIXTH INTERNATIONAL CONGE&aS ON TDBERCULOSia.
Ausnahraen eingeborene Patienten, welche von den dieht bevolkerten Teilen
von Baltimore kommen. Sie sind sehr vorsichtig aiis der Clientel der
"Phipps Dispensary" des Johns Hopldns nospitals ausgewablt und sind
dfther in einem, fiir eine schliessUche Heilung ausserordentlich gunstigea
Stadium.
Bei einer Anzahl von ihnen war die Diagnose von der Krankengeschicbte
gemacht worden und weder Symptome noch physikalische Zeichen waren
erschienen gewesen. Dies sind die Falle, bei welchen vollstandige Genesung
erwartet werden kann, wenn sie geniigend lang m gesunder Umgebung best>rgt
werden konnen, bevor sie in die Verhaltnisse zuriickkehrea, aus denen sie
kamen. Eine Farm von 180 Acker^ dem Sanatorium angegUedert, \si gepach-
tet, ein Oberfamner, eine Hauehalterin und Kochin in einem bequemen
Fanniiaus Lnatalliert, und 8 Patienten der Arbeit augewiesen worden. Der
Schritt vom Sanatorium zur Farm ist nur eln kleiner, da man im Sanatorium
von alien Patienten durch ihre Behandlung Arbeit erwartet, nicht nur
HUfeleistungen im Betriebe dea Sanatoriums, sondem um das mussige
"Sanatorium-Leben'* zu vermeiden, welches so geeignet iat, die Moral der
Patienten au schwachen. Die Arbeit iat sorgfaltig der Kondition des
Patienten angepasst, und ist niemals erlaubt, ausser wenn von ihren Resul-
taten eine Besserung, oder ^um mindesten keine Versetilimmerung erfolgt,
Deshalb ist der Patient, wenn er zur Entlassitng bereit ist, schon durch ver-
schiedene Stunden des Tages in der Arbeit gewesen, und sein Leben auf der
Farm wird nichts anderes als eine Fori^etzung des Lebens im Sanatorium
eein. Die Lohne sind Im Anfange klein, einige der Manner arbeiten fiir ihre
Unterkunft, andere erhalt^n 12 Dollars per Monat. Die achwerste Arbeit
auf der Farm wird von regelrechten Farmarbeitem l>esorgt.
Der gansse Plan ist unter der direkten Leitung des Hausarztes dea Sana-
toriuma. Er ist der Ansicht, dasa trotz einer ungunstigen Saison der Wert, den
die Emte erreicht, etwas mehr als die Auslagen des Experimentes decken
wird.
J d'une colonie-fennifere. — (Jacobs.)
Cet article h pour objct le rapport prC*limiiuure sur un essai de colonle-
fermi&re entrepria par le Hospital for Consumptives of Maryland, k son
sanatorium Eudowood, pr^ Towson, Maryland.
II est de toute necessity pour la cat^gorie de patients rcQiia au sanatorium
de prendre des dispositions pnSventives, apr&s leur sortie du sanatorium.
Ces patients, 4 part quelques cas iaol6a, appartiennent h la claase pauvre
venant des quartiers les plus populeux de Baltimore, lis sont choisLs avec
6oia parmi les clients du Phippa Dispensary du Johns Hopkins Hospital et
sent dans T^tat le plus favorable pour une gu^risom definitive, Dans
«
A FABU COLONY EXFSRIMEMT.— JACOBS. 397
phisieurs cas le diagnostic a 6t4 fut seulement d'apr^ sympt6mes ou ren-
seognements recueillis, les signes phymques n'ayant pas encore apparu.
Ge aont done des cas oil une gudrison paif aite peut 6tre obtenue, si durant
le tonps n^oessaire les soins propres k leur ^tat leur sont donnas dans un
milieu salubre et avimt leur retour k leurs conditions premieres.
Une fenne de 180 acres, pr^ du sanatorium a €t6 lou6e.
Dans une habitation confortable, un chef fennier, un intendant, un
cuionier sont log€s et huit patients y sont employes.
La difference entre la fenne et le sanatorium est bien faible. Au sana-
torium les patients sont obliges de traveller. Tout en suflSsant aux soins du
sanatorium ils 6vitent aussi I'^tat d'oisivet6 si d^favorable k leur moral.
Le travail des patients est soigneusement adapts k leur 6tat et n'est permis
que si des rdsultats favorables se font sentir, ou a du moins il n'en r6sulte
aucun detriment.
II s'en suit que lorsqu'il quitte le sanatorium le patient a d6}k travuU^
plueoeurs heures par jour, et sa vie ik la fenne sera une continuation de celle
du sanatorium.-
Les salflires au d^but sont modestes; les uns regoivent simplement leur
nourriture et logement, d'autres arrivent k gagner jusqu'^ 12 dollars par mois.
Les travaux de fenne les plus p^nibles sont faits par des ouvriers or-
dimures.
La ferme est dirig6e par I'inteme du sanatorium, qui est enthousiaste sur
les r^sultats certains de i'entreprise.
Malgr6 une ann^ d^favorable la valeur des r^coltes sera plus que suffisante
pourcouvrir lee d^penses de cet essaL
A COMPREHENSIVE PLAN FOR THE TREATMENT OF
THE TUBERCULOSIS PROBLEM.
By Victor G. Bloede,
It is not the purpose of this paper to discuss any new plan for fighting
tuberculosis,"nor, indee^:!, have I such tooffer, but my object will be toconsider,
aa the only comprehensive and really adequate plan for the treatment of
the whole matter, the coordination, bringing together and worldng in con-
junction, under one harmonious management^ the various powerful single
factors already so successfully at work in this field.
Tactical Eerors.
It is a strange fact that nearly every communityj which has awakened
to the importance of taking measures against this disease, has commenced the
work by the establishment of sanatoriums for the incipient cases, while the
advanced patients, the chief factors in the spread of the disease, and directly
or indirectly responsible for the large majority of all our incipient cases^
have remained uncared and unprovided for.
In another way thia general beginning at the wrong end, so to speak,
in giving sanatorium^ the first consideration while the advanced cases are
neglected, has deprived the cause of much of its force with the public, in
that the care of the incipient cases^-dealing, as it does, with people who look
well and recover, and whose real condition is apparent only to the skilled
physician — does not appeal to the sj'mpathy of the masses as do those
advanced cases in which the extreme illness and suffering of the afflicted
person becomes apparent to the most unobserving and instantly enlists the
Byropathy and aid of their fellow-men.
This all but universal first attention to the early cases insftead of the
advanced has been one of the great drawbacks to the progress of our work,
Sound Bubiness Management,
Another drawback is to be found in the fact that not sufficient effort
has been naade to convince the larger public that every community within
itself is amply able to finance the battle with this great problem, if only ita
full dgnificance to every home and household is clearly understood. Right
A COMPREHENSIVE PLAN. — BLOEDE.
399
here it may be advisable to call atteatioD to the fact that in order to avoid any
just criticism and to hasten the progress of the cause,, it is absolutely necessary
to secure a sound, businesslike, and economical administration of the funds,
and to be able to show clearly that every dollar that is given by the public
or State is bearing fruit in restored health, activity, and usefulness, and
providing the greatest possible comfort and happiness to those unfortunates
who are marked for death.
Just as Good Work cak be Dorra at Home as Eibbwhehe*
It may be proper in these prelinunaiy remarks to refer to the question
of the best location for the hospitalj sanatorium^ and farm colonies. Not
many years ago it was the general opinion that the successful treatment
of consuoiptioD required a high altitude, and the result of this was that
patients, to recdve treatment, had to go long distances from the centers of
popidation. Dr. Philip, of Edinburgh, Scotland, was among the first to com-
bat this theory, and prove the entire efficiency of treatment near home by
the establishment of the Victoria Hospital for Consumptives just outside of
the limits of this classic Scotch city. His opinion, based upon long practical
experience, is, I believe, that both hospital and sanatorium ^ and especially
the former, should l>e in close proximity to the great centers of population.
Dr. Flick, of Philadelphia, holds the same view, and claims that in his
hospital, in the very center of the busy city of Philadelphia, he can effect
practically as many cures of cm'able cases as the average institutions far from
the din of the great cities. My own experience confirms this view. While
no doubt the air at high altitudea is more grateful and healing to the lungs of
the sufferers, and the low temperature, especially in midsummer, may be
conducive to more rapid recovery^ it b nevertheless a fact that the best kind
of work can be done right at home, say, in some quiet place just outside of our
great centeiB of population.
One of the explanj^tiona for this, I think, lies in the mental attitude of
the patient. Near home, and within easy reach of those dear to him, the
pangs of homesickness are practically unknown, the patient's mind is at
ease, and he gives himself up wholly to the treatment without experiencing
the gnawing and destructive mental suffering the large majority of patients
who are removed far from home and friends are subject to. The mere feeling
that they are within thirty minutes* ride of their friends and family, and can
communicate with them at any moment, begets a mental quiet more potent
in effecting a cure than the finest mountain air, with a spirit of melancholy
gnawing within.
1 now proceed to the consideration of a plan which my experience of
several years in this work leads me to believe would prove the most effective
that can be devised to secure rapid and permanent results.
400
SIXTH IXTEBNATIOS^AL COXGRSaS OX TUBEECTTlJOeiS,
This plan contemplates the combined and amultaneous operation of the
four great agencies, each one indispensable: viz., firsti the dispensary; sec-
ond, the hospital for advanced cases; third, the sanatorium; fourth^ the
farm colony — ail of these four great forces to be cooperating, and each one
forming an integral part of one great system* I believe where such a com-
bination can be made (and I see no reason why it should not be fea&ible
everywhere) the end of the *' great white plague" is within aght, at leasts
of our coming generation.
I should say that the first requiate is the awakening of the pubUc of any
given coLnmunity to the importance of this work, not in the abstract^ but in
itfi bearing upon every home* There is no better or quicker method of
accomplishing this than through the press, and I know from our own ex-
perience in thia work that the power of the press is the greatest and most
potent single element available for stimulating the public conscience and
educating and awakenii^ the pubhc to the importance of the subject, I
believe that to the work of the press of Baltimore, unselfishly and freely
given at all times, a large part of our success, as well as financial support
(contributed by all classes of our community), is due.
The Church and Church organisations should also be a great factor in
this work, but for some reason or other this great influence has not yet taken
ita proper place in our work or made its power felt ettber by adequate co-
Operation in the spreading of the propaganda, or financial aid secured
through its appeals.
The next most important step to be taken in the line of organization ts
the selection of progressive men and women to direct the work, men and
women who are workers and not too busy to give some time and thought to
the cause of their less fortunate fellow-men. These should be selected
from different social orders, and from all walks in life, from the Church, from
professional, business, and political life, from labor circles — in short, wherever
true interest is ghown. Next one should select, from this varied material,
a competent and aggressive managing committee. This committee should
he made up of men possessing executive abihty, who have a good business
training, and who command the confidence of the pubhc. Last, but not
least, a medical director must be found, willing to put bis best into this work.
The limits of this article will not permit my going into further details,
and I therefore have to content myself with this merely cursory reference
to this most important subject of proper orgamaation. Before leaving this
subject^ however, I desire to emphasize the fact that it is not desirable to
seek ^d from State or municipality at too early a stage of the work, because
the amount given is usually small and Inadequate, while the general pub-
lic, aa a rule, assumes that when the State or city takes up a given problem,
the reaponsibiUty of the individual ceases^ and, as a consequence, their
A COMPREHENSIVE PLAN. — BLOEDB. 401
interest in the work lags, and the contributions from private sources
dwindle.
After the proper organization has been effected on the lines indicated, the
first important step is the establishment of —
The Dispensary.
To this dispensary all suspicious cases should be sent for investigation,
diagnosis, and classification. The dispensary has been fittingly called the
"clearing house" for tuberculosis cases, and is the surest means the com-
munity can employ to promptly and accurately learn the condition of its
sick, and to accomplish the greatest possible amount of good for the least
expenditure of funds. In the larger cities this dispensary might form part
of some general dispensary or hospital. In Baltimore, our institution has
depended almost entirely upon the Phipps Dispensary of the Johns Hopkins
Hospital for the diagnosis and classification of cases, although we invite
and receive the cooperation of other hospitals and dispensaries. All appli-
cations for admission to our hospital are first referred to the dispensary,
where a thorough examination and diagnosis of the applicant are made, and
upon this report our admission or rejection of the patients is based. Those
who have been active in this work know how difficult it is for those in charge
to reject patients whose admission is insisted upon by strong political or
social infiuences. The appUcant may for various reasons be unfit for ad-
mission, yet it may be a very difficult task for the board of directors to re-
ject him. By requiring the certification of all patients by the dispensary
physician as an essential step, this [trouble is wholly overcome, and when
it is once understood that all social or poUtical infiuences, in the absence of
such certification, are disregarded, a very unpleasant duty and responsibility
is lifted from the shoulders of the directors. The dispensary, of course,
should be in charge of some active physician who has made a specialty of
the diagnosis and treatment of tuberculosis, and who has had the widest
possible experience. To be productive of the highest good, the dispensary
should also be provided with visiting nurses who report upon the home con-
ditions in cases where home treatment is considered sufficient, see that the
instructions of the doctors are carried out, and persuade those who are
exposed to possible infection to come to the dispensary for observation,
diagnosis, and instructions. It is not always necessary in the beginning to
have paid nurses, as the work of the visiting nurse may be done with fair
success by earnest volimteer workers drawn from the Church or society.
As the work grows, the medical director will have no difficulty in securing
assistance from doctors interested in tuberculosis, and his volunteer staff
will generally be large enough to meet aU requirements. Those who desire
a fuller and more detailed knowledge of the great work that can be done
un
Birm t?0TCB3rATH»f AL cosGsaam osr rvvsacmjoem^
bf tkm *<f*'f*c house for Qsa wfaote ^stem (and wfaidi coostitoteB its fiisi
fliemeDt) I vtnild refer to Dr, lonis Hahudod., the able izid dented head of
the Hifppa Di^ieottiy, an io^hutioQ wtuch I believe, ffiMdrring the
miall amotutt of wooef eipended in Ha nolnteoaoee, prodiMeB m pnat
resulls as are achieved anywhere.
The HofiPTTAL jor Aditanccd Cases.
Of aD the am^ efevientfi, I consider the ho^tal for advmoed riwiti the
fii8t in importaRce, for there is do arguiuent which caa gatosaj its sbBohtte
oeoeanty. It seems mmply moompn^ieosble that a great SU^ tikE Mary-
land and many otbers, up to the present time, have provided no place for
tbe care and treatment of advanced caaea of tuberculoas, or even a piaoe for
the bopeleee invalid to die. Indeed, up to last year we had only ooe sana-
torium in the entire State, and that accommodating onlj aboot 30 patients
for the 10,000 or more consumptivee — \£ss, than the proverl»al "drc^ in the
bucket"
Advanced caaes, tjeing the chief means of propagating and spreading the
diaeaser should tlwrefore in every instance be fiist provided for. This is the
practical view of the situation; but in addition to this, from the hum&nitar
riflu standpmnt, to leave advanced caa^ in their homes, gradually approach-
ing death, after montlifl or even years of worse than death, with improper
food and inadequate cafe, is such barbarism as to make those of us who
know these conditions wonder whetber civilization ia more than a name.
If conditions are such that only ooe of the various elements necessary to
properly battle with tuberculo&ia can be employed, the hospital for ad-
vaooed cases should receive first attention. The site selected for such a
hospita] aboidd be as near the center of population m possible, convenient to
railroad or trolley, with a pleasant view, plenty of shade, and good water.
It has been deemed advisable by some to locate such hospitals in the cen-
ter of cities, but in view of the fact that land can always be obtained in the
Buburbfi, with freedom from noise and dust, and within easy reach, I see no
possible advantage in B^ch a plan. It is now generally conceded that ad-
vanced cases should be treated as though they had every chance of recovery,
and macb treatment can certunty be be^ given in the country.
The type of building most efficient and economical is, in my opinion, one
combining small wards with individual rooms for the isolation of dying
oaaea or th<^e with disturbing or distreaaing symptoms, such as persistent
night cough. A building of this type, has just been erected near Baltimore.
The hospital referred to has a central administration building of two stones,
with assembly hall, office, dining-room, and kitchen on the first floor, and
staff quarters on the second floor. On each side are one-storj*^ wings con-
fining four wards of six beds each, ^ isolation roomSj lockers, bath-rooms.
A COUPREHENBITE PLAN. — BIiOBBB. 403
and wide piazzas upon which the beds can be wheeled. In the basement
of the main builcUng, in addition to the necessary heating apparatus, is a
well equipped autopsy room for post-mortem work. A laboratory for
sputum and other examinations and research work is also to be provided for
later.
A hospital for advanced cases built upon these lines gives the greatest
efficiency in the treatment of these cases at a minimum cost bqth as to
construction and maintenance. Our plan also contemplates the construc-
tion of shacks and cottages later on for the accommodation of those advanced
cases which have improved sufficiently during their hospital treatment to
become ambulatory.
The Sanatorium.
In our plan the sanatorium for incipient cases is built upon ground im-
mediately adjoining the hospital for advanced cases, but at a distance of
about one-quarter of a mile, so that while the two institutions are entirely
separate so far as the communication of the patients is concerned, the entire
S3rstem is imder one management. This insures the greatest economy in
control and maintenance of both institutions, the necessary supplies being
furnished through one central station, and the same resident ph3rsician hav-
ing the management and control of both, thus avoiding imnecessary duplica-
tion of working forces.
In this country the cottage or shack system for sanatoriums has been
found most suitable. The buildings may be of comparatively inexpensive
construction, but expense should not be spared in making the patient's
surroundings not only comfortable and hygienic, but as home-like as pos-
sible, for the tuberculous patient, unlike the patient in a general hospital,
spends months under care, and the more comfortable and attractive we can
make his surroundings, the more rapid and thorough will be his progress.
If it is true that the chief value of the sanatorium is educational, then the
nearer it approaches the ideal home condition, the more impressive and
lasting will be its teaching.
We have found in omr work, where there is a blending of all classes,
that the smaller the groups of patients, the easier will be their administra-
tion, for the administration of large and heterogeneous groups of patients in
close quarters becomes impracticable and undesirable.
Before leaving the subject of sanatoriums, I wish to speak of occupation^
mental and physical, for the patients during their enforced idleness of weeks
or months.
I cannot ima^e a more demoralizing influence than taking men and
women whose days have been filled with useful work and bread-winning,
and condemning them to a life of idleness, with absolutely nothing else to do
404
SIXTH INTERKATIONAIi COKORESe ON TUBERCULOSIS,
than sunning themselves in easy chairs^ and dwelling upon their own physical
ilts. Useful occupation is the greatest blessing, next to healthy that can be
vouclisafed a normal human being. Its spiritual as well as therapeutic
value to every human being cannot be overestimated, A healthy normal
mind craves for it and finds relief from much bodily and mental suffering
through its benign influence, Those who would be content in a life of ab-
solute idleness are fortunately feWj and even these few would be better m
every way if compelled to do something useful vdthin tbdr strength, I
think we are making a very great mistake in not giving this all-vital question
at least as much care and consideration in the conduct of our sanatoriums as
the purely physical condition of our patients. There is no truer saying than
that '*Satan finds some mischief still for idle hands to do"; for, even if the
adage is not taken literally, idleness will turn the mind of the patient upon
his own ills, and he will mirse these until the whole world seems to center ia
his case. The average sanatorium is a great school for the teaching of indo-
lence to those who can least afford to practise it — if, indeed, ajiy of us can.
The Faem Colony.
Fraught as this whole tuberculosis question is with grave problems,
there is none greater than the after-care of the arrested cases, for we must
all admit that amply prolonging life in those whom we can never hope to
again restore to the world of workers, or make fit to earn their living, is, to
say the least, po doubtful a charity that many truly humane and generously
disposed persons have questioned its desirability.
It does, perhaps, eeem a strange paradox that we gently put a hopelessly
sick or crippled animal out of its misery on the score of humanity, and yett
are bent on prolonging to the utmost the useless suffering of our hopel*
sick. Yet such are the ethics of our age, and this is the condition we hai
to deal with, not as a theory but as a concrete fact. We must, therefore,
deem of the highest importance the after-care of the hundreds of arrested
cases — men and women who, although temporarily endowed with a furth(
lease of life, are not able, through their physical disabilities, to return to their
accustomed avocations.
Patients Should be Pot in Way of Earning Their Own Livtko,
For such cases the farm colony must be provided, where, through light
work in field and garden, these patients can contribute toward their own
support as well as that of the patients in both hospital and sanatorium,
Not only does this reduce the cost of the general maintenance, biit it restores
the patient to the ranks of self-reapecting workers, thereby lessening their
caree as well as their physical ills. In this great work we have scarcely
the initial or experimental stage, and yet we already see great
A OOMPRBHBKSIVE PLAN. — BLOEDE. 405
therapeutic, epiritual, and material benefits. We have patients at work a
few hours each day on our farm colony who never expected to leave theur
beds again, and, largely as a result of their labor, our cost of maintenance
in this chain of institutions has fallen far below that of any similar institu-
tion in our country, of which we have the records.
The farm colony should be located in immediate proximity to the hospi-
tal and sanatorium, as so to bring it under the same general management.
To carry out its purpose it must, of course, have a lai^ tract of arable land
at its disposal for raiong hay and other fodder, fruits, vegetables, flowers,
and garden stuff. On this farm colony should be located a dairy of suffi-
cient eize to furnish all of the milk required by the various institutions.
Poultry-raising adds another profitable branch of industry within the scope
of the labor available. In a farm colony of this kind, once fairly established
and in full working order, sufficient work can be done to make any number
of patients practically self-supporting; indeed, I believe that it may be
possible under the most favorable conditions, and by the addition of some
other light industries, to make the care of the patients return some profit,
at least enough to render the payment of small wages possible.
This whole plan for the treatment of the tuberculous problem, I am
happy to say, is not entirely a Utopian dream, but to a large extent an
accomplished fact. It is perhaps too soon to say what the future of our
ambitious plan may be, or whether we will be able to fully compass the
high ideals we have set, but we have each of these integral parts of the
proposed system in codrdination and harmonious work under one manage-
ment in Maryland, and you will grant, I think, that this comprehensive plan
is fraught with great possibilities for suffering humanity.
Ce qu'O faut pour le Traitement €tenda et suffisant du Probltoe de la
Tuberculose. — (Bloede.)
Ce n'est pas avec les m6thodes actueiles ni en nous bomant k un seul
agent ou facteur que nous pouvons atteindre le succ^ dans la lutte contre la
tuberculose. Ce qu'il nous faut absolument, c'est une combinaison de
tons ces agents et facteurs pour r6soudre le probl^me.
Nous allons discuter cette proposition sous les cinq divisions que voici:
(1) La meilleiu-e mdthode d*organiser et de conduire la lutte, en ^veillant
les sympathies et en gagnant la cooperation de toutes les classes du public
pour cette grande oeuvre; (2) la meilleure m^thode de d^couvrir et de
soigner les tuberculeux, le traitement des malades chez eux, et la meilleure
m^thode de contr61er Tadmission k Thdpital et au sanatorium; (3) la tr^s-
grande importance du spin des cas avanc^; (4) le traitement des cas com-
men^ants en rapport ausujetentier; (5) Timportance du soin de ces malades
405
SIXTH INTEBNATIONAL COKQRESS ON TUBERCUliOSIS.
Qombreux que la tuberculose a rendus incapables de reprendre leur ancienne
occupation ni de trav^er dur on longtemps h, quoi que ce soit. On donnera
atissi des suggestions pour faire travailler de tela malades dans les colonies-
fermi^res, etc., oe qui les rendrait k moitifi indfipenclants.
j>as Hotwendige fUr eine tmiia^ende und Mnl^gliche Behandlung des
Xuberkulose-Problems. — (Bloede. )
Zur Bekampfung der Tuberkulose rait Aussicht auf Erfolg dnd sowohl
die heutigen Methoden als auch irgeud eines der gegenwartig gebrauch-
lichen Mittel an sich unzureichend; nur einer Combination und Coopera-
tion aUer dieser Factorea mag ea gelingea, an das Problem in eatsprechonder
Weise heranEUtreten.
Dies soil in den folgenden fiinf Abschnitten BesprecbuGg findea: (1)
Der beste Weg, auf welchetn der Kampf praktisch organisirt und gefiihrt,
das ailgemeiae Interesse erweckt und fiammtUche Bevolkerungsschicbten
zur Mitwirkung herangezogen werden konnen; (2) die bestc Methode, um
Falle von Tuberkulose zu eruiren, behandeln und unter Aufsicht halten zu
konnen, die Pflege und Behandlung der Kranken im Hause, sowie das beste
Verfahren bezuglich der Controlle iiber die Aufnahrae der Kranken in Spi-
talern und Sanatorien; (3) die primare Wichtigkeit der Pflege vorgeschrit-
tener Falle; (4) Behandlung im Friih- und Anfangsstadium; und (5) die
wicbtige Frage der Versorgung jener grossen Klasse von Kranken, die ihrem
Leiden zufolge unfahig sind, ihrer frtiheren Beschaftigung nachzugehen oder
irgend eiu Handwerk auszuuben, Bowie Plane und Suggestionen, wie solche
Patienten durch Feldarbeit oder sonstig aulassiger Beschaftigung zu ihreu
Erhaltungskostea beisteuem kdaateo.
TRAINING FOR PROFESSIONAL NURSING IN INSTI-
TUTIONS FOR TUBERCULOUS PATIENTS:
A REPORT OF THE TRAINING SCHOOLS AT THE HENRY
PHIPPS INSTITUTE AND THE WHITE HAVEN
SANATORIUM.
By Charles J. Hatfield, M.D.,
PhiladdphU.
The practice of using arrested cases of tuberculous as attendants upon
bed patients in institutions for the care of the tuberculous is by no means
new. The purpose has been to economize in the cost of attendance and to
provide occupation for the patients who are on exercise. There is a marked
tendency also in the same class of institutions to employ arrested cases in
positions where the work is not too heavy for them, thus securing for the
arrested case a longer period of residence under good conditions. Where
the arrested case has had previous training as a nurse, it has been most
natural to employ her as a regular attendant.
The organization of schools for the systematic training of arrested cases
in the nursing of the tuberculous is, on the other hand, a development of the
last four or five years, and the practical advisability of the plan is still a
subject for discussion. The views of the writer upon the subject have been
published in a former article, but he ventiu'es to summarize the points made
by way of introduction. In considering the question, it may be well to look
at it from the different viewpoints of the prospective nurse, the patient, the
phjrsician, and the sociologist.
To the selected young woman who has had tuberculosis and has been
restored to physical health, the study of nursing offers many advantages.
While a pupil, and even after graduation, she is given an opportimity to
complete her cure. It is natural, when employed in an institution devoted
to caring for patients afflicted with the disease, that the opportunities for
seciuing the necessary supply of fresh air, abimdance of diet, and a regular
daily routine of exercise are most convenient. In private work, where there
is constant association of nurse and patient, it is easy for the nurse to share
in the essentials of the cure. When we contrast with this the alternative of
a return to the occupation in which she had broken down, the advantage is
obvious. The enormous difficulty of obtaining suitable employment for
407
40S
SIXTH INTERNATIONAL CONGRESS ON TTIBEBCULOSIS,
arrested cases is so much a matter of common experience with all who have
been interested in the problem that no f m1.her comment is necessary, \yhile
in training, the pupil nurse receives a salary sufficient to support hei^elf;
she is at the same time inspired by the thought that she is entering an hon-
orable profession. The mental effect of such an experience is in itself most
valuable during this critical period. With working people, the question of
earning capacity is naturally important. By entering the profession of
nursing, it is shown, in the eases at hand for study, that the earning capacity
is often doubled and is alwa}^ increased.
The chief objection to this plan of employment of arrested ca3e3 is the
doubt whether such cases are able to perform the hard work required by
their profesaon. In considering this point, there are several facts that must
be borne clearly in mind. These yoiing women must work for a Uving; the
only alternative is a hfe of pauperism. There is no choice between work
where many of the essentials of cure are at hand, and the return to an indoor
occupation. In the next place, it has been demonstrated beyond the
possibility of doubt that an arrested case of tuberculosis is capable, und^
good conditions, of performing moderately hard work. In the writer's
opinion, the actual experience in connection with the training schools
already estabUshed strongly encourages the belief t hat^ for the selected case,
the profesdoQ of the nursing of tuberculosis is entirely suitable. The ob-
jection also is made that constant association with the dck is too depressing
for those who have been ill iidth the same disease* This objection is theo-
retical rather than practice, as it has been demonstrated that the thought
of alleviating or preventing the troubles from which the nurse has herself
suffered has an inspiring rather than a depressing influence.
The danger of reinfection or of contracting a new implantation of the
tubercle bacillus is urged as an objection to this profession. This danger is
probably so slight as to be negligible. The nurse is trained to destroy every
particle of infectious matter given off. She knows exactly what precautions
to use. In this respect she is far better equipped to avoid infection than Is
ihR nurse with the general training. She is probably much safer in an inati-
tution devoted to the care of the tuberculous where modem methods are
used than she would be in a general hospital, where, at the present time, the
care of tuberculous material is not as rigidly insisted upon as is advisable.
Moreover, the records of health of attendants at institutions for the care of
the tuberculous give no endence of especial danger of infection.
The value of a nurse who has had tuberculods to a patient suffering from
'ftQ tetive form of the disease is very great. The nurse^ from her own ex-
peiienoe and trainings knows the best methods of taking diet, of living in the
open air with comfort, of proper ways of resting and of taking modified exer-
cise. Sympathetic attendanoe is assured. She is thoroughly equipped to
THE TRAINING OF TUBERCULOSIS NURSES. — ^HATFIEU), 409
Doeet any emergency that may arise. Moreover, she is an ever-present object-
lesson. With a recovered case always at hand, the patient cannot help
but feel more hopeful of his own fate.
To the physician, the tuberculous nurse is of great assistance. Her
knowledge of the det^ of treatment not only insures skilled supervision of
the patient, but is of great importance in saving the time ordinarily given to
instruction.
To the sociologist, any practical plan which provides emplo3rment for
even a limited class of arrested cases of tuberculosb must be of great interest.
The question of suitable work for those who have recovered from the disease
is perhaps the most pressing and difficult of all problems that must be solved.
Moreover, in the campugn for the prevention of the disease the tuberculous
nurse should prove an agent of great value. As a teacher, she can speak
with authority, and can enforce her teachings from her own experience and
well-being.
It may be asked whether emplo3rment is easily found for these nurses,
trained for the especial care of the tuberculous. In answer to the question, it
is only necessary to refer to the superintendent of any sanatorium or hospital,
who is fully aware of the extreme difficulty of securing proper attendance for
the tuberculous patients. The average nurse, with only a general training,
is at present unfitted to carry out intelligently the modem treatment, with-
out at least a great expenditure of time on the part of the physician. She is,
moreover, often ignorant of the precautions to be taken to prevent a spread
of the disease. On account of this ignorance, she is fearful of her own
health, and this fear prevents the proper discharge of her duties.
It should be distinctly understood that this profession is not a suitable
one for sentimental or notional young women, who have perhaps had some
experience with the disease and feel that their mission in life is to relieve
fellow-sufferers; but who have no liking or stamina for moderately hard
work. Pupils of this class are a drawback to any school of nursing, in that
their attendance is for a short time only, and their tales of woe on leaving
the institution give an exaggerated account of the difficulties and labor of
training.
The training school of the Henry Phipps Institute was opened in the
spring of 1904. For a year previous to the opening of the school the nursing
in the Institute was done by graduates of regular training schools. This
method of procedure was altogether unsatisfactory. Difficulty was ex-
perienced in getting competent women to take up the work, as trained
nurses are especially afraid of prolonged contact with tuberculous cases.
The best class of nurses, therefore, was not available, and in consequence
the care of the patients was often unsatisfactory. It was, moreover, found
that graduates of good schools were ignorant of the modem methods of
410
SIXTH INTERNATIONAL CONGRESS ON TUBBRCULOSIS.
treating tuberculosis, and also of the proper ways of taking care of iofectioua
material; thus a preliminary course of training was necessary even for grad-
uated nurses. The school was opened with the idea of securing competent at^
tendance, and at the same time of trying the experiment of training young
women who have had the disease and have recovered physical health.
Since its organization the pupils have been, with possibly two exceptions,
arrested cases of the disease.
The school has a capacity of sixteen pupils; fifteen of them are on active
duty, and one is a substitute or "house sister." The work is arranged on
an eight-hour schedule, the time of duty each day being divided into two
periods; thus, a chance is given for rest and study. The diet is adapted
to the peculiar needs of the pupils, and a period of outside work is secured
by alternating in the duty of inspecting the homes of outrpatients; to this
duty the pupils are assigned in groups of three. The physician to the
training school has constant supervision of the physical condition of the
nurses. To him a report is made each week of weight, diet, and general
condition* He is ready to consult with any pupil who has a cold or other
intercurrent affection. By means of this medical supervision, the pupil
nurses are about as carefully watched as the patients in the average sana^
torium. As to salary, each pupil is admitted to the Institute upon two
months' probation, during which time she receives no salary. Afterward,
for twenty-two months, or untU graduation, she receives 110 per month,
out of which she must provide herself with uniforms*
The course of study covers two years, and includes lectures by the medical
staff on anatomy, physiology, materia medica, general medicine, and surgery.
A course of dietetics is taken in the Drexel Institute. Practical bedside
instruction with text^book work in the class-room is given by the head
nurse. Oral and written examinations are held at the end of each year,
and proficiency in each department of the work must be demonstrated
before the pupil can graduate. Upon graduation a certificate of proficiency
in the nursing of tuberculous is given. This certificate does not entitle
the graduate to compete with the graduate of a general training school. It
is for special tuberculous work.
To graduates of regular trauung schools, a post-graduate course in tuber-
culous nursing of six months' duration is ofifered. In the case of a nurse
who has had a partial training at a general hospital, and has left that hospital
and ent^^red the Institute training school, an allowance of six months for
each year of general training is given.
In order to secure reliable data concerning the physical condition of the
nurses who have been graduated from the training school, a set of question^
were sent to each graduate, and the answers were received about June 1,
1908- On that date twenty-two nurses liad been graduated. Three of
THE TRAINING OF TUBERCOIiOSiS NUKSES. — HATFIELD.
411
them were stUl in the training school compieting the course of practical
work; one bad died from a recurrence of the disease; and one was not
working on account of ill health. Seventeen graduates were occupying
profitable positions in institutions or at private nursing. In the cases of the
seventeen nurses who were actively at work, the periods of time ^ncc
leaving the sanatorium in good condition varied from three to six years.
The periotia of work ainee graduation from the training school varied from
one to three years. In reply to the following question — "How do you
estimate your present condition compared with your condition at the time
you entered the training school? Are you in about the same condition,
better, or not so well?" — ten graduates reported themselvea in better con-
dition; five were about the same; and two were not so well as when they
left the training school. In reply to the question as to the present earning
capacity compared with the capacity previous to illness, the answers without
exception reported earnings greater in amount than previous to illness; five
were earning double; and one, three times the amount previously earned.
As to satisfaction with their present occupation, all reported themselves
to be happy in their work, and seven reported greater enjoyment than in
previous work.
It may be welt to state that with two exceptions all the nurses from
whom reports were received had had at least moderately advanced lesions.
The above record of present physical condition will, I believe, at least equal
that of any cases of the same degree of involvement whose physical condition
has been recorded after a similar period of work. Those who have studied
the progress of the training school of the Henry Phipps Institute consider
the experiment a success.
The training school at the Whita Haven Sanatorium was opened Sep-
tember 1, 1907. It has a capacity of eighteen pupils, and on June Ist
had three vacancies. The superintendent on that date was a graduate
of the Henry Phipps Training School for Nure^. The class of cases that
are admitted as pupils and the remuneration given and the course of study
are the same aa at the Phipps Institute. The prospects for the school
are bright, but it ia too recently organized to report definite results.
La £ducaci6Q de Enfenneras Profesionales en las Instituciones para
Pacientes Tuberculoses.— (Hatfield,)
La educacs6o aobre el cuido de pacientes tul:>ereulosos 68 de gran valor
para las mujcres j6venea en las cuales la enfemiedad esta estacionaria, porque
que esto prolonga el tiempo de la cura, proved el so^tenimento y ayuda en
La preservaci6n del tono mental. Las condiciones flsicas son mejor manten-
Idas durante el estudio del aprendizaje que en cualquier otra ocupaci6a;
412
mXtB ENTHRNATIQNAL CONGRf£d ON TDBEBCUL06IS.
esta claae de mujeres j6vene8 deben trabajar para vivir. Para el paciente,
la enfertnera es una ayuda por medio de su simpatia, s\i experiencia ea cuanto
a la dieta, en el procuramienio de aire piiro durante el dia y la noche en todaa
las estacioDes del aiiOr en el restrenimiento del ejercicio, etc.; ^Ua es una
leccit^n objetiva pennanente. Para el medico, la enfermera es valioaa por
fiu conocinuento Entimo de los detalles del tratamiento. Para el sociologiata,
este plan es una 8oluci6ii parcial del problema de empleos de loe cases estacion-
aiios. Como maestras estas enfermeras son de gran valor en la campana
contra la prevenci6n*
La escuela de enfenneras del InsUtuto de Heniy Phippe, fue abiera en
1904* Las enfermeras graduadas de las otras escuelaa regulares no ban
side satUfactorias. Las aprendices ban ado en la mayor parte ex-pacientes
del Sanatorio de White Haven. El cuiso es de dos anos e incluye confer-
encias en Anatomla, Fisiologia, Materia medica, Medicma General, CLrugfa,
principios eobre la dieta, con inBtrucciones practicas de la jefe enfermera.
La escuela puede acomodar dle^ y seis aprendices; el trabajo ea de ocho
oros: la dteia es adaptada a las necesidades de la apranrllz: ^llas alteman
en SUB tareas en las afueraa en calidad de inspectoras. Como grado se les
di un oertificado de aprovechamiento en el cuido de pacieates tuberculosos;
veinte y dos enfermeras se han graduado; dos de estas ban muerto; tres
estan todavla en el institute completando el curse del trabajo practicoj
diez y eiete estan en buena condici^n, desempenando empleos lesponsables
en sanatorioSj bospitales y en empleos privados. Todas las eafermeras en
la actualidad ganan mejores salarios que los que ganaban anteriormente a
la enfennedad. EUas^ dn excepci6n, eetdn contentas con su ocupaci6Q. El
Cuerpo del Institute considera el experimento de mucho dxito.
La Escuela de Enfermeras de \MLite Haven se abri<5 el primero de Sep-
tiembre de 1907. EI curso es de dos afios y conesponde mas 6 menos al
cui^ que se d^ en el Instituto de Heniy Phipps* La escuela puede acomo-
dar a diez y ocho apiendices. La supenntendente es una graduada del
Institute de Henry Phipps,
Formation d'lnfirmi^res dans les Institutions pour le soin des tuberciileux. —
(Hatfield.)
Apprendre k soigner les tuberculeux est une chose avant.ag^use pour
certaines jeunes feinmes dont la maladie a 6td enray6e: C'est un moyen
pour elles de prolonger le temps de la cure, de pourvoir k leur entretlen
pendant letu" instruction, d'augmenter leurs moyens d'existenoe k leur
graduation, et de garder leur vigueur mentale. La condition physique
est mieux con5erv<5e en soignant les malades que dans d'autres occupattoos;
ceite classe de jeunes femmes doit travailler pour vivre. Quant au m^j^dOt
THE TRAININQ OF TUBERCULOSIS NURSES. — HATFIELD. 413
la garde lui est utile & cause de sa sympathie et de son experience k suivre
le r6^me, k vivre confortablement au grand air, nuit et jour, par tous les
temps, k modeler I'exercice, etc. Elle est un exemple toujours present et
un encouragement k la perseverance. Au medecin la garde est d'un prix
inestimable par son intime comuussance des det^ du traitement. Au
sociologiste, le projet est une solution partiale du probl^me de I'emploi des
tuberculeux dont le mal est ari^te. Gomme profeeseurs, les infirmi^res sont
pr6cieuses dans la campagne de prevention.
L'ecole d'infirmi^res de Tlnstitut Henry Phipps a ete ouverte en 1904.
Les soins donnes par des graduees des ecoles ordinaires avaient cause peu
de satisfaction. Les ei^ves ont ete, pour la plupart, des ex-malades du
Sanatorium de White Haven. Le cours est de deux ans et comprend des
conferences de professeurs sur Fanatomie, la physiologie, materia medica,
la medecine generale, la chirurgie et la dietetique, avec des instructions
pratiques par Tinfirmi^re en chef.
L'ecole peut recevoir seize ei^es; le travail est arrange pour une joumee
dehuitheures; la di§te de recole est adaptee aux besoins des ei^ves; celles-ci
remplissent altemativement des fonctions exterieures comme inspectrices.
A leur graduation, elles regoivent un certificat de capacite pour le soin des
tubercxUeux. \^gt-deux grades ont obtenu ce dipldme; deux d'entre
elles sont mortes; trois sont encore k Tinstitut achevant le cours de travail
pratique; dix-sept sont en bon etat et occupent des positions responsables
dans des sanatoriums, des hdpitaux et chez des particuliers. Toutes les
gardes qui travaillent gagnent des salaires plus grands qu'elles ne faisaient
avant leur maladie. Elles sont, sans exception, contentes de leur sort Le
personnel de Tinstitut croit que cette experience a reussi.
L'ecole d'lnfinni^res au Sanatorium de White Haven a ete ouverte le
premier septembre, 1907. Le cours d'etudes est de deux annees et est le
m^me que oelui de Tlnstitut Heniy Phipps. Elle peut recevoir dixhuit
eidves. La surintendante est dipldmee de recole d'infirmi^res de Tinstitut
Henry Phipps.
Erziehung von professionellen Krankenpflegerinnen in Anstalten f Ur die
Pflege von tuberkulSsen Patienten* Bericht tiber die Ausbil-
dtmgsschulen des Henry Phipps Instituts imd des
White Haven Sanatoriums. — (Hatfield.)
Spezielle Vorbereitung fiir die Pflege von tuberkulosen Patienten ist
von grossem Werte fiir passende junge Frauenzimmer in denen die Krank-
heit zum Stillstand gebracht worden ist; die Behandlungszeit wird dadurch
in die Lange gezogen, es verschafft Unterstiitzung wahrend der Erziehungs-
zeit and eine erhohte Erwerbungskraft nachdem die Erziehung voUendet ist,
imd hilft den geistigen Tonus zu bewahren. Der kdrperliche Zustand wird
SIX PAPERS
ON
The Prevalence and Treatment of Tuberculosis in
Certain Population Groups.
TUBERCULOSIS AMONG THE JEWS.
By Maurice Fishberg, M.D.
PhyiicUn to the United Hebrew Charitiea. New York.
Among the many peculiarities observed among or attributed to the Jews
the most noteworthy is their allied immunity to the noxious effects of
contagious diseases, especially tuberculosis. Physicians practising their
professdon among Jews have repeatedly spoken of the rarity of Jewish con-
sumptives; vital statistics compiled in registrar's offices of various coimtries
and cities have shown that the number of Jews who die from tuberculosis
is proportionately smaller than among the non-Jewish population around
them. About fifty years ago physicians stated that a Jewish consumptive
was very rare; to-day it is only stated that while there is no lack of tuber-
culous Jews, and although the Jewish sanatoriums for the treatment of
tuberculosis are crowded with patients, and have, as a rule, long lists of
patients waiting for their turn to gain admission to the institutions, still,
demographic statistics, wherever available, show that tuberculosis is propor-
tionately less often a cause of death among Jews than among other citizens
in the same cities and coimtries.
In a report on the vital statistics of the Jews in the United States the
Census Bureau has given proof of the incidence of consumption among the
Jews in this country.* From the returns of an investigation among 10,618
Jewish fanulies, including 60,630 persons living in the United States Decem-
ber 31, 1889, it is seen that the death-rate from consimiption per 1000 total
deaths was among Jews 36.57, and among Jewesses, 34.02, as against 129.22
among men and 146.97 among women in Massachusetts in 1888. This would
lead one to conclude that the general population of Massachusetts is liable
to die from tuberculosis about four times as much as the Jews in the United
* Cenfius Bulletin No. 19, Dec. 30, 1890, Washington, D. C.
416
416
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
States* But coosideriQg that the Census Bureau while collecting these
Jewish statistics has dealt with a select class of people whose addresses have
beea obtained by its agents, it must be concealed that comparisons with the
general population of any State may lead to rather odd results. Indeed,
among the Jews included in the above investigation, 1S>115 reported as
having some definite occupation, and of these 14^527 were wholesale or retail
dealers, bankers^ bookkeepers, clerks, etc., while only 84 were reported as
being laborers and 333 as engaged in agricultural pursuits. Such a group
of persons should only be compared with another group which, in the main,
follows the same class of occupations, before attempting to draw conclusions
as to the liability to tuberculosis of either group.
In 1901 I reinvestigated this problem in New York City. Not having
any deiaominational statistics, it is impossible to determine the exact
death-rates of the Jews in any city in the United States. But owing to their
voluntary segregation in certain parts of a city, especially in New York, the
mortality of the Jews can often be ascertained more or less near the true
coefficient. My results showed that in the fourth ward, inhabited mostly
by Irish and some Italians and Greeks, and very few Jews, there was tlie
highest rate of tuberculosis mortality — 566 per 100,000 population; the first
and sixth wards, inhabited by Irish and Italians respectively, also showed a
mortality of between 400 and 500 per 100,000 population. In the wards
inhabited mainly by Jews, I found that the tenth showed ft luberculosia
mortality of 172; the eleventh ward, 155; and the seventh WiirdfSlSper 100,000
population* This showed that the Jews of New York city have only one-
quarter of the tuberculosis mortality observed among the Italians and Irish
who live in the same neighborhood.* Moreover, we are not dealing hero
with a select class of Jews, following certain occupations wluch are not coa-*
ducive to morbidity, as I pointed out was the case with the statistics (rf'
the Jews compiled by the Census Office. The Jews living in the seventh,
tenth, antl thirteenth wards, wliich are well known aa the lower Eiust Side
of the city, are not all merchants. Most of them are artizans, working for
long hours daily iu tailoring shops, often of the sweatshop variety. Their
dwellings are of the worst tj^s of tenements, and an idea of the overcrowd-
ing can be gained when I mention that at the time this investigation was
made there were in the seventh ward 360, in the tenth ward 643, in the
eleventh 407, and in the thirteenth ward 539 persons to the acre of land. If
it IS recalled that a very large proportion of the Jews living there were immi-
grants, i. e.t adults between the ages of fifteen and forty-five, when tubercu-
losis is moat apt to occur, it is the more surprising that the mortality was
foimd to be so low.
Nor is New York city unique in this regard. In eastern Europe, where
• "The Infrequewcy of Tuberculoeia among Jews/' Amenc&a Metiidne^ Nov. 2, 1901.
TUBERCULOSIS AMONG THE JEWS. — FIBHBERG. 417
7,500,000, out of a total number of 12,000,000 Jews in the world live in the
three countries, Russia^ Aastria-Hungary, and Roumanian the same has been
observed. Statistics collected in the just mentioned countries show that
when compared with the Christiana among whom they live, the mortality
from tuberculosis is lower among the Jews. In Vienna it was elicited that
during 1901-1903 the following were the proportions por 10,000 populatioa : *
PnLJioNAKT ALt. Forms or
TvfeiEJicvLOiia' TcfiERCLTtoam*
Cfttholies 38.8 4S.6
ProUsatanta 24.fi 32.8
Jews , 13,1 17.8
Roughly speakings the Catholics in Vienna have a mortality from tuber-
culosisi about three times^ and the Protestants about twice, that observed
among the Jews. In the province of Galicia^ where the poverty among the
Jews is known to be appalling, they have a liigher mortality from tliis disease
than in Vienna, hut still not as high as that observed among the Christiana
in that region. Thus in Lemberg, a city with 159j6]9 population, 44,258
of whom were Jews, during the census of 1900, the average annual number
of deaths due to tuberculosis during the six years 1897-1902 was 734.3
Christians and 135.6 Jews; in Craco^w there were 25,670 Jews among a total
population of 91,653, and the average annual numl.>er of deaths due to
tuberculosis during 1896-1000 was among ChristianSj 436, and among Jews,
52,6*t The tuberculous mortality per 1,000 population was consequently aa
follows :
JewH,..., 30.64 20.40
Christiatifl ...63*51 66,41
In other words the tuberculosis mortality ia proportionately among the
Jews only one-half that observetl among the Christians in Lemberg, and only
one-third in Cracow.
In Budapest, Hungary, the census of 1906 shows that among a total
population of 791,748, there were 186,047 Jews, or 23.5 per cent. During
1905 there occurred 3195 deaths due to pulmonary tuberculosis^ of which
408 were JewSj i. e., 12.8 per cent. Per 1000 population there succumbed
21.93 Jews and 46.01 Christians to this disease; again one-half the rate
among the Jews, when compared with others*
In Roumania, where the mortality from tuberculosis is very high among
the general population, although most of the people are engaged in agri-
cultural pursuits, the Jews are also less often victims of this disease, Proca
* S. Rodonfeld/'Dic Sterfalichk^it der Juden in Wien," Archiv far Rassen- und Ge-
EeLichaftfibi(jlogie« 1907, tieft 1 uud 2.
t 1 compiled tbes^ figurefi from J. Thoiij "Die Judeu in Oesieireich/' Berlin, 1^7.
VOL. ni— 14
? .,:■?* ■ -?S3:». -KiWL OOVGRESS ON TUBERCULOSIS.
'^ ...:-^rs .:k nonaliiy was 3S.7 per 10,000 Roumanians,
:, - -J — ^^r "'.i*! ani demographic statistics about con-
T ^ =-:'"*. j--^ TiiTTibK- of Jews live, I am unable to state
— - ^ ' — . ^ :^ . r-.v-^rx from tuberculosis in those regions.
^- ■ " . •. :x-- si "V :v-'TrT««r. spoken of it in a paper on the
— • • *■>.-• -;.:. -V - j^iT :r. Tunis during 1894-1900 the
-. -^^ ?*■ *^..Ti; ,?tf V.i^.L:::An Arabs, 11.3; among the
^— ' -"• -x -y*- «'•»> -i'-:" ^To per 1000 population. Any
- -r.. - -"Si.: :j.^ -s..— . w-iv-it^ aiid the poverty in the Jewish
- ^ — ?<'. >. M*> fivcrable showing made by them in
•^ ^ ■*> .-s^ -4.t:.;:ir7?Lvrt^ are available. The most recent
•o -ir»; 'lia: :he tul»erculosis mortality of the Jews
. . ^ _^:-.:;w' :^a; .•csfr^Txl among the general population.
. --. r - v,^r i ieachs due to tuberculosis constituted 5.2
^ <^ . Mjh, >.■> wr cent, of the total number of Je^h
.^..at V :>? ACSEtstrar-General's returns, tbe number of
... . *»»'.c\^w- uiake up in London 9.2 {vr w^nt, of the
> vv vvaiaciou. the mortality was among the Jews
--^ ^ ^~^..T* ;vyuiaiWU, 17,9.{
(.^ - A^-^vmieocionthatthebulkofthe Jewishpopula-
5 -* »«u".ci\>wii Whitechapel district, and the major-
„^. 1.1. u|.n»iwns» especially tailoring and bootmaking.
. ^ .-: * jetwral pt.ipubtion of London, or England
. ,^.v >.i.;i uoerculoias is much lower. Similar con-
^ . . ^u -^--a Viisiralasia, especially New South Wales,
l] -^ . .,.iw:> *iKi uiortality of the Jews are stated to be
tc; ~ *^.-^.-r*-JklCU.
f ,^ i»jw».>^. » 'i*? United States Census Office, I pointed
2^j^, '^ >,.tj >^AU8» au unxisual proportion of mercliants
^j^^.^. ^ ^^ -> Aviiwed, among whom tuberculosis is less
. ^. "* ^^^^ •>h>objtfv'Eion does not hold when we speak
matle * .,-^-*.^ - » '-oudt^u. New York, Chicago, St. Louis,
gjgygjj . ^%3- -tt** ■*» ^^^y dweller is more liable to con-
it |g ret '\ ^ ,^i^3fcaw -»* the open countr>'; agriculturists
-.j^j^^ ^ ^ •,*:«* aU owr the worid is a city dweller
losis is I * • ** '**^' ^*^ *^^ population live in the
found to i ""^^^ " ,%«.i.«J«r ^*' '^**'^ ^^® ^^ ^^^^ communities.
IM,.-. :^ ^'^ * ■" "^ J, „-» ' T\ibereuloBi8, vol. v, U)06. p. 187.
^^^ *^ ^ .. .--: ^^T^irV lanrflitee Tunisiens," Revue d'hy.
TUBERCULOSIS AMONG THE JEWS. — FlSHBEilG.
419
I
I
I
In Riiasia, while only constituting 4 per cent, of the total population, they
make up 15.6 per cent, of the total urban population. The same is true of
Austria, Hunga-n', and Rouuiania. Of the two million Jews in the United
States, I have calculated that over 60 per cent, live in the nineteen cities
whif-h during the last census were found to have had over 200,000 population,
while only 16 per cent, of the general iiopulation of the country were found
in those cities. The Jews are essentially urban dwellers, and are n:iore in-
clined to Hve in the great pities than in the emal! towns. This is naturalj
considenng their occupations; they can only find an outlet for their activities
in the large modem commercial and industrial centers* This again ia im-
portant in its bearing on the Hability to contract tuberculosis. It is well
known that Jews prefer to work at tailorings but few appreciate, when speak-
ing of pulmonary diseases, the extent to which they are thus working at these
dangerous trades. According to the Russian census of 1907^ 782,454, or
one-seventh of the total number of Jews who were gainfully employed,
were dependent on the garment industry for sub^atence. In this class
were included tailors, shoemakers, hatters, cap-makers, milliners, glove-
makers, etc. In Austria also it was found during the census of 1900 that 81
per 1000 Jews were engaged at the garment industry, as against only 40 of
the Catholics. The same is true of the Jews in Hungary and Roumania,
While we have no denominational statistics about conditions in i\\e United
States^ still the figures compiled by Rubinow from the Reports of the Com-
missioner-General of Immigration show that the same obtaina here. Among
the 330,573 Jews who were admitted io the United States during 1901-
1906, there were 78,502 tailors and 13,123 shoemakers,* u 6., 28 per cent,
were garment-workers. Here many of the Jewish immigrants who were not
tailors in Europe learn the simpler kinds of machine operating, so that an
estimate that 36 per cent, of all the immigrant Jews in the United States are
garment-workers will be about correct.
We all know the sweatshop worker. In the first place, he is, as a rule, of
poor physique even before he engages in tailoring. Men with well developed
muscles find more remunerative occupations, Hia chest is flat, presenting
all the stigmata of the so-called habitus phlhisicus. This chest, while to a
great e^ctent due to the malnutrition and anemia which are very prevalent,
still owes its miserable appearance mostly to defective muscular development.
Flabby muscles cannot keep the riba at a respectable elevation, but permit
tliem to drop down at an acute angle in relation to the spinal column* The
result is that the so-called "Jewish" or tailor's chest is not only flat, but also
of inferior capacity. In healthy individuals the horizontal circumference
of the chest ia over 50 per cent, of the height, but in the majority of tailors
*I. M. Rubinr>w^ ''Economic Conditiona of the Jews in Russia," Bulletin of the
Bureau of Labor, Ko* 72, Waehrngton, 1907,
420
SIXTH INTEHNATIONAL COXGRESS ON TUBERCULOSIS.
in New York city I have found by actual measurement that the girth is
hardly one-half the height of the body. The cramped attitude of the tailor's
body whUe he is at work, as well as the lack of muscular movement, because
sewing by no means involves free exercise of most of the muacleSj in con-
junction with the defective ventilation of the usual sweatshop, all conspire to
reduce the \itality of the tailor and render his lungs predisposed to infection
by the tubercle bacJUuSi As a matter of fact, statistics collected all over
Eurojje show conchisively that tailors are more liable to tuberculosis than
workers at other trades, except stone-cuttings printing, and the like.
It is remarkable that in spite of this large contingent of Jewish tailors
in eastern Europe, England, and America, their mortality from tuberculosis
is lower than that of any other class of artizans. The causes of this lesser
liability to die from tuberculosis have been discussed by many medical au-
thors. Some are inclined to attribute it to a epecial inherent vitality of the
Jewish '* race/' which is also alleged to manifest itself in a low mortality from
all other contagious diseases. Some have even maintained that the "Sem-
itic" blood which flows in his veins renders the Jew immune to the vims
of infection, and gives him an advantage in the struggle for existence wlien
comparetl with the " Aryans " among whom he lives. But this argument is
fallacious for various valid reasons: The Jews are by no means as pui'e a
race as has been thought by some who depend more on sentiment than on
scientific observation in their judgment of the subject. When we recall that
we have about 30 per cent, of blond Jeu^, that there are tall and short Jews,
dolichocephalic, mesocephalic, and brachycephalic Jews, we must acknowl-
edge that we lIo not deal with a pure ethnic group* I need not enter here
into details, beyond saying that anthropologists of to-day deny the purity
of the Jewish race as much as they deny the purity of the soMjalled Latin,
Anglo-Saxon, Slavonic, and similar "races/' Be that as it may, we knowthat,
on the whole» tuberculosis displays no racial preferences. Within certain
limits, depending on social conditions, the wliite, blacky yellow^ and red divi-
sions of mankind are attacked by this disease in the same manner, and the
variations observed in the frequency, type, and course of the disease in differ-
ent groups of people are alike traceable to the same causes^ irrespective of
racial affinities. We know that the variations displayed by the various social
groups of white humanity, such as the differences in the incidence of the db-
ease between city and country dwellers, rich and poor, those engaged in
indoor or outdoor occupations, persons active in a dusty atmosphere as
compared with such as are working in clean, air^' shops, and the like, are
just as great as, often greater than, the differences observed in the while,
black, red, or yellow races. When we find that the morbidity and mortality
from tuberculosis of the black and yellow races in the United States are ex-
ces^ve and appalling, we cannot say that this is due exclusively to the dlHer-
I
I
I
TUBERCULOSIS AMONG THE JEWS. — FISBBERG.
421
ences in the anatomy and phyaology of these and the whiles. There are
many social groups of whites who have just as high, even a higher morbidity
and mortality, as can be seen from demographic statistics publLHhe<^l in many
countries, where causes of death are ^veii according to the occupations of
the inhabitants. Stone-cutters, furriere, uphol^tcrersj printers, and others
who are engaged in an atmosphere laden wltli orgaidc and inorganic parti-
cles of dust have also an excessive mortality from tulierculosis. On the
other hand, the Indian li\'ing in our west-eni plains, unaffected by modem
conditiona of civilized life, — which in his caseoften conmsts mainly in tlie abuse
of alcoholic beverages,— and the negro in hia home in Africa, or even here
during slavery, are only very rai"ely affected by tuberculosis. The same is
true of the native trilies in Austraiasia, among whom tuberculosis was
very rare, some even say it was unknowia, Wore the advent of the tvhite man,
who, wliile introducing a civilized motle of life, brouglit along the white phigue
which is to-day decimating the native population. Similarly in Polynesia
fcubercuJoHis has been spreading like wildfire among the natives, and it is
stateil by competent observers that the majority of deatks are due to this
diiica.se.* One hundred years ago a i>hy8ician traveling among these races
could justly say that tuljerculoaia is a ver}^ rare disease in Australasia^ and
Polynesia, or in the western region of the Uniterl States, and try to explain
it as due to the su]>eriority of the climate of those re^ons, or to the great
power of resistance displayed by these raceSi
Another potent reiison against the theory that the lower mortality of
the Jews from this disease is due to an inherent racial resistance to the
disease is the fact that intermarriage with non*Jew3 does not at all incrca^
the numl)er of consumptives among them. One exanaple will suffice. In
Berlin the number of mixed marriages between Jews and Christians is very
large, reaehing 44 per cent, of the full JeAvish marriages in 1905, We know
that certain racial immunities, Uke those of the negro against malaria ami
yellow fever, are impaired in the mulato. By analogy we shoulc! expect
that the number of Jewish consumptives should be highor in Berlin than in
Austrian Gallcia, where practically no intermarriages are taking place
between Jews and Christians. As a matter of fact, however, conditions are
ad follows, There were in 1905, according to the census returns, 9S,S03
Jews among a total population of 2,040,148 in the city of Berlin. During
the same year there occurred in that city 4302 deatlis as a result of pul-
monary tul)erculosis, of which only 97 were Jews,t showing a mortality per
10,000 population of 2i.66 Ciiristians, and only 9.81 Jews, In Cmcow,
where no int/^rraarriage takes place, the tuberculosis mortality was 30,64 —
three-fold that observed among the Jews in Berlin. The fact that inter-
*A. Bordit?r, "La, Q^^ymphk MAhfaie.** p. 329. Paris, 1884.
t StatistiBchefl Jahrbuch dcr 8tadt B^riiti, vol. xxx, 19QT.
AL COKOREB8 ON TUBEBCULOBIS.
Uie mortality from tuberculosis is, I believe,
B BO ethnic immunity to be elicited.
the lesser mortality from iu1>erculoda is
«f Moet qI the Jews wbo were prefUsposed in former
is itifmeUnj to the effects of the tubercle
tfaiB resstance was Bxed within the race.
thwcY, maintains that the Jews may abandon
■i as kms as they ab&t^dn from intermarriage
to coati^ous diseases^ including tubercu-
«ilL iau% b» kK^* BtaW as «« Inve seen, iutermarrloge dues not render
b«rt, on the oontrar>% the numl>er of Jewish
JK Bertin, and also among the native Jews
etc.* than among the Jews in eastern
with non-Jews. As I will soon show,
eooditions and not to racial causes.
that the ritual dietary taws practised
tm Ite iBSOer number of deaths from tuberculosis
W * ^w* laowa^ Jew^ before pronouncing meat as fit for
object ever>' carc^iss to a thorough examina-
c;$«aa> •itanlioci is paid to the condition of the viscera,
llviert ^^ spleen. Those animals whose
*.ihmMt6 W the thoracic vHh or adhesions between the
"1 ^ateib 9BQiati nodules are discovered scattered over
kfl^fitMiineed (ax fa, or tmfit for human consump-
<^ >£*u0a that bovine tuberculosis is thus prevented from
4te<Wtina of Israel In the light of our present
Wtt flfftad of tuberculosis, some of the foremost
xJM^ awl otefs) being of the opinion that tuber-
^ kfBolioa than by inhalation, the Jewish
piwwttive when strictly adhered to,
life* vvrnkoce b again£t this view. In eastern
o« ife* dieiaiy U^^, strictly adhering both to
i^ml QldittBlkOe, there is more consumption
^it Q»-f<iligkHUsts in western countries wbo
% ptfl 9t cocnpletely. In Germany, France,
of the native Jews are constantly
^mi MMy are not particular to procure
among them than in eastern
Side of New York city^ where
^MtriMtant prices for meat which is,
Mbnadien," Ldpu^g, 1S97; '*Die
TUBERCtTLOSIS AMONG THE JEWS. — FTBHBERG,
423
The incidence of tuberculosis among Jews depends more on their economic
and social environment tlian on racial or ritual affinities. In Berlin, where
they are as a clasa econotnically prosperous, there is but little of tuberculosis
among them* The death-rate of pulmonaiy tuberculosis during 1905 was
9.81 per 10,000 Jews. La Vienna, where a large proportion are on a high
plane economically, but where many poor Jews are found, the death-rate
is higher than in Berlin, reacliing 13,1 for pulmonary and 17.9 for all forms
of tuberculosis. In Budapest and Bukharest, where there are more poor
Jews than in Vienna, the rates are higher — ^21.93 and 25.6 respectively. In
Galicia the poverty of the Jewa ia appalling; in fact, I do not know a poorer
lot of humanity than is met with in the small towns of Austrian Galicia.
It b there where we have found the highest mte of mortality among Jews,
reaching 30,64 per 10,000. The influence of economic conditions on the
incidence of tuberculosis among Jews is well illustrated by conditions in
New York city* In a recent report of the Charity Organization Society*
T find an analytical table of the cases of tuberculosis registered in New York
city. Altogether, there were in Manhattan and Bronx registered with the
Board of Health 10.29 cases of tuberculosis per 1000 population. In the
fourth, ajtthj eighth, and t«nth assembly districts, which are almost wholly
inhabited by Jews, the majority of whom are poor artizans engaged in the
garment industry, the number of registered cases was 11.9* 12.0, 1S.5, and
11.7 respectively per 1000 population; wliile in the thirty-first assembly
district, in Harlem, where the majority of the population consists also of
Jews, but of those who are on a higher economic plane, most of them mer-
chants, manufacturers, professional men, and the hke, the number of cases
Ls proportionately the lowest of any assembly district in the city, being only
3,6 per 1000 population. The Jews in the lower East Side are more ortho-
dox, more strictly adhering to their faith and traditions, and still have
proportionately a higher rate of morbidity from tuberculosis than their
co-religionista in Harlem, who, as is characteristic of Jews all over, with
their prosperity have more or less discarded many of their religious practices,
the fir^. of wliich consists m consuming meat not prepared according to the
dietary laws.
The social and economic aspect of tuberculosis has been st-udied quite
carefully dui'ing recent yeai-a. Demographic statistics have shown that there
are more deaths from tuberculoBia in cities than in rural districts, and that
it is essentially a disease of people who live indoors. The concentration of
population in cities Ls a comparatively recent phenomenon. Only about
one hundre<i years ago the urban population of any European country was
only a small percentage of the total population. To-day there is a constant
* Fourth Annual Report of the Committee on the Prevention of Tuberculosis, New
York, lEWe,
424
SIXTH INTEHNATIONAI* CONGRBSS OW TX7BEBC0LO919,
migration of the country dweller to the large industrial centera, where the
opportunities for advajicement are better than in the village. But that
the average country dweller is more or less incapalile of resisting the deleteri-
ous effects of overcrowding, with its concomitant facilities for the spread
of contagious diseases, i^ evident from the fact that very few of the inhabi-
tants of the modern large cities in Europe can trace back their ancestry
for more than three generations. It appears that the country dweller^
after immigrating to the city, is the most vulnerable; he has the most
chaacca to contract contagious diseiises, particularly consumption. To
begin Avith the extreme type of country dweller, those who live always in
the open air, — as the nomadic Kirghiz Tartars in the Siberian plains, or the
aboriginal inhabitants of Australasia, Polynesia, or North and South Amer-
ica,— we find tliat tuberculosis was quite unknown among them before the
advent of the white man, who brought to these tribes not only civilization,
often in the shape of whisky, but also the tubercle bacillus- Never having
met with these bacilli, these tribes were very vulnerable, like virgin soil.
This is not only the case with tuberculosis. We know that the same Is
tr-ue of measles, scarlet fever, smallpox, etc. Whenever they are imported
into a country where these diseases were unknown before, they attack
almost everybody- Similarlyj the rural population of our modem civiUzed
States, owing to their open-air life, not having undergone as rigid a process
of selection in which most of thosse predisposed to tuberculosis haA'e suc-
cumbed, are more often infectecJ when they migrate to the city and begin to
live in overcrowded houses^ lacking fresh air and sunshine, and enter the
modem factory and millj where they often meet with fellow-workers who
suffer from tuberculosis. It is this class of rural dwellers, not adapted to
indoor city life, that is lacking among the Jews, who have for two thou-sand
years lived exclusively in cities, and during Medieval ages were confined in
the worst parts of cities, the Ghettoes. Indeed, only rarely was the Ghetto
enlarged to meet the demands of a growing population, but the Jevs^ were
compelled to accommodate themselves the best way they could on a small
area. Under such conditions, those Jews who were predisposed to tubercu-
losis succumljed, while many of those who survived left a progeny re-
fractory to the disease* The same process is to-tlay going on with most
other inhabitants of large cities. The Jews have only the advantage of
having passed through a process of infection during past centuries. Hence
their low-er mortality to-<lay from tuberculosis.
An excellent illustration of this process is going on before our eyea in
New York city. The large number of immigranta who hiive settled in the
East Side of the city consists mainly of Italians and Jews. The former
come mostly from southern Italy, Sicily, Calabria, Basilicata, etc., where
the mortality from tuberculosis is the lowest in that country, and lower
TUBERCiriiOSIS AMONG TSE JEWS, — FISHBERG,
425
than in many northern and western European countries. Duiing iri04
the mortality from tuberculosis in Italy was 16.4 per 10,000 population^
while in CalabrU it was only 9.6; in Basilicata, 10,6; iind in Sicily^ 11.5;
while in northern Italiiin provinces, where ti large proportion of the popu-
lation lives in. modern cities, the tuberculosis mortaiit}^ was much higher —
21.6 in Ligiiria; 21.1 in Ijombardy, etc.;* and in the citiejs of Rome, Tuiin,
Genoa, etc., the rates are even over 30 per 10,000 population* It is thus
seen that in his native home the southern Italian does not display an exces-
sive vulnerability to tuberculosis. But coming to the United £>tates, as
was pointed out by Dr. Stellaj three-quarters of them settle in large cities,
though in southern Italy nine-tenths of these immigrants lived in rural
tlistricts.f In New York city their mortality from tuberculosis is 276.3
per lOO.OOO population, J nearly three times as high a rate iis in their native
land; and even this does not at all give us the real rate, because many
Italians contracting tuberculosis in New York city return home for a cure
or Ui <-lie. Every steamer going from New York or Boston to Mediterranean
ports has in its steerage many tul>erculou3 Italians who return to tlieir
native land.
The exact opposite is the case with the Jewish immigrants in New York
city. Although their overcrowtting is not as great as that of the Italians,
and their standard of life is much superior on the average, still they more
often engage in indoor occupationSj where the opportunities for infection
are very great. But in spite of the unfavorable surroundings in wliich
they find themselves, their mortality from tuberculosis is lower than that
of people of any other faith. According to Gilfay, it was 172.4 per 100,000
Russian Jews in 1906. The main reason is, as was already indicated, the
fact that the Jew dcjes not make any material change in his milieu by chang-
ing his al_>ode from eastern Europe to America, He lived there in a city,
and here again settles in a city; he worked there at some indoor occupation,
and does the same here; he lived there in an overcrowded dwelling, and
moves here into a "double-decker" tenement. He has paid the price for
urbanization already for several hundred years, wliile the Italian, Syrian,
Irish, Slavonic, and Hungarian peasant coming to the United States meets
with the urban conditions for the first time, and must pay an exorbitant
price for it in the shape of victims to the white plague.
The eflfect-s of the thorough urbanization of the Jews are manifesting
themselves in many other ways. It has l^een observed by many physicians
that even when infected by the tubercle bacilli, the progno^ is more favor-
* See Statistic delle cause di morte nell anno 1904, Romaf 1&07, pp. Kxxii.
t A. St^Ua^ "The Effects of Urban Congestion on Italian Women and Children,"
ModicoJ Record, vol. 73, pp. 722-732.
i W. H. Giiilfoy, "Die Death Rate of New York City aa Affec(«d by the Cosmopoli-
tan Character of the Population/' Medica] Recordj vol. bcxiii, pp. 132-135.
INTERKATIdKAL CONGRESS ON TCJBERCULOfllB.
Few than in other people. The course of the disease b slo^ner.
verj' few cases of tuberctiloeis of the fulminant or galloping
se\'eral thousand cades of consumption in Jews, Acute miliarj
is very rare indeed awmw^ thent. The cases in which the victim
Ip stricken with high fever, rapid extenaon of the disease with cavity for-
■fttion wit liin a few weeks^ or months^, are also rare. But cases of the extrecne
cfefonic type, running on for years, still percnitttng the \'ictiEn to make
f useful lit some easy occupation, are common — more so than among
people of t!ie same aocial status. Of course, to a certain extent this
iiabo due to the infrequoncy of alcoholics among them, but this alone does
•Ol explain the uomliiion. It appears that thoroughly urbanized humanity
dast wA i*ffcr a g(x*ci soil for tho growth and development of the tubercle
whik* the inhalntant of the open plain, and less so the peasant or
in modern Eurt>t>pn[i and American villages, offers a virgin soil for
iWn fiounuatcs. This is tho only reasonable way we can explain the high
M^Mt of morbidity ami mortality from tuberculosis of the rural dwellers
iRlva tNOAifrnte to cities, Binnj^ more predisposed to infection, they also
MiMN^ \4>«i supply cases of tho ficute fulminant or galloping type, as well
4wi Hi^iH^ iiuUary tuberculosis,
'|li«l<e ttn^ imiications tluit this advantage of the Jews is not permanent.
Il |i^**l¥ Utal i" ertstern Europe tuberculosis has been on the increase
^jt^V(^ *¥«mU wirs, and the same has been reported from London. In
))^ Ywrk cilY the miniber oi applicants to the United Hebrew Charities
^ll^^uMtf it\^i\ tulwrculosis has exceeded 1000 during 1907, while six years
l|^ ^»#^> ki^^i^lwdf lUnt nuiuber applied. The total number of appHcations
IV^4 Iw^-* n^*t increased materially during these years. It seems that,
>...^i.^l »^, x\ve^y nn* to indoor life, they still camiot resist infection w^hen
V M\\w ixMuUUons become very unfavorable.
4
I
111 Tvterculose parmi les Juifs. — (Fisebehg.)
HH^Ulit^ *W* la tulH>rculofie en Autriche, Hongrie, Roumanie, Alle^
\ti^MiM'rt«, Am^^ritiue, Australie, etc, est environ la moiti^ ou le
h\\h tk* IV qm s'obser\*e chez les gens des autres religions qui
^tMHHHANM^^ ^Wmi Iw lu^nuMi pa>*8. A Berlin h proportion qui meurt de k
u^^iMt!^ yw lU,iHX> |!en*onne!* est de 9,S1 parmi les juifs, tandis qu'elle
\ltt \^ii\\si Itvt chi-^^tiens; h Menne: juifs 17,9, protestants 32,8;
li; A U^dapertte; juifs 2L93 et chr^tiens 46*01; h Cracovie;
^>k^Mitilu WV41; h Lembei^: juifs 30.64, Chretiens 63.51; en
UlV f^hi^tien^, 3S,7; k Londres: juifs 13*3 et toute la
' \ W'.^i A Nvw York: juifs (ruasea) 17.24 et toute la population
TUBERCULOSIS AUONG THE JEWS, — FISEBERG,
^7
A cet ^gard il est int^reasaat de se rapeller que les juifs sont essentiellement
les habitants des grandes villes; quatre-cinquiSmea dea Juifs du monde
demeurent daas les grandes villes et en general dans les baa quartiers,
D^ailleura les jiiifis qui suivent I'agriculture sont peu nombreux; ils s'occupent
plutdt des metiers qm se font ^ I'abri de-s ^l^ments. De 25 ^ 40% de tous
lee juifs gagnent leur vie en fabricant les habits. Ces consid^ratioris, Bura-
joutefe k la frequence des poitrines creuses et muscles moux parnii les
juifs, doivent plut6t augmenter luer pr6:iisposition k Tinfection par le
bacille de la tuberculose.
La diminution de leur mortality provenant de tubereuiose n'est pas
d^rivfe d^une particularity etlinique quelconque; parce que dans les com-
munity ou les juifs se marient ordinairement avec lea chrfitiens la mortality
des juifs n'est pas plus ^lev^; et, en sonime^ cette maladie ne di^montre
nulie pr^f^rence de race. Non plus vient^elle de la aun^eillance du rituel
des boucheries; car m^me dans les conimunltds juivea ou Ton ii'obi^it pas
aux r^elments alimentaires la mortality due h la tuberculose ne monte pas*
Les chifEres de mortalite dependent des conditions soctales et ^onomiques.
Dans quelque endroit que ce soit oit les juifs prosp^rent, au point de vue
Iconomique, la tuberculose est moins fr^quente que parmi les juifs qui ont
descendus T^chelle aociale et ^conomlque.
La cause principale de la diminution de la mortality parmi les juifs
eonsisie dans ce quails ont demeurds dans les grandes villes pendant cea
deniier deujc oiiLes ans; et par consequent lis ont ^t^ compl^tement" ur-
banises/' c'est^a-dire, ils se sont adapts k la vie de Tinterieure dea 'villes.
Ces conditions sont en g^n^ral nuisibles aux gens qui ont v^cu des sii^cles ft.
la cumpagne. Ce proc^d^ "urbanisateur'^ se montre pour la plupart par
la diminution de la niortalit-^ tuberculeuse, et aussi par la rai'ete parmi
eux de la plitisie galopante et de la tuberculose miltaire aigue» La maladie
prend un coura plus lent et plus chronique cliez les Juifs; et on pent le tracer
ee ph^nom&ne h leur adaptation plus parfaite h la vie d'int.^rieur. Ce trait,
cef)endant, n'est pas permanent chez lea Juifs parmi ceux qui ont r^cemment
subi un milieu trSs-nuisible, eomme dana lea usinea et les ateliers, o^ la
tuberculose est, au contraire, augment^.
Tuberkulose unter den Juden. — (Fishbehg.)
Die Sterblicbkeit an Tuberknlose in Oeaterreich, Unganij HumSnien,
Deutsehland, England, Amerikaj Australien, etc., ist ungefahr die Halfte
bia zu einem Drittel unter den Juden, welche unter den Anhangern anderer
ilaubensbekenntnisse beobachtet werden, die in denselben Landem leben.
Die Raten fiir 10^000 der Bevolkerung waren: in Berlin, 9,81 unter den
Juden und 21.66 unter den Christen; in Wien, Juden: 17.9, Protestanten :
428
SIXTH INTERNATIONAL COSGBXS3 OS TUUMBCUUm^
32^uiidKatboUkeD: 49,6; b Budapest, Juden: 21.93 imd Christen: 46.01;
In Krakau, Juden: 20.49 iind Christea: 66.41; in Lembog, Juden: 30.64
und Christen: 63^1; in Humaniea, Juden: 2S.6, imd Chiislen: 3S.7;
in London: Juden, 13.3 irnd aUgemeine Bev^kenmg: 17.9; in New YoA
(Ruaosche Juden) ; 17.24, und allgemeine Bevolkening: 2^^
Eb ist von Intereaee, sich in dieser Beziekung inft Gedaehtnis surucknzFil-
fe^Xf dass w^hrend die Halfte oder drei Viertel der airoptifldieii Bevoik^ung
atif dem LAude lebt, die Juden im Gegensatxe dazu liauptdad^cb Stadt-
bewohner and, — vier Funftei der Juden auf der ^anxen W^t l^sen m
Stjdten, oft in den dicht bevolkerten Teilen. Fsner giebt es sebr wmig
Ackerbauer und de sind mehr geeignet, Beschaftigungen in geerhioesa^en
R&umen nachzugehen; 25 bis 40% aUer Juden and in der Kkidennduslne
beschiftigt, welche aebr einti^lcb ist. AU dies in Verbindtuig mit der
HS.ufigk^it fiacber Bnist-korbe und wejchlicher Maskeln soUte ae eher fur
die InfektioD durch dtn TuberkelbazLUus empfanglich mAcben. Ibre
geringene Sterblichkeit von Tuberkuloee ist nicbt im ZiM»mmpwhangP mil
irffmd wetchen VolkseigontQinlicbkeiten^ weil im Gem^nweaen, wo Zwiachen-
beiiaten mit Christen vorzukommen pfiegen, die Sterbticbkeit vter den
Juden nicbt groBser ist, und dicae Sj^nkbeit uberbaupt keioe toil einer
Raaae abhAngige gei^teigerte Tendenz seigt. &ie ist aucb nicbt der ritaeUea
Fleiscbbescbau zuzuschreiben, weii tn judiscben C^mdnden, in denen die
Spebegesetze nicbt befolgt werden, die Slerblicbkeit an Tuberkuloee keine
hohere ist.
Die Sterblichkeitsrate bangt von sozialen und okonomii^chen Umstanden
ab. Wenn die Juden okonomisch prosperieren, ist Tuberkuloee seltener
eane Todesursache ab unter Juden, welcbe auf der tintersten Stufe gesefl-
scbaftlicber und okonomischer Entwicklung steben.
Die ILiuptUJ^acbe fur die geringere Sterblichkeitsrate der Juden Ist
der Umstand, daas ^e durch zweitauaend JahiB hindurcb Stadtbewobzker
gewesen und dabef grundUcb urbanisiert worden sind, d. h. sicb an das
I^eben in der Stadt und in geecblossenen Raumen gewobnt baben, was im
GrosBen und Ganjen fur Menscben, die durcb Gcnerationen hindurcb &uf
dem Lande gelebt baben, von feindseligem Einflusse ist.
Dieser Process der Urbani^erung tut deb bauptsacblich durcb d^
geringere Sterblichkeit an Tuberkulose kund, und ebenso in dem seltenen
Vorkommen gaUopierender Schwindsucbt und akuter ^liliartuberkuloae
unter ihnea. Die Krankbeit niromt unter den Juden einen langsameren
und mehr cbronischen Verlauf. Dies ist jedocb keine permanente Eigen-
•chaft der Juden. Tuberkulose hat sich unter jenen vermehrt, welcbe aich
kurzlich in etn sebr ungunstiges Milieu begeben baben, in die modonea
Fabnken und Uublen*
I
THE PREVALENCE OF TUBERCULOSIS AMONG
ITALIANS IN THE UNITED STATES.
By Antonio Stella, M.D,,
N»w York.
Whoever is at all familiar with the abnormal conditions of life and labor
prevailing among the Italian working people, herded together in the crowded
tenements of New York and Chicago, and at the same time realizes the
agnificance of iu*ban centers for the genesis and spread of tuberculous, is
forced to the inevitable conclusion that, under the circumstances, this disease
must be extremely common among Italian immigrants, Thdr enormous
concentration in the large cities is sufEciently illustrated by a few statistical
data bearing on this subject.
In the sixty years, from 1820 to 1880, only 68,633 Italians made their
way to America, while during this period the total foreign immigration was
over 10,000,000. The census of 1890 gave the Italian population of the
United States as only 182,580, and at that date not over a half million in
all had come here. The rapid increase during recent years is shown in the
following table:
1890 52,003 1899 77,419
1891 76,065 1900 100,136
1892 51,631 1901 135,996
72,145 1902 178,376
1894 42,977 1903 230,622
1895 35,427 1904 193,296
1896 68,060 1905 221,479
1897 59,431 1906 273,120
1898 58,613 1907 285,731
This shows that in five years (1900 to 1905) 959,768 Italians more have come
to this country.
Of the total Italian population in the United States, three-fourths
(79 per cent.) are settled in cities having a population of more than 50,000,
the North Atlantic regions absorbing the greatest proportion (72 per cent.).*
The State of New York alone has 586,175, and the city of New York not
less than 500,000, or more than four-fifths (78.7 per cent.) of the entire
* The last census places the proportion at 62.4, but, of course, does not take into
account the million more of arrivals smoe 1900.
429
430
SIXTH IKTEHNATIONAL CONQHESS ON TUBERCULOSIS.
Italiau population of the State — a population equal to that of the third
largest city in Italy. Taking into consideration the fact that nine-tenths
of these immig^rant^ are of the peasant class, or laborers from rural districts
in Italy^ who in this country take up the most injurious occupations instead
of the wonted agriculture; and that the vast majority among them (80
per cent.) are between fifteen and forty-five years of age, — the epoch in
which consumption is most prevalent, — the result is very easily foreseen.
While we all agree that urban life lowers the physical standard of the
people and is detrimental to the national physique, few of us are aware that
this injury is more profoundly and more extensively felt by the robust
peasants than by the tliin and pale city dwellers. Whether it is that the
abrupt transition from rural to city life does not give the nomad people,
BO to speak, accustomed to an outdoor existence, time to prepare and
elaborate stifficient means of protection against or adjustment to the new
environment — epeuial enzymes or opsonins, or we do not know what, that
all animals and even plants develop when transferred to a new environment;
or whether it is that the very high tension to which the nervous system is
subjected by city life, often accused as a factor of disease, is in reality the
mainspring of that hyperacutenesa and overactivity of all our functions
wliich braces the system constantly to a higher degree of vigor and vitality —
it is certain that death and diseases are more prevalent among the rural
people settled in cities than among the city people themselves, in spite of
the more robust appearance of the former. The example of the Indians, of
the negroes^ of savage people, and presently of the ItaUans in Atnericai
furnishes an irrefutable proof of this fact.
Official statistics are unfortunately lacking, and, moreover, not even a
trace of literature on the subject is obtainable, since there never has been
any concerted action on the part of the two governments in regard to a
Bystematic investigation of the prevalence of tuljercular diseases, and of the
extensive deterioration of Italian working people in the United States,
the result of the intensified struggle for eodstence^ under the onslaught of
oertma economic factors which assail and crush the laborer from every
The two subjoined statistical tables are among the few official documents
which indicate the mortality from tuberculosis^ and the general mortality,
according to the nationality of the various colonies. Both include males
and female between the ages of fifteen and forty-five years (ordinarily
considered and d^gnated as "the first generation of emigrants"), and refer,
respectively, to the city of New York for the year 1902 (Table No. 1), and
to the registration area of the United States for the year 1900 (Table No. II).
The former shows that the mortality from tuberculosis among the Italian
residents of New York city reaches 21.90 per cent, for the men, and 23.98
I
J
I
I
I
I
mrBSBCOLOfilS among the ITAUANS. — STELLA.
431
pet cent, for the women, of the total death-rate in thdr colony during the
^rear 1002.
TABLE I.— crry of new york (1902).
NuMBsa or Deaths, Males
NuMBEH or Deaths, Femaub.
Au. Causes.
TCBEBCU-
LOSIS.
Feecent-
AGE OF TU-
BBBCUL06IS.
Au. Causes.
TUBEKCU-
Pebcbmt-
AOE or Tu-
BBBCULOaiS.
Chinese
Irish
44
2,103
219
66
87
1.101
119
319
838
48
358
452
22
831
91
26
30
357
36
96
252
14
104
99
50.00
41.98
41.55
38.24
34.46
32.43
30.25
30.09
30.07
29.17
29.05
21.90
mi
234
56
66
741
82
263
726
58
380
342
609
79
10
21
184
29
54
215
16
63
82
34.39
Negroes
French
Gennans
Scandinavians.
Austrians
United States.
Oanada
Russians
33.76
17.86
31.81
24.83
35.37
29.05
29.61
27.69
16.58
23.98
TABLE n.— REGISTRATION AREA OF UNITED STATES (1900).
NuiCBEH or Deaths, Hales.
Number or Deaths, Females.
Axx Causes.
Tubercu-
losis.
Pebcknt-
AOE or Tu-
berculosis.
All Causes.
Tubercu-
losis.
Febcemt-
aob or Tu-
berculosis.
Caiinese
Irish
386
10,354
6,743
542
232
5,794
1.056
398
13,298
2,217
1,022
1,126
172
3,045
2,171
160
67
1.695
311
111
3.281
724
227
204
1
44.56
38.10
32.20
29.52
28.88
29.25
29.45
27.89
25.42
32.66
22.21
18.12
32
8,912
6,075
482
178
4,896
894
276
13,801
2.559
732
693
8
3,117
2,135
136
53
1,334
312
60
3346
1,006
155
159
25.00
34.98
N^ioes
Sootch
French
Gennans
Scandinavians .
Austrians
United States .
Canada
Russians
Italians
35.14
28.22
29.77
27.25
34.90
21.74
27.87
39.31
21.27
22.94
The tuberculosis mortality among Italians appears somewhat lower in
the second table, being exactly 18.12 per cent, for the men, and 22.94 per
cent, for the women, of the total death-rate of Italians throughout the coun-
try. The smaller figures are accounted for by the fact that the compendium
includes many rural districts, in which the mortality is never as high as in
the urban centers.
433
SIXTH INTERNATIONAL rONGRESS ON TTTBERCUUieiBv
These tables furnish the first proof, and the oflScial conGrmation, of a
moat significant fact, to which I have been calling attention for many years,
namely, that Italian women in America become far more sust^ptible to
tuberculosis than do the men, although their number is far smaller,* and
this is in direct contrast to the statistical findings for women of other nation-
alities.
The annual death-rate from tuberculosis in the city of New York, accord-
ing to the United States Census of 1900, is 149.9 per 100,000 living. These
figures would naturally lead to the conclusion that mortality from tubercu-
losis among Itahans is comparatively low, but any medical man who has
been brought into close contact with the Italian poor of large cities will bear
witness to the fact that only a certain portion of the Italian tuberculous
population die in the district in which they have contracted the disease,
"Thdr fear of consumption is much greater than among any other national-
ity, and the belief in climate as the only cure for pulmonary disease is so
firmly rooted that the first suggestion of anything abnormal with the lungs
leads them to immediate preparation for a change to better climatic condi-
tions/' Men and women in very destitute circumstances will seD all Ihdr
belongings, and without second thought start back to their native towns.
If for some reason they fail to secure the free transportation tickets which
the ItaUan Government places at the disposal of Italian consuls in America,
to meet just such contingencies, their relatives and friends come t<t their
rescue. The faith in the home climate as the only cure for any chronic
cough JB so widespread that plans for change of residence are frequently
made without consulting a physician^ and at times ag^nst his advice.
Thus the mortality quotient of their bir(.hplace is increased, whereas the
statistics of the center in which the tuberculosis was contracted and de-
veloped do not reveal the existing conditions. Information to this effect
may be gathered from the reports of the medical department of the Italian
Commissariato d'Emigrazione, since they began to keep an account of the
* Eighty per c^nt. of Italian iininigrant« are malcSr as can be seen from the following
daasificzktion for 1905, the year of high mark of Italian immigration:
I
I
I
I
i
Male.
PXMALK.
TOTAI^
H TO 44
Year*.
AS Ykaui
Italian
(North),.
1 tat Ian
(South) .,
31,095
153,007
8,235
31,383
39,930
186,390
3,5e0
16,915
34,561
159,024
1,800
10,451
Is 1907 the number «f It»liftii womeo lauding »i the port of New Yorit ww 6l»133
TUBERCULOSIS AMONG THE ITALIANS. — STELLA. 433
'iBtuming Italian sick in 1903. From such reports we gather that the
proportion of Italian tuberculous emigrants returning to Italy from North
America has been increasing steadily every year. This constant return of
Italian consumptives to their native land results in the erroneous impression
that the mortality among Italians is very low, and shows that conclusions
as to the prevalence of tuberculosis among Italians, based only on the rate
of mortality, are necessarily misleading to a very large extent.
The proportion of Italian consumptives returning to Italy in 1903 was
2.92 per thousand, in 1904,2.75; in 1905,5.66; and in 1906, 5.61 per thousand.
But this average is very much below the real condition, because it only takes
account of the very advanced, bed-ridden cases among steerage passengers,
isolated in the ship hospital, who constitute a small fraction indeed, as com-
pared to the large army of those in the incipient or moderately advanced
stages, and those traveling second or first cabin. The walking tuberculous
steerage passengers escape detection, there being no special law compelling
systematic examination of suspected cases; the cabin passengers escape
medical supervision altogether, because they do not fall under the provision
of the present laws. However, it is a well-known fact to the writer of this
paper, to ship surgeons, and to all those conversant with the situation, that
an exceedingly high number of consumptives (the percentage being unob-
tmnable for the reason stated above), travel second class and exceptionally,
first class, during the rush season, even when their immediate relatives go
steerage, for the following reasons: (1) To avoid the rush and crush' of the
steerage quarters and enjoy better accommodations (fearing that the suffo-
cating atmosphere of the steerage might shorten their days or aggravate
their condition). (2) To escape detection at the hands of the ship surgeon,
who, they imagine, will impose on them undue restrictions; and to avoid the
stigma of being pointed out as consumptives. (3) Because almost every
returning Italian has enough money to pay for the difference in price be-
tween third and second class, and they feel that money thus spent is the first
investment made for the sake of their health — the object of the journey.
From what I have seen and heard, I am ready to venture the statement
that fully 50 per cent, of the second-class passengers are suffering from tuber-
culosis in some form or other, and during certain seasons, and on certain
cheap lines, the percentage may be still higher. When we confront this
fact with the comparative lack of sanitary provisions in this class, the truth
of the statement made by Dupuis is brought home to us: viz., "that the
protection of the passengers from infectious diseases on board is in inverse
ratio to the price of the ticket,"
•MiKEiki OS
iJEii:
:>si:
:iISK.V.SES •'} n. -.:-.>: IKKIGRANTS
SUED STATE^ IMIM*.. •
.■\:Trn
} Hf»- TrrTTKi
T VT».*.
H/.rn,
.:•-,■
.
52 1.
-.-
;
1
5
•.:
11
-4
9
• 4
1
*
'*."
48
:,=
,
4
^
• t>
2S
->:
2
".4
li
2
■■*-»
■*)
13
7' J
2 (b)
^
3(;
<%5
1
5
.
X
10
12
:>
2^
»
1
4
4
I
1
'■i
3
mR;
437
8
o
i
29
»/
1329
N lil
ITALIAN IMMK'.RAXTS
OOSDITION or AvKRAC.B FEB
THK SU-K 1000.
/^
1
1
B
t\
^ i
O
•*!.*
2S0
72<)
28
15,05
0.40
-■-*
70
121
3
30.57
0.47
«l>
■2l\
12
1
15,44
0.43
■ i
1 1
24
15
32.00
4.14
^ti 45l> 883 47 ; 17.02 0.,58
"^N
TCBEBCULOSIS AMONG THE ITAUANB.— flTELLA.
435
CONDITION OF IHHIQRANTS SUFFERING FROM PULMONARY TUBERCU-
LOSIS DURING AND AFTER THE TRIP ACROSS THE OCEAN *
-
Condition.
Unimproved.
Improved.
Assravated.
DMd.
•3
1
^
1
BotO-BOUltD.
1
1
i
•3
1
I
•5
I
•s
1
a
•3
1
"5
1
'S
,
1
i
1
i
i
1
i
§
H
»
A,
»
^
y^
Pi
2
^
From North America . . .
441
22*2
50^4
150
34.01
54
12.24
15
3.40
A more approximate approach to the truth may be gained by studying
the figures of those emigrants assisted with free passage by the Italian
Benevolent Institute and the consurs office. A table, kindly compiled for
me by the secretary of the former institution^ shows that nearly 20 per cent,
of those who applied for assistance were suffering from pulmonary tuber-
culoos:
STATISTICAL TABLE OF PERSONS RETURNED TO ITALY BY THE ITAL-
IAN BENEVOLENT INSTITXTTE FROM JANUARY, 1906, UP TO
AND INCLUSIVE OF AUGUST, 1908.
Ybui.
1^
H
&&
1
63
25
18
n 9
>
1
1
1906
1907
1908
47
17
14
87
17
15
21
6
2
16
2
2
19
2
2
139
47
33
153
157
200
534
273
286
Total..
78
119
96
29
19
23
219
610
1093
To see at a glance or prove that tuberculosis instead of bang imported
into the United States by Italians, is contracted by them in this country or
from here carried back to Italy, it is instructive to read the figures of the
official report, giving the proportion of cases of tuberculosis found among
those west-bound and those east-bound. Among 309,503 Italian immigrants
who left Italy for the United States in 1903-04, there were only two cases of
* BoUetiao dell' Emigracione, No. 2, Jan., 1908.
:
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
tuberculoaia treated in the ship's hospital, a rate of 0.006 per cent, (due to the
strict vigilance of the United States Government at the ports of embarka-
tion and debarkation). Among 169,220 homeward bound from the United
States to Italy during the same two years, there were 457 in the ship's hospi-
tal, besides 17 who died at sea.
To ascertain for one's self the discrepancy between official statistics, and
the evidence of actual facts, to which I have called public attention since
1808, it suffices to cast a glance at the first column of the subjoined table,
which ^ves the number of deaths from tuljerculosis among individuals under
fifteen j'ears of age (children are not usually sent home to Italy, but remain
in America to die), and to note that at this age Italians figure for 50.7 in
every 100,000 cases, or, in other wonls, ahow the highest death-rate of any
race except the negro; whereas between fifteen and forty-four, when the
mortality from pLthisia is admittedly iiigber, they barely reach the tenth
place in order of frequency.
DEATHS FROM OONSUMPTTON FOR EVERY 100.000 INHABITANTS,
ACCORDING TO AGE, RACE. AND PLACE OF BIRTH OF
THE MOTHERS.*
RuTli AMD BotTBrLACE OW UOTHEBS^
Negtoea
Jlolhers born in U. S
Ireland
Gcrmanv ,
Etiglancl
Canada
Scandinavia , . . .
Scotland , .
Italy
France , . . .
Hungary „
Bohemia
HuBtiia
Poland...
Other Naliotmlltiea..
24G,0
27.5
42.2
26.G
27.2
34.5
32.4
32.0
5a7
47.1
3S.S
13.2
26.7
11.4
45.9
IS TO U.
4StoM.
587.4
518.0
162,5
131.8
482.0
340.9
205.9
207.5
151.4
173,1
190.7
163.8
233.7
267.3
20hl
201.S
149.0
iS7.0
2-20.0
195,5
113.4
125.1
235.2
124.0
131.1
178.8
67.4
103.9
1S9.1
263.6
65 AVP Om.
648.7
176,4
324.7
235.3
234.0
237.3
236.6
23S.5
144.1
162.5
187.3
101.0
249.4
243^
233,7
From this discrepancy between official statistica and existing facts it
natumUy follows thiit the deternu nation of the frequency of tuberculosis
among the Italians in North America is rendered impossible upon the baaia
of the official mortality records. Attention must be given inatead to the
tuberculous morbidityj and the number of cases of diiily infectT^P^including
both the pulmonary type and the various surgical mamfestatioos/Sfc ^^
to attain a relatively approximate insight Into the condition as It e^f^
With this object in mind, I have been collecting for the past ten 'Wirs
* United Static Q^na^ia, vol. Vital SlatUUca, xjtviil.
TUBERCULOSIS AMONG THE ITALIANS.— STELLA.
437
of my professional Life in New York, the scattered material which, after
careful sifting, I presented at the Tuberculosis Congress held iu Milan in
1906, and which, with newer data, I have the honor to submit to your atten-
tion at the present time. The first series of notes, relating chiefly to surgical
tuberculosis, has been obtained from the records of various hospitals and
cUspensaries frequented mostly by Italians; from the public school health
records; from the consular registers of the militfiry recruits examined in thia
country ; from the partial list of needy emigrants who have returned to Italy
tlirough the Benevolent Italian Institute or the Society for Italian Immi-
grants; finally, from cert^iin important records of the TenemenVHouse
Commission and of the Board of Health.
The second series, altogether SOO cases, includes patients who came under
my personal observationj either in private practice or at the Itnlian Hospi-
tal, and a few seen in consultation -with other physicians. These cases are
representative of all sorts of emigrants, as well as of all Italian provinces^
and illustrate the t}^ical aspects of tuberculosis as it manifests itself among
Italians in America.
FmsT Sei^ies,
(A) Eeginmng with the first series, we may say that the relative frequency
of surgical tuberculosis is difficult to determine with any degree of accuracy,
because the disease is often recovered from, thanks to the advance of modern
Kurgery, or js rarely registered as the cause of death in the mortality statis-
tics when the outcome is fatal* However, it is extremely prevalent among
Italians in America, more particularly among the children of immigrantSj
as shown by tlie Pediatric Clinics and the records of certain dispensaries
frequented by Italians. A review of these records, as carried out under
my direction, in 1904-06, with special reference to Italian conditions, serves
to show that among every 12 Italian children brought for treatment, at
least 1 presented evident signs of tuberculosis in one form or another,*
The proportion is superior to the figures given by Leonte, and the more
generally known statistics of Straus and Nothnagel, the only race which
sur[3asse3 that percentage being the negro. The most frequent tubercular
lesions encountered among Italians are those of the glands, bones, and
joints, affecting adidta as well as children. Next in order follow affectiona
of the peritoneum, observed with striking frequency among womeu, prefer-
ably from the sixteenth to the thirty-fifth year, and characterized by an
extremely irregular cUnical picture, with all sorts of complications. Lesions
of the gem to-urinary organs come next; and, last of all, those of the meninges,
which are alwaj's most conunon in infancy and cliildhood.
(B) Tuberculosis of the glands and the general habitus scrofuloaus are
♦Records for 1904 of St, Mary's Hospital, Hospital for the Ruptured aod Crippled,
Columbua Ho^pilalr Post-graduate Hospital, Cornell Dispensary.
TCTBBBCULOBXS AMONG THE rTAUANB. BTBLLA.
439
passages were supplied by the Benevolent Institute of New York, in the five
years from 1901 to 1905, to 973 emigrants. Fully two-thinls of these were
men, and tuberculosis was stated as the reason in 391 of the caises. Tlie
records of the same institution for 1906, 1907, and up to September I^ 1908,
ehow that pulmonaiy tuberculosis existed in 197 out of 1093 returning Ital-
ians,— that \8, nearly 20 percent., — ^including cases of ^'chronic bronchitis/*
often a euphemism for consumption. (See table of the Italian Benevolent
Institution.)
(E) The data contained in the i-eporte of the Tenement^House Commjssion
(Health Department) show with even greater clearness the frequency of
tuberculosis in certain Italian quarters. In the famous "Lung Block/*
which is the poorest part of lower New York, — at first occupied by the Insh,
and now almost exclusively by Italians, — among 4000 inhabitants counted
by the Board of Health, in 1895, there were 404 deaths from tuberculosis in
four years and nine months; whereas in the upper part of Fifth Avenue,
where the wealthiest Americana reside, the number of deaths for the same
period and from the same disease was scarcely 12 for every 10,000. In an-
other section of New York, characterized by the most abject squalor and
poverty j^between Mott and Pell Streets, — inhabited by Chinese and in part
by Italians, there occurred 31S cases of pulmonary tu1>erculosis in four and
ono-half years, among 2102 inhabitants (Dr. H. Biggs, Health Report)*
Second Series.
The 800 cases of pulmonary tuberculosis (319 men, 481 women) which
form the basis of this second series of my study have been selected fmm
among a largo number on account of the completeness of their history, ren-
dering them especially well adapted to certain etiological conMderations of
immense prophylactic impoi-tance.
With thia object in mind I have considered them separately: (1) In re-
gard to the most frequent mode of onset of the disease and the subjective
eymptoms; (2) in regard to the average interval of time between the landing
of the immigrant and the appearance of the first objective sympt^^ms; (3)
in regard to age; (4) in regard to sex; (5) in regard to occupation; (6) in
regard to certain regional elements,
1. The Mode of Onset of Tttberadosis among Italian Immigrant. — This
special line of investigation was suggested to me by the frequent occurrence
of cases coming for examination with subjective sj''mptoms entirely indepen-
dent of the respiratory tract, while well developed lesions of one or both
apices were present. Selecting among the SCO cases under consideration
300 patients (150 men and 150 women), in whom this constituted a promi-
nent feature, I was at once impressed with a highly significant fact, namely,
that in over one-balf of the cases (166, including 73 men and 03 women) one
440
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
of the first symptoms complained of, and for which professional advice was
sought, consisted in: (1) General weakness and loss of weight. (2) Anorexia
and* dyspepsia, often obstinate in character. (3) Simple pains in the chest,
often associated, in the case of women, with anemia and amenorrhea, which
for months had resisted all treatment. Cough and hemorrhage were en-
tirely absent. The average duration of the disturbances described by the
patients, up to the characteristic manifestfltiona of the disease [expectora-
tion, night-sweats), varied from six to nine months.
In the remaining 136 cases of this group, on the other hand, the loss of
weight had l>een preceded by coughj and there had been cough with hemor-
rhage in 22; cough without any expectoration in 30 per cent, of the cases;
coygh with profuse exi)ectoration, referred by the patient to cold, or pro-
gressive bronchitis, in the remainder. There was a history of pleurisy in
22 instances and of acute alcoholism {first appearance of hemoptysis in
connection with drunkenness) in 3 instances,
2. The Interval between Landing and the Appearance of the Disease. —
Women figure (or the greater number in the period of three to six years;
the shorter period (from one to three years) applying chiefly to young girls
employed in tobacco factories, to seamstresses at home, and young dress-
makers or tailors. Two or three years of this existence in the workshops
or tenement-houses of New York are enough to render this human material
a fertile soil for the grow^th of the tubercle bacillus.
Avvbjlok Tuch ntou Ab-
UTU. TO BlMTlVllA.
From 1 to 3
I!^DM 3 TO «
Fhqh e to to
Total.
Women
95
340
87
146
155
481 i
Men
319 ^
It is not a theory, but a demonstrated fact, that very youthful immigrants
are more severely affected by the pathogenetic influences of urban centers
than is true in the case of adults. To be more definite, I will say that boys
and girls who emigrate to Nort^h America before the twenty^fifth and twenty-
first year, respectively (namely, the period of theii- normal growth), coming
from the rural dLstricta of Italy to become city dwellers, seeking and finding
work in factories and sweatsliopg, are inexorably destined to illness, and a
full third among them to death, from tuberculosis.
DIVISION OF THE 800 CASES OF TUBERCULOSIS ACCORDING
TO THE AGE.
Aoi.
0 TO 15 Yaaab.
le TO 25 YtAM,
24 TO 45 Yeau.
4fl AKS OVEft.
Miilni
26
4S
162
230
loa
161
33
Wmt^W'
48
TPBKRCULOBIB AMONG THE ITALIAKS. — STELLA*
441
Bold as this assertion may appear^ my wide experience and my numerous
observations give me the right to sustain it without fear of contradiction.
Briefly stated^ the proofs are aa follows: From the study of the 800 cases
under consideration, it results that about one-half (392 cases — -162 men,
230 women) had come to America when between fourteen and twenty-five
years of age, being perfectly healthy at the time of their arrival, (That
they were healthy is ahown^ aside from the fact that only the pick of the
youthful laboring population ennigrate, by the strict examination to which
the immigrants are subjected by the Ferleral authorities^ at the time of em-
barking, and even more when landing.) But tlie changed and execrable
surroundings, the unwholesome and crowded dwellings^ the long hours s^jent
in the factories, and the thousand privations imposed by poverty and the
insane desire to save money-^all of this, coupled with the overwork which
is kept up until utter exhaustion, without the resistance of food proportion-
ate to the demands of the ejcaggerated tissue waste and rapid growth of tliis
period of life, shows only too clearly why so many youthful lives in America
fall an easy prey to tuberculostjs. The invasion of the Koch baciSlus is
merely a coincidence in their already weakened state of health; the coinci-
dence consisting in the fact that the period of the greatest prevalence and
diflfusion of tuberculosis {fifteen to forty-five years) exactly corresponds
with the age of the majority of Italian immigrants, as already pointctl out-
At this time of life, according to the incontestable statistics of Nageli, ones
half of the urban population is infected with tuberculoms, and more than
one-third of the deaths are due to phthisis. This particular point is borne
out with two-fold force among the youthful Italian emigrants in North
America,
4. In Regard to Se:i, — Among the 800 cases, as already stated, 481 were
women and 319 were men. This preponderance of females, in regard to
tuberculosis, has !>een previously pointed out in the ofiicial statistics quoted
above. The cause of the e^rtreme susceptibility to thedisease shown by Italian
women must be sought in the sudden transference of these unfortunatea
from the open air and the freedom of the fields to the restraint and aemi-
asphyxiation of tenemenl^house and factory, whereas the men chiefly seek
and find their work out of doors.
Urbanization exercises all its baneful influence and works ita greatest
injury among the girla at the critical period of puberty, and this more es-
pecially among those who arrive in New York, fresh from the country^
between the ages of ten and twenty. The hardahips and privations ex-
perienced in their first struggle in the new city, coupled with the vile tene-
ments and overcpowdetl rooms wliich they are compelled to occupy^ explain
their high mortality. Many such girls die from acute miliary tuberculosis
within a year or two of their landing in New York,
442
SIXTH INTERNATIOKAL C0N0HES3 ON TUBERCULOSia.
Tuberculosis of the adnejca and peritoneum is also seen with great fre-
quency among them, and carries off many of the young Italian women.
Thia fact can be attested by surgeons of wide experience in our general
hospitals.
5- In Regard to Occupaticn. — Among the SOO cases under consideration,
85 of the 319 men worked in the open air, and the remaining 234 in confined
quarters. The women, practically without exception, were employed either
in factories or sweatshops.
The following list show^j the distribution of the various occupations;
MEN WORKING OirroOORS.
Fruit vcndem 9
Bricklayers 8
Stoaecuttors, 3
Kowspaper dcalera. , J8
Dru'ora 4
I^oiigHhoreinen 2
Bootblacks 8
Stre^l-aweepers 10
Retailers (ice, coal) ■ 13
Mti^kians ....,., . , 5
Total
M
MEN WORKING IN CONFINED QUARTERS (234).
Tnilai><. 43
l^ltUIMlllC'Ii 10
&urb«n 29
Work^ni in tobiiccQ 21
Workfim in braaa 9
VVorkom in Rlaaa 6
\Vt>rkL*rii in akins ...,.,...,. 11
Wiirknra Id rubber 8
Uakun 10
PJflitt^rera 10
StatuDtte makera - . . 9
Various shopkeepers , . 18
UplioLstercra , ft
Cahitiet makew ............ 18
Shoemakers ....»., 10
Painters , 5
Mo8atc workers .......... ^ , 5
Mjuers....... ...,,,. 8
OCCUPATIONS OF
■•MMtriiMt 68
lifcohtw optmiora 44
BMIoBhotenwktn.... 31
nuiU«eww« 46
VV*.iiki»i>t iit loUwn* * . 52
VVockvM ill wtitirial fluwers, 24
Wudbvo ui f tHuiilnlii .,..., 38
^uri^vi« iu IihhI pn'Mcrvea . . II
Rac^Atfton... 17
WOMEN (481).
Shopkeepera,, 17
Sehool-teiLchei^ , 4
Mosaic workers ..,...-. . 8
Janilrenses , ,,,...,... 22
Waaherwomcn ,,,,,. , 9
Housewives without specif
dettignation 45
Fruit-aellera 13
Countiywomen * 7
la iw jjwwnjJ yf*y» the various occupations may be divided into two
fCkll;>V9d iu the open air^ and those pursued in confined qiiar-
^wn, It is seen at once that the susceptibility to tubercti-
li>««r in tin* first than in the second group. It ia found that
«ttL oiuMMI^'KW workers^ sailors, longshoremen, peddlers, and
lykV««.lMi VIprUdity nnd morbidity percentage, as compared to
printers, mosaic workers, and all those engaged
and mechanical industries. The Italian
TUBERCULOSIS AMONQ THE TTAUANS. — STELLA. 443
women, whose occupations are almost exclusively limited to the second
group,* for that very reason present a high rate of tuberculous morbidity.
Accurate statistics of Italians engaged in the various callings in the
different cities of the Union do not exist; but an approximate idea of the
distribution among the most common occupations may be derived from the
account published in the Annual Report of Immigration for 1905. According
PROFESSIONS, TRADES, A>ID INDUSTRIES OF THE ITALIANS
ADMITTED IN 1905.
Occupation. Ix^u^t. Italt.
Architects 10 10
Clergy fi2 69
Editors 9 6
Electricians 24 20
Engineers, professional 20 24
Lawyers 12 26
Literary and scientific persons 19 16
Musicians 38 240
Physicians 34 72
Sculptors and artists — 116 62
Teachers 31 45
Bakera 201 671
Barbers 82 1,718
Blacksmiths 168 909
Butchers 66 278
Carpenters and cabinet makers 367 1,867
Dressmakers 161 616
Gardeners 30 165
Masons 1^74 3,161
Miners 1 ,843 492
Shoemakers 287 4,004
Stonecutters 409 667
TaUors 239 2,691
Farm laborers 6,181 60,629
Farmers 1,397 4,814
Manufacturers 14 32
Merchants and dealers 557 1,416
Servants 2,752 8,669
Laborers 14,291 56,040
No occupation, including children under 14 7,632 32,116
to the report of 1905, the bricklayers (4226), with the plasterers (1978), rep-
resent the highest number, with a total of 6204; next follow the barbers,
4145 in number; tailors, 3464; carpenters, 2979; and, in decreasing numbers,
shoemakers, painters, and so forth.
Certain occupations are known to be especially injurious, more par-
ticularly those giving rise to a considerable amount of dust, and have, for
this reason, been designated as "phthisiogenic" (tobacco, glass, metal, skins,
coal; the work of carpenters, plasterers, bakers, tailors, upholsterers, boot-
blacks, street-sweepers, rag-pickers, etc.)- Large numbers of Italians are
found in the great American centers engaged in these occupations, some of
♦ According to the official report of the Inspector of the New York State Bureau of
Labor, 95 per cent, of the garment workers in New York are Italian women.
444
SIXTH INTERNATIONAL CONGaESS ON TUBERCULOSIS,
whicb they practically monopolize, as rag-pickers, Bcavcngers^ ice and coal
peddlerSj bootblacks^ etc. It is chiefly the peasant popululion from Baaili-^
cata and Calabria who crowd into the cities, and, finding it impossible to
reach the interior on account of lack of means and ignorance of the language,
take up such occupations as have long ago been abandoned by other imnii*
grants (Irish^ oegioea).
The phthi^dogenic action of certain trades was clearly demonstrated in
the case of the strGet-sweepera of New York city. An investigation carried
out by Commisisioner Woodbury in 1904 showed one-third of the 5000 raen
in hia department to be affected with tuberculosis. The greatest number
of cases was found among Italians, who \verc strong and well at the time of
enlistment, but after three or four years of service had contracted phthisis
by the inhalation of the germ-laden dust swept from the streets.*
Opposite conditions prevail in the case of ItaUan bricklayers and stone-
cutters, who show a relatively low percentage of tuberculous morbidity in
comparison with their American fellow-workers, and the Bohemians, Hun-
garians, Iriah, etc*, among whom it is notoriously high. As far as the Ital-
ians are concerned, the reason seems to mc to Ijg referable to the high wages,
(S4 to $5 per day), the short hours (eight), and the work in the open air.
In comparison with othei-s, the habit of drinking is not marked among them.
Ttie type of tulTerculosis affecting them h of gradual evolution, with a rasp-
ing cough, similar to that of pottery workers^ and more akin to pulmon&ry
sclerosis and pneumocunioMis than to true tuberculosis.
But aside from the kind of occupation, It is the intensity of the work
itself and the overstrain, characteristic of every phase of life in the United
States, wliich most efficiently undermine.-? and prepares the soil for the in-
vasion of the lut>erclc bacilluis. This immoderate and relentless work, more
suggestive of a wasting fever than a normal function of life, kept up for
months without an interval of rest, promptly induces a state of fatigue and
exhaustion in the whole body, preparing the way for tuberculosis and de-
generation.
6. In feganl to certain regional dements, we find a very high percent-
age of tubercutotsis among the Sicilians, and those from the southern part of
Italy in general, as compared with immigrants from central and northern
Italy. This must be inteipreted simply as a parallel to the larger contingent of
immigration from the south of Italy in the last ten years, rather than as an
indication of special susceptibility to tuberculosis in these provinces.
However, the fact remains undisputed, nay^ confirmed, by daily observa-
tions that the peasant women from Calabria and Basilicata, together with
thoae strictly primitive ones from the provinces of Girgenti aJid Caltaniaetta,
give in New York a very high percentage of tuljerculous diseases, compared
^^^^^^^^ * The Gkbo, April, 1Q04.
I
TUBERCULOSIS AMONG THE ITAUANS. — BTELLA.
445
with any other rcgiona of Italy, while the geograpliical distrtbution of tuber-
culous in Italy showa, oa the contmiy, the very opposite condition. In
fact, the death-rate from this disease is lowest in Sicily and the aouthem
proviaces in genera!, especially along the eastern coast (14 to 16 per 10,000
in the province of Messina), and highest in the northern part, as in Leghorn,
Milan, Genoa, and Venice (30 to 32 per 10,000) (Prof. G. Sormani),
The Economic Factor.
Undoubtedly, certain additional factors must be held responsible for the
rapid breakdown of Italians of both sexes engaged in various occupations
in America. The ecos^omic factor, and their alimentation, are of especial
importance in this connection, and tf properly understood, help to throw
a light U])on the situation.
The Italians now resident in the cities of America must be classed as
pooTt and as such respond, of necessity, to the law or equation established by
Bcrtillon and Gebhardt, \iz,, that the mortality and morbidity in connec-
tion with tulicrculosis of a given social class is in inverse ratio to its average
inconte. The poverty among Italians in the United States is of the kind
economists are accustomed t« call "secondary*' — that which throws a
working class into want as soon as a suspension of work or a crisis of any
description arises. The vaunted remittances of money to their relatives in
Italy, instead of being proofs of an abundance of wealth, almost invariably
represent the most humiliating deprivation of the bare necessities of life,
the money they send toeing the result of sorrow and drudgery, and every
dollar remitted representing a lack of food and lodging sustained by them^
with a proportionate decline of the syBtem, cachexia of the race, and the
deterioration of an entire people.
The amount of earnings on which the greater part of It^^lian families live
in the cities is so ainall, and the ccNst of rentes (it alisorbs more than 30 per
cent* of their income) and the expense of living are so high, that they are
compelled to work every hour of the day in order to obtain the means in-
dispensable for a livelihood, John Mitchell, in his book ^'Organized Labor''
(page US), considers that not less than SCKX) a year is nec^aary in the coal
regions for an orflinary family of five or six. The Si5ecial Committee on
Stamiard of Living, appointed at the eighth New York State Conference of
Charities, in November, 1907, and which investigate<l many Italian familiee
(56), expressed the opinion that *'an income between $600 and S700 j^er
annum/' as generally founds '*is insufficient for a family of five to maintain
a proper standard of living in the Borough of Manhattan, Leaving aside
the exceptions, it is apparent that on an income of $600 to S7(X) many fami-
lies in Manhattan have a fierce struggle for existence/' The conituJtt.ee
further stated that "within an income of between $700 and $800 a family
446
BIXTH tNTERNATlONAI* COXGBE8B ON TUBERCULOSIS.
can barely BUpjiort iteelf, provided that it is subject to no extraordinary ex-
ixjnditiiro by reason of ackneas, death, or other untoward circumstances."
A stoppage of work, an economic depression, as we have witnessed this
yoar^ a wckness or death, suffices to throw the family into want.
The fif^uro of $10 per week, which in a large number of cases is the average
earnings of Italian laborers, is therefore absolutely inadequate to the wants
of life in tho larger cities, the more &o when one considers that work is not
reiKuhir and irj winter-time the interruptions are of from three to four months.
TliE) interde(Xiialence of the economic and physical evolution and of
povorty as the cause of tuberculosis lias been fully studied in late years;
to rcjirochice here the deductions would be an unnecessary compilation.
HoueiNU Conditions.
Every otie is familiar with the unhygienic and overcrowded condition
of the d\a'ellings of Italiana in tho large cities of the United States. It is
a well-known fact that they reside in the poorest quarters and in the slums,
so callod, not liecause they like to be there, but because their poverty com-
Ifcin thein t-o live there. They have notliing, in fact, in common with the
slum i>opulation proper, nor do they bring or contribute any of the degrad-
ing characteristics of the professional vagrant or tramp which w^ meet
among the ''people of the abyss/' They live there because, many tim^,
their work is there.
Without heie repeating the results of the more general inquiries made
ill that connection by the Tenement-House Department of New York, the
South End House of Boston, the "Oct^via Hill Association*' of Philadelphia,
Hull House mid the City Homes Association of Chicago, and others which
every one may consult, I will simply quote a few recent data gathered by
myself and by the Committee on Congestion of Population, with the support
of the It^an Government, which I have the honor to represent here.
Them will ^ve you an approximate idea of the almost incredible conditions
in wliii'h the greater part of Italians live in New York-
The tyiiical Italian blocks were investigated by this comnuttee^ beades
174 fiunilies scatt^rwl throughout the lower part of Manhattan, and some
300 houaes m various piirl^ of Brookl^Ti.
Of the familtes examined, 18 per cent, occupied one room, »nd 34.4 per
oenk only two rooms, showing a condition much worse than the aven^ on
tho Edi9t Sde. In the ''Barracks.^' as that portion of Elixabeth Sti^ei be-
tw<BQci Houston and Friace is known to the police, l^s than three out of every
huocbsd fimiHea had five TOomSt and }iet, as if one and tvi> roomfi for a
bonily wan OTendHiudaat, about one-third of the families hftd one lodger,
41 per oeiit two lodgos, 16.5 per oeaU three lodseis, and 3.1 per ooat fcMB'
iod^Bn. Thus, counting two d^drefi uxider twdye 10 equi%'»leot to ooe
TUBERCULOSIS AMOWG THE ITAIilANS,^ — STELLA.
luiult, one^sixth of the rooms in this block were found to be housiog as
many as four adults each.
In the same block the great majority of the families were paying over 25
per cent, of their income in rent, and some families over 50 per cent.; in
most cases the number of cubic feet of air for the occupants of sleeping-rooma
was less than is provided in hospitals and prisons.
Out of the 174 families investigated in scattered portions of Manhattanj
only seventy-one were not overcrowded. The rest had from two adults and
one child per room up to five adults regularly occupying the rooms. Of
tliis number, there were 32 one-room apartment^f 60 two-room apartments,
61 three-room apartments, 26 four-room apartments, and 5 five-room
apartments. One hundred and thirty-iive had lodgers, some of them a3
many as five and six* The moral condition can better be imoLgined
than described.
The results of my own investigation in some other parts of the city were
just as starthng. On Third Avenue, near Twenty-sixth Street^ a family of
eleven — four adults and seven children — and three clerks were living in a
dark middle room and a large, bare rear room, an average of seven people to
the room. In the section of the Bromt bounded by East 14Sth Street and
East 153d Street, Morris, Cortlandt and Park Avenues, I found some of the
very worst conditions. In a rag-shop on Morris Avenue, there were no less
than 18 people, men and women, working, eating, and sometimes sleeping
there. How can health be presen*ed under such conditions?
The Ultimate relation that exists between the quantity and quality of air
respirable for each individual, and the amount of diseases and the number
of deaths resulting therefrom, is too evident and has been too exliaustively
studied by hygienists to need repetition,
Paul JuiUerat, Chief of the Paris Sanitary Office, proved at the Inter-
national Congress, held in 1905, that the prevalence of tuberculosis varies
almost arithmetically with housing conditions, and Lagneaii h^is shown,
from statistics collected from 062 cities in France, that the denser the popu-
lation the greater is the number of deaths from tubereubsis. " Thus, while
the death-rate per 1000 of the population from this cause, in cities of 5000
Inhabitants, was 1.81 ^ in cities of 10,000 inhabitants it waa 2.16, in cities of
20,000 inhabitants it was 2,71, in cities of 30,000 inhabitants it was 2.8Sj in
cities of 100,000 it was 3.05, in cities of 450,000, it was 3.63, and in Paris,
with upwards of 3,000,000 inhabitants, the death-rate per 1000 of the popu-
lation rose to 4.90." From the Report of the Health of Towns Commission
for Great Britain it appeal's that the ratio of phthiais and other similar
diseases in Dundee, Scotland, increases with the overcrowding in dwellings.
"Taking the ratio of dwellings of 4 rooms and upwards as 10, it was found
that the other ratios were: For three rooms, 17; for two rooms, 20; and
SIXTH INTEltNATIONAL CON
ON TUBERCULOSIS.
lor OfM room, 23/' The saaie thing has been observed in London. Accord-
ing to the Annual Report of the Officer of Health in London, 1S9S, in diB-
txicte with under 10 per cent, of ovcrcmwding (overcrowding being taken
to mean where more than two poraons occupied & room in tenements of lesB
than five rooms) the death-rate per 1000 living from tuberculosis is 1*10;
in distncta with under 15 per cent, overcrowding, it is L43; in districts with
under 20 per cent, overcrowdings it is L61; in districts with under 25 per
cent, overcrowding, it is L80; in districts with under 30 per cent, overcrowd-
ing, it is 1^,07; in districts with under 35 per cent* overcrowding, it is 2.42;
and in dLstricta with over 33 per cent, overcrowding the death-rate per lOOQ
living from consumption is 3.63, The tables arranged by Dr. Herman
BifEffS, of the New York Health Department, are very itluminating on lliis
point, and must be reported in full here.*
inrnUSIfi— DEATH-RATES PER 1000 LIVING. ld&4-1898, INCLUSIVE.
|*fci*n«Tli)N orTtrpw. Popiji.atioh Livinq Mob£ tiia,?i
'I'wi) IN jk Uo<iu ttH TidNKMKrrra of Lew tsam
<Mlil«lto» per cetit
^^lOtoJfl
" lA to 30 "
•' aotoaa "
" aA lo :v) "
" :u) to art "
" ovcrafl "
0KAtit-nATEa rui 1000 Linnd.
l»&i. 1S95. IfiBO. IBd7. IH&a.
1,07
L3S
1.57
1,58
t.8l
2.11
2.46
1.18
L49
K64
1.83
2,09
2.42
2.66
L07
1.46
1.61
1.67
2.06
2,13
2,55
1.14
1 42
1.75
2 10
2.32
2.64
1 10
1.43
1 61
1.80
2 07
2.42
2.03
VKU Ittbio nhowH an obvious relation between the amount of overcrowd-
tlM Vkiul tht« [ihihimK death-rate.
rurni^lrt — DRATIi-RATES PER 1000 LIVING, 1898.
IV'I.A-rtUW
ir I.KU
I'll AN
0
s
30
25
35
45
56 Atm
Up.
VMkkM ^\\^ ^^^t^l^'^' tU t^'i* ■'<'l^^* ' ■
0.23
0.39
1,19
1.50
1.&4
2.05
1,77
^*^ u' tU»lft
"' . . •
0.39
0.34
1.44
2.13
3.09
2,68
1.91
% ^ ft Ui «1
O.02
0.36
1,05
2.01
3.41
3 43
2.36
% «
m lu )A
"
D.fi7
0.37
1,59
2,39
3. (56
4.01
2.78
J !
M Hi mi
0 78
0.33
1.57
2 58
4.16
4.58
3.04
WHi:>A
D.81
0.49
2.00
3,00
5.53
6.26
3.26
|.
^miA
"
0,85
0.50
1.82
3.25
6.04
6.12
4 41
Alimentation-
l^iKvkl liii^mi of preparing the organic soil among ItaEaitf]
•^mIivuh iin found in their insufficient and deficient &li-
«*^. ^,^^h4MJt K.4 Teucmcmt Houses to Tuberculosis," vqU u
TUBEBCULOSIS AMONG THE ITALIANS. — STELLA. 449
mentation. Already the important agrarian investigation (Romei 1895)
made evident the low proportion of nitrogen in the diet of the Italian peas-
ant and the notable difference in the character of the food between the in-
habitants of the north and those of the south. This deficit of nitrogen is
met with in a more marked degree among our immigrants in America, where
ezoeasiye labor involves a greater consumption of energy. For a while,
indeed, they endeavor to accomplish the most intense and tiying tasks upon
the same vegetable diet to which they were accustomed in Italy, and when the
signs of emaciation, anemia, and exhaustion appear (which usually manifest
themselves in the first six months), they seem to fall away in the vortex-like
movement of American industrial life, upsetting more and more that equi-
librium between demand and supply which regulates the body metabolism.
If, from that standpoint, the Italian investigation found the alimentation
of its peasantry deficient where the loss of energy is less, and the natural
compensations of salubrity of air, sunshine, and light more than offset the
lack of food, most deficient indeed would their alimentation be considered
in America, where the increased demands, added to the unhealthy homes,
exist side by side with the same scarcity of nutrition. If we accept the
theoiy of Moleschott, and the results obtained from the experiments of
Bunge, Atwater, Chittenden, Celli, Albertoni, and others who agree in
fixing the minimum of daily consumption for a working-man at 130 grams
of albumin, 404 grams of carbohydrates, and 85 grams of fats (the food
ration of the Italian soldier), we find at once that the ordinaiy alimentary
ratio of Italian immigrants in America is very much below the average.
Unfortunately, there has been no scientific investigation in that direction
which, by precise data and chemical analysis, would go to prove my asser-
tion. Nevertheless, if we accept the estimates of Dr. Frank P. Underbill,
of Yale, adopted by the Special Committee on Standard of Living mentioned
above, and examine the findings of said committee in what pertains to the
Italians, we are forced to admit that their alimentation is both insufficient
and deficient. The table on the quantity and cost of food sold to Italian
laborers at commissary stores and camps, published in Bulletin 72 of the
Bureau of Labor, more than confirms this view.* According to this official
report, the average cost for food per man for one month was 15.21, and
the table (page 477) is self-explanatory of the deficient quality of food
employed.
The almost universal practice of abstention from breakfast, which ex-
* On page 478 is quoted the case of a subforeman on the P. R. R., who lived on
$4.48 a month, spending for
36 loaves of bread at 8 cents $2.88
7i lbs. of fat-back (lardo) 90
10 lbs. of macaroni .70
Total cost of food for month $4.48
VOL. in — 15
450
SIXTH INTERKATIONAL C0XGRES9 ON TITBERCULOSIS.
perience haa taught the Americans to be indispensable, coupled with the
absence of sufficient food at the time when the greatest demand calls for the
greater supply (mid-day), induce in these people a kind of alow starvation,
with an arrest of the material and dynamic exchange, together with altera-
tions of the interna] titructure of the tissues, which, in its effects^ may be
compared to the results of prolonged inanition. Thus the custom of the
Latin race to make little of the morning meal, which is probably justified in
the warm climates and the land of dolce jar nienie, assumes in America an
importance paradoxically great when one considers the disastrous influence
that its absence exerts in the organic economy of those immigrants called
upon to undertake the most intense labor on an empty stomach in the long
houits pi-eceding noon. These are the hours of autophagia and the combujs- .
tion of their very selves, the hour in which the organized albumin of the
tissues is broken up and destroyed, the hours in which the last vestige of
reserve energy ia consumed, and a wide avenge opened to the invasion of
anemia, tuberculosis, and premature death.
What shall be the remedies?
The exposition just made of the most common causes of tuberculoaia
among Italians points out clearly the way along which the scourge may be
cheeked and effective methods of prevention established-
Two sets of recommendations force themselves upon us from the above
facts — one to be eutrustetl to the Italian Government, the other to the Fed-
era! authority.
First of all, the necessity for the collection of more adequate statistics,
based not on the death-rate, but the morbidity rate; this should be done
either by a special Committee on Health and Sanitation^ to be attached to
the Italian Consular Service, or to some other organization — like the Tuber-
culosis Clinic at the Italian Hospital in New York, to be further evolved.
For the rest, I offer the following resolutions:
I. Whereas, the number of Italians returning from the United Statesto
Italy and suffering from tuberculosis is increasing eveiy year, iind the spread
of the disease on board the ships and in the towns of destination is becoming
of more frequent occurrence in proportion thereof,
Whekeas, many such immigrants return as second- and first-class pasaen^
gers^ and thus escape all measures of isolation and disinfection which the
pitisent law provides only for the steerage:
Resolvedj First, that a HeaUh CeriificaUy properly authenticated, be
require(i of all Italian emigrants bound for Italian ports, and a medical
examination be made of suspected cases immediately before or after embark-
ation, not for the purpose of rejection, but with a view of separating on board
the infectious from the non-infectious cases^ and in order to furnish a more
complete liist of the cases to the sanitary authorities at the porta of landing,
TUBERCULOSIS AMONG THE ITAUANS. — STELLA.
451
who should further transmit the same to the local health boards in the towns
of final destination.
Second, that the same sanitary measures which are now compulsory for
the third class be extended and applied to second and first cabin passengers.
IL Whereas, in congested urban conditions are to be found ail the etio-
logical factors of the prevalence of tuberculosis among Italians in the Unite<l
States^ and the lack of adequate information on the part of the immigrants
is the chief reason for their concentration and gravitation in the most popu-
lated centers*
i2c80?redj that the Contract Labor clause of the present immigration law
be eo amended that the spread of proper information about the resources
of this country out and beyond the large cities, in the home country of pro-
spective immigrants previous to their coniing, be allowed and encouraged
without appearing to unduly stimulate immigration.
III. Whereas, Tuberculosis is known to be very prevalent among garment
workers, and operatives in tobacco factories, makers of artificial flovTere, etc.,
where Italian women and men are employed to a considerable extent; and
Whereas, it is known that many such operatives suffering from tuber-
culosis will continue to work and spread the infection in such shops and
factories, when they are already in an advanced stage of the disease;
Resolved^ that this Congress recommend that special power be given
jeither the Board of Health or the Department of Labor (or what is cane<l
State Police) to conduct systematic medical examination of the operatives
in such factories and shops, before admission to work, and afterwards at
stated periods during the year, in order to detect incipient eases of tuber-
culosis and prevent the spread of the infection.
VerbtltuBg der Tuberkulose unter den Italienem In den Vereinigten
Staaten* — (Stella . )
Tuberkulose ist ausserordentlich vorwiegend unter den Italienem in den
Vereinigten Staaten, mehr als das allgemein angeuomraene Gegenteil; tat^
sachlich aber viel mehr als es unter derselben Klaese des Voikes in Italien
selbst ist.
Daa jahriiche Zuriackkehren hunderter erwachsener Italiener, die an
Schwindsuclit leiden, nach ihrem Hcimatlandc, veiringert die Tod&srate in
diesem Lande und erklart den Widei'spruch zwischen den offiziellen Daten
und den Tatsachen, die diesen besonderen Punkt betreffen.
Mit Riictisicht auf die strenge Wachsamkeit der Einwanderungsautoritaten
der Vereinigten Staaten in den Einschiffung^ und in den Ausachiffungshafen
Und wegen der natiirhchen Auswahl, welche nur die korperlich Tuchtigen in
Stand setzt, ihr Gliick jenseits des O/^ans zu suchen, kann als sicher ange-
T^ommen werden, dasa alle hier landenden Italiener gesvmd und frei von
Tuberkulose oderirgend einer anderen Krankheit sind; andererseits sind jene,
*=iie von diesem nach dem Mutterlande zuriackkehren, nach einem Aufenthalte
462
BIXTH INTEKXATIONAL CONGRESS ON TUBEJ^CUIiOSIS.
von wenigen Jahren in den Vereinigten Staaten in einein hohen Grade der
Krankheit nahe gebracht worden oder leiden an dereelben.
Tuberkulose wird daher nicht wie una manche glaulien machen wollen,
durch die Italiener eingeschleppt, sondem wird in diesem Lande erworben,
und von den Vereinigten Staaten nach Italien in die Geburtsstatte getragen,
in welchen die Krankheit, die friiber unbekannt war, slch jetJt in einem
alarmierenden Grade verbreitet.
Von diesem besonderen Gesichtspunkte aua betrachtet ist das Problem
vonviel tiefercm Interesse fiir Italien als fiirdie Vereinigten Staaten und meine
Schlussfolgerungen und Besprechungen iiber die bestehenden Verhaltnisse
bei dem nationalen Tuberkulose^Kongress in Mailand 1906 erweckte die
italienische Re^erung zum Bewusstsein der Notwendigkeit besserer Quaran-
tane-Masaregeln an Bord sowohl als bei der Landung.
Die Ursachen des grossen Uborwiegens der Tuberkulose unter einem
uisprunglich der Krankheifc nahezu immun gegeniiberstehenden Volke tdnd:
1. Der plotzliche Ubergang vom landlichen i^um Stadtlcben; wahrend
neun Zehntel der italienischen Einwandeper von den Ackerbaudistrikten nuH
Italien l<ommen^ lassen sich hier 77% von ihnen in grossen Stadten nieder.
2. Leben in den Zinskasernen. Unsanitar oder uberfiillt oder beidea.
Venirsacht angegriffene Ge^^undheit und schafft einen fruchtbaren Grand
fiir daa Wachstum des Tuberkelbazillus.
3. Gefahrliche Arbeit und Staub verursachende Beschaftiguugen, Bei-
nahe immer von armen, unwiasenden Einwanderem alJer Rassen^ haupt-
s&clilich Italienern^ Poien und Ungarn aufgenommen. (Strassenkehren,
Steinhauerarbeitj Marraorarbeit, Bergleute, Backer etc.)
4. ScKlechte Beschaftigungen fiir Fi-auen und Hausarbeit: Barbiere,
Kellnei', Schneider, Bugler, etc.; Blumenmacher, Zigarrenarbeiter, Zucker-
werk.
5. Uberanstrenfijiiag bei der Arbeit der M&nner und Frauen. Uber-
stunden und Nachtarbeit.
6. Kinderarbeit und die Arbeit der Frauen wahrend Schwangerschaft
und Saugung, vcrursacht durch die Sehundlohne, die fiir gewohnlich den
Neuankommenden gesahlt werden,
7. Ungeniig^nde und schleehte Ernahrung, (Vergleiche den Bericht des
Arbeitiibureaus, No. 72*)
Armut und niederer ^'Standard of Living*' im allgenieinen.
Die^, etitweder ciazeln oder zusammenwirkenden Ursachen sind die
Hauptfaktoren, denen das Uberwieg^n der Tuberkulose unter den Italieneni
auzuschreiben Ist. Das Kliraa hat nichts damit zu tun, trotz zahlrGseher
auf diesen Zweck bedachter Konstatierungen* Einige istadte in Calabrien
uiid BjLsilicata, nicht eininal von jeuen in den nordiichen Teilen Italiens zu
eprechen, halicn kaltere Winter ab wie wir sie hier haben ohne die Moghcb-
I
^•:^fm
TUBERCULOSIS AMONG THE ITALIANS. — STELLA. 453
keiten eines Schutzes gegen das Wetter, welche hier vorgesehen sind. Der
sprechendste Beweis, dass es das Stadtleben und nicht das Klima ist, was die
Italiener tuberkulds macht, kann gegeben werden durch einen Vergleich der
Italiener, welche hier auf dem Lande und in kleinen Dorfem leben, und jener,
die sich in den grossen Stadten niederlassen. Die Gesundheit der ersteren ist
kraftig, ihre Eander sind abgehartel und gedeihen, alle die urspninglichen
Lebensbedingungen, die in Italien ihnen zu eigen waien, ednd hier vorgesehen,
und es gibt kein Leiden. (Vergleiche " Die Italiener auf dem Lande, " Bulle*
tin des Arbeitsbureaus, No. 70.)
Die Abhilfsznittel sind:
1. Bessere Verteilung der ankommenden italienischen Einwanderer und
das Streben, sie in Fann- und Ackerbaudistrikte hinweg von uberfiillten
Centren zu bringen.
2. Erziehung der in der Stadt lebenden, indem man ihren " Standard of
Living" in die Hohe bringt und sie die Grundsatze persdnlicher und sozialer
Hygiene lehrt.
Die Tuberkulose-Ausstellung und die vielen, kiirslich in New York xmter
den Auspizien der Charity Organization Society abgehaltenen Vortrfige hah&a.
bereits grossartige Resultate in diesem Sinne gezeitigt, und mit der ErofTnung
der Tuberkulose-Klinik im italienischen Hospital blicken wir vertraueosvoll
einer sogar noch beruhigenderen Zukunft entgegen.
IS THE PREVALENCE OF TUBERCULOSIS AMONG THE
NEGROES DUE TO RACE TENDENCY?
By Robert WiiaoN, Jr., M,D.,
Charleston, S. C,
Every one who has studied the American negroes in recent years has
been deeply irapressed by their excessively high death-rate, as well as by
the prominent place occupied by tuberculosis as a contributing factor to
this abnormal mortality. According to most writers, this condition has
developed to its present inordinate proportions only since the negro was
forced to sliift for himself by the results of the CMvil War, which at once
removed him from under the protection of his white master and imposed
upon him the unaccustomed responsibilities of social and political freedom.
"There is no fact more fully established in the minds of the oldest physicians
of the South," writes Dr. J. F. Miller, "than that consumption, prior to
emancipation^ was an exceedingly rare cUsease among the negroes.*'* From
this opinion there ia practically no dissent. There is no question, oa the
other liandj that in late years both the total mortality and that from tubercu-
losis have reached enormously high figures. The following table, quoted
from the cxliaustive work of Frederick Hoffman, compares the death-rate
from consumption in the two races in fourteen American citi^.*
TABLE L— MORTALITY FROM CONSUMPTION— FOURTEEN AJIER-
ICAN CITIES. (Ratio per 100,000 op Population.)
Wbjtk, Colobkd.
Charieston, S. C, ......335,4 686. 6
NewOricana, La , 250.3 S87.7
Savannah, Ga .,... 371.1 544.0
Mobile, Ala ..,.304.1 608.2
Atlanta, Ga 213. S 483.7
Richmotid. Va. 230.5 411. 1
Ba!timt>rts Md..... ...,.,. 2fi0. 6 634.6
Wayhiogton, D. C 245.0 691.8
Brooklyn, N. Y , 284.9 239,0
New York, N. Y. .379.6 g45.2
Boeton, Mafis 365.8 8S4.8
Phiiaddphia, Pa 269.4 S32.b
St Louis, Mo ..........159.9 655.9
Cinrinnat], Ohio 239. 1 633,3
The rlisparity between the incidence of tuberculoais in the two rac^, wVdeh
19 well shown in this table^ is so great that some students of the £ubject
454
TUBEBCULOBIS AUOISTO THE NEGROES,— -WILfiON.
455
h&ve sought to explain the phenomonon by supposing that the negroes
recently have developed a peculiar racial susceptibility to tuberculosis,
and ma-ny seem to see therein the doom of the race, *'This chiinge in the
Busceptibility of the colored race to consumption,'^ writes Hoffman, '*if
supported by other facta, may be couaideredj next to the excess in infant
mortality, a distinct race characteristic, and one wliich must have the most
pronounced effect upon the numerical as well as the social and moral progress
of the race.*'" And after tf careful and exhaustive review of the situation
the same writer reaches tlie following conclusion: **The fact, therefore,
that the negro should show such an enormous increase in the mortality
from this cause is one of great significance. The large decrease In the
mortaUty among tlie white race may permit ua to indulge in the hope that
a decrease in the mortality for the colored race is also possible. But at
present the tendency is the other way; and a close study of related phenom-
ena will convince the reader that only the most radical changes in the race
traits and tendencies of the colored race can accomplish this, if it is at all
possible,"* This is a gloomy outlook. If it be true that susceptibility
to tuberculosis already has become a race trait, burnt in, aa it were, by
heredity, it is manifest that the problem it presents is far more profound
than if environment and habits of living be the factors chiefly concerned*
It is the object of this paper to inquire if the facts do not give us good
ground for believing that, on the contrary^ environment and mode of life
are the most important influences which have operated to produce the
excessive death-rate from tuberculosis, and if we may not find cause to do
a little more than hope that the situation is capable of }xmg relieved. That
the problem is not one for the humanitarian alone is manifest upon even
ffuperficial consideration* As an economic problem tuberculosis among the
negroes may not be of equal importance to the problem among the whites^
but it is far from being inconsiderable. If we estimate an average period
of disability of only one hundred and fifty days, and the average ilaily cost
of maintenance as low as 75 cents, the annual cost to the city of Charleston,
a C, alone is between S23,000 and S24,00(X This is probably a very
conservative estimate, and does not include the cost of burial and what has
been called the potential loss due to the shortening of productive lives.
Furthermore, the presence of a large number of tuberculous negroes is a
serious menace to the entire community in which they reside, by reason of
theif forming the servant class to such a large extent. This means that they
are intimately associated ;\'ith the whites in all walks and relations of life,
an association wliich cannot but be fraught with gravest danger^ in view of
their careless habits and dense ignorance. As Dr. T. J. Jones has pointed
out, a very high death-rate from tuberculosis among these people constitutes
a much greater danger to the vitality of the nation than a high death-rate
4fi6
SIXTH INTEHNATIONAL CONGRESS ON TUBERCULOSIS.
among the other nationalitiea which form part of our population, inasmuch
as the negroes form about 11 per cent, of the total.*
Instead of reviewing statistica gathered from a number of locahties, I
propose to study a single series obtained from one city* My reason for so
doing is that in no soutliern city except Charleston, S. C, is it possible to
obtain a practically unbroken series of mortality statistics extending from
the early years of the last century until the present day. The Charleston
returns cover a period of seventy-six years, beginning with 1822. We are
able, therefore, to study the death-rate iti the Hght of changing conditions
as we can do nowhere else. It is perfectly fair to assume that the conditions
in Charleston differed in no essential from those prevailing in other com-
munities in which negroes formed a large proportion of the population, and,
therefore, that the conclusions which may be reached by a study of these
figures may be applied reasonably to other localities, A referenceto Table
I will show that in 1890, at least, Charleston was an average city from the
point of view of negro mortality. The objection mil probably be raised
that such figures, especially of the early years^ are not rehable. That they
are not absolutely correct is doubtless true, but there is probably only a
small percentage of error, and the effect of this would be to give them a
minimum value, since it is far more probable that deaths from consumptioa
were wrongly reported than that deaths from other causes were reported as
consumption. In the following tables the Charleston statistics are pre-
sented for the first time in their entirety, with the omission only of the
troubled periods of war and reconstruction when the death returns and census
reports were of very questionable accuracy,
TABLE U.— RATIO OF DEATHS FROM ALL CAUSES AMONG THE
NEGROES PER 1000 OF POPULATION,
J822TO
1S31 TO
1841 TD
ISAlTO
IBS] TO
iSfrlTO
IMl TO
1830.
1^40.
IHQO.
ima.
1S90.
ifiOO.
1007.
1
26.1
20.6
23.1
46.7
44,0
36.4
2
35.3
17,8
21,5
30,7
41.8
42,3
36.7
3
32 9
17-5
29,7
29.6
45.6
41 3
35 .6
4
30.2
22.0
22.4
32.2
42 3
41.6
34.3
5
27.8
22,3
14.1
25.5
42.9
41 6
33.5
6
26.0
52.5
16.1
37. S
54 1
34 0
34.5
7
24.1
21 -fl
14.3
43-3
44 0
36.7
32.3
8
24.9
30.8
13.5
37.7 ■
45.4
39.0
g
26 I
25.9
15.9
33.4
46^8
40 5
10
24 9
21.4
19.9
42.1
41 3
39.3
Aveni^ ......
28,0
25 8
18.7
33.5
46.1
40.9
34.7
T0BEHCULO6IB AMONG THE NEGROES. — ^WILSON.
457
CHART I.
-AVERAGES OF TEN-YEAR PERIODS PER 1000 OF
POPULATION.
468
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
A study of Table II and Chart I is extremely interesting. Heretofore
all compilations of ante-bellum statistics ended with 1848, and the steady
improvement observed down to that year was very strikiDg. When a
comparison is made between the average mortality of the fifth decade and
that of the ninth, the difference is truly startling, and, standing alone, may
well give cause for the gloomiest forebodings.
At the end of the fifth decade an increase in the death-rate began, and
was practically continuous until 1860, when the mortality was higher than
it has been in the last sixteen years; and the average of the decade ending
with IStiO was almost a& high as that of the last period on the table.
TABLE III.— RATIO OF DEATHS PROM CONSUMPTION AMONG
THE NEGROES PER 10,000 OF POPULATION,
182^10
183119
IMl TO
1851 TO
isai TO
iseiTo
1901 TO
1S30.
1S40.
iBAa
LS&O.
ISOO.
leoo.
1007.
1
3^.3
33.3
21.3
79.1
83.3
50.4
2
67.2
28.7
25.8
30.4
80.2
78.1
56.4
3
62.9
26.4
44.3
33.9
82, S
83.9
51.0
4
32.5
25,8
31.0
37.8
S9.4
87.5
50.4
5
61.5
25.2
32 0
31.3
92 ;7
79.1
52.9
B
30.6
31.4
31.3
51.9
86,5
87.5
50.4
7
■11.3
31.4
21.7
48. 9
81.3
62.5
51.0
S
40.8
35.1
11.7
41.9
80.7
7oa
9
33. &
43.7
22.1
37.9
92.0
70.7
10
33.3
32.6
24 3
46.6
68.4
61.5
Average ......
45, S
31. g
26.7
39.1
83.3
76.4
51.7
CHART II.— AVERAGES OF TEN YEARS PER 1000 OF POPULATION.
1S22TO
1830.
1831 TO
1840.
1S4ITO
IB 50.
LSSIto
1860.
TCTBERCULOSIB AMONG THE NEGROES* — ^WIldON.
459
Table III and Chart II, giving the death-rate from consumption per
10,000 of population, show changes which follow the same periods. These
figm*es are very signiiicant. They show that tuberculosis was by no means
uncommon prior to emancipation, the average death-rate from this cau^e
in the two races being about equal, and also that the increase began appar-
ently about the end of the fifth decade, and, consequently, was due to ciittses
which were in operation before the changes in mode of life and surroundinga
which followed emancipation.
In seeking to account for the phenomena revealed by our statistics we
meet the first difficulty in finding an explanation of the liigh mortality of
the first period- It was either an exceptional condition or else it was the
end of a longer or shorter period of high death-ratea. Dawson and De-
Saussure, writing in 1848, incline to the former opinion, attributing it to
the prevalence of whooping-cough, "which in the black population termi-
nates in consumption much more frequently than in the wliitea."* A study
of the records, however, seems to indicate that whooping-cough was not
very active until 1824, when the death-rate from tuberculosis had begun to
decline, I am rather disposed to believe that it is more probable that our
records open about the time when a change in health conditions had begun
to be apparent. That the death-rate should have been higher previously
is very probably on account of the activity of the slave trade in the eariier
years of the century, the effect of which could hardly have been other than
injurious to he-alth. Tom suddenly and violently from their homes, sub-
jected to tlie hartbhips of transportation in a slave ship, and forced amid
Btrange surroundings to undergo labor to which they wore not accustomed,
it would be remarkable if they did not fall easy victims to disease. But,
as Livingston remarks^ the negroes seem to possess a "capabiUty of with-
standing the sorest privations^ and a light-heartednesa which, aa a sort of
compensation, enables tiiem to make the best of the wonst situations,"'
and they could adapt theniselvea, therefore, to their now environment in
the course of a few years, with the consequent improvement in the conditions
of health.
It is easier to account for the progressive Improvement and the sudden
and rapid change for the worse which the tables reveal A reference to
Table IV will show a marked decrease in population between 1830 and 1848,
TABLE IV.^-OOLORED POPITLATION OF CHAfiLESTON, S. C,
FROM 1S20 TO 1900.
ia20 14.127 1860 17,146
1830 17,401 1S80 27,276
1840 16,231 18S0 30,970
1848 12,264 1900 31,669
1850 22,fl73
This fact is commented upon by the above quoted contemporary au-
460
SIXTH INTERN ATIOKAL C0NGRB3S ON TtTBEBClJtjOSIS,
thorities, who attribute it to the removal of a great many of the negro popu-
lation to a suburb King just beyond the city limits* The effect of this would
be to materially lessen the congestion within the city. It is very si^oifi-
cant that the increase in death-rate was synchronous with the sudden
increase in the density of the city population. Compare again the great
increase in the population which has occurred since the war, bearing in
mind that it has not been associated with a corresponding territorial ex-
pansion^ and^ therefore^ means congestion. Without houses enough to ao-
commodate the growing populLLtion^ several families frequently are compelled
to occupy a single house, all the members of each family often living in one
room. The evil efFect-s of this congestion are aggravated manifold by the
negroes pernicious sanitary habits, violating, as he does, every rule of
ii^t living. His house is usually dark, and poorly ventilated at best ; but if
he happens to be blest with windows, he scrupulously closes the blinds or
draws the curtains to exclude air and light, while a smoking kerosene lamp
at night further vitiates the air. When asleep he covers his head vith the
bed-clothes — a habit which I find most difficult to overcome in my hospit^
■work among tuberculous negroes* This state of things prevails wherever
the ttegro is found in large numbera. The visiting nurse of the Charity Or^
ition of New York city writes; " On visiting the houses occupied by col-
^ored tenants we find famihes crowded together in dark, ill-ventilated rooma
where a breath of pure air seldom enters and the sunhght never."* A
physician who has a large country practice among the negroes in the interior
of South Carolina says: "The average negro house is about 32 feet by 16
feet, with an eight-foot ceilingf divided into two rooms. In these rooms it
is not uncommon to find six to ten people living." Furthermore, the negro
earns small wages^ and, improvident to an extreme degree, he will spend
to-day in pleaaui^ and dissipation all that he possesses, thoughtless of to-
morrow* In consequence he is inadequately fed and poorly clothed, and in
winter often is without the means ol obtaining sufficient fuel.
Add to this a growing addiction to alcohol, and other drug habits, and
we have a mass of removable causes amply sufficient to account for the
negro's excessive death-nnte from tuberculodsp without reaching after a
hypothetical race susceptibility, which, because of its nature^ can only
be eradicated with the greatest difficulty, if at all.
A further corroboration of this opinion seems to be furnished by the
apparent tendency to a lower death-rate which our tables indicate has taken
piace in recent yeai^ I have not been able to determine what causes par-
ticularly may have contributed to this result, but it is highly probable that
the general improvement which is going on slowly among the negroes, as
^frkfenoed by decreasing illiteracy* and increadog property owoer^p. which
higher and better Uvingj may be in large part responsibte for it.
I
TUBERCULOSIS AMONG THE NEOROEB. — WILSON.
4C1
In Augusta, Ga., "an irregular decline" in the last few years has likewise
been observed, and in the thirtieth annual report of the Department of Pub-
lic Health the following hopeful explanation is offered: "Our negro popular
tion, almost without exception, are living better than ever before, and are
ready and willing to co5perate with your health officers in all matters looking
to their sanitary betterment. The progpes^dve negro physicians of the city
have aided the work of your Department in every way possible, and have
been important factors in reducing the death-rate in their race."
The conclusion that environment and ignorance, and not innate tend-
ency, are the chief factors in the production of tuherculoaia among these
people, both imposes upon us the obligation to strive more strenuously for
the betterment of existing conditions, and points to the two-fold way along
which our efforts should be directed^ while at the same time holding out
hope that our work will not be unavailing. 1 wish to lay emphasis upon one
point of fundamental consequence, A well planned and judiciously directed
system of education is of paramount importance in the fight with tuberculosis,
because without it the best conceived and most thoroughly enfopoed sanitary
measut^ will be disappointing in their results* We must bear in mind that
we are dealing with a race whose intellectual and moral development is
inferior to that of the white mam What Sir Richard Burton wrote many
years ago of the African negro is largely true to-day of the American negro,
" In the negro the propensities and pas^ons are tolerably well grown, the
perceptives and reflectives are of inferior form, and the sentimental or
moral regions remain almost undeveloped,"^^ The negro shows a childlike
immaturity of mind and morals, the failure to recognize which in practical
educational work is perhaps the main reason that well intended efforts are
80 often futile. In the fight which we have in hand, the best results will be
obtamed only when the sanitarian studies his problem with the aid of the
anthropologist.
BIBLIOGRAPHY.
1. Transactions of the Tri-State Medical Association of the Carolinaa and Yirgimap 1900.
2. Race Traits and TendencJos of the Amcric^u Negro.
3. Loc. cit.
4. Lo<^. rit.
5. American Journal of tbe Medical Scicaoes, Oct., 1905.
0. Census of the City of Charlo»ion.
7. Narrative of an I^xpedition to the Zambesi. David and Charles Livin^ton.
8* Third Annual Report of tbo Com. on the Ppevcution of Tuberculoaia of the Charily
OrgatiuHtion Society, New York City,
8. Bulletin H, Bureau of the CenfiUa.
10. A Muuion to G^ele, King of D&bome, vol. ii
4m
SnCTH INTERNATIONAL rOHOREas ON TUBEBCULOSIB.
Tuberculosis Entre los Negros Debida a una Tendencia de la Raza. —
(Wilson),
Cualquiera que haya estudiado el problema se impresiona fuertemente
por la euorme frecuencia de la tuberculosis entre los negroa* Esta es fre-
cuentemente atribuidji A una teadencia peculiar de la raza que se ha desar-
rollado ultimamente. Las estadfsticas de Charleston cubren iin periodo de
26 afJos. La estadlstica de la moi'talidad total y la mortalidad de la tubercu-
losis, demuestra un aumento en 1S22 con una dismlnucidn constant© hasta
1848, la cual aumenta hasta 1860* De 1S81 i 1890 la mortalidad auineiit6
hasta Ilegar i ser de un 45.1 por cada 1,000 de poblaci6n de todas las causas
y 83*3 por cada 10^000 de poblaci6n de la tuberculosis solamente. Desde
entonc^ ^sta ha disminuido graditalmente. Una comparaci6n con la pobla-
ci6n, demuestra que la mortalidad fue menos cuando la poblaci6n era
menos y que recientemeute ha aido asociada con una marcada congesti6ii-
Este hecho, las condicionea extremas de poca higiejie de los negros, y sua
pemiciosos habitoa sanitarios y su prediaposicion al alcohol, etc*, 3on sufi-
cicntes para explicar la mortalidad. El remedio consiste en la extricta
compulsion de las medidas samtarias y la educaci6n- La ultima se compH-
cada debido k la incompleta madurez de los aegros.
*
La tuberculose panni les n^gres est-«lle due h, une teadance de race 7—
(Wilson.)
Quiconque a ^tudi^ la question doit ^tre frapp^ de l*€nonne frequence
de la tuberculose parmi lea n^gres. On I'attribue souvent k line tendance
inh<5 rente It la race, qui se serait d6velopp^ r^cemment. L'objet de oe
m^'moire eM de d^raontrer qu'au eontraire ce sont le milieu et rignoranoc
qui sont les causes les plus importantes. Les statistiques de Charleston,
S. C, couvrent uae p^riode de 76 ans. Lea statistiques, tant pour la mor-
tallt45 totale que pour la mortalite due k la tubei*culose, accusent un cbiffre
a^se^ 6tev^ en 1822, qui s'abaissa progressivement jusqu'en 1848, et apr^
stie dpoque se releva jusqu'en 1860. De 1881 k 1S90 la mortality totale
!va jusqu'^ 45,1 par 1,000 habitants, et la mortality due k la tuberculose
nit 8.'i.3 par 10,000 habitants. Depuis cette ^poque elle s'abaiasa.
lison avec la population r^v^le le fait que la mortality est h son
it quand la population est au minimum, et r^cemment elle a
e que la population devenait tr^s-deose, Cette correspood-
Dar trop malsain du n^gre, sea mauvaL^iies habitudes
is de Talcool suffisent pour expliquer I'excfes de moi^
date dans Tobservation stricte de mesurea bygi^niques
Jelle-ci est rendue difficile par le manque de d^veloppe-
. du n^gre.
PULMONARY TUBERCULOSIS AMONG THE SCANDL
NAVIANS.
By George Douglas Head, M.D,,
Bliiuiespolis. Hicn.
The fiood-tide of Scandinavian immigration to the United States reached
its climax in the decade ending with the year 1890, when more than a half
million persons from Norway, Sweden, and Denmark landed upon our
shores. Banning in the years immediately following the Gvil War, this
inunigration movement gradually increased through the decades to 1890,
falling off to some degree in 1900.
So great has been the influx of these people that in the year 1900 the
persons of Scandinavian birth immigrating to the United States had reached
the grand total of about one and one half millions of people. It was but
natm^ that this hardy race in coming to America should seek a home in
that part of the country similar in climatic conditions to the land of their
birth. We find, therefore, a large percentage of the Scandinavians settling
in the northwestern States — Minnesota, Wisconsin, North and South
Dakota, and to a less degree in Michigan, Iowa, and Nebraska. The State of
Minnesota especially received a large part of this immigration movement.
It began early in the sixties and has steadily continued to the present day.
In the year 1890 Minnesota led all the other States of the Union with a
foreign-bom Scandinavian population of 204,000, or about one-sixth of its
total population.
The northwestern States in general, and the State of Minnesota in partic-
ular, would seem, therefore, to be a promiang field in which to study out
the problems relative to tuberculosis of the limgs among the Scandinavians,
dealing especially with the prevalence of the disease among them, the effect
of immigration in increasing or decreasing the mortality, the comparison of
the death-rates among the native-bom and foreign-bom, and other associated
questions of interest.
The Scandinavian immigrants to this country present two pronounced
types. The one, more common, is a tall, long-boned, long-chested individ-
ual, with ashy hair, blue eyes, high cheek-bones, pale complexion, promi-
nent forehead, and active ment^ty. Physically this type suggests the
463
^H INTEKNAHONAL CONGRESS ON TyPERCUIOSIS,
ie American Intlian. The second type is short and thickset, with
head, broad features, deep-set eyes, and blond complexion. These
indi\'iduals are slower of movemctit and more stolid in nervous make-up.
Both of these types develop pulmonary tuberculoas-^the former more fre-
quentiy than the latter. The Scandinavians are among the most intelligent
of our foreign population, and are a religious and moral people, more Inclined
to settle in rural districts. They are temperate for the most part. In their
home hvea they rear large families, live hi small quarters, eat rather poorly
prepared foods \vith little meat. They despise fresh air in their houses and
live with the doors and windows closed. In tliis respect they are, however,
ao worse offenders than most of our Eurojiean population.
That they are not a race of weaklings, but of a hardy type, is shown by
the low general death-rate in Norway and Sweden. Since the beginning of
the nineteenth century the general death-rate in these countries has be^i
progressively diminishing, until to-day they lead all the European countries,
with a death-rate of 16.1 per 100,000 li\^ng for Sweden, 16.3 for Norway,
and 17.5 for Denmark. When we exaniine the death records of these coun-
tries relative to tuberculosis of the lungs, however, we find that despite their
low general death-rate they show a high mortality from this disease. The
more recent mortality records (1900-19tM) show Norway with a death-rat©
from consumption {200.4 per 100^000 living) greater than that of any oth^
European country e^icept Russia, In 1902 Norway had a death-rate of
189.7j standing third in the list of European countries, Hungary being first
(383,7), Ireland being second (212.1). In the decade ending with 1900
Norway stood fourth among the European countries, and the cities of Swe-
den fourth among European cities, in the death-rate from tins disease.
It 13 difRcult to explain these facta upon any other ground than that of a
natural susceptibility to the disease. Pulmonary tuberculosis was unknown
among the Scandinavians in their early history. The diseasej having se-
cured a foothold among this primitive people ignorant of its cause and the
avenues by which it was conveyed, spread among them as rapidly as it has
among our American Indians. The increased mortality within the last few
decades may be explained in part by the emigration of a oonaiderable body
of their healthy adults to this country, leaving the sick and invalid to aweU
the mortality records at home>
That Stockholm, the chief city of Sweden, has decreased its death-rate
from consumption 38 per cent, in the last decade by the segregation of 400
of its tuberculosis cases in hospitals argues strongly for the view that other
factors besides a natural susceptibility are at work in producing this high
mortality. If it can be showTi, however, that the Scandinavians and their
children, under the favorable conditions which they obtain in their new
environment in our northern States, still maintain a high death-rate from
PULHONART TUBERCULOSIS AMONG THE SCANDINAVIANS. — ^HEAD. 46|7
tuberculosis of the lungs, it would argue stron^y for the view of natural^
susceptibility, unless it can be proved that immigration, with the radical '
changes of life associated with it, tends to increase the disease among them.
It does not seem reasonable to admit this condition. Inomigration selects
the young, healthy, ambitious individuab of the race. The weaklings and
invalids are left at home.
Tuberculosis of the lungs is not, as a rule, aggravated by a change of
climate or environment, even though considerable hardship is thereby
endured. In the northwestern States the native population have a very
low mortality from pulmonary tuberculosis; the density of the population
is much less than that of Norway and Sweden. The chances of infection,
therefore, in the United States for the Scandinavian immigrant are much
less than in Ms native land. While it must be admitted that the draft upon
the physical and nervous enei^ of Scandinavians immigrating to this
coimtry is large, it cannot be admitted that it plays any prominent part in
developing latent foci of the infection or producing the disease in healthy
individuals. That immigration does not tend to increase the disease among
these people is further proved by the fact that at no time has the death-
rate in this coimtry from pulmonary tuberculosis among the foreign-bom
Scandinavians reached the present death-rate in Norway, namely, 200.4
per 100,000 living.
The death-rate from consumption in the United States has always been
low as compared with Norway and Sweden. The introduction of one and
one-half millions of Scandinavian immigrants, contrary to what might be
expected, has not raised our national death-rate from this disease. From
1870 to 1900, years of the largest immigration of these people, the death-
rate from pulmonary tuberculosis has been steadily falling, and, as our most
recent (1905) mortality records show, is still falling. When we further con-
sider the death records from this disease for the eleven-year period 1890 to
1900 in that group of States rich in Scandinavian population, States border-
ing upon the Great Lakes and coimtry tributary thereto, — ^tfinnesota, Wis-
consin, Michigan, the Dakotas, and Nebraska, — ^we find a lower death-rate
from tuberculosis of the lungs than in any similar group of States in the
Union. These facts would apparently tend to prove that, even though the
Scandinavian in his native land had a high mortality from consumption, in
the land of his adoption it was not more prevalent than among the general
population.
This evidence, however, is not convincing. The States here dted are
comparatively young States, settled within the last thirty to forty years.
The density of their population is low, with a high percentage of it ruraL
They have a low general death-rate. To reason, therefore, that pulmonary
tuberculosis cannot be very prevalent among the Scandinavians in this
\
-^TEBNATIONAL CONQHESB ON TUBEBCtTLOSIS,
jB these northwestern States with a liigh percentage of Scan-
olfttion have a low death-rate from consumption, is to come to
jU without sufficient ciircfu! stufly of the facts. It is only when
jne into the death records in a State rich in Scandinavian population,
jB Minnesota^ determining the prevalence of consumption in the foreign-
fl and native-bom ScandinaviaiiBj and comparing these figures with the
xeath-rate among the native-bom of native parents, that the true facta
become known.
Before ent-ering into this inquiry I wish to point out what has already
been ascertained by the United States census studies. The United States
vital statistics have conclusively demoiLstrated that the death-rate from
pulmonary tuberculosis in whites is higher among the foreign-bom than
among the native-bom; that it is higher among the native-bom of foreign
parentage than among the native-born of native parentage. In respect to
the Scandinavians, the information furnished by our national vital statistics
covers only those States included in the registration area, namely^ the New
England States, District of Columbia, Miciiigan, New Jersey, New York,
Maryland, Indiana, Pennsylvania, South Dakota, Colorado, and California —
States jxjor in Scandinavian population.
The census of 1900 places the death-rate from con>sumption in the registrar
tion area among those born of Scandinavian mothersat 170.3per 100 ,000 living j
the Irish coming first^ with a high death-rate of 339.6; the French second,
with 1S4.7; the Scotch third, and the Scandinavians fourth. In the census
of 1890 in the registration area in cities, the Scandinavian stood sixth among
those of foreign parentage; in the rural districts third. In the non-reg-
istration States the Scandinavian stood third. The most recent 1905 reports
place the Scandinavian second, being only exceeded in the death-rate by
those of Irish parentage. In the study by Stone of the Boston death records
for consumption (years 1901-1903) those of Scandinavian parentage ranked
ond in high death-rate^ being outranked only by the Irish.
These statistics, taken as they are from States in which Scandinavian
population is small, probably cannot represent the true death-rate from
pulmonary tuberculosis among these people in the United States, With a
ew of securing more definite information upon the subject, your attention
called to the death-records of the State of Minnesota. Minnesota is a non-
ration St^te. Its vital statistics are complete enough, however, for
purpose of this study, Scandinavians began immigrating into this State
to the Civil War* It was not until 1870, however, and subsequent to
^te, that they began to settle in Minnesota in large numbers. In 1S{)0
h of the entire population of the State was composed of foreign-bom
ivians. The decennial census of 1905 shows more than one-fourth
jntire population of Scandinavian parentage of these 14.2 per oent.
PXTIMONAKY TUBERCtriiOaiS AMONG THE BCANPINAVIANS, — ^HEAD. 467
were native-bom Scandinavians and 12.S per cent, foreign-bom Scandinavi-
ans. Minnesota has for years had a low death-rate from pulmonary tuber-
culosis. In 1890 the death-rate was 98.5 per 100,000 living, in 1900 it was
105.3, in 1906 and 1907 it was 93.4. This death-rate compares very favorably
with that of Michigan, a State similarly situated to Minnesota geographically,
with about the same percentage of foreigners, and the same rural and urban
population. Its Scandinavian population is, however, only about one-sixth
that of Minnesota,
Michigan is the banner registration State in low mortality from pulmonary
tuberculosis. Its deatb-rat« in 1890 was 105,4, in 1902 84.3, in 1905 it was
89.5 per 100,000 living. Only in the decade of ISSO was the death*rate from
consumption in Minnesota unusually high (128.7), and this was due to the
large influx of consumptives to the State, attracted there by the reputed
healing value of its pine forests. That the immigration of Scandinavians into
the State had nothing to do with the high death-rate in ISSO is proved by the
fact that subsequent to that time larger numbers of these people settled in
Minnesota, and yet the death-rate from consumption was not increased, but
diminished. In 1890,* 1291 persons died of tuberculosis of the lungs in
Minnesota. PersoTis of Scandinavian parentage, comprmng £S per cenL of
the total po'puldtimif furnished SS per cent, of the deaths. The foreign-bom
Scandinavians, comprising 16 per cent, of the population, furnished 33 per
cent, of the deaths* The native-bom Scandina\1an8^ with 12 per cent, of the
population, furnished 3 per cent, of the deaths. The native-born of United
States parentage comprised 23 per cent, of the population and fTimished 17
per cent, of the deatlis. The death-rate among the Scandinavians was less
than among those of Irish parentage — 125.4 as against 138.
The decennial census of 1905 placed the population of Minnesota at
1,979,912; of this number, 27 per cent, were of Scandinavian parentage. In
1906, 1832 persons died of pulmonary tuberculosis in Minnesota, The Scan-
dinavians, with 27 per cent, of the population, furnished 39 per cent, of
these deaths. The foreign-bom Scandinavians, with 12. 8 per cent, of the pop-
ulation, furnished 27 per cent, of the deatlis. The native-born Scandina-
vians, with 14.2 per cent, of the population, furnished 18.6 per cent, of the
deaths. The other nationalities^ combined with 37 per cent, of the popula-
tion, furnished 31.6 per cent, of the deaths. The native-bom of njitive
parents^ comprising 34 per cent, of the population, furnished only 18.4 per
cent of the deaths.
The death-rates in 1906 per 100,000 hving were as follows:
* In this study the years 1890 and 1906 and 1907 have been chosen, in order that ihe
mortality rocordn sub^uent and pKi>r to tbe seoQcd generaticn of Scaadinaviiuis
mi^t be obtained.
airra international coNOREsd on tubehculosis.
F^reigu-hom ScantlinaviaaB . . , ....*-.... 156 7
Native-bom Scandinavians. 111.4
Foreign ^born of other n&Uomdities ,.,.,... 95 , 0
Natives of Um(«d SUtea pazvtitag)^ * , - 49 . 4
Total of S<^ii(lma\-ian parpnta^ . , . . . , 133.9
Total bom of other foreign parentage * 79 . ft
Tot«d of tiftUve4»oni of other nationklitm „ , , 77-5
The State records of the year 1907 are not \^ry different from those of
1906. Those of Scandinavian parentage furnished 40.3 per cent, of the deaths,
ft slight increase over 1906* The foreign4x>m Scandinavians furnished 21.7
uu) the native-bom Scandinavians 18.6 per cent, of the deaths, the same 10
for 1906. The other nationalities furnished 32,3 per cent., a slight iacreftse
om 1905; while the native-bom of native paieni^ fumtahed 18.4 per eeaWr
ttw same as in the pievioua year.
The moitality mtes per 100,000 li\*ing for the year 1907 m aa follows:
Fbiwgn-bons ScandinaviKns 159 . S
Naliw bom SeattdJn^viana ^....,. 116 7
ftitjf Vi-rm ftf TTthrr *f >V>*b*^ 112 S
Katnv-bora of IniSpd States parail^e..... 50 3
Wattle bofa ol other nliopaMyea 75 4
ftrtolrfaiacMMliiiaTMMipai^rt^i I3B.3
riw tnTil nf nlliia liirMn riinBtam S2.d
From these figures it vill be seen that the deAth-rate from polmooaiy
tubcfcu&oab in MixuM8i>to b hi^Kr among the foreigD-bora SrandinaTiaas
Usui amoag the iukim4Mni BoKu&umMas; Hut it is more tiiaa tmse ashi^
■DOBg ifaik natm-boRt SeaiidiiiaTiaDa as amoos ^^ ulm-bom ttf Umtnl
States paicntaice; that it is hi^^r among the fotogm-bom SeandinaviaBs
the forap^nn of the other BataoBaikiBB; thai it is higiKr ttHii«
oKHv-IXMni oOmBBHTlliBa IBall """'"C W DBItre-DOfll 01 BK OtmBT
, that it is hi^wr among the ScaBe&kaTtaas uallie-bim tibaa
the loteipi-boc& of oAer nalioiMBliui, tittt the dwtli lato
m 1S90 the <feath-rate per 100,000 iring of Seaafinram
UK.4, whae a 1906 it ««s 1319^ and in 1907 it v«b 138JL
is kq^ doe to an iBtfOMB m the <lBilh>fa4e ammiKthe 1
SmttrtmYtans. because in 1890 w find the mti^v^bofn
tSpemnL of the pofwilalaon, au|)||i j ung ^m^ 3 per cent, of the
in liOr.viA 14^ portcnL of the popidiSiQn, tky are
ofthedeatbs. Tins Ugh dnth-ntea ^ong the
is ft Matter of eneft iwjiiiftantB tnthe people of
PDLMONAKT TUBERCULOSW AMOffO THE SCANDINAVIANS, — HEAD* 469
and 50.3 for 1907. These facts wouJd seem to justify the concJuMon that the
low death-rate from consumption in Minnesota is due, in part at least, to the
low death-rate among its native-born of native parents* This conclusion is
further warranted by a comparison of Minnesota's death-rate from conaump-
tion with that of Michigan in reference to native- and foreign-bom. In 1890
the death-rate among Minnesota's native-born was much lower than that
of Michigan (82 for Minnesota, 98 for Michigan, per 100,000 living); while
among the foreign-born Minnesota's death-rate was higher than that of
Michigan (143 for Michigan, 154 for Minnesota, per 100,000 living). The
same holds true for the year 1900 (Minnesota 73 -h , Michigan SO -H , for native-
born: Mimieaota 161 + ^ Michigan 125+ , for foreign-bom).
The statistics, heretofore offered, relate to the mortality from consump-
tion among the Scandinavians in the State at lar^. To determine the death-
rate among the Scandinavians in our urban population the writer has gone
over the death records of Minneapolis, the largest city in the State^ with a
population in 1905 of 261 ,000. Minneapolis is a city built over a large area,
with aide streets^ many parks and boulevards. It is a city of rapid growth.
Its people live for the most part in detached houses. It is in ever)' sense a
city of homes. Tenement Ufe in crowded quarters is as yet only in ita begin-
ning. Minneapolia has a larger percentage of its population Scandinavian
than any other city of its dze in the United States, In 1905 the Scandinavi-
ans comprised over one-fourth of its total population^ 16 per cent, being
foreign-born and 13 per cent, native-bom. The city of Minneapolis has for
the last fifteen years had a low death-rate from pulmonary tu^jerculosis. In
1S90 it stood 23 among 28 large cities of the United States, with the low
death-rate of 114.8 per 100,000 living. In 1905, with a mortality of 93.1
per 100,000 living, it led all the registration cities of ita dze in the United
States in low death-rate from consumption*
So low has been the death-rate in this city from pulmonary tuberculosis
that in the 1905 United States vital statistics doubt is expressed of the correct-
ness of the published mortality records. The writer has examined the death
records of Mhineapolis to aseortain the correctness of the reports published
by its health department, Wliile my figures do not agree with those published
by the city (for 1905 my mortality 104.5, city health report 93.1, per 100,000
living), there is not sufficient difference to alter the position of Minneapolis
in its death-rate from pulmonary tuberculosis among the lar^e cities of the
United States. That this low death-rate is maintained in spite of a high
death-rate among its Scandinavian population tlie following will show: In
1S90 the Scandinavians, with 27 per cent, of the population, furnished 37
per cent, of the deaths. The foreign-bom Scandinavians, comprising 20 per
cent, of the population, furnished 30 per cent, of the deaths. The native-
born Scandinavians comprised 7 per cent, of the population and furnished
470 SIXTH INTERNATIONAL CONGRESS ON TUBBRCULOaiS,
7 per cent, of the deaths. In 1905 persons of Scandinavian parentage, with
29 per cent, of the populatdon, furnished 40.9 per cent of the deaths. This
is a higher proportion than for the State at large, and an increase for the
city over 1890. The foreign-born Scandinavians, with 16 per cent, of the
populationj fumishetl 26.5 per cent, and the native-born Scandinavians, with
13 per cBnt. of the population, furnished 14.4 per cent, of the deaths. The
native-bom of native parents, with 4 1 per cent, of the population, furnished
only 27 per cent, of the deaths.
The death-rate per 100,000 living for the city of Minneapolis In 1905 is as
follows:
Foreign-bom Scandinaviana ....... .............. .... 169-1-
Nativ&-bom Scandinaviana . . , . . ...,....,,,..,.. 114 +
Natives of United States parentage ,..,., 69-|-
For total of Scandiimvian parentage 144
For total of other foreign parentage 102
I have compared these figures with those of other years prior and sub-
sequent thereto, and find no material difference in the results obtained.
Among the nationalities those of Irish parentage leadj with a death-rate of
153+1 the Scandinavians second with 144+ , and the Canadians third with
137+ . Comparing the records of the city of Minneapolis with those of the
State at large, we find the mortality among foreign-bom Scandinavians
higher in Minneapolis than in the State at large; that the percentage of deatha
among the native-born ScandinavioES is lower in MiiineapoUs than in the
State at large; that the percentage of deaths among the native-born of
United States parents is higher in filinneapohs than in the State at large;
that the low mortality in Minneapolis, as in the State at large, is due, in part
at leastj to the low death-rate among the native-born of native parents; that
in Minneapolis, as in the State at large, the Scandinavians stand next to the
Irish in high mortaUty from tuberculosis of the lungs.
We have thus far been dealing only with the death-rate from pulmonary
tuberculosis among the Scandinavians, Just how accurately the Lteath-rate
expresses prevalence of consumption among these people we have no means
of determining. We beheve, however^ that mortality is a fair expression of
the frequency of the disease. From observation among Scandinavians for
the past fifteen years in hospital, dispensary, and private practice, thewriter
is of the opinion that these people, when once infected, succumb more quickly
to the chsease than persons of any other nationality except the Irish. The
foreign-born Scandinavians certtdnly do not withstand the disease as well a3
the native-bom Scandina\'ians. We have not been able to observe, in thdr
mode of living, habits, or environment, any reason for greater prevalence of
the disease among them.
The high mortality among the foreign-bora Scandinavians is a matter
■
PULMONARY TUBERCULOSIS AMONG TEE BCAKDINATIANS, — ^HEAD, 471
of great importance to our national government It calls for a rigid physical
examination of tlie lungs of all immigrants from the countries of Norway,
Sweden, and Denmark,
The high mortality among the native-bom Scandinavians is of no less
concern to our State and the nation at large. It forces home upon us the con-
viction that the native-bom Scandinavians are not developing the immunity
to the disease possessed by our native Americans. Two factors play a part in
producing this high mortality — the multiplied avenues of infection to which
the children and adults are subjected through contact with others of thdr
own nationality; and, second, the lack of resistance to the tubercle bacillus,
which is a national trait of the Scandinavian people. Who shall say which of
these two factors is the more potent?
That the mortality is less among native-bom Scandinavians than among
those of foreign birth suggests the development of a natural immunity which
is the only ray of hope in this dark chapter of Scandinavian immigration in
its relation to pulmonary tuberculosis. The nation and the interested
States cannot afford to wait for the slow processes of nature to work out a
partial immunity for these people. Scientific medicine points out a far more
certain and speedy solution. In the light of our present-day knowledge, the
most effective method of dealing \Wth consumption among these people is the
isolation of those individuals affected with the disease.
IVom our study of the death records of pulmonary tuberculosis among
the Scandinavians in the State of Minnesota and in its chief city, and the com-
parison of the same with those of the registration area of the United States,
we conclude: (1) That pulmonary tuberculosis shows a higher mortality among
the Scandinavians than in any of our foreign population except the Irish.
(2) That this mortality is lower in iOnnesota than in the registration area of
the United States. (3) That the death-rate among the foreign-bom Scan-
dinavians is higher than among the native-bom Scandinavians. (4) That
the death-rate among the native-born Scandinavians is about t^ice that of the
native-bora of native mothers. (5) That the reason why Minnesota and its
chief city, with a large Scandinavian population, have such a low death-rate
from pulmonary tuberculosis is, in part at least, because of the low death-rate
among the native-bom of native parentage*
Ltingentuberkulose unter den Skandinaviem. — (Head.)
Einwanderung von Skandinaviem nach den Vereinigten Staaten. An-
aedlung in den nordwestlichen Staaten. Physischer Typus des Einwanderers^
seine Gewohnheiten, Art zu leben, InteUigenz^ Umgebung und Wirkung der
Einwanderung auf ihn. Skandinavicr eine kraftige Rasse; niedere allgemeine
Todesrate in Schweden und Norwegen. Hohe Todesrate von Lungentuber-
472
SIXTH INTEHKATXONAL CONGRESS OM TUBERCtJLOSIS.
fkulose in Schweden und Norw^ea. Tuberkulose untcr den Skandinaviem
-der Vereinigten St^aten. Todesrate von Lungentuberkulose in den Ver-
eiiii^n Staaten nicht durch die skandinavische Einwandenmg beruhrt.
Lnngentuberkulose unter den Skandinaviem der nordwestlichen Staaten.
Niedere TodesraUj von Lungentuberkulose in diesen Staaten, ^Onnesota,
ein Staat mit hohem ProaentsatsEe skaodinavischer Bevolkening und niederer
Todesrate von Lungeatuberkulose. Todesrate von Lungentuberkulose in
,Minnesota imter den fremdgeborenen Skandinaviero, die hier geborenen
ISkandinavier; in den Vemnigten Staaten geborene und die fremdgeboreneri
[ftnderer Nationen* Todesrate von Lungentuberkulose in einem registrierten
Telle der Vereinigten Staaten und in Michigan verglichen niit MinnesotA
beziigUch hier und auswarts geborener. Niedere Todesrate in Minnesota dem
Projsentsatze der niederen Todesrate der hier geborenen der \ereinigten
Staaten juzuschreiben. Die haaptsaehlichen Stadte von Minnesota mit
einem hohea Proaentsatae skandinavisuher Bevolkening und einer aiederen
Todesrate von Lungentuberkulose; UiBachen dieses diskutiert,
Todesrate in diesen Stadten von Lungentuberkulose unter den fremd*
geborenen Skandinaviem, den hier geborenen Skandinaviem, den fremd-
.geborenen anderer Natiooen und den hier geborenen der Vereinigten StaAten-
Vergleich dieser Todesratcn mit jenen von Lungentuberkulose inbenach-
barten Stadten, Diskussioa der Wirkung der Einwandenmg auf die Lun-
gentuberkulose unter der skandinavischea Rasae, Diskussion der \Mrkung
des Aufenthaltes in den Vereinigten Staaten auf die Todesrate von Lung^-
tuber kulose unter den Skandiuaviern, Schluasiolgerungen.
I
TUBERCULOSIS IN THE IRISH RACE.
By Lawrence F. Fuck, M.D.,
Fbiladalphia.
The death-rate from tuberculous of the lungs in Ireland was 2.12 per
thousand in 1902; 2.16 per thousand in 1903; 2.23 per thousand in 1904;
and 2.09 per thousand in 1905. The average for the four years was 2.15
per thousand, while during the same period the average for Scotland was
1.46 per thousand, and for England and Wales 1.21 per thousand. As
compared with these, the average during the same four years was 0.85 per
thousand for Australasia; 0.93 per thousand for Ceylon; 1.14 per thousand
for Italy, including all forms of tuberculosis; 1.20 per thousand for Belgium;
1.33 per thousand for the Netherlands; 1.41 per thousand for Japan; 1.49
per thousand for Spain; 1.53 per thousand for Jamaica; 1.69 per thousand
for the United States; 1.87 per thousand for Germany; 1.87 per thousand
for Switzerland; 1.94 per thousand for Norway; 2.79 per thousand for
Servia; and 3.36 per thousand for Austria. These data are from the United
States mortality statistics published in 1906.
The mortality from tuberculosis in the Irish race on Irish soil, as shown
by these statistics, is veiy much greater than the mortality from the disease
in any other part of Great Britain, or in any of the coimtries to which the
Irish people have emigrated. One's fu^ impulse is to ascribe this to the
oppression of the Irish in their native countiy. We have evidence, however,
to show that it is not due to this cause, nor to any conditions, habits, or
environments of Ireland itself. If it were, the Irish people in other countries,
imder other conditions and environments, ought to have a lower death-rate.
Apparently they have a higher.
It is difficult to get accurate data on the mortality from tuberculosis in
the Irish, in countries to which the Irish emigrated, because many of these
countries either have no statistics at all or have not got them in form to be
of much use. There have been statistics taken in the United States, how-
ever, which throw light upon this subject. According to the United States
Census Report of 1900, the death-rate from consumption in the re^stration
area was 1.12 per thousand for natives of native parentage; 3.39 per
thousand for natives of Irish mothers; 1.67 per thousand for natives of
473
i74
STXTH INTEHNATIONAL COXGKE8S ON TUBERCULOSIS.
German mothers; L35 per thousand for natives of EngU&h and Welsh
dothei^; 1.43 per thousand for natives of Canadian mothers; 1.70 per
thousand for natives of Scandina\"ian mothers; L72 per thousand for
natives of Scottish mothers; 1.13 per thousand for native of Italian mothers;
L84 per thousand for natives of French mothers; 1.07 per thousand for
natives of Hungarian and Bohemian mothers; 0.71 per thousand for natives
of Russian and Polish mothers; and L5S [}er thousand for nati^^es of mothera
of other foreign birth.
As sho\^Ti by these figures, the mortality from tuberculosis in the
Iriah, one generation removed from Ireland as a place of birth, under new
environments^ in a free land where, as a nile^ they are prosperous, is
one-third greater than it is in Ireland itself. With the children of
emigrant mothers from other countries the mortality is practically the
fiame as it is in the countries from which the mothers came. With some
it is a little more, and with some a little less; but with none is the
difference very striking.
The increase in mortality of children of Irish mothers reading in the
United States over that of the Irish in Ireland, is perhaps in a measure due
to change of diet and mode of life* In Ireland diet and mode of life are
both much simpler than in the United States. Overeating and overwork
are predisposing causes of tuberculosis. In the United States many people
indulge in heavy meals three times a day, eating meat at each meal. In
the struggling competition, which prevails everj-where, work is harder than
in Ireland. The Irishman who has lived a quiet, peaceful life in Ireland,
subsisting on milk, eggs, potatoes, and bread, loses his ruddy complexion
and fine physical form in the intense mode of life with ita heavy diet. His
offspring suffers somewhat by this process, and no doubt is less redsting
to tuberculosis than he himself is.
Is the higher mortality from tuberculosis in the Irish race due to hj^jer*
susceptibility or to hypo-immunity? And why does it exist? Hem we have
some interesting problems. That there is a difference between h}^rsu>
ceptibility and hypo-immunity, although the result of the two conditions
is somewhat similar, can scarcely be doubted. In hypereusceptibility
implantation takes place very easily, although development may be mild.
In hypo-immunity implantation may take place with difficulty; but when
it has taken place, development may l>e rapid and virulent. Of couraej
it goes without saying that hypersusceptibility and hj^po-immunity may
coexist.
A good illustration of apparent hypersusceptibUity with strong immunity
is found in the Jewbh race. Hebrews seem to get implantations of tubercu-
losis very easily, but to resist its development in a remarkable manner.
4
TUBEncuLosra in the i&ish race* — fuck.
475
PhysicalJy the Jews are ill-developed and below standard, showing many
of the stigmata of latent tuberculosis, and yet the mortality among thera
is very low. Often the delicate form of a Hebrew^ when carefully examined,
will show landmarks of serious damage by tuberculosis, and yet the spirit
which animates that form defies it throiigh a most active career, through a
long life to old age.
In strong contrast wHth this condition of the Hebrew is that of the
Irishman, The average Irishman is a well-developed , healthy-looking indi-
vidual. When he gets an implantation of tuberculosis, however, he goes
under rapidly. As a rule, he resists implantation fairly well, but development
poorly* The mortality in the Irish is much greater than that in the Hebrew^
and yet could a census be taken of all Irishmen and of all Hebre^vs who
have tuberculosis, it would undoubtedly be found that a much larger per-.
centage of Hebrews have tuberculosis than of Irishmen.
That the high mortality among the Irish is due rather to a hypo-immu-
nity than to a h}'persusceptibility would appear to be indicated by the fine
physical form and healthy appearance of the Irish people. Good physical
form and vigor are inconsistent with dormant or mild tuberculosis. It is
true one may have tuberculosis and look exceedingly well, and the best
physical form may get tuberculosis; but usually when a pei-son has tubercu-
losis, unless he recovers before there has been destruction of tissuCj and
unless his recovery m comj)lete, he betrays hie condition by the earmarks
of the disease in one form or anotiier.
Why the Irish should have a hj^xf-imraunity to tuberculosis is a matter
of mere speculation. My own belief is that it is due t-o immaturity in the
struggle against the disease. The shorter the time during which a race has
been exposed to tuberculosis, the less immunity that race seems to have
against the cUsease, The American Indian, who apparently had never
been in contact with tuberculosis prior to the European invasion of America,
had no immunity at all. For him implantation meant death, and to some
extent that is true still, although he has been exposed to the disease now
for four hundred years. What is tnie of the Indian is equally true of the
black race. The black race of Africa has been in contact wilh tuberculosis
for only a few hundred years, and in some parts of Africa has apparently
never been in contact with it. The black man develops tuberculosis in a
very fatal form, and this fatality seems to increase in proportion to the
shortness of time since his ancestors have left the jungles of Africa. The
Indian and the black man are, in the chronolo^ of exposure to tuber-
culosis, young races, and have not developed racial immunity. The
Hebrew, on the other hand, is perhaps the oldest race in the chronology
of exposure of which we have knowledge. They were exposed duriiig their
^
476
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
enslavement in Egyptj and probably even before that day, when they dwelt
in the far East.
Historically we have a glimpse of tuberculosis in the far East prior to
the Egyptian civilization. That the disease was prevalent in Egypt is
testified to by the Bible and by excavations. Apparently it was carried
from Egypt into Greece^ and from Greece to Rome. Hippocrates and
Galen both wrote prolifically about tuberculosis. It is not a wild speculation
i-o assume that the disease was carried with the Roman civilization into the
north of Europe. Traditionally, at least, the people of northern Europe
looked back to a time when tuberculosis waa not the scourge it became
later. Sir Thomaa Browne wrot« from London in 1690, where at that time
tuberculosis was exceedingly prevalentj and was the cause of practically one-
half of the deaths: "Some think that there were few consumptives in the
old world, when men lived much upon milk, and that the ancient inhabi-
tants of this Island were lesa troubled with coughs when they went naked
and slept in caves and woods than men now in chambers and feather beds."
If tuberculosis was brought to northern Europw by the Roman, we
have, in the intrepid, unconquerable character of the Irish race, a plau^ble
explanation of its hypo-immunity to tuberculosis. The Irish were not
conquered by the Romans, and for a much longer period than the other
races of Europve avoided contact with them. It is a younger, more immature
nation in the chronology of exposure to contagion than the other races, and
therefore has developed less racial immunity.
Mihtating against this \dew, however, is the very high mortality of Austria.
Austrians are a mixed race, it is true, and that part of Austria which is in-
habited by the oldest races, such as Poland and Bohemia, has a low mortality.
The bulk of Austria, however, is ranch nearer the old civiUzation than mother
Europe, and its very high mortality must make one chaty about Inferring too
much from the meager historical data at our command.
It is gratifpng to watch the rise of the crusade against, tuberculosis in
Ireland, coming up with the brillisincy of a sunburst. In work accomplished,
the rest of Great Britain is far ahead, but the Irish people, led by the Count-
ess of Aberdeen, are throwing theni^selves into the movement with a vehe-
mence which will accomplish great results in a short time. According
to the present outlook, the Irish race will win its emancipation from the
arch-enemy of mankind, not by the slow powers of immunity, but by the
more rational and more rapid method of the extermination of the diseaac.
La Tuberculosis en la Haza Irlandesa. — (Fuck.)
La tuberculosis es mas prevalente entre la rasa irlandesa que en ninguna
otra de las razaa europeas, excepto aquellas que habitant ciertas partes del
TUBERCULOSIS IN THB IBIBH RACB. — ^TIJCK. 477
Austria y la Servia. Esta es aun mas prevalentes en los nifios nacidos de
madres irlandesas en los Estados Unidos que en los iriandeses de Irlanda.
La actividad de la vida y la dieta tan pesada en los Estados Unidos en
contraste con la vida simple y una dieta mas natural en Irianda, probable-
mente explica la diferencia en la mortalidad entre los irlandese de Irlahda
y los de los Estados Unidos de origen irlandes.
La alta mortalidad por tuberculosis en la raza irlandesa, es probable-
mente debida a la hipoinmunidad mas bien que a la hipersuceplibilidad, la
implantadon toma lugar dificilmente, probablemente, mas cuando esta se
efectua el desarrollo es rapido y virulento. En la hipersuceptibilidad la
implantacion se efectua facilmentef mas el desarrollo es lento y la enfermedad
es leve. Hipersuceptibilidad e hipoinmunidad pueden existir jimtas.
Los judios poseen una hipersuceptibilidad, mas ellos tienen una buena
inmunidad. La tuberculosis entre los judios es muy comun, mas la mortal-
idad a consecuencia de esta afeccion no es tan marcada. Entre los iriandeses,
la afeccion es relativamente poco comun, en comparadon con los judios,
mientras que la mortalidad es grande. La mayor parte de los judios afeo-
tados de tuberculosis, sucumben por lo general a consecuendas de otra
afeccion; la mayor parte de los irlandese afectadcs de tuberculosis muren
por lo general de esta enfermedad.
De que la mortaiodad por tuberculosis entre los iriandeses es debido a
una hipoinmunidad y no a una hipersuceptibilidad, se encuentra confirmado
en la remarcable apariencia de buena salud entre los iriandeses. Buenas
formas fisicas, y vigor son inconsistentes con la tuberculosis latente o cronica.
Las formas delicadas y la apariencia de los judios forma un contraste bien
marcado con los iriandeses.
La hipoinmunidad de la raza irlandesa^ puede ser debida a la inmadurez
de la inmunidad de la raza. La raza irlandesa no ha estado expuesta a
la enfermedad por un tiempo tan prolongado como lo han estado las otras
razas.
La Tuberculose dans la Race Irlandaise. — (Fuck.)
La tuberculose est beaucoup plus fr^uente dans la race irlandaise que
chez les autres nations de I'Europe, si Ton en excepte les habitants d'une
partie de TAutriche et de la Serbie. On la trouve plus souvent encore
chez les enfants n^s aux Etats-Unis de m^res irlandaises que chez les Lrlandais
de TMande.
La vie intense et le r^me trop substantiel des lrlandais aux Etats-
Unis, compares ^ la vie simple et au regime ample de I'lrlande, expliquent
probablement la difference de la mortality des lrlandais d'Irlande et des
Lrlandais n6s aux Etats-Unis de m^res irlandaises»
478
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
La haute mortality des IrLandais par la tuber culose est probablement
due k une insuffisant^ d'immunit^ plut6t qu'^ un exc&s de susceptibility.
Dans le premier cas, rimplantation pent ^tre difficile; maLs, une fois produite,
Boa d^veloppement est aussi rapide que virulent. Dans le dernier cas,
rimplantation se fait faci5ement, mais le d^veloppraent peut toe lent et la
maladie tr5s-b^mgne, 11 peut y avoir A la fois manque d'immunit^ et e^ecds
de susceptibility.
Les Juifs ont cette susceptibility excesave, mais lis posaOdent une bonne
immuxut^. La tnorbidit6 tuberculeuse eat tr^grande chez les Juifs j mais
en revanche la mortality y est tr&s-basse. Chez les Mandais la morbidity
est rektivement peu considerable, eurtout quand on les compare aux Juifs,
mats la mortality est extreme. La plupart des Juifs chez qui il y a eu im-
plantation dc tuberculose meurent d'une autre tnaladle; la plupart dea
Irlandais atteints de tuberculose en meurent.
Que la mortality par la tuberculose dans la race irlandaise soit due plut6t
k une immunity! infdrieure qu' k une grande susceptilit^, cela semble indiqud
par la belie forme physique et I'apparence saine du peuple irlandais. Une
bonne et vigoureuse forme physique est incompatible avec la tuberculose
latente ou chronique. La fonne et Tapparence d^Hcates des Juifs font un
grand contraste avec la forme vigoureuse dee Irlandais,
L'immunit^ inf^rieure de la race irlandaise peut etre due k rimmaturit^
de rimmunit^ de race. La race irlandaise n'a pas ^t^ espos^e k la maladie
auBsi longtempB que les autres races.
Tuberkulose bei dcr IrMndischen Rasse.— ^(Flick.)
Tuberkulose ist viel mehr vorwii?gend in der irlandiscben Rasse als in
irgend einer der anderen europaiscben Rasaen, auagenommen jener, die
einen Tell von Osterreich und Serbien bevi'ohnen, Sie ist noch mehr uber-
wiegend in den Nachkommen Irlandiscber Mutter, die in den Vereinigtea
Staaten geboren werden, ab unter den Irlandem Irlands.
Dfts harte Leben und die schwere Koet in den Vereinigten Staaten Im
Gegensatsse %u dera einfachen Leben und der leichten Diat Irlands sind
vielieicht fur den Unterschied zwischen der SterblichkeLt der Irlander in
Irland und der in den Vereinigten Staaten von irlandiscben Miittem gebo-
renen Kinder verantwortlich au machen.
Die hohe Sterblichkeit an Tuberkulose in der irlandiscben Rasse ist
moglicherweise eber einer Unterimmunitat als einer UeberempfangUchkeit
auzuschreiben, Bei trnterimmunitfi-t mag eine Einpflanzung mit Schwierig-
keit Plata greifen, wenn sie es aber einmal getan hat, dann ist die Ent'wicklung
rapid untervirulent. Bei UeberempfangUchkeit mag eine Einpflanzung
TUBERCULOSIS IN THE HUSH RACE. — ^FUCK. 479
leicht vorkommen, aber die Entwicklimg kann langsam und die Elrankheit
mild sein. Ueberempfanglichkeit und Unterinununit&t k6nneQ zu gleicher
Zeit existieren.
Die Juden rand uberempfanglich, haben aber gute Immunit&t. Die
Kranklichkeit an Tuberkulose Lst unter den Juden ausserordentlich hoch,
aber die Sterblichkeit ist sehr niedrig. Bei den Irl&ndem ist die Morbidit&t
relativ, niedrig wenn man sie mit den Juden ver^eicht, wahrend die Mor-
taUtfit sehr hoch ist. Die meisten Juden, welche Tuberkulose acquirieren,
sterben an einer anderen Krankheit; die meisten Irl&nder, welche tubcr-
kulos werden, sterben daran.
Dass die Sterblichkeit an Tuberkulose unter der irl&ndischen Rasse
eher von Unterimmunitat als von Ueberempfanglichkeit abh&ngt, konnte
durch die gute korperliche Form imd das gesunde Aussehen der Irl&nder
erklart erscheinen. Gute kdrperliche Form und St&*ke mnd imvereinbar
mit schlummemder oder chronischer Tuberkulose. Der schw&chliche
Korperbau und die Erschdnimg der Juden ist in eincm starken Gegensatze
zur kraftigen Erscheinung des Irlanders.
Die Unterimmunitat der irlandischen Rasse mag die Folge einer Unreife
von Hassenimmunitat sdn. Die irl&ndische Rasse ist dieser Krankheit
noch nicht so lange ausgesetzt, als andere Rassen.
CONTRIBUTION TO THE STUDY OF TUBERCULOSIS
IN THE INDIAN.
By Dr, Ales Hrdlicka,
AAqd4tant Curatidr, irt Chfirsfi of the Divifloa of PhyaieflJ Aothropology, United Slatn XaiioD&l Mifs^um,
WflnblnfftoQ, D. C,
Tuberculosis among the Indians appeals to the physician as a diseaae
which within recent times has spread to an extraordinary extent in a special
people; and it concerns the anthropolo^st, in that it threatens to extermi-
nate before long whole units of the Indian race, and deteriorate much of the
remainder.
The presence of tuberculosis in any form among the Indians before the
advent of the whites, and in many places for a con^derable period after the
same, must be regarded^ in the light of our present knowledge, as doubtful.
It would seem to the speaker an improbable exception that an entire
race of people should be exempt from a disease so prevalent and universal
as tuljereulosis; but the weight of evidence at this date indicates Ita great
former rarity, if not absence.
There is, firsts the scarcity of references to phthisis, or other forms of the
infection^ among the Indians in the early writers; second, an absence of
remedies and other specialized forma of treatment for the disease among
the Indiana; third, we are confronted with the testimony of the old Indiana,
who declare that such disease was not known among tliem before they came
into closer contact with the whites, or that it was rare, and with the marked
freedom of the old men and women from tuberculosis of the glands or bones;
fourth, the whites who have been long in contact with the Indians ail speak
of the great increase in the disease within their memory, and the observations
of explorers and scientific men indicate its lesser frequency as we proceed
backward into the past; fifth, there is thus far an absence of lesions that
could be ascribed to tuberculosis in the bones of the Indians recovered from
old burials; and, sixth, the Indian manifests to this day less immunity
toward the disease than the white, pointing to ita later introduction or
spread. In addition, it should be recalled that the former mode of life of
the Indian, with his clothing, food, exercise, and consequent higher physical
tone, were all saf^^uards against the disease, and would have minimiaed its
frequency, even had the tubercle bacillus been present on thb soil.
4fi0
TUBERCULOSIS AMOXG THE I^'DEANS. — HRDUtKA,
4S1
It is difE-cuIt to determine when tuberculoiiis among the Indians^-or
rather among the separate tribes^ for they differ in this res]>ect— began to
^read. Actual knowledge regarding the sanitary conditions in the race
only began to accumulate after the contact of the Army and Indian Service
medical men with the people. Records in print concerning the infection are
scarce, and all pertain to the last seven or eight decades, those of Treon and
of Matthews deserving especial attention.* An approach to regular, definite
information was made about twenty-five years ago, when the Indian Office
obliged its physicians to present periodical sanitary reports on the condition
of the Indians among whom they served^ but, owing to peculiarities of the
aer\'ice, these reports are not always complete or accurate^ which nuikes it
difficult to utilise them for scientific purposes. The firtft extensive published
data, relating to tuberculosis in Indians, are found in the United Stat*^8
Census^ particularly for 1890 and 1900; but they, also, cannot be regarded
as wholly reliable.
Direct research into the subject of tuberculosis among the Indians is a
matter of recent years only, and is, in fact, as yet in its beginnings. In 1894
Dr, H, R. Bull published observations on the disease among the pupils of
the large non-reservation school at Grand Junction, Colorado;! ^ series of
statistics has been collected among the Sioux within the last fifteen years
and reported by Dr. J. R. Walker;^ in 1906 an account of the disease in
Arizona and New Mexico was published by Dr. L W. Brewer;§ and a year
later an interesting paper in this line appeared by Dr. Woods HutcMnson.j]
Since 1908, inquiries as to the disease have been carried on among the various
tribes of the southwest and of noilhem Mexico by the speakefj and in 1904
he collected, under the auspices of the Indian Office, information from all
ph3^cians in the Indian Service on tuberculous morbidity among the In-
dians; the results of these studies have just appeare<:l as A Bulletin of the
Bureau of American Ethnology. Tf At the commencement of last summer the
Indian Office called on its physicians for statistics as to the mortality from
tulierculoais during the past fiscal year, and the resulta, abstracted by the
•Treon, F-: "Consumption among the Sioux iinliana," Cincin, Lancet -Clinic,
18S9, N. S., xxiii, 14S-1S4. Matthews, Wnahingtoni "Caufiumptlon aruon^ the In-
diana/' Trans. Amer. CUm. Assoc., Phila., I8S6, 234-241, ** Further Contribution to
the Study qf Confiumptioti among the Indiansi" Ibid-. 1888, 136-156, For further
reference see Bull. 34, Bureau Am. Ethn., 1908.
t "Tuberculosis oniDng the Indians," Tr. CoL Med. Soc., Denver, \^9i, 314-321.
t *'Tuberculosis among the Oglida Sioux IndJarm/' Am. Jour. M&d. Soi.. Phila,
and N. Y., 1906. N. S., cxxxii, 600-605.
$ "Tuber(^Likitii4' anioiig the Indiana of Arizona and New Mexico/' N. Y. Med.
Jour., 1906, IxEciv. 981-983.
ll^Varieties of Tuberculofiis accoitling to Elace and Social ConcUtion,** N. V. M«l*
Jour., Oct. 3 and 12, 1907,
IjHrdlicka, A16j: Physiological and Medical Obsorvationa among the Indians of
South ^vestorn United 8tateu and Northern Mexico; Bull. 34, Bur. .A^. Klliuul.^ I908j
i-x, 1-125.
VOL. Itl— 16
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484
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS,
author^ are eliown in the accompanying table (Table I). Finally, in prep-
aration for the International Congress on Tuberculosis, the Indian Office
and the Smithjsonian Institution called on the author for a plan of brief,
direct research into the subject in a number of selected tribes^ and detailed
him, with Dr, P. B. Johnson, bacteriologist, to carry out this investigation*
Its outcome is presented to the Congress in a separate exhibit of charts
II to V, and in this communication.
The special work just mentioned extended to five tribes, which by the
former reports on morbidity were shown to be among the most affected with
tuberculosis, and to one of the large non-reservation schoolsp The tribes
in question were the Menominee, northeastern Wisconsin; the Oglala Sioux,
South Dakotaj the Quinault, on the sea-coast and along the river of the
same name, northwestern Washington; the Hupa, northwestern California;
and the Mohave, on the Coloradoj between Needles and Yuma* The school
was that at Phoenix, Arizona,
The tribes were selected not only in view of the prevalence of tubercido-
sis, but also because they differ widely in regard to climate, environment,
civilization, and mixture with whites; and the investigation was carried on
during the two months of midsummer, when the people everywhere are
mob-t free from various bronchial and pulmonary affections that might com-
plicate diagnosis.
On account of the short time available and the extensive ground to
cover, the study had to be limited to what was most essential toward ob-
taining reliable statistics and observations. In the two larger tribes, the
Menominee and Sioux, where it weis impossible to include all, it was extended
in each to one hundred families.
The actual work consisted in vbiting every dwelling and making a per-
Bonal escamination of every member of each family, healthy or not healthy.
Each one who could be reached was subjectcfl to an examination of the lungs
and heart, inspection of the glands of the nock, an<l an inspection as well as
inquiries, regarding the skeleton. Ordinarilyj but little questioning was
done, as this takes much time with the Indian and is often unsatisfactory;
but an effort was made to obtain full anamnesis in all cases where abnormal
condition of the lungs, pointing to ttiberciilosis, was detected* Inquiries
were al.^o made with each individual regarding glandular swellings in the
past wliich did not suppurate; it was found, however', that the positive
answers applied to diffei^nt conditions, that the exact nature of the swell-
ings could not always be discriniinatetl^ and as a result all data obtained on
this item were abandoned. Wlienever a case in which phthisis could be
suspected was come across, an effort waa made to secure a sample of the
sputum, wtiich was sent back to the bacteriologist, who meanwhile fitted
himself out in a convenient phice at the agency. The endeavor to obtain
TUBERCULOSIS AUQNO THE IKDIANS.— HRDUCKA,
4S5
a satisfactory isample of what was coughed up by the patieut was, however, not
always successful. Tuberculin tests would have been very desirable, but,
owing to lack of time and the susceptibihties of the Indians, they had to be
excluded.
In making the reconis the cases w^re divided into those in which the
presence of tubercle bacilli or the physical condition and history of the patient
allowed no doubt of the nature of the disease, and those in which the diagno-
sis was not quite certain* The data regarding tuberculous neck-glands were
reduced to three categories, namely, "had, suppurated," "has, suppurated/'
and "has, not suppurated/' Under the last were included only those in
whom the enlarged glands were visible and of prolonged standing. The
number of cases in which some enlargement is palpable, but not visible, is
much larger, but is quite impossible of exact determination and non-tubercu-
lar enlargements of shorter duration are not infrequent.
The study was helped along every^where by the Indians themselves, who
welcomed an Inquiry into the condition which is dedmating them, and
against which they feel utterly helpless. In many cases absent members of
the family were brought for examination from miles of distance.
The results of the investigation would best be presented tribe by tribe^ but
the Umited time makes it necessary t^ give the whole in a more concrete form.
The principal statistical details will be found in the accompanying charts.
The tribes studied include some composed almost entirely of mixed breeds,
and some that are still almost wholly fuU-bloods; they differ widely in grade
of civiUssation; their reservations are much unlike in topography, soil,
extent of woods and quantity of water; the chmate ranges from one extreme
of that of the moderate zone to the other, and from one with excessive moist-
ure and sub-average quantity of sunshine, to one quite arid and with pro-
portion of sunshine far above the medium; they diifer in occupation, being
woodsmen, or fishermen, or farmers, while in one tribe they do but little
work of any nature; their habitations range from an open brush shelter to a
substantial, well furnished frame dwelling; they all approach the whites in
clothing; in foods, some have relative abundance, others often a scarcity;
some live predominantly on meat, others on fish, and etHl others on a mixed
dietj a large proportion of which consists of native seeds, fruits, and greens.
Alcoholism is frequent in one of the tribes only; uncleanliness prevails, but
it is principally found with tlie old people; some of the Indiana are as domes-
tic in their habits as the whites, while others, such as the Sioux, like greatly
to move about and visit from place to place; frequent exposure in inclement
weather is a serious factor in some localities, and insignificant in othei^s.
And, lastly, these Indians belong to more than one physical type. Yet,
notwithstanding these many differences, they suflfer greatly, and in quite
alike proportionsj from tuberculosis in its varioua forms, tlie frequency of
486
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
the disease being withiJ much in excess of th&t among the whites living in
the same regions*
TABLE IL— TUBERCULOSIS IN THE INDUNS.
Hw&m/m OF Ejumojatjow, Jult, 1908, or 100 Familt Groups or ram
1907-OS Cenaufl of whole tribe = 1406; censiia for previous y^ir = 1375.
Birtbn during imcal year 19Q7-QB'=h2; deaths '=61; deatofi from tuberculofiia 12, of
which pulmonary 11 (=8.0 per loUO popul&tioD).
Total number of individuals in the 100 groupe =403 | ^ femaJ«
Caeefi of phthiaia po»itivdy established, 16 (4.0^) ( T 8 ( tw)
Cases iudicatiDg phthisiB, but admitting doubt, 20
/m. 8
\L 12
Nature of the diseaae (positive cases) , , .
1 ( 6.0^,)
3 (19^0%)
12 (75.0%)
14 (77,8%)
2 (11 1%)
2 (11.1%)
II \ 34 (84.4 per 1000 exam-
3 ; ined)
acute .,,,,,.. f .*-,.... .
subacute..* , , , . . , .
chronic
Distribution of pofiitive caeea according [ aduita (above 20).*.. ., ,
to age , , ,..-.. i. adnlesM*<?nts (14 to 20 incl.
[ children (below 14).*....
TuberculosU of neck-glanda T bad, suppumted.. .... 3
(acfof ula) -I have, suppurated ..... 3
[ have, not suppurated, H
Tulwreulosis of bonea^ healed 3; active 2.
Individual free from a.11 suspicion of phthisis and from all other forma of tuberculosui
=316 (78.5%).
Family groups free from all fiigns of phthifiid and from oU other forms of tuberculoeis
-40(40%-!),
TABLE IIL— TUBERCULOSIS IN THE INDIANS.
Results of Examination, JulTj 1908, op 100 Family Groupb or tbi
OqI'ALa Sioux.
Census of whole tribe =5663^ cenaua for previoufl year =6681.
Births during fiscal year 1907-08-392; deaths =310; deailia in 4 districta, or 4099
population, from tuberculosiB 67; of which pulmonary 51 (b>12,4 per 1000
population).
Total number of individuals in the 100 groups examined -428 j ^ fcmaLs
Ctaeosof phthisis positively CHtabliahed, 21(4.9%).., , {ri2{ SWl
Cases Indicating phthisis, but admitting doubt, 34...,,,. I * \^
Nature of the disease (positive cases) . . ,
Dtstributton of pottitive cased according
lo age.. .,,..».,.....
acute ,.,.,*
subacute
chronic .................
adults (above 20) ,
adolc^-^nt^ (14 to 20 incL)
children (below 14) ..*....
0 ( 0.0%)
5 (24.0%)
16 (75.0%)
17 (81.0%)
2 ( &.5%)
2 { ^.5%)
Tuberrutosis of neck-glands { had, suppurated... .. . 25 \ 32 (74.8 per 1000 exam-
(scrofula) .,.....-....-. i have, suppurated .... 7 / ined)
[ havcj not suppurated, U
Tuberculosis of bones, healed 6; activo 3.
Individuals free from all ^uspieion of pbthi^i^ and from all other forma of tubercuIoBiB
-333 (75.5%).
Family g^roupH free from all signs of phthisis and from all other forms of tubcrculoaia
^3-1 (34% Of 1).
TUBERCULOSIS AMONG THE INDIANS. — HHDU<aCA. 487
TABLE IV.— TUBERCULOSIS IN THE INDIANS.
RcsiTLTs OP Examination, August, 1908, op 15 Fauilt Groups op ths
QUINAIOB.
Census for previous year=141; for present year=142.
Total niunber of individuals in the 16 groups examined —62 | ^ ?*^?J^
Cases of phthisis positively established, 3 (4.8%) I™ 2 f 61^)
Cases indicating phthisis, but admitting doubt, 5 l^' ?
Nature of the disease (positive cases) . .
Distribution of positive cases according
to age
acute 0 ( 0.0%)
subacute 0 ( 0.0%)
chronic 3 (10.0%)
adults (above 20) 2 (66.7%)
adolescents (14 to 20 incl.) . 1 (33.3%)
children (below 14) 0 ( 0.0%)
Tuberculosis of neck-glands f had, suppurated I \ t /tai •_ m/ww
(scrofula) .^. . . ] has, suppurated 0 / ^ ^^^^ '° ^^'<*^>
[ has, not suppurated . . 2
Tuberculosis of bones, 0.
Individuals free from all suspicion of phthisis and from all other forms of tuberculosis
-50 (81%).
Family groups free from all signs of phthisis and from all other forms of tuberculoeis
-6 (40%).
TABLE v.— TUBERCULOSIS IN THE INDIANS.
Results op Examination, August, 1908, of 87 Family Groups op thb Hupa.
Census of whole tribe— 426; census for previous yearM424.
Births during fiscal year 1907-08—8; deaths— 9; deaths from tuberculosis— 6; of
which pulmonary 4 (—9.43 per 1000 population).
Total number of individuals in the 87 groups examined -331 { |S ?^?|^
Cases of phthisis positively established, 9 (2.7%) /™' ^i fg^)
Cases indicating phthisis, but admitting doubt, 20 / f* 10
f acute 0 ( 0,0%)
Nature of the disease (positive ciises) . . . < subacute 3 (33.3%)
[ chronic 6 (66.7%)
Distribution of positive cases according f adults (above 20) 5 (55.6%)
to age \ adolescents (14 to 20 incl.) . 3 (33.3%)
I children (below 14) 1 (11.1%)
Tuberculosis of neck-g^ds
(scrofula)
had, suppurated 21 \ 27 (81.6 per 1000 exam-
has, suppurated 6 / ined)
has, not suppurated . . 13
Tuberculoeis of bones healed 4; active 1.
Individuals free from all suspicion of phthisis and from all other forms of tuberculosis
-257 (77.6%).
Family groups free from all signs of phthisis and from all other forms of tuberculosis
-30 (34.5%, or little over J).
TABLE VI.— TUBERCULOSIS IN THE INDIANS.
Results of Examination, Augubt, 1908, op 79 Family Qboups or the
Colorado River Mohave,
Census of whole tribe— 465: census for previous year— 482.
Births during fiscal year 1907-08-14; deaths -31; deaths from tuberculosis 7; of
which pulmonary 6 ( — 12.5 per 1000 population).
488
SIXTH INTERN ATION At CONGRESS ON TtTBERCtTLOSIS.
Total Dumber of mdivldimla in the 79 groups e?camiiied ^357
Caaefi of pbttuAU positively cBtablished, 15 (4.2%)
Cabss indicating pbthieis, but admitting doubtj 10 .,»....... .
Nature of the dtaeaae (poaitive caises) . . .
acute.,.,
subacute
chronic . .
1S5 males
ITS females
m,7 ( ZS%)
t S C 4-6%)
m. 2
f . B
0 i 0.0%)
4 <27
11 (73
%)
%)
Diatribmtton of positive rases according f adults (above 20) ,,.,...
to aj^e ,.,..,,, \ adolescents (14 to 20 inel.
cbildr^D (below 14),,,,.
13 (86.7%)
1 ( fi.7%)
1 ( 6.7%)
Tul>ercula»ia of neck-glands f had, suppurate 18 \ 21 (—588 p^r 1000 ex-
- \J i ■ '
atnined)
(scrofula). ,,.,,.,...... ^ have, suppurated ■ * , . .
have, not suppurated .
Tuberculosis of bones healed 1; active 3.
Individuals free from all suspicion of phtblsia and from all other forma
-315 (88.2%).
Family groupEi free from all signs of pbthiaiii and from aJl other forma
-46 (58.2%).
of tuberculosis
of tuberculosis
The causes of tbe prevalence are multiple. The most important of all
factors is the facility of infection. The average Indian has no idea of the
nature of tuberculosis and the possible methods of its propagation. The
tuberculous are in no way isolated; they eat with the same utenailfl as the
rest of the family, and these are not effectively cleaned. Their soiled
clothing is in no case washetl separately. They expectorate on the floor,
about the house, and wherever they go, without any reatraint. Articles
such as pipes^ fruit, spoons, and dishes, which a patient has held in Ids
mouth, are frequently passed, without any cleansingf to others. The pipe-
passing habit is particularly in vogue among the Sioux. And at the Bchools,
and occasionally on the reservations, bugles and other wind instru-
mente, never sterilize<l, pass from mouth to mouth. Infection through
actual contact of the lips need not be conaidered, because of the rarity of
kissing in the Indian. On the other hand, the danger from using the same
utensils in eating and drinking is greater than in whites, for there are still In
use wooden spoons and basket or gourd dishes, which are more difficult to
clean than metal or crockery articles. The danger of infection from expiec-
toration is of particularly high d^ree in dwellings with earthen or sand
floors, such as are still common among the Siouji and tbe Mohave* The
healthy and the unhealthy spit freely on these floors, the sputum being
usually covered with a pinch of sand or earth, and thus remaining* lis
removal is at best rare and imperfect, and often, as in the pole-and<bnish
dwellings built on sand, impossible. In a dwelling where a consumptive has
lived for some weeks or months the earthen or sand floor cannot but be
badly infected, and the dust from it be very dangerous to others in the
TUBERCUIXffllS AHONG THE rNDIANS. — HHDUCKA.
480
family &a weU as to visitors. Besides this, in almost every dwelling where
consumptives were found there were also seen on the floor articles^ such as
bags^ quilts, blankets, etc., which are never washed or otherwise cleaned^
and must, in the course of tinie, become impregnated with the infected dust
if not soiled with the direct expectoration.
All exposure to wet and cold which is liable to bring on abnormal condi-
tions of the respiratory apparatus, actual diseases of the bronchi and the
lungs, favor strongly the development of pulmonary tuberculosis in the
Indian, who frequently neglects such conditions. Many of the patients who
are questioned date the beginning of their tuberculous lung trouble from
an attack of pneumonia, bad cold or influenza, and even measles. The
infection in such cases would, however, be less frequent were the presence
of the infecting bacillus less common.
The influence of other diaeases outside those of the respiratory tract on
tuberculosis among the Indians is not certain; that of syphiLs has surely
been overrated* Parasitic conditions need special attention. Heart disease
— mitral insufficiency of rheumatic origin — ia very common among the
Menominee, nearly 30 per cent, of the whole population being thus affected j
but no causative relation could be detected between this trouble and
tuberculoeds.
Dissipation, indolence, and all other debilitating conditions ^ntribute
doubtless as much to the susceptibility of the Indian to tuberculous infection
as they do among the whites. In this category must also be classed the
effects of closer intermarriage^ rendered necessary, especially in the smaller
tribes, by the system of reservations.
Seventh: Want and consequent debihtation are surely responsible for
not a small percentage of the cases of puImonarTp-^ tuberculosis among the
Indians. This is particularly true of the old people, who, often of neceo-
mty, habit, and other causes, are neglected by their relatives. There ex-
ifits, however, also, a certain form of marasmus not visible to the casual
observer, among the younger Imiians in certain localities, due to food
which, while sufficient to sust-ain Hfe, furnishes, on account of either its
quantity or quality, but little surplus or storage of energy. With such
people any extraordinary demand on the forces of the body is liable to be
followed by a breaking down in which they become easy victims of tuber-
culous infection.
In the non-reservation schools an etiological factor of much importance
is the depressing effect on the newly arrived child of the numerous regula-
^ODs in vogue in these institutions, A child taken from a reservation, and
used hitherto to an almost unlimited degree of freedom of movement and
will, is subjected to discipline which extends to from four-fifths to nine-tenths
490
SIXTH INTERNATIONAL CONGRESS ON TtTBERCULOSIS.
of its waking hours. This, with the additional exertion of learning in a
strange language, the strain of atlditional lectures or preaching in the even-
ing, a change of associations accompanied by more or less of homesickness,
often a lack of sufficient or diversified outdoor exercise, with food to which
the child is not accu>storaed^ anil in which, In some places, there is much
sameness, cannot but have a depressing and physically exhausting effect on
the pupil which makes him easier prey to consumption.
It was noticetl that on the reservations^ as well as in tlie schools, white
consumptives come in contact with the Indians, and these are not guarded
enough jigainst contact with diseased whites, which can only increase the
Indians chances for acquiring the infection.
It was found that some of the tribes, particularly the Menoniinee, poBseas
a number of cows^ the milk from which is used especially by the children
in their families. None of these cows, in any of the places visited, have
ever been tested for tuberculosis. In one place some of them are seen daily
feeding along a much frequented road where a part of the grass must have
l>een soiled by the expectorations of passing consumptives.
The majority of the cases of phthisis in the Indian begin^ as in the whites,
in the rainy or cold season, and the disease manifests itself in two main forms,
namely f (1) the acute, or rapid course, entUng fatally within a few weeks or
months, and (2) the chronic form, of irregular progress, often of years' dura-
tion, and not seldom manifesting periods of tendency toward recovery.
The rapid phases are characterized by all the symptoms met with in simi-
larly acut-e conditions among the whites. The subacute, and especially the
clu'onic cases, show some interesting differences. These are found mainly
on percussion, and consist in the absence^ in the Indian, of pronounced dull-
ness. Among the many chronic cases examined there was no instance in
which the dullness of the infected lobes was as pronounced as we often find it
in the whites; and in numerous cases where the presence of the bacilh con-
firmed the otherwise made diagnods, it would have been impossible to make
the same on the basis of the results of percussion. In cases of many years'
duration, and in those who have recovered from chronic phthisis, there
is a more or l^s flat sound over the apices or whole upper lobes, which differs
from the dullness of consolidation. In the acute cases seen in former >*ears
dullness seemed to be present to a greater degree. lu a largo proportion
of the more severe cases a secondary infection of the larynx is noticeable.
Blood-spitting seems to be the rule in these chronic cases^ but large hemor-
rhages are heard of seldom. The upjier lobes — the right and left in about
the same proportion — api>ear, as a rule, to be affected firsts and suffer always
to a greater extent than the lower.
The acute form is seen predominantly in adolescents and young adults.
TUBERCULOSIS AMONG THE INDIANS. — HEDUCKA.
491
and occurs mostly in winter or spring; the chroaic form is noticed more, but
by no meana exclusively, among the adults and the old, and is best observed
in summer. The sexes seem to be susceptible in nearly the same propor-
tion. The mixed-breeds, proceeding from regular marriages between the
Indian and the whites, appear to be freer from the disease than either the
full-bloods or the raixed-breeds due to clandestine unions.
One of the most important results of the investigation was the finding of
a considerable number of cases on the way to recovery or actually recovoted.
Such cases were seen in all the tribes, and in a number of instances have been
watched for years by the local physician. These cases prove clearly that
pulmonary tul^erculosis is by no mc-ans always fatal in the Indian, and jua-
tify any steps that may be taken for the cure of the Indian consumptive.
A word about glandular tuberculosis. Taking only cases in whiuh the
cervical glands were affected and have suppurated, their frequency ranged
among the different tribes from 6 to 9 per cent. Some of the cases were of
great severity.
As to other forms of tuberculosis ^ it was found that the disease is eape^
daily apt to manifest itself in the meningeal form in 3'ounger children, while
in older ones and in adolescents it attacks the bones, preferably the spine,
hip-joint, riba, or tibia. Abdotnlnal tuberculosis seems to appear only as
a complication of other forms. Lupus is rare.
The prevention and cure of tuberculosis in the Indians are only in their
be^nnings. It must be regarde<l as a misfortune for the Indian that be
is so isolated from the whites. Had he been in close contact with the same,
the white man in taking care of himself would have been obliged, before this,
at the same time to take care of the Indian, and tuberculosis would not have
acquired in the latter such proportions. But even as it is, steps will have
to be devised for curbing the infection on the reservations, for, besides all
considerations regarding the Indian himself, the white man needs to act
for self-protection.
The subject of ** Fighting the Scourge among the Indians" will be dis-
cussed more extensively in another paper before this Congress by the most
progressive man the Indian Ser\'ice has known, namely, Mr. Leupp, the
Indian Commissioner, and 1 shall myself enumerate the more important re-
medial steps as they appear on the basis of our investigation.
In the struggle agoinst the disease among the Indians the first, most
important, and most difEcult task will be the combat of ignorance. The
Indian must be taught how to live, how to prepare his food^ how to take care
of his sick, what precautions to use against the spread of consumption*
And this teaching must Ije applied not only to the grown by means of lectures,
demonstrations, special bulletins, and through the physicians, but, above
SIXTH INTERNATIONAL CONGBESB ON TUBERCULOSIS.
all, by meims of regular instruction to the childrenj from their entrance into
the Bchools, for the children are free from many of the prejudices of the
adult' Indian, and what is imparted to them in a proper way will become a
stable part of their mental equipment, regulating their actions. Not only
that, but the children thus instructed will themselves influence, more than
the outsider could, their parents and relations, Care must be taken, how-
ever, to make the hygienic rules not a burden of blindly accepted dogmas,
but a part of the clear understanding of the Indiiin, Instruction in this line
is entirely practicable at the great majority of the reservations and in the
larger schools.
An immediate urgency is the introduction of some simple and practiciU
means for the disposal of the in/ected sputum of the tuberculous Indian.
Practical steps should be taken without delay to improve the hygienic con-
ditions of the people. Cleanliness would be greatly fostered by monthly
inspection of the dwellings by the Indian police, instructed by the phy^cian.
An ideal sj'stem of counteracting the spread of pulmonarj^ tuberculosis on
the reservations would be the isolation^ in special camps or dwellings, of all
cas^ of the disease, under the care of the nurse and the physician. The
difficulties are the expense and reluctance of the Indians to part with an
ailing member of the family. The proposition, nevertheless, is practicable,
but will demand careful study of the local conditions on each separate
reservation.
In the line of prevention it is further urgent that wherever possible the
earthen floors of the dwellings give place to those made of boards, which, as
a rulej can be aud are kept cleaner. The habit of passing the pipe should be
discouraged, and the same applies to the use and passing of dishes and spoons
that cannot be properly cleaned. The use of clothing worn by consumptives
an<l of articles made in their houses should be prohibited until these shall
have been rendered aseptic. In this connection it is well to point to the
advisability of obliging the dealers in Indian curios to disinfect all fabrics
and old articles coming from the reservations. Such articles lie often on the
floor of the infected dwelling and not a few are made (exclusive of the Navajo
rugs, the Navajo being still about the healthiast of our Indians) by consump-
tives* The danger of handling such articles before disinfection needs to be
well appreciated also in the various museuma.
With all the means employed more directly against the disease, an im-
provement is n^<led in the nutrition of many of the Indiana, particularly
the old. More suitable and paying work for the able men would, above all,
be beneficiaK Alcoholism ought to be repressed. Inclination to drink is,
however, often due, as in whites, to a deficiency of proper nourishment.
The ludian medical service needs attention, and no effort should be spared
TUBERCtTLOaie AltfOKG THE INMANB.^HRDUCKA.
493
to bring it, where it can be dispensed with in favor of free phyf^icions and
pharmacists, to the possible maximum efficiency.
Special prerautions are called for in the large, and particularly the non-
reservation, schools. As it is, the latter are dangerous institutions for the
health of the pupils. Introduction of the chikl into the changed conditions
of life should be more gradual ; ample means of outdoor play, as well as more
of systematic and pleaaurabie exercise, are needed; swimming-pools must
not be allowed to become polluted; more variety of food and less rules of
the table, and more attention to individual pupils, would be teneficial;
the mouth*pie(^3 of musical inatnmients, cups for water, and faucets demand
regular disinfection, and indiscriminate use of the musical instruments
should be discouraged. Excursions away from the school^ particularly into
the hills, have shown very encouraging effects on the children. Finally,
all pupils who begin to ail should, without delay, and without being made to
feel that they are seriously illp tie separated from the others, relieved of
school duties, and given special attention, particularly in regard to food and
outing. As it is, the child is left until it has a well-developed case of phthisis,
and then sent back to the reserv^ation. The school-rooms are generally
good, yet the open-air school-room about to be introduced by the Indian
authoritie.s must be regarded as a step in the right direction ; the principle,
however^ should be extended, wherever possible, also to the workrooms for
the children and the dining-rooms.
If speedy progress can t)e effected along the above lines, it is certain that
the mortality as well as the morbidity of tuberculosis among the Indians
will be much lessened. If not, there is nothing to look for except a gradual
aggravation of the condition, and in many places the Indian's annihilation.
*
Tuberculosis Entre los Indios, — (Hrducea.)
Desde 1898 el autor ha hecho averiguaciones sobre la tuberculosis ^ntre
los Indios, en conexi6n con otros trabajos. En 1904 se reunieron estadfs-
ticas sobre esta enfermedad, bajo sri direeei(5n, en todas las esculaa y
reservas de los Estados Unidos; y durante los meses de verano de este atio
se emprendid por 61 una espedici6n para el estudio directo de la enfermedad
y para suministmr una conveniente exhibici6n para el Congreso Interna-
cional de Tuberculosis por cuenta de la Oficina <le Indios y el Institute
Smithsonian. El Dr. P. P. Johnson acompafi6 al Dr. Hrdlicka en este viaje
como bacteriologist a. La investigaci^n fu6 llevada A cabo diu^ante la mitad
del verano, cuando podfa contarse que los Indios estuviesen librcs de toda
afeccidn catarral de la via respiratoria que pudiera complicar el diagn6stico.
El estudio se extendi^ ^ cinco tribus de las m&& afectadas por tuberculous
i
404
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS,
y en un& de las mas grandes escuela no de leserva. Las tribus elejidaa
difieren auipliamente respecto §, sua alrededores y iriodo de vida. Fueroa
la Menominee (Wis.); la Oglala Sioux {S, D.); la Quinault (N. W. Wash,);
la Hoopa (Cal,), y la Mohave (Cuenca del Rio Colorado, Arizona)* La
escuela incluida de no reserva fue la de Phoenix, Arizona,
Eo todas estas localidodes se encontr^ que la tuberculosis en todas sua
fonnas era prevalente. Las causas, y especial mente las causas de la propa-
gacidn de la forma pulmonary son mi^ltiples^ En su oaturateza la enfermedad
pulmonar ea generalmente cr6nica, 6 sub-aguda, y solo excepcionalmente
aguda. Afecta ambos sexo y d todas la edades, Es generalmenete mortal,
pero no son poco comunea caaos de contensi6n de la enfermedad y aun de
restablecimiento mis 6 menos completo. El tratamiento de la tubercu-
losis entre todas estaa tribus ea muy imperfecto. Ellos mismos estdn en
este cuanto enteramente ignorantes y ain ayuda. Ea un problema complejo
el procediniiento que deba seguirse en el futuro con esta enfermedad, pues
envuelve la necesidad de batallar contra todas las dificultadee que se en-
cuentran entre los blancos pobres, y adem^ con obstiiculos desconocidoa
en la raza blanca, Stnembargo^ es posible indicar sicrto ntlmero de puntos
en los cuaJes pueden darse passe prActicas immediatamente que resulten en
beneficio de loa Indloa, Principal mente debe ejercerse, como entre los
blaacos, en la prevenai6n, de la infeccidn^ mientras que en el tratamiento
de la eufennedad el primer cuidEdo debe dedicarae i la CQiidici^n del sistema
del paciente.
SECTION V.
Hygienic, Social, Industrial, and Economic Aspects
of Tuberculosis {Continued).
FIFTH SESSION.
Thursday, October 1, 1908, 9.30 A.M.
NURSING IN ITS RELATION TO TUBERCULOSIS.
This meeting was arranged by a special committee of nurses, of which
Miss M. Adelaide Nutting was chairman, and Miss Lavinia L. Dock secretaiy.
The other members of the committee were:
Mrs. Hunter Robb, Cleveland. Miss S. H. Cabaniss, Richmond.
Miss Anna Maxwell, New York. Miss Isabel Strong, Washington.
Miss Annie Goodrich, New York. Miss Matilda Johnson, Cleveland.
Miss Harriet Fuimer, Chicago. Miss Louie C. Boyd, Denver.
Miss Tillinghast, Chicago. Miss Lucy Fisher, San Francisco.
Miss Lillian D. Wald, New York. Mrs. Quintard, Philadelphia.
Miss Jane Hitchcock, New York. Mrs. Lupinski, Grand Rapids, Bfich.
Miss Mary McKecknie, Orange, N. J. Mrs. Gretter, Detroit, Mich.
Miss Elizabeth Upjohn, Boston. Miss Maiy Kershaw, Columbus, Ohio.
Miss Martha Stark, Boston. Miss Maiy Hills, New Haven, Conn.
Miss Louise Coleman, Boston. Bfiss Mary Gardner, Providence, R. I.
Miss Mary E. Lent, Baltimore. Miss Florence Baldwin, Portland, O.
Miss Ellen Lamotte, Baltimore.
Miss Annie Damer, Yorktown Heights, N, Y.
In the absence of Miss Nutting, Bfiss Lillian D. Wald presided. The
meeting was called to order at half past nine o'clock.
405
EXPERIENCES OF A SANITARY INSPECTOR WITH
TUBERCULOSIS.
Bt Johanna von Wagner,
With no raortgage on fresh air^ nor trust to monopolize the supply, it
seems unnecessary' to have the largest death-rate from a disease which is
directly due to the lack of air and light. When the general public knows
more about the laws of health, dark unwholesome dwellings will not be
rented any more, even if advertised as very cheap, because disease is too
expensive for most people. We have improved building laws, so that wet
cellars, dark, unventilated halls, and air-shaft rooms will soon be crimes of
the past,
Cleanliness, real surgical cleanliness, as known in hospitals, will have to
be introduced in households to safeguard the family. Sanitary chemistry
will do a great deal to improve household hygiene. Underfed and neglected
children, such as are found in drunkards' homes, should be taken care of in
proper institutions, and the tribute to untimely death will be lessened. The
h»ck of cleanliness I hold responsible for much tuberculosis in our congested
tenement-house districts. Suppose I wish to be clean; but my neighbor
docs not wish to be, does not recognize his duty to the community, expec*
toratee in public places, is not clean in dre^ or person^ inside or outside his
dwelling, I shall surely suffer, as all humanity forms one chain, not stronger
than its Tveakest link. Give us clean air, clean water, dean food, clean
utensila, clean bodies, clothes, homes, and streets; and the record of preven-
table diseases will become a part of our past, painful history.
The musty smell of damp cellar air, the collective o<.lor of six or twelve
family cookings, the odors of overcrowded bedrooms, all that we notice on
entering the usual tenementr-house; the pernicious habit of two or three
uiembers of one family .sharing one bed, the fear of night^air — let us live in
these conditions and soon we see the decline of health and beginning of tu-
berculosis. The mother, who is most confined at home» is usually the first
victim, the baby and other members of the family following, until in some
instances whole families are wiped out. The mother coughs very often
into her handa or apron, prepares the food with unclean hands, her breath
coming in close contact with it, tasting it, sowing germs broadcast.
496
EXPEHIENCBS OP A SANXTART INSPECTOH. — VOy WAGNER.
One day while visiting a woman who had lost all belonging to her from
this disease, I saw an illustration of this kind: She stopped m the middle
of getting her meal and said^ "I must get some of Jim's letters and papers
for you to read**' These letters had been kept in a box abice his death
without being fumigated, and looked over often by other members of the
family. All had died but the parents. The woman Icwked them all over,
handed them to me, and went on preparing the meal without washing her
handSj cutting bread and cake and offering me a piece because it was home-
made.
In another house I found a man with tuberculosis of the throatj and
beside him a pan of ashes for the discharges. 1 asked him what was done
with the ashea, and wjis told that they had a double purpose — to fill in the
yard and make a seratching-ground for the chickens. On my way to the
street I passed through the yard, found the chickens enjoying the rough
ashes, and, far worse, the children of six families digging in them, as more
fortunate ones do in the sand.
In a Slavic home, where the mother of the family had the disease in its
last stage, her bed, in the kitchen, was shared by husband and three children,
the baby l:«side her in a cradle, the bedrooms sublet to boarders. The
woman had to get out of bed three times a day to prepare the meals for the
family and boarders. It was near noon, and the patient was staggering
around from table to stove, coughing ternblyj using her hands to expectorate
in; also tearing the meat and tomatoes in pieces at the same time, putting
thera in a frying-pan, cutting bread and getting the coffee kettle to boil, and
the meal was ready. 1 begged of her t-o stay in betl and let the boarders
look after their own meals, but she said her husband would beat her if she
did not get up^ so I waited to see the husband, and told him his wife needed
a doctor, good care, and a bedroom to herself, and as 1 had found out that
he could well afford it, told him it must be done. The man was furious, and
said: "My wife, she is no more good to me; she will go in the box soon;
I will not spend my money on her/* The mother of his four children,
Ids young wife, who had to cook for ten boarders, who had been at the docks,
summer and winter, carrying heavy loads of coal and wood on her back,
barefooted up the steep Yonkers hills, working and slaving so that the
man could put his money in the bank, now had to listen to this brutal speech,
and had also to feed the woman that was to be her BucoeaBor.
I told the man to help at once to get one of the bedrooms ready, or else
be arrested, cleared out six boarders, made the woman comfortable, sent for
(Joctor, supplies, and milk, and also for the priest. I went once or twice
dly to see that the patient waa well cared forj the children and the father
^pt in the kitchen. The poor young woman at last ended her life in clean'
iiness and quiet.
498
gEXTH INTERNATIONAL CONGRESS ON TCBEBCULO&tB.
When a baker has worked until three days before his death, it is iM
likely that the bread he handled was wholesome, especially since he was
careless, coughing and using his hands to ^^ipe away the expectoration.
This man boarded with a nice family, but was as careless in his room^ ex-
pectorating wherever convenient. The woman, mother of five children, who
had to clean the room, contracted the disease, and must now lose her life,
and five little children will be motherless.
A certain Hebrew, who was too sick to work any longer, thought he could
support his family by going into the milk business. The milk was bought
in cans and the bottles were filled in the dirty tenement, the sick man cough-
ing and spitting all around the place. The children carried the bottles of
milk to unsuspecting customers. It took just one day for the Board of
Health to put an end to this enterprise.
In another instance 1 had to report a butcher, who was far advanoed,
coughing badly, hardly able to be up, and handling a great deal of meat
and sausage, though no one seemed to object to buying at his store.
t^even successive cases of tuberculosis occurred in one basement, found
while the last victim lay on the bed in the kitchen, rocking a baby in the
Btuall cradle beside him, walls green-moldy and mattress soaked in damp-
ness. Two small bedrooms, occupied by boarders, were just as damp;
water running down the walls. It was winter, very cold, only a small fire
in kitchen and windows kept tightly closed, all vapors from washing and
cooking condensed on walls and woodwork. I reported the basement as
unfit for human habitation; the place waa vacated and the Commissioner
of Charities helped to move the family to healthier quarters.
The second-hand man and rag peddler should be labeled dangerous, and
either his trade abolished or premises carefully inspected and fumigated,
Most people are anxious to sell clothes^ bedding, and furniture after a case
of contagious disease, and, for some reason or other^ it is always done before
the Board of Health arrives to fumigate.
When I found the wives and children of rag peddlers, many having skin
and eye infections, in the small sheds, busy tearing up rags and sorting them,
I brought it to the notice of the Board of Health, and women and children
were prohibited from working in rag shops. Most of these peddlers were
Italians.
Dumping grounds where women and children get second-hand cinders
must present another source of infection, as a great deal of sick-room refuse
goes into the ash-barrel. It behooves each city to protect the ignorant and
prohibit such custom.
Boarding- and lod^ng-housea where homeless consumptives abide until
death must be deadly to newcomers unless cleaned thoroughly, which is
very seldom done. One old man who was d3dng said, speaking with diffi-
4
EXFERIENCES OF A SANITABY INSPECTOR.— VON WAGNEB.
499
culty, ** If I had a million dollars to-day 1 would — -." As he seemed tired,
I said, '* Would you buy your health back?" *^Ohp no; I would build a big
hospital for the likes of rnCj so they need not suffer like a dog, as I did."
Tenement- house dogs and cats are, as a rule, not kept clean; they are
handled by the sick and other members of the family and neighbors, and
so distribute germs wherever they go. Flies, roaches, bugs, etc., must,
through their scavenger trmts^ contaminate food and the blood of inmates.
Dry-sweeping, whether of street, echool-rooras, carpetefl halls, or Hving-
room3, should be prohibited* Janitors and housekeepers should realise the
danger lurking in dust to themselves and others.
What a lot of teaching it took to do away with the dim religious twilight
in aiek-rooms, and to allow the patient the benefit of daylight, and night-air,
and daily ablutions. Dirty fijiger-nails are a great source of infection.
Children, playing on floors, scratch their skin and tubercular abscesses may
result. Several babies died with tubercular meningitis within two or three
weeks after having been vaccinated. The babies had been healthy and
strong up to that time. There waa no history of tubercutoals in the families.
The mothers were careless ainl the wounds had not been kept clean.
Food exposed to street dust in open meat wagons and [bread wagons
cannot be wholesome. Restaurants and public drinking-places, whetlier
soda-fountains or bar-rooms, all need inspection.
The most practical solution of the large problem of prevention of tubercu-
losis would be in enforcing civic and domestic cleanliness, which cannot be
done alone by making laws, but by educating the general pubhc to the whys
and wherefores of such laws, and so obtaining their cooperation.
Better housing conditionsj abolishment of cellar habitations and work-
shops, better isolation of patients ill with contagious diseases, more super-
vision from departments of health by intelligent officials capable of teach-
itig hy^ene, domestic and personal, prevention of overcrowding among our
large foreign population, and much will have been done to prevent sickness
and poverty.
DISINFECTION IN TENEMENT^HOUSES:
BY THE DEPARTMENT OF HEALTH OF NEW YORK CITY; WITH
INSTRUCTIONS GIVEN BY THE VISITING NURSES,
By Ei^ie Thaver Paitehsqh, R.N.,
KvwYork.
The Department of Health.
All cases that are sent to hospitals, aanatoriums^ or country, change of ad-
dress or death, are reported at once by the nurses. An inspector is sent to
investigate each case and the landlord is ^ven instructions to renovate the
apartments when necessary. In all cases where the patient has been ill
a long time, or in case of death, the rooms are fumigated with formalin,
using fram six to eight ounces to every thousand cubic feet, from four to
six hours' exposure. The bedding, mattress^ pillowSj etc., if old, are de-
stroyed; If new, are taken away, disinfected, and returned. In the Hand-
Book of Information of the Division of Communicable Diseases of the
Department of Health, on pag^ 51 and 52, the further routine work on
diMnfection may he found.
The instructions given by the visiting nurses concern the patient and
his home.
The Patient — 1, Advice given as to personal cleanliness; daily bathing,
washing the hands before eating, care of the finger-nails and teeth.
2. When coughing or sneezing, to turn the head, keeping cloth or hand
before the mouth.
3. To avoid kissing on the lips.
4. When expectorating, to use paper napkins, sputum boxes, or old
cloths, these to he burnt up at once. If spittoon is used, it must be kept
half full of water, with or without disinfectant, washetl out with boiling
water, and emptied into closet, not sink. It must be kept covered, with a
paper also underneath, especially in warm weather.
5. The patient is instructed to keep his clothes as clean as possible and
free from expectoration.
The Home. — 1. The patient should have a separate bed always, a separate
room if possible. The latter to be the largest, lightest and best ventilated
one available* Windows to be always open. Reasons are given for not
occupying dark, inner rooms opening on shafts.
500
DISINTFECnON IN TENEMENT-HOUSES. — PATTEBSON. 501
2. The carpet should be taken up and all unnecessary ornaments and
curtains removed. The floors, when swept, should be sprinkled with water.
Dusting should be done with a damp cloth; sometimes a solution of bichloiid
is advisable.
3. In advanced cases the bedding and patient's body-linen should be
washed separately, put in cold water and cooking soda, and boiled.
4. Table dishes, spoons, forks, etc., should be both washed and kept
separately.
5. Instruction is given by the nurses in exterminating bed-bugs.
As many of these patients are visited regularly for months, and often for
two or three years, by the nurses, it is their £dm, during that time, to gun
the confidence of their patients, and make them see the necessity for disin-
fection, not only for their own sakes, but for the sake of others.
THE DISINFECTION OF HOUSES.
WHAT IS NOT DONE.
By Marie T< Phelan,
It was my great privilege to be associated as visiting nurse witb one
of our most active and intelligent health officers, the health officer of
Ptocheater. Although recognized as an authority on public health questions
outside his own community, he is handicapped in liis work at home by the
indifference of the medical profession and by the antagonism of politicians.
Tuberculosis was made a reportable disease in Rochester in 1900; that
ia, physicians were supposed to report all cases coming under their obser-
vation. About 25 per cent, of the cases known to exist in the city are re-
ported, or, in the words of the health officer, " no more cases are reported
than we have deaths." It is absolutely essential that the location ajid dis-
tribution of these cases be known to the health department, if proper meas-
ures are to be taken to disinfect the premises from whicih these patients
have moved, or where they have died. No provision whatever b made
by the city for cleaning and disinfection. I include cleaning, for I do not
ttiink that gaseous diainfection is enough to render some of the homes I have
vi^ted free from danger.
In 1904, largely through Dr, Goler'a efforts and the pliilanthropy of one
of our public-spirited citizens, one visiting tuberculosis nurse was appointed
to work in connection with the health department. As we had no tubercu-
losis cUnic until last January, we relied on the physicians to put U3 in touch
with the patients who needed our advice and care. The medical profession
was apathetic. Very few cases were reported unless the patient desired to
go to the city sanatorium^ Often I have been aent to a patient who had
been reported as in the incipient stage, and found he had been under a
doctor's care for many months. Sometimes several physicians had treated
him. When ho was beyond help, we were called in to instruct, and do
what we could to protect the family and make the patient comfortable, or
send him to the hospital to die* We still have doctors who depend on cod-
liver oil and change of climate; who never think to advise a patient how to
care for his sputum or pay any attention to the conditioua of his home.
£02
THB DISINFECTION OF HOUSES. — PHELAN.
When will the medical profession grasp the opportunity that is open to
them where private philanthropy has provided means to assist tham in con-
trolling this most dreaded disease of modem times?
One of my duties as visiting nurse was to provide for and oversee the
cleaning of premises which had been occupied by the patients under my care.
Many and varied were the experiences I had in visiting landlords and real
estate agents. Sometimes they were very pleasant, and promised to do
what I asked, but we never knew what ivas or what wag not done. Often
I think the owner promised in order to get rid of me; he kaew 1 had no special
authority, and he could rent the house whether the house w^as cleaned or not.
Again, I was blamed for all the faults and mistakes of the health depart-
ment. After the first year, the efforts which had been made met with so
Uttle response from the people that gradually this part of the work was
neglected^ and at the present time I do not think an>^hing is done by the
viaitLng niu^se to see that the homes of her patients are cleaned.
The tuberculosis law^ which passed the Legislature of New York last
spring, and went in effect May 17th, is the broadest and most far-reaching
piece of le^slation that has been passed to prevent the spread of tuberculoas.
Definite Unes of procedure are laid down for the medical profession and the
boards of health. Cleaning and disinfection receive special attention. Do
the people realize that it was for their own prot-ection that this law was
passed? The community can have what it demands in the enforcement of
thii* law, but it will have to make its demands so forcible that they cannot
be disregarded- Although our health officer was one of the active supporters
of this bill, and is anxious and willing to enforce it, nothing has been done by
the city to provide the extra help to do the work which the rigid enforcement
of the law entails on the health department,
Rochester, a city of nearly two hundred thousand people, provides its
health department with a staff of two persons^ a man and a woman, to do
all the difiinfection that the law requires* I understand it has been suggested
that the present staff is ample to look after the tuberculosis work too.
Another law which apparently does not interest the public is the one
which prohibits expectorating in the street-cars, on the sidewalks, and in
public places. Once in a while a complaint is made, but the people have
never demanded the enforcement of this ordinance^ therefore Rochester still
has filthy sidewalks and dirty street-cars.
The National Association for the Study and Prevention of Tuberculosis,
in its efiForts to know to what extent preventive work was being done in the
United States, sent out letters last spring to the health officers of several
hundred cities, asking a series of questions relating to the attitude of the
community regarding tuberculosis. Recently I had the privilege of looking
over the answers to these letters. Owing to lack of time, it was necessary
504
BIXTH INTEBNATIONAL CON<
lEBCUU^6t£
to confine my investigation to the reports from the cities where I knew
active preventive work was being done. The one fact thut is recognized hs
that tuberculosis h an infectious and therefore & preventable disease. But
the laws which are on the statute books to prevent its spread are by no
meaas enforced. It is not compulsory for physicians to report caaes, except
in one or two cities, therefore the health officers have no complete record of
the number of cases within their jurisdiction. The cleaning and dLsinfection
of premises occupied by the victims of tuberculoais is not a regular or popular
procedure. Some departments disinfect "on request," or "when notified/*
or " when the force is able to do so." Philadelphia, with the great influence
of the Phipps Institute, does not disinfect, and Chicago is one of the cities
which does, "on request."
It is readily seen that the people ^lo not know or realize the extent of
the danger that exists in houses that have been occupied by tuberculosis
patients. The well-to-do consuraptive ordinarily receives competent medi-
cal advice, and is int/clligent enough to take the proper precautions in
his own home. When he falls a victim, eveiy care is taken to clean and
disinfect not only the patient's apai-traent, but the whole houae. The
int-elligent people are waking up to the infectious nature of tuberculosis;
but the importance of providing means so that the homes of the poor may
regeive the proper attention, and that they may be taught how to protect
themselves, does not seem to permeate the minds of the people or even of
the raetUcal profession.
So long as tuberculosis was supposed to be a fatal disease, indifference
was to be expected; but with the light that modem science, and especially
hygiene, has thrown on the subject, pubUc apathy is indefensible.
ANTITUBERCULOSIS WORK IN THE PITTSBURGH
PUBLIC SCHOOLS.
By Bertha L. Stark, R.N.,
Pittsburgh.
The value of public education in antituberculoais work can hardly be
overestimated, since it is to an enlightened public we must look for effective
legislation for the prevention and control of this dread malady. Much has
been said and written on the best methods of this sort of education, and the
systematic campaigns carried on in some of our smaller cities, such as
Yonkers, as well as in New York, Boston, and Baltimore, are surely examples
of the best methods, and are most encouraging in their results.
While the educational work in Pittsburgh has never reached the degree of
organization found in many other cities, it does have one feature which
is absolutely unique and can be recommended as a very satisfactory means
of education — ^that is, an attempt to give systematic instruction in the cause
and prevention of tuberculosis to school children.
In Dr. Trudeau's address at the first meeting of the National Association,
he advocated teaching the public school children the mfdn facts relating to
the transmission of tuberculosis and hygienic measures of prevention. If
many tuberculous infections have their inception in childhood and remain
latent until some period of lowered vitality, we can hardly teach children,
at too early an age, measures of prevention.
Surely, if every school child in our city could be taught the simplest
facts of preventive medicine, and urged to tell his parents why it is best to
boil the drinking-water, why certified milk, though more expensive, is
cheaper in the long run, and why we have antispitting and disinfection
laws, the pubHc health would be benefited in proportion to the enthusiasm
of the teaching. For too many years effective legislation with regard to
municipal hygiene has been thwarted because the people ask, not "How
many lives will this law save?" but "How much money will it cost?"
Teach the children that a pure water-supply is cheap at any cost; that
effective tenement-house inspection will lower the death-rate; that municipal
parks where the people of the crowded districts may breathe fresh tor are
cheaper than municipal hospitals to care for the sick; and you have done
£05
606
8IXTH LNTERNATIONAL CONGRESS 01* TUBERClTLOSIS.
much t-o teach the future lawmakers of the city that health is of more im-
portance than money.
it is a difficult undertaking for an organization with absolutely no
connection with the city s school system (and the Tuberculosis League of
Pittsburgh has none) to introduce into the schools talks on a disease, and
particularly such a tliiieaae aa tuberculosis. In the first place, it seems to
be generally thought that a greater knowledge of this malady will create a
greater fear of contracting it — a fear almost amounting to a phobia. What
little reason there is for this fear is overcome by omitting all discussion of
symptoms, and symptoms are in no way an essential topic in a talk on the
cause and prevention of tuberculosis. Another difficulty encountered h
the fact that any talk on the prevention of this disease must deal with the
proper disposal of sputum, and this subject must be approached with the
greatest care or the children become disgusted. Every school-teacher
knows that too vigorous denunciation of a habit often encourages it. To
say to a child, " Don't spit on the sidewalk/^ and to be continually reiterating
this command, is often the surest way of making him break it-
Even if these obstacles of presenting the subject were overcome^ there
remained the greater one — that of obtaining permission to enter the achoob.
Pittsburgh is divided bto forty-three school districts, and each district is
governed by its own school board. There is a central board of education,
but it has little power over the individual districts. The tuberculosis
hospital is not widely known in educational circles; the very idea of talking
about tuberculosis in the school-room is regarded with suspicion, if not
with disfavor, by many of the boards; the idea that the children are already
overburdened with subjects and can ill afford the time to listen to a health
talk has to be controverted; and many boards have to be convinced that we
are not propagating a money-making scheme; that we are not advertising
a patent medicine, and that we will not "waste" more than twenty or
thirty minutes of the ehildren*3 time. The boards, when they fully under-
stand our project, however, are uniformly considerate and help to further
the work in many ways.
Our work in the public schools is divided into three parts — lectures,
literature, and exhibitions*
We have felt from the Hrst that it could have little lasting value without
the cooperation of the teachers. We may teach the child the value of
fresh air and sunshine, may tell him of dust and its dangers, but unless
the teacher emphatically sets the stamp of her approval on what has been
said, it will do little good. With thia idea in mind we have tried to meet
all the teachers of a district at a teachers' meeting before giving any lectures
in the school. It has seemed better to m^t the teachers, district by district,
rather than in the larger institute or grade meetings, because whei« there
AXTITUBERCULOSIS WORK IN PirrSBURGH PUBLIC SCHOOLfi. — STARS. 507
are only fifteen or twenty preseot, a general discussion often follows the
lecture, and there is much more freedom than in the larger assemblies* Thenj
too, members of the school board often attend the meeting and discuss
questions of school hygiene.
We tell the teachers just what we are trying to do^ go over the ground
we expect to cover in our school lecture, and try to emphaaiae the value of
fresh air and sunshine, and the fact that a welt-ventilated school-room is
the best object-lesson of this value. We epeak of the best ways to sweep
and dust and the absolute necessity of damp sweeping and dusting in the
school-room. W^e mention the fact that the pubhc school-teacher often
molds the character of her pupil more than any other factor in his life, and
that she can do much to teach the love of municipal cleanliness and the laws
which make forit. Theteachers arenas a rule^ alive to the fact that a mo re gene-
ral knowledge of preventive measures will do much ta stamp out tul^erculosis.
After meeting the teachers, we talk to the chilclren of the district. In
the high schools the lectures were given at the general aasemblieSi where the
number of pupils ranged from three hundred to one thousand, but, aside from
them, it seemed best to speak to the children in their school-rooms* There
is less confusion and greater freedom if each child is at his own desk, and
the decided break in the day's routine tends to make the child remember
what is said.
The subject-matter of the lectures remains practically the same in all
grades, and they are given to all pupils above the third grade, but the
manner of presenting the lectures differs in different grades and localities.
One may speak quite plainly to a group of children from a mill district of
the way infection may be spread by a careless consumptive, but in some of
the readence districts the subject has to be approached more carefully.
To introduce the matter too abruptly is often to antagonize the pupila,
and we have found that to designate the lecture "Preventive Medicine"
rather than "Tuberculosis" gains closer attention.
An outline of a typical talk would be something as follows:
PREVE>mvE Medicine.
Examples — Vaccination to prevent smallpox; boiling impure
water to prevent t\'phoid.
Tuberculosis:
(A) Cause — ^tubercle bacillus.
1. Where found.
2* Portals of entry*
3* Predisposing factors.
(B) Prevention,
1. Healthy bodies.
2. Simple nile-s of hygiene,
(a) Nccesait)' of a pure milk supply.
SIXTH INTERNATIONAL C0NGHES3 ON TUBERCULOSIS.
(b) Disposal of sputum,
3. Enforcement of antispitting laws.
4. Disinfection of homes.
5. Beat ways of sweeping and dusting,
6. Laws which make for a healthier city.
7. Dangers in the use of patent medicines.
8. Phthisiphobia — the harm it does.
In teaching we try to build on what the child alreatly knows, and the value
of the talks is greatly increased by the teachers keeping the children inter-
ested in the subject and by giving them the cardboard folders with instruc-
tions, to be read carefully and passed on, and by urging them to repeat at
home what they have learned.
The literature consists of two pamphlets. One is the cardboard folder
published by the Tuberculosis Committee of the Charity Organization
Society of New York, entitled ''Don't give Consumption to Others, Don't
let Others give Consumption to You." This has a list of the free dispensaries
for treatment of tuberculoas in the city, and many patients have been in-
duced to enter dispensary classes through it. The other pamphlet is espe-
cially for teachers, and is on the cause, prevention, and cure of tuberculosis.
It has on its inner cover a partial list of the sanatoriums in Pemisylvania.
We have fivQ traveling exhibits distributed among the schools. Each
one consists of a collapsible wooden frame and easel, canvas to cover the
frame, and two wooden boxes, each holding twenty pictures. The picture
were chosen with the idea of showing, as graphically as posdble, cause,
prevention, and cure of tuberculosis. Since each exhibit is changed weekly
to another school, the expense of having an expressman do the carrying
would prove great, and the one described obviates this. The frame and e-aael
are taken apart and rolled up in the canvas, the whole making a compact
bundle which one man can easily carry. The pictures are packed in the boxes
and two of our hospital patients carry the exhibit from school to school and
set it up.
We iMjgan the school work January 13, 1908, and finished June 6, 1908.
During that time we covered twenty districts, speaking in about 250 rooms
and reaching over 10,000 children. Aside from the regular school lectures^
about thirty others were given at teachers' meetings, church eocietiesj
clubs, etc. While the number of children reached seems eompamtively
small, we feel that the work was more thoroughly done than is possible in
large assemblies. In several schoob the principals have asked the children
to write what they learned from the lectures, and the results have been most
encouraging* Not only have they a fair understanding of the cause and pre-
vention of tuberculosis, but they often give concrete examples of the harm
done by disregarding existing health laws.
ANnXUBERCULOSIS WOBK IN PITTSBUBGH PUBUC SCHOOM STARK. 509
If teaching preventive medicine could be made a permanent and promi-
nent feature in the public-school work throughout the coimtiy, we might
reasonably expect a diminution in the death-rate, not only of tuberculosis,
but of typhoid and other preventable diseases. The work could be carried
on in conjunction with medical inspection, which must eventually find its way
into all our city schools. The nurse who gives the instructions (and it seems
that a nurse is peculiarly fitted for this work) could receive from the doctors,
if medical inspection exists, or from the teacher, a list of the children who
are suspected of tuberculosis and are not under the care of a regular physi-
cian, and lists of those exposed to infection. These cases should be investi-
gated and sent to some regular tuberculous dispensaiy for examination, and,
if tuberculous, come under the care and supervision of a regular visiting
tuberculosis nurse. Much could be accomplished by meeting the various
school boards, if the school system b like that of Pittsburgh, and discussing
questions of school hygiene with them. There is always need for reform
along this line, and sometimes a brief explanation of the value of damp
sweeping and dusting will cause its installment. Abolition of the common
drinking-cup is not so easily obtained, but it has been accomplished in several
districts. Periodical as well as special disinfection of school-rooms can be
ui^ed, and the ever-present question of ventilation can be discussed.
Immediate results cannot be expected, but that results will show in ten or
fifteen years we feel reasonably certain.
THE DISTRICT NURSE IN PROVIDENCE, RHODE
ISLAND, IN THE CAMPAIGN AGAINST
TUBERCULOSIS.
By Dr. Jay Perkins,
CStkinnsn l^^emsiw For tbe Supprowap of Tubermiloiw, ProvKtecae, lUiotk laUocL
A dispensary' for the treatment of pulmonary tuberculosis was estabtisbed
as a part of the out-patient work at the Rhode Island Hospital, July 1, 1900*
Its patients were those referred to it from the other departments as suspected
of having pulmonarj^ tuberculosis. As to the number of patients, the
clinic was satisfactory from the start, but the work accomplished was un-
aatLsfactory because of its incompleteness. Patients appeared and disap-
peared without our knowing whence they came or whither they went.
There were no beds at our disposal for either sanatorium or hospital treat-
ment- Medicinca were furnished free so far as needed^ but the other essen-
tials in the treatment of pulmonary tuberculosis were wholly lacking^ and
there was no supervision of the homes. It was a waste of time to adviae
rest and a special diet when the wage-earner was the afflicted. It was a
waste of time to advise fresh air in the homes without giving a practical
demonstration of what fresh air meana and explaining the benefits to other
members of the household. It was a waste of time to explain the danger of
conta^on when the patient was unwilling to tell those at home of this danger
for fear of ostracism, and for the same reason it was impossible to enforce the
use of the spit-cups furnished by the State Board of Health. Those who were
improving would come as long as they gained or until they felt able to work,
when they would go to work, disappear until another breakdown, and then
reappear in a condition worse than at first. Many of those who were not
improving would get discouraged, stop coming, and all trace of them would
be lost. Others would be so discouraged upon the mere statement of their
disease that we would never see them again.
In February, 1904, St. Joseph's Hospital established a branch at Hills
Grove for the treatment of pulmonary tuberculosis in all stages. This
hospital now has Hixty beds. In Oclol^er, 1^5, the State sanatorium for
early cases was opened* Thus some of our troubles were abated, but these
institutions can accommodate only a small i>ercentage of the total number
of patients having tuberculosia, and su|>enision of the homes of the patients
610
I
THE DISTRICT NURSE. — PERKINS. 511
themselves was wholly lacking. It is, and undoubtedly always will be, true
that the majority of tuberculous cases must of necessity be treated in their
homes. Here is where the real warfare against tuberculous must take place.
March 1, 1906, the Providence District Nursing Association imdertook
the home observation of tuberculous patients through their regular nurses.
April 1, 1906, we were assigned a nurse whose time was given exclusively to
this work, and at about the same time the League for the Suppresmon of
Tuberculosis was organized as a Committee of the Providence Society for
Organizing Charity. Looking back, we now appreciate that, from both
medical and sociological standpoints, this was the real begiiming of effective
work in the treatment of this disease among the poor people, where the
disease is especially prevalent and where the greatest dangers of contagion
exist. This nurse started in with 26 patients, and the first month 22 new
cases were placed under her care and 219 visits were made. The work in-
creased gradually throughout the year as follows:
Casm
Cabsikd Orxm. Nsw C*Bm. Tot&j^ Visits.
April, 1906 48 48 219
May 40 16 56 192
June 43 19 62 225
July 49 26 75 353
August 60 23 83 373
September 66 29 95 279
October 63 23 86 351
November 72 21 93 234
December 77 14 91 264
January, 1907.- 72 13 85 284
Februaiy 74 9 93 218
March 76 26 101 201
Total, 1906-1907 267 3193
April, 1907 94 61 145 353
May 100 38 138 381
June 113 34 147 344
July 122 37 160 335
August 136 26 162 382
September 125 20 145 315
October 125 33 158 468
November 135 41 176 597
December 146 34 180 485
January, 1908 156 34 190 525
Februaiy 160 48 198 474
March 169 59 228 604
Total, 1907-1908 549 5163
April, 1908 187 52 239 687
May 187 39 226 655
June 195 35 230 607
In March, 1907, the last month of the first year, the nurse had under her
observation 75 old cases and 26 new ones. At this time a second nursa was
512
SIXTH INTERNATIONAt CONGRESS ON TXTBERCITLOSIS,
added, and a combined exhibit of the National Association for the Study and
Preveation of Tubepcuiosia and of the Boston Association for the Relief and
Control of Tuberculosis was held in Providence. This gave a great impetus
to the Tvork and increased the number of cases under observation, which
increaae has been more than maintained, so that in October, 1907, a third
nurse wa^ added to the tuberculosis staff; in April, 1908^ a fourth nurse went
on duty, and during the present summer, for the summer, we have a fifth
nurse in charge of the day camp. During the first year the nurse had under
her observation 267 different patients and made 3193 visits. This, together
with being present at the hospital clinic, was too great a burden for one nurse,
and cauf^ed the adoption of the policy which has since been maintained of
turning over the bed-ridden cases or those needing much actual nursing to
the regular district nurses for such nursing^ though the tubercidosis nurses
also visit them as social workers and teachers as to the prevention of tuber-
culosis and to keep the other members of the family under observation.
During the second year the number of different patients visited was 549 and
the total number of visits made was 5163. The number of visits made de-
pended upon the ability of the nurses to make visits, and not upon the need
for these visits. It was this condition which led to the increase in the nursing
staff as rapidly as money could be raised to pay for the nurses. Unlike
acute illnesses, this disease demands prolonged obsei^ation, except those
cases which are transferred to the sanatorium, to St. Joseph's Hospital, or
to the almshouse, or such as are in the last stages of the disease when first
visited.
Some of the most effective work of the nursing staff has been in getting
patients, so far as possible, located in some institution, and in the dispc^-
tion of the families when the wage^amer is thus removed, this last being one
of the most difficult problems they have to solve. Another hard problem has
been to try to suitably locate patients returning from the sanatorium.
The expense of the first nurse during the first year was borne by a special
fund raised for the District Nursing Associatiou. Since April, 10O7, the
salaries and expenses of the nurses, as well as the relief given to the families
they were visiting, have been provided by the League for the Suppression
of Tuberculosis.
One of these nurses is always present at the dispensary clinic, thus be-
coming acquainted and getting into friendly relations ^-ith the patients,
as a part of their first examination and treatment^ and^ as soon as a diagno-
sis of tuberculosis is made^ each patient is visited at home. The patient
and liis home associates are instructed by her, by precept and by demonstra-
tion, as to the proper method of preventing the spread of the disease and as
to how to carry out the treatment advised. Beddings sometimes beds^
reclining chairs, and food are furnished, so far as necessary, through the
1
4
THE DISTRICT NUHBE.— PERKINB.
513
nurses. Besides the patients received from our dispensary, the nurees are
ready to take under their care the patients of any physician, and to work in
conjunction with that physician the same aa with the dispensary. Notifi-
cation of cases of pulmonary tuberculosia is required by the City Superin-
tendent of Health, and, so far as the physicians are willing, the cases so re-
ported are referred to these nurses. Their work has been so well performed
that many patients, not under any physician's observation, have been re-
ferred to them by other patients, and many have voluntarily come to them
for help. They bring to the hospital cUnic, or take to some phj'^cian, other
members of the families or the intimate aesociates of the tuberculous, aa
well as many other cases suspected of being tuberculous because either of
their appearance or of marked exposure to the disease* They have to a large
extent selected the pupik for our fresh-air school and the patients for our
day camp. They, with the other district nurses, have been largely instru-
roentat in selecting chikh^n for fresh-air outings during the sunmier. Their
work is, in fact, far more sociological work than actual nursing, but the work
is of such a nature that no other social worker could begin to compare in
effectiveness with trained nurses. Their success^ however, depends more
upon their tact in dealing with people than upon their nurses' training.
The ofBce of the District Nursing Association is in the same rooms with the
Society for Organizing Charity, and the nurses are thus familiarized with
the methods of social work and have received instruction from the manager
of the Society for Organizing Charity, who is a thoroughly trained social
worker. Greater care is needed in the selection of nurses for this branch of
work than for general nursing, for many nurses who are well qualified for gen-
eral nursing are not successful in this work, and we feel that our success is due
in no small degree to the ability of the superintendent of our District Nursing
Association in securing for us nurses having a temperament suitable for the
work. This success is shown by the fact that while in the beginning objec-
tion was sometimes made to the first visit, subsequent visits were almost
always not only welcomed but dedred, and at the present time objection
Is rarely made to even the first visit. The time of our head nurse is now
largely occupied at t!ie haspital clinic and in interviewing patients who come
to see her at the office of the Association, The variety of subjects concerning
which her advice is sought is surprising. It includes everj^hing relating to
;he physical, mental, and material status of the families. Among other
problems are the dispoaitioa of drunken or worthless heads of households,
the securing of work for those able to work, the disposition of helpless de-
pendents, as children or those sick from causes other than tuberculosis, the
placing of children in suitable homes or institutions, and the care of those not
demonstratably tuberculous (the so-called pre-tuberculoua condition)^ so
that they may live under better conditions. She ia abo called upon to adviae
T(M*. m— 17
514
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
concerning the multitude of things enteriiig mto the lives of the weU-meaning
but ignorant.
These nurses not only vidi and instruct the patients, but also get such
lis are suitable for the sanat^>riam ready to go, and see that they do go,
often furnishing the outfits needed; attend to the care or disposition of de-
pendente, especially children; and when the wage-eamer is the aflfljcted,
trj" to make some other member of the family a wage-earner. They also,
as far as possible, find provision away from home^ usually at St. Joseph's
Hospital or the almshouse, for such of the advanced cases as can have no
care at houie or are a special danger to others. As a part of the general
educational work, the nurs&s have also talked Ijefore associations of women,
especially mothers' clubs, in regard to general hygiene, but especially with
reference to tuberculosis.
As illustrating the work of the tuberculosis nurse, two cases are given:
A mother came to the clinic with a cough and was found to have tubei^
culosis. The nurse visited her at her home, found that her husband also
coughed, brought him to the clinic, and he also was found tuberculous.
There were seven children in the family, ranging from four to eighteen years.
At the present time the mother and father are both in the State Sanatorium.
with excellent prospects for complete recovery, four of the children are at
St, Aloysius' Infant Asylum, and the youngest, four years old, ia in St. Mary 's
Orphanage. One, a boy, is earning hia living at the Working Boys' Home,
and during the school year attended the School of Design through the kind-
ness of a man who became interested in him while he was in the Rhode
Island Hospital for an illness not tuberculous. The other, a prl, is living
at the Working Girls' Home and working in one of the department stores.
In another case a mother came to the clinic in the last stages of tubercu-
losis. On her \isit the nurse found that she was sleeping in the same bed
with four children, and that the husband, who worked nights^ slept in the
bed by day. No precautions whatever were taken to prevent the spread of
the disease* A separate bed was immediately provided for the mother.
One of the children died of tuberculosis two weeks later, and the mother soon
died. Through the efforts of the nursoj the husband came to the clinic,
and is now at the State sanatorium, with an excellent chance for recovery.
Also tlirough her efforts one child was ailmitted to the St. Aloysius' Infant
Asylum, one was admitted to the St. Vincent de Paul Infant Asylum, and
board is still being paid for the third, until there ia an opening for it at the
St, Vincent de Paul Asylum.
TUBERCULOSIS IN RURAL NORTH CAROLINA.
By Lydia HouaAN,
Lodter, North CbrDlina.
In nature's health resort^ the mountains, with fresh, pure air, sun, good
watCFp altitude, everything nature can provide, it seems unreasonable even
to suspect tuberculosis; yet at all times can be found sorae cases in every
snmll settlement^ and all over the mountains, in the little cabins scattered
here and there* Mortality runs high in such isolated districts. Records
are not kept; regular phydciana, or educated men practising, are rarities;
so it is impossible to give any figures. Many people pass out ^vithout even
having the simplest examination. Most people accept coughs and colds as
too trifling to bother with* Rarely is medical help called for in tame for pre-
ventive measures. Consumption is known only as an incurable disease;
80, aa of oldj are the patients humored, regardless of the wisdom of the de-
sire. Numberle^ times is the question asked, '*Why tuberculosis in the
mountains^ among the nativeSi when people come from elsewhere to get the
best cure provided by nature?"
Until years have been spent in studying living conditions, a cause could
not be apparent. The majority of people in these isolated mountaiti places
are handicapped by their Uving conditions — large families in small cabins,
frequently as many as five or twelve eating and sleeping in one room, which
is seldom we!l furnished, always insufficiently ventilated, and otherwise
unhygienically kept inside and out; uncleanly food-supplies, uncleanly
cooking and handling of utensils, poor quality of food, insufficient in nourish-
ing qualities, and wretched cooking; a family, or rather neighborhood,
dipper, used by any tuberculous case who happens along; no bathing facili-
ties; it is safe to say no privies, for the people here mcntlonod use any part
of the grounds about the dwelling, often in winter not even leaving the poi*ch.
The springs are infected in this way. Promiscuous spitting indoors and out-
doors, and kissing, especially of children, are prevailing habits.
Superstition plays an important part against improving any of these
conditions. A child with "phthisic" can be cured by splitting a sorrel wood
sapling and passing the child through this opening, then binding the tree up
so it will grow together again; or by cutting a twig the length of the child
from an oak and hiding it so that it "can never be found" — the child then
outgrows the disease,
515
516
SIXTH INTERNATIONAL CONGRE^ ON TUBERCULOSIS.
With vitality lowered so that there is no power of resistance^ perhaps
exposure is the surest ally of this disease. Atypical pneimionia is com-
rnoHj is seldom diagnosed or treated aright. Often a pneumonia caae is
found sitting up before the fireplace with little or no treatment; for very
few of the physicians are graduates, and many practise under the protection
of the "grandfather's clause" — ^in the State medical laws. Each case of
pulmonary tuberculosis, under personal observation, has presented a history
of "pneumonia fever" or repeated attacks of "aide pleurisy." The patient
always tells of the number of years he has been **puny" before the tuber-
culosis comes. Cases of tuberculous joints, glands, etc., report marked
aymptoms of scrofula from infancy. One old woman *' herb doctor^' boasts of
the number of bones "drawed out'' of scrofulous joints with a wonderful
ealve. All afebrile incipient cases coming under personal observation have
been treated as typhoid by the man in attendance.
Except, then, for what nature has to offerj there is little chance for the
mountaineer consumptive, until enlightened — educated; for the hopeless-
ness of consumption has been proved and confirmed* The people are not
8o eaaily influenced as other unenlightened people, nor are they different in
other respects, except in a native dignity and reserve — barriers against every
improvement. They do not become unprejudiced^ enlightenedj or educated
in a day, and in nearly all matters are one hundred years behind the
times.
A married woman, aged twenty-eight years, mother of five children,
a family history (maternal) of tuberculosis, had an attack (diagnosed by
herb doctor) of influenza. In two weeks she was up, with a nagging cough,
feeling '^puny." For the cough she took a patent cough mixture- Rid-
ing horseback a few weeks later she had a hemorrhage of about two
ounces. At this time ahe came under nut^e's care, and was instructed as to
restj bathingf food» etc* and, when strong enough, to go to Asheville for
examination and advice, the nurse promising to help cany out all inst^nic-
tions. Relatives helped to furnish the funds, the farm was mortgaged,
and the little woman was persuaded to go to Colorado, which she did
with the family of children, and there she had a good physician, but lived un-
comfortably in a tent. The family learned the true value of good medic^
Attention, prophylaxis, etc. She did not gain, and in a few months took
the wearisome trip home, and died a month later. This woman, aside from
doing her housework, helped tend stock, hoe com, stack hay, etc.
A case now rather advanced, a young married woman, with two children
in a period of twenty-eight months, called the nurse in to advise about
weaning the baby, suspecting pregnancy. She was doing a woman's work
indoors, and a man's work on the farm, — milked two cows twice a day,
cooked, churned, etc.^ — and was in a state of exhaustion during her entire
married life, She slept in a room with the two children, her husband, and
his mother — a chronic consumptive, careless and stubborn in every respect.
She had also an irregular chronic diarrhea. The room was protected against
4
TUBEECULOSIS IN HURAL NORTH CAROUNA. — HOIAIAN,
517
all ventilation^ except for the fireplace. The nurse spent much time in-
structing the family (two years) in better living conditions, but little im-
pression had been made. A physician from Bahimore examined the patient.
He gave all necessary instructions, and the nurse followed them up. The
baby waa weaned, the mother advised as to raw egg diet, milk, beef, and
other oouiishing food. No medicine was given^ except laxatives when
necessary. A bed was arranged on the porch, properly protected from drafts
and storms. The patient improved wonderfully, and the diagnosis was
doubted by family and friends. Assuming that she was well, she became
careless, and at the end of six months was losing rapidly. The physician had
gone, the nurse was away on a vacation. One of the numerous quacks was
called in, diagnosed " Uver trouble/' and treated her without benefit; then he
treated the kidneys. The patient continued to complain, and until a few
weeks past, was being treated for tapeworm. Another Baltimore physician.
found the lower part of the left lung and the right lung involved. Again
she was induced to go back to proper treatment, but recovery is doubtful.
A young man of eighteen worked bard for eight years (doing a man's
work on the farm) to earn money enough to take him to school. The
hard work, exposure^ p<x>r food, and anxieties over his studies caused
gradual weakening of rei?istance, and he had an attack of pleurisy. He
conval^ced slowly, returned to school, delicate and with a cough, took
cold easily and repeatedly until it became chronic. In vacation a physician
found active inflammation of the right lung, and the left lung slightly in-
volved, with profuse expectoration. He was persuaded to move out of a
dark corner of an ill-ventilated, dark room to the porch. Directions were
written for him and he was ad\Tsed to leave school for a term, which he did, de-
voting this time to outdoor life. He is now apparently stronger than he has
ever been.
Girl about twenty years of age, Uving in small town in badly kept house.
She gave a history of scrofula, is anemic, and always had morbid appetite.
Went to bed wath high fever, and case was diagnosed as typhoid, for which
she was treated with antefebrin, turpentine and strychnin. Three weeks
later, she still had temperature of 102**, and was having hemorrhages when
the nurse was called. Seven or eight excited friends were In attendance, and
two of the medicine-men were plugging the anterior nares, putting a cold
key down the back^ cold cloths to head, etc. Prejudice played a strong hand
against the nurse, for the men were not graduates, and their notions of medi-
cine would do poor credit to the seventeenth century. However, the mother
was persuaded to keep the room and patient quiets to encourage appetite, to
ventilate and give baths, nourishing foods, beef, eggs, and milk, but no medi-
cine except laxative. In six weeks the patient was going about. There was
no examination of the lungs made, and to the parents that seemed reason
enough for believing the girl had had typhoid. The nurse urged a visit to
Asheville for examination, but to no purpose. In three months the condi-
tion was rapidly becoming worse, and again the nurse advised a thorough
examination, an outdoor life with rest, forced nourishment, etc. Patient
improved again, but in a few months caught cold and failed rapidly. A
Philadelphia doctor found the caae too f^r advanced to be bene^ted. She
Uved four months.
SANATORIUM ATMOSPHERE.
- Bt Fiomxsscm R. BcHoaB^
i« canied oat in the modem auiftlommiSy is
tiaDj diffcfcot horn the work of the gndoste nurae in other bnkocbes oi our
prafeaaoo. In the genenl boepital the CMea, bdh medical and sozgicU,
are thoae of more or le» acute '^inp-^^^ and vb m the bo^tal for a abort
tiiua onlj. With them the ooe main nhjfiei of the nurse's work is the im-
provement of their physical wdiare. hi the saoatoriiun for tuberculosiay
however, the nurse meets with an entir^ dlfimnt probleoi. The cases
mder her charge present a diseaaa c^ a very duonic tvpe, usually with few if
way aeti\-« symptoms, and aic under ber chaz^ for seii-'eral months at a time.
With a laiige titajontj of cases all feeling ^ iMness soon disappears* and the
problem becoiuea more one of management than of treatment. The physi-
cal welfare of the patient, while of course the principal objective of the
Dur9e*s work, is by no means the only one. To a lai^:er extent that in any
other bnuich of aumng the mental and the moral welfare of each case is to
be oon^dered. The nurse can accomplish much towivrd creating th&t at-
mosphere which will aid in restoring the patient's healthy and will also send
them back to tbdr homes awake to the value of many details which add
Ip'eaUy to the health and comfort of home.
Sanatorium nursing concerns itself with more than taking temperatures,
issuing diets, nibbing backs, and doing one's routine duties conscientiously.
The patients in a saoatorium come mostly from those closss whose lives
have been spent in hard phy^cal labor, and whose pleasures have been
chiefly characterized by the element of nervous excitement. The time, the
means, and the environment have all been lacking for them tolcam to make
their homes really homelike. The shops have often made of them mere
machines, and their lives have become so cramped by constant work and
unattractive environments that there has been very little opportunity for
mental development. Under the enforced idlen^s of sanatorium treatment
they have but little initiative or imagination to prevent their becoming
morbid. Patients of this type must be diverted, and the nurse will search
out, arouse, and stimulate their dormant tastes and ambitions. It is not
always an easy matter to inters, them in anything outside of their own
ach^ and pains, but this must be done. Many patients have not the sUght-
518
SANATORIUM ATUOSPHERE. — BUItOESS.
519
est coQception of the beauties aad wondeiB of oaturei and often the nufse
finds her opening wedge through nature studies. During our first year we
were fortunate in having a nurse who really loved flowers. She would put
a simple wild flower on the tray of each bed patient, and on making her rounda
after meala would tell the patient its name^ where it grew, and any legend
which might be connected with it. In a short time their interest was orouded
to such an extent that they were aa eager as she over the discovery and
Btudy of a new flower, and she had established a common ground on which
to meet them. The sanatorium library furnishes one of the main sources
of diversion for the patients. Left to themselves many patients will be but
little benefited by it. There are few influences more refining than good liter-
ature, and by aiding patients in the selection of their books the nurse can help
them a great deal. Then too some patients read with difficulty and others
Buffer from defects of vision. To these the nurse can read aloud, and this
enables her to obtain a closer insight into the personality of the patient-
There are many other direct means of entertaining the patients which enable
a nurse to come into that personal relation to them which is essential to the
best work. Music, theatricals, and games all have their part, and where
the patient lacks the initiative^ the nurse can supply it.
Aside from the personal relations with the patients, there are many wa}^
in which the general surroundings may be made effective. Because they
may have been poor ia no reason why they should not have and enjoy the
.little refinements of life. There is no reason why sanatoriuras should re-
eerable prisons. A building with cheerful surroundings costs no more than
one suggestive of pauperism and sickness. Who does not know that en-
vironment has a most potent influence in the treatment of tuberculosis?
*In most of the new sanatoriums a nurse is placed second in command, and
often has the opportunity to aid in the planning and furnishing of the
buildings so as to avoid all unpleasant institutional features. The diet in
tuberculosis is seldom restricted, and as the patients are usually more or
less subject to loss of appetite and to slight digestive disorders, the nurse
has ample scope for ingenuity, both in the preparation of the food and the
manner in which it is served. Decorated china, tray cloths, and flowers add
practically nothing to the cost* They go far to stimulate a flagging appetite,
and more than compensate for the slight additional labor. While observing
strict medical routine, each patient should be received and treated as a guest.
In this way you can insist from the first upon the little conventionalities of
life that many have had neither time nor opportunity to cultivate. The
patients must be the nurse's family, and she must create her own atmosphere
of refinement and culture. They are under her charge not for a term of
days, but of months. She should strive to make the sanatorium a home for
them, to see to it that each patient should bo better for having known her,
and should return home with a knowledge of the essentials of a true home life.
THE N^FltSE A*m THE TUBEHCCTLOUS PATISNT, — FEW8MITH-BOYD, 521
elevation to insure a bracing atmoaphere during the year is very desirable
for patients in the first stages of pulmonary tuberculosis, and removal to
such a climate often stimulates the patient's appetite and relieves disorders
of the gastro-intestinal tract. The extreme exhaustion due to prolonged
intensely hot weather is avoided, and such complications as pleurisy, which
is frequently brought on by extreme coM and prolonged dampness, and pro-
fuse night-sweats are often eatirely relieved. The pernicious practicse of
sending patients in all stages of the disease on a long exhausting journey,
with perhaps no surety of obtaining proper accommodatioas, at least im-
mediately on their arrival, cannot be too strongly condemned* Patients
with extensive lung involvement who run high temperatures and are greatly
emaciated should be kept and cared for in or near their own homes.
An abundance of fresh and uncontamlnated air is very essential in the
treatment of a tuberculous patient^ since the sound portions of the lungs are
called upon to do an extra amount of work. A porch, to remain on the
greater portion of the day, and to be used at night for sleeping purposes, is
a necessity, and will add to the comfort and progress of the patient if the
exposure is such as to give the maximum amount of sunshine in the i^inter
and the minimum amount in the summer; in this country these conditions
are obtained by a southern exposure. During the summer, screens add
greatly to the comfort of bed patients, or mosquito netting, drawn lightly
over the bed, will serve as a very good substitute. At all times of the
year canvas curtains or eliding glass windows are needed for protection
against winds and storms.
In Colorado the direct rays of the sun are too powerful for a sick person
to remain in for any length of time, except in cold weather* Certain cases are
benefited by an exposure of the bare chest to the sun for from three to ten
minutes, but this should be done only by direction of the physician. Large
assemblages should be avoided, because of the contaminated air the patient
is forced to breathe and the excitement.
The best food obtainable is demanded; and three meals a day, with liquid
nourishment once between meals^ seem to give better results than more fre-
quent feeding. Forced feeding is not so popular now as formerly, because
the fight against the disease is long, and no patient can stand taking an
abnormal quantity of food for any length of time. The method of giving a
reasonable amount of nourishing food, such as the stomach will tolerate for
months, seems to give the most beneficial results. Rare meats, especially
beef, eggs, butter, cream, and milk, are the important items in the diet^ and
should be eaten three times a day, if possible; and, besides, three ounces
of beef-juice should be taken twice d^ly. Eggs may be eaten raw or soft-
boiled. If the patient eats three fairly good-dzed meals and takes a raw
egg whole, with a httle salt or cream added, directly after the meal, and some
522
6IXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS-
foriD of liquid nourishment, such as beef-juice, eggnog, or tmlk, twice or
three times during the day, he is getting eiifGeient nourishrnent. When the
appetite at regular toeaKtimes is poor, two eggs shouJd be given three times
each day, and enough liquid nouriBhinent added to make up for the lack of
solid food. A piut of milk containing as much cream as will be digested
should be taken with each meal until the normal weight is regained, when the
quantity may be diraimshed- Fruits and vegetables that cont&in much acid
should be used with discretion, since the system of a tuberculous patient
gives a decided acid reactiou. Cooked fruits are preferable to uncooked,
for the latter have a tendency to cause intestinal disorders. Coffee, tea, and
all stimulating drinks should be used in moderation. A patient may thrive
on a diet that does not include meat, though such a diet is more bulky and, if
the digestion is poor, may greatly tax the patient's system. A meat-free
diet, because of its lower cost, may appeal to patients of limited mea.ns.
In order, however, to render a vegetable diet palatable it is necessary to
prepare the meals in a careful and appetizing manner.
It is esaential that the excretorj' oi^ans be made to functionate in as
nearly normal a manner as possible. Free drinking of water helps greatly
to rid the system of poisons. A glass or two of warm water taken before
breakfast helps to dissolve and carry off the mucus that has collected in the
stomach during the night.
A tub-bath, if the patient is able to take it, otherwise a sponge-bath twice
a week, with a light alcohol rub evety eveningj keeps the skin in good condi-
tion. A cold sponge over the chest in the morning stimulates the respira-
tory organs. Shower-baths are also very beneficial for those who are strong
enough to take them* When expectoration diminishes in quantity and the
patient complains of a tightoning in the chest, the temperature will rise,
because absorption has taken place from the retained sputum. Generally,
some emollient preparation, applied freely, will in a few hours increase the
amount of the expectoration and thereby reduce the temperature. Oo-
casionally, expectorants are necessary. Moderate sweating now and then
is not harmful; on the contrary, it may be helpful in ridding the sj'stem of
poisons. Profuse and frequent sweating is weakening, and a rubbing with
strong alcohol or a sponge with vinegar will often greatly relieve this condition.
Complete rest and freedom from all responsibility are essential features
in the treatment of pulmonary tuberculosis. After the patient is completely
rested, the routine is likely to become monotonous, and some light and suit-
able form of recreation may be planned. It is imposisible to give any set
rules for rest and recreation, since each patient is affected differently. A
short walk may cause a rise in temperature in one patient, whereas in an-
other it may have the opposite effect. For patients with normal tempera-
ture] rest in a recumbent posture om hour before and after each meal may be
I
THE N^RSE AND THE TUBIIBCULOrS PATIENT. — FEWSMITH-BOTD. 523
ample. Reading, a walk of gradually locreosing length twice daily, short
drives, quiet games, and light work, such as may be carried on in the open air
and does not require much physical exertion, are all pennissibte if the
patient does not get too tired. In some cases a wisely conducted course of
study may be taken without harm.
If the patient runs a slight evening temperature, continuous rest ia ad-
visable, with, possibly^ a short walk in the morning and reading at short in-
tervals during the day* If the patient carries a temperature most of the day,
continuous rest in bed is necessary, and very little company is advisable.
If the temperature is 102° F. or over, a tepid sponge or light alcohol rub is
cooling, and helps to reheve the nervousness that generally accompanies the
fever. It is essential that the patient's feet be kept warm. Emaciated
patients often find comfort in an oil rub following the alcohol rub. The rub-
bing is soothing, and creates a good mental impression. It is well to dis-
courage patients from discussing their symptoms among themselves or with
relatives and friends. They should be kept cheerful and interested in things
apart from themselves.
In case of hemorrhage, even though slight, the patient should be kept
quiet, and the attending physician's orders strictly carried out. If profuse^
and the physician cannot respond immediately, put the patient to bed,
apply an ice-bag to the chest, and give morphin J to | grain hypodermat-
ically. Stop alt nourishment^ and give only enough water or chipped ice
to keep the mouth moist*
The patient and those caring for him should be extremely careful that he
does not infect himself and those li\ing with him. Too great care cannot be
taken in handling and disposing of the sputum. There are very few per^
fectly reliable methods of destroying the sputum of tuberculous patienta.
Incineration ia probably the most commonly practised and most effective.
A 4 per cent, solution of sodium bicarbonate, which raises the boiling*point
to 102° C. and prevents the coagulation of albumin, is also efficient. It has
been stated that a 2 per cent, solution of cblorid of Ume is a practical method.
If possible, metal cups, the impervious paper holder of which can be burned
and tlie metal cup itself boiled^ should be usetl, or the impervious paper
pocket^cups that may be burned after using a few times. Cuspidors and
metal bottles should always contain a disinfectant, such as a 10 per cent,
carbolic acid solution, and should be cleansed with hot soapsuds, and disin-
fected with pure carbolic acid. The patient should hold his handkerchief
over his mouth when coughing, to prevent particles of sputum from flying
outside the cup. If a visible amount of sputum does escape, it should be
removed with a cloth, which should be immediately burned, and the area
upon which it fell sponged with a 10 per oent> solution of carbolic acid,
:
624
BIXTH INTERN ATIOK All CONQBI»S ON TtTBE»CUMJ6I8.
letting some of tliis remain on the spot, if possible, for soma time, Male
patients should be urged to keep the face shaved clean.
The most suitable rooms for patients are those having plain walls with a
hard finish that may be washed down every few months; also all ordinarily
sharp angles should be rounded. The floors should be hard finished^ and the
rugs washable. Many pictures on the wall are not advisable, since tbey
collect dust. AH bruslung and dusting should be done with moistened
brushes and cloths. The room and the clothing of the patient should be
fumigated occasionally. Upon the patient's departure, the rooms he
occupied require thorough cleansing and fumigating. There are several
methodB of reliable fumigation^ potassium permanganate and formaldehyd
being the subatancea in most common use for this purpose*
In conclusion let it be said that the tuberculous work organized and car-
ried on by the nursing staffs of a number of hospitals shows that these in-
stitutions have begun to realize their debt^ not alone to the public at larg^,
but to the nurses under their especial training. It now remains for the
individual trained nurse to perform her duty to the rank and file of the nurs-
ing profession by spreading the knowledge of prevention and cure through
the channels of her alumnae and local and State aocieties.
THE FIRST OPEN-AIR SANATORIUM FOR
TUBERCULOSIS IN ITALY.
By Amy Turton,
There being no sanatorium for the open-air treatm&nt of incipient tubercu-
lous cases in Italy, an attempt was made, in 1902, by private Initiative to start
a very small institution near Florence — commencing with from six to eight
girls. A most ideal spot was found, on the edge of a fir wood near Settiguano,
sheltered from the north wind, and with the whole valley of the Amo stretch-
ing beneath it. The piece of ground bought was actually an olive field, and as
many of the trees aa possible were retained. The house was built with two
wide terraces facing southeast — the lower one being covered, so that patients
could lodge in it, and eat in it, in every kind of weather. The money for
land and building was subscribed, and we hoped that the town of Florence
would supply means for the maintenance of the little home, aa the doctors
were much interested in the experiment. The furniture was ^ven entirely
by friends, and was very simple, being carefully chosen with a view to
making dusting, disinfection, and cleaning easy.
But difficulties confronted us from the beginning. Although the bit of
ground was quite isolated (only one small cottage being on one of its confines,
which was uninhabited when the sanatorium building was commenced), yet
Bome of the residents of the villas within sight took exception to its relative
proximity, waged active warfare, signing protests, and attempting even,
to have it suppressed by influence in parliament. Happily, the legal dis>
tonce was proved to exist, and an energetic Italian canvassed for public
sympathy, explaining how much better it was for phthisical patients to be
put where the use of pocket apitoons was enforced, than that they be free
to expectorate wherever they went. Gradually the ^torm of opposition
died aw^ay, and the public showed itself to be either favorably inchned or
indifferent. The home promised some profit to the tradesmen in Settiguano,
gained their approval, and our canvasser judiciously insinuated the pros-
pect of its growing into a larger institution, and so employing more work-
men and giving ultimately larger profit to tradesmen. Consequently the
threats of boycotting, as well as those of legal processes, came to nothing.
The next difficulty that we encountered was the insuMcieucy of water.
5QA
junamu^
ttaJHan i^yKtcm wouid be the ttleiL This was to nm & ws^te-fApe for the
HqBid poftMQ of the dmni^B »«*f to the kfi,t«Bid^
lar depoflt bdow the mS, ao tfttt noifatog eoidd fitar inco it.
The 9(Aid p4^irti(>n <yf tbe sewage was retained in » specml receptacle,
piMed uxMler the water-ctonet^; in thia chloride of lime was pUeed, and tbe
eoutMlU were buderi in ttie pounds of tbe neighboring pe:&simts.
A lung speciaJiftt »nd two doctors who were aIso Anfestt advocattes of tbe
"open-air treatment" cooperated with us, tbe Brst in chooang, tbe oitbeffs in
treatiog, the patienta. Only tboee in the incipient st^ge oi pfalfain were to
be taken. Two rooms were set apart for those who could pay 5 lire. A
larg0 room containing four and another with two free beds made up the eiglit
we hope^I to filL Tlic rules were few^visitors' hours were to be linnted and
absolute ol^jedienco to tbe nurse was inaisted upon.
T)u! KanAt4^>riuii] woa placed in charge of a nurse who had spent several
monthj) at the .Sanatorium P*opulaire at Geysln, studying the system of
treatmcTit. Hhe waa aaaisted by a woman who acted aa housekeeper and
cxHiV, and nGiKhJx>ring peasants were engaged for washing and for odd jobs,
Wc opened in K«i>teml)er, 1904, with one pay and one free patient.
The troalmcnt included hypodermics of guaiacol, with, of course, res^t and
mf^Ierate hypernutrition; the foml was varied aa much as possible^ and the
rCfvultN, OH n^i^finU'A incr(»a.'« of weight, were extremely satisfactory. The
pationtH' winflowB were fitted with a catch that prevented their closing them,
but wii hiid very little dlfbcuUy in convincing them of the necessity of breatU-
iii^ mntinunl pure air, Even the housekeeper soon came to sleep ^ith open
windows tind inntructed her family to follow her example. And certainly
oiu! of the moat ftatjafiictory outcomes of the little experiment haa been the
Bpnnul of liygiontc truths among the relatives of every one who came under
itH influence. The <lH,ily routine consisted of abort htrolb in the tir woods^
lying at rrnrt on chiun* or lounges on one or other terrace, and reading by the
niinte. (V^i*! t^pouKing or batha^ weekly weighing, the rigorous use of spit-
toons, or hollaiid bags coritaintng a handkercluef, were carefully supervised
by the nurHO, She herself deatroyeti the sputum in a sort of cauldron ar-
rangod for tlw purpose.
Cuuld wo have devoted ourselves entirely to the Uttle place, I have do
FIRST OPEN-AIR SANATORIUM FOR TUBERCULOSIS IN ITALY. — TURTON, 527
doubt that we could have obtained many of the cures that rewarded us dur-
ing the first six months. But our hopes of obtaining public help were not
fulfilled. The Florentine societies (antituberculari) had not the necessary
funds to cooperate. The building, etc., had absorbed the money meant to
help with the maintenance of the place during the first year, and, finally,
for financial reasons, it was found impossible to continue beyond the month
of March. We decided, therefore, to make the little home a gift to a society
that was slowly struggling into life, and that was purely Italian, and conse-
quently better able to obtain funds. Our sanatorium has consequently
passed to Dr. Pieraguote's " Piedisposte," and from twelve to fourteen little
boys do the "open-air" cure instead of our "incipiente" girls or women.
So far as I know, only two cases entirely failed; one developing the
"galloping" phase, and the other going steadily downhill for about a ^'ear
after the place was closed.
REPORT OF THE NURSES' WORK IN THE TUBERCU-
LOSIS CLASS OF THE PRESBYTERIAN HOS-
PITAL. PHILADELPHIA. PA.
By Frances Hof^TFiTEB,
Tbe out-patient department of the Presbyterian Hospital presents a
good field for the home treatment of tuberculosis* The people in this district
are, as a rule, of the thrifty^ working class, with fair intelligence, living in
small houses and not in tenements.
In making up this work there were two problems to solve at once — the
method of treatment and the financial end. The medical chief decided that
the class method, such as Dr, Cabot and others have worked out so success-
fully, was the one to adopt. The hospital management already had as
many lines of activity as it could finance. The Ladies* Auxiliary of the
hospital were appealed to, and they appointed a special committee to rmae
a special fund for this work. This committee went to work with a wili,
and soon raised sufficient money to carry on the work for one year. This
includes the printing of blanks for records^ preventive suppUeSj and the
expenses and salary of a visiting nurse, WTiile the hospital management
decided that this work must, in no way^ draw money from the general fund
of the hospital, they granted the use of two rooms in the dispensary building.
These questions settled, the medical chief appointed two doctors who
had made a study of tuberculosis to plan and carry on the work. A nurse
was also appointed to assist in the clinics and classes, and to do the social
work in the homes of the patients.
It was decided to have clinics on Monday, Wednesday, and Friday,
with class on Friday^ I ^ve briefly the routine of the clinics and classes:
When a new patient comes to the clinic, the nurse takes the family
history, personal history, temperature, pulse^ respiration^ and weight,
A general statement of how the patient hves at home and the financial
condition is also taken. These facts the nurse carefully records on blanks
for this purpose. The patient then goes to the doctor to be examined.
This includes a chest and a physical examination. With the record the
nurse has made the doctor is better able to decide what is best for the patient.
He explains the condition^ and advises the patient as to the best course
628
A TTTBERCtTLOSIS CLASS FOB OUT-PATIENTS* — HOSTBTTKH.
529
to pursue to get well. The patient then goes back to the nurse, where he
is given the preventive supplies, and their use is explained. He is also
given a set of printed rules. Each patient is required to see the doctor
every two weeks for an office visit and attend class every Friday,
The patients assemble on Friday at 3 p. M. for class. At first the clasa
work consisted of a talk by the doctor. Here he explained every detail of
the treatment, answered questions, and the patients were given an oppor-
tunity to tell how they take the treatment. After they had the rules well
grounded, certain cases were selected, and the advanced clasa was formed
to meet on Wednesday. In this class the patients were giveo thermometers
and record book, They were taught bow to take R.P.I. , and to record,
then also to keep a careful record of their daily doings. Of course, the
ceases are selected for this class, and some never reach it, because they do
not possess sufficient intelligence. When they have learned to keep the
records, tuberculin will be gi^'en to the proper cases. This brings us to
the social side of the work. The nurses visit in the homes. Here we have
the teaching of the family as well as of the patient.
There are three things that the nurse hopes to secure for her patient:
(1) Good food; (2) rest; and (3) fresh air — one quite as important as the
other. For the family she hopes to prevent infection.
My first effort on entering a home is to get acquainted and make the
family feel that I am interested and ready to help; thus I secure their con-
5dence. It requires no small amount of tact to go into these homes and
get all the details. Sometimes my fii^t visits are little more than formal
calls, but when I get their confidence^ I find them most ready to cooperate-
One patient refused to see me on two occasions, but on the third, after I
had taken the trouble to tatk freely with her at the hospital, I saw my
patient and all the family on a friendly footing. In some families the patient
is most read>' to take hold, but the family as a whole, or some one member,
does not see the necessity for all this trouble. We are more apt to find
this condition where the patient is still in fairly good condition. This is
a situation for the nurse to work out. By going carefully I find much can
be overcome.
While I am getting acquainted I get, incidentally, as many of the essential
points as possible for my first report. Quite often, without the patients
knowing what I am after, I get them all. I never take out my note-book
ia the houses.
The mast important jxnnts for my first report are:
1, Sanitary condition, Including dust, smoke, sunshine, etc.
2, Patient's room.
3, Porch, balcony, yard, or roof,
4, Family history*
THE TUBERCULOSIS WORK OF THE SOCIAL SERVICE
DEPARTMENT AT THE MASSACHUSETTS
GENERAL HOSPITAL OF BOSTON.
By Ida M. Cannon,
Thuee years agp the experiment of social service in connection with the
Out-patient Department of the Ma^acbusetta General Hospital was initiatecL
This experiment was the outgrowth of the conviction, in the mind of Dr.
Richard C. Cabot, that only by investigating and remedying the social
condition of the patient could the dispensary treatment of many diseases be
effective. The limited time given to each patient, the physician's lack of
knowledge of home conditions, the failure of many patients^ from whatever
cause, to cany out the prescribed treatment, gave rise to Dr. Cabot's con-
viotion. The three years' experience has proved that the idea was distinctly
practicable, and that such work is essential to the proper conduct of dia-
pensary treatment.
The Social Service Department of the Massachusetts General Hospital
is independent of the hospital, and supported by voluntary contributions.
It is permitted to carry on its work in the out-patient department, and is
ready to undertake, on a social side, alt cases that the physicians refer to It.
During the three years the staflf of the department has increased from one
to seven paid workers, and there are fifteen volunteers* Two workers are
giving their time to the patients referred from the neurological clinics, one
to the unmarried pregnant girls, one to the tuberculosis classes, and two
nurses to the general work, a large share of which includes the referring to
other agencies and the dealing with those tuberculous patients not otherwise
disposed of* We shall here consider only that part of the work that deals
with the tuberculous patient. Thiii group constitutes about one-third of
the patients referred. The Massachusetts General Hospital faces a unique
problem, namely, that about 45 per cent, of the patients receiving out-
patient treatment come from outride of Boston. This necessitates a knowl-
edge of the resources of the suburbs in outlying towns.
The majority of the tuberculous patients resorting to the hospital are
referred to the department for disposition. If the patient comes from a
community in which there is an association ready to deal with his problem,
631
532
SIXTH INTERNATIONAL CONGRESS ON TCTBERCirLOSIS,
he is immediately referred to that association. In all cases the existence of
the tuberculous patient is brought to the attention of those who ought to
be interested. If an infected patient has been worjdng previously hx a
factory, this fact is reported to the board of health. This is done not ordy
for the good of the patient, but also for the iBstruction of the commumty*
Because patients with tubercuJosb habitually come to the large city for
consultation and medical care, many of the outl>^ng towns fail to appreciate
the extent of their tuberculosis problem. At the beginning of the work,
aasociationB for the care of the tuberculous patient throughout the city
were very few. During the last three years, in eighteen of the smaller
communities of the State, through the cooperation of the State Committee
on Tuberculous, the Women's Clubs, and our department, interest has been
aroused, many organizations have been formed, and classes and day camps
established. With a sincere desire not to duplicate what b already being
done by existing agencies, the department deals actively only with those
cases that cannot be referred.
Patients in the advanced stage of the disease are always ur:ged to enter
hospitals* To this end it is necessary to know the resources of the Stale in
public and private institutions, and to arrange for the patient's adraissioa.
Fumigation after removal and advice to the family are always involved.
Patients in the incipient stage of the disease are urged to enter the State
sanatorium. Such disposition of the case frequently necessitates the
organization of the resources of the family, and frequently involves the
cooperation of relief agencies. In some instances the boards of health
have been persuaded to bear the expense of the patient's treatment.
It is with the intermediate stages of the disease that a special problem
arises. Because of the limited capacity of sanatoriums, the expense of
sanatorium treatment, and the necessity of meeting the problem of home care
for many poor patients, tuberculosis classes have been organized by Dr.
Joseph Pratt, of Boston. To meet the needs of the suburban cases two
tuberculosis classes have been carried on in conjunction with the Social
Service Department under the supervision of Dr. John B. Hawes, Sr.
The success of sanatorium treatment is due chieBy to careful supervision
and discipline, abundance of good food, and fresh air. These benefits the
class treatment aims to give to the patient in his own home. Each class
consists of a group not exceeding 25 in number, under the supervision of the
physician and a home visitor. To secure the best results the patient should^
I believe, be rather carefully selected, not so much with a view to admitting
only early cases, as for the sake of choosing those of at least average intel-
ligence, who have the right spirit of cooperation. The patient must himself
assume a large part of the responsibility of getting well, and herein lies one
of the principal virtues of the claas treatment, and perhaps it^ chief limitatioo.
TUBEBCtJLOSlS CIlASS IK A GENBBAl. aOSPlTAL.^-CANNON,
533
Upon admission to the class, the patient k given a thorough physical
examiimtion. The treatment is explained to him^ and he is taught to
observe and record his temperature and pulse-rate. Each patient is pro-
vided with a diary record book for registering every item relative to his
physical condition, such as temperature, pulse, itemized list of food, the
daily summary of the amount of milk, eggs, and oil consumed^ number of
hours out-of-doors, and various symptoms. Once a week he reports to
the physician at the meeting of the class. The careful keeping of the daily
record, the faithful following of instructions, and regular attendance at
the class are the patient's responsibilities.
The visitor's duties consist of visits to the patient's home and super-
vision of his daily life* In her first visit she must get a grasp of the situation,
and make a detailed report to the doctor concerning the house, the situation
of the patient's room, the sleeping facilities, and the family group. She
must discuss the financial situation, to learn whether or not the patient can
have the extra nourishment and the slight equipment necessaty. She
must frequently plan with the patient and relatives to meet these extra
demands, and sometimes aak the cooperation of a charitable agency. She
must plan, if poasible, to have the patient sleep out-of-doors by making use
of a porch^ yard, or roof. If thiB is impossible, the next best sleeping facili-
ties, where be can get the maximum amount of air, must be arranged. The
improvement of his condition often consists in transferring a patient from
a bed-room with one small window to a parlor where there are two or three
windows* Occasionally the visitor must persuade the patient to move to
a better tenement house. She must satisfy herself that the milk supply ta
good, and that it is possible for the patient to obtain freah eggs and oil.
Her visits vary in frequency and length according to the needs of the patient*
When he understands and is faithful in his treatment, only weekly visits
are made.
By means of these reports, the patient's record, his weekly visit to the
class, and the periodic physical examination^ the physician can keep a
careful oversight of his condition and treatment. If there is a hearty co-
operation of the patient with the visitor and doctor good results often follow.
And if the patient does not really get well, the treatment has, at least, been
distinctly educational, not only for the patient, but for his family as well.
The class treatment in contrast with sanatorium treatment implies
bringing improved hygienic conditions to the patient, rather than taking
Mm from an ignorant family group and bad surroundings into ideal hygienic
conditions. We are all of us too familiar with the ex-sanatoiium patient.
He is not imaginative or intelligent enough to apply to his home conditions
the truths he has learned during his stay at the sanatorium, and in conse-
quence he relapses.
BU
6IXTE INTERKATTONAL CONGRESS ON TUBEBCULOSIS.
A corps of volunteer visitors under the charge of our visitor. Miss Ellen
T, Emerson^ have assisted in the supervision of the patieat in his home.
These volunteers can frequently establish a fiiendly relationship, which
may be very helpful in maintaining the class work at a high standard. la
eome cases the visiting nurse has consented to act as viator.
During the three years there has been a noticeable change in the type of
cases admitted to the class. Since the establishment, one year ago, of the
Boston Municipal Dispensary, with its excellent corps of nurses, and the rise
of various associations in the suburbs, the number of pulmonary cases dealt
with has greatly decreased. For the first two years all the cases were phthia*
caL The class now includes several patients with tuberculous infection
of the bones and glands^ and a large number of cases of tuberculosis of the
eye. The very encoura^ng results in many of these patients have proved
the value of hygienic treatment in other than pulmonary tuberculosis. It
has also suggested that class treatment by similar methods might be effica-
cious in other diseases in which hygiene is of prime importance. It might
also wall serve as a regular method of supervision of the ex-sanatorium
patient.
In the class treatment, as in other methods of treating tuberculosis, the
success of the method is largely a question of the character of the patient.
A person who has always been self-indulgent and undisciplined will not
readily submit himself to a rigid regime. In the class it is essential, however,
that each patient take a large share of responsibility, as the members cannot
be under such rigid supervision as is possible in a sanatorium. This, it seems
to me, is one of the most wholesome elements of this form of treatment, but
the patient must be selected for it. Sanatorium hfe is largely abnormal,
and there is little wonder that the patients frequently lose their "moral
backbone" after sitting in a steamer chair for months in an atmosphere
of idleness, with no responsibility.
We f^l confident in asserting that the patient whose disease has been
anested under class treatment is not so liable to relap^ aa is frequently the
case with the ex-sanatorium patient.
For the sake of prevention, we urge that the pretuberculous patients be
referred to the Social Service Department for hygienic instruction. By
means of various simple explanations of the function of the lungs, the relative
effects of good air and bad, good food and unwholesome food, the value of
baths for the proper action of the skin, and by subsequent visits to the home,
and supervision, an attempt is made to arouse intelligent interest in proper
living.
The further use of public baths, parks, and playgrounds is encouraged.
To summarize: First: The department is a referring agency, a hnk
■
TUBERCULOSIS CLASS IN A GENERAL HOSPITAL. — CANNON. 535
between the patient's needs and the agency or institutions of his community
that can meet their needs.
Second: Disposition of advanced and incipient cases that cannot be
referred.
Third: Selected patients are referred for care in their home to tubercu-
lous classes.
Fourth: An attempt is made to stimulate the suburbs to their respona-
bility for the welfare of their citizens.
Fifth: For the object of prevention, hygienic instruction and supervision
in their homes is given to the pretuberculous and debilitated patients.
The Social Service Department of the Massachusetts General Hospital
finds itself facing many unsolved problems, but I feel that we are making
a step in the right direction. The establishment of tuberculosis dispensaries
and social service work in various hospitab throughout the country is most
encouraging. When all dispensaries shall have organized such work to
help make the treatment effective, and when the hospitals shall seek for the
causes as well as the results of tuberculous infection, when they shall feel
the responsibility of admitting to their clinics the tuberculous patient, then
will it take its rightful place as a great social factor in the community.
THE TUBERCULOSIS NURSE AS A SOCIAL WORKER.
BT EUfiABETH P, VfJOBS,
Boatofl.
Bmmim one may hftV6 tbe disease many months before he xs wmfiw^ to
hil tml| and educational work rather than actual bedside numng is demanded,
ihtn k ft growing fe^Iini; that the trained social worker or a woman of average
ooDUDon wtomt Bnd able; to read a cUiilcal thermometer^ is quite sn&ieQi for
tftt ftome care of tubflrculoHia patients.
BinoB thft Htate and luimlcipal sanatonumB and hoapitala can care for
ooiy 2 per oeoi. of our tuberculosis patients, the remaining 98 per cent, most
be corod for in tticir honieH. Thus the homes become the battle-field of the
vMtinfE mime*
Thin i«iea is not peculiar to the laity. It m with humiliation I recall
the word* of a Bo«ton physician, well to the fore in the antitubercukMS
movement, who B^d that tie would rather have the trained social worker for
tufoerculofiiH work than the graduate nurse who had no knowledge of soda!
and economic que«tione» If It m true that some one less medically trained
and leea experienced than the graduate nurse b going to give the greater
oatiafftctkrn, why not igniire the 6eld of social progress and content our-
mlven with institutional and private nursing?
Bhall we consider the trained social worker, who she is, and what it is
that fihe posaeBses that haa so enhanced her value to both the lay and pro-
fessional claaBes?
I'^rom an education^ standpoint she has advantage beyond the average
woman in the nursing profession. From a financial standpoint, the small
aalaries offered the social worker are not sufficient to permit one wholly
dependent upon one's earnings to enter its ranks. This fact alone debars the
mercenary clement and claime those who are able to follow the occupations
of their choit^e rather than one of necessity. The nursing profession, on the
other hand, has always offered to the graduate a fair ftnaneial return.
A very small number of women who enter the hospital training schools
have any independent incomCj and the very need of earning one's living ia too
often the primary reason for choosing nursing as a profession.
The very term," social worker, " indicates that she is a student of the com^
bined social forces controlling a community and protecting the individual.
THE TUBERCULOSIS NUHSE AS \ SOCIAL WORKER. — UPJOHN.
537
A knowledge of State and municipal administratioiii of the neoeasary
complexities of our city life, of its numberless influences for evil and good,
and a familiarity with local resources are the A B C of social training.
All methods that take the worker into the home, to be successful, must
become personal, affording a close acquaintance with uncompromising facta,
and teaching sincerity in the homely ways of life. It shows educated men
and women what there is for them to do in the world; it lets them into the
secrets of human nature by laying bare its needs, defects, and contratlictlons.
With this bigger human uoderstanding the worker roust learn how to be
Birople, direct, sympathetic, and forever tolerant. All these qualifications
aad resources are essential to the success of the social worker.
Our training schools for nurses in the large hospitals offer little oppor-
tunity for personal or initiative work on the part of the nurse. Here she is
a pupil, and the patient to her is an individual only as his physical condition
renders him an acute or clironlc cose. All that can be done for hia imme-
diate comfort and ultimate cure is her first interest. The knowledge of
the underlying causes of disease and the necessary means to prevent its
recurrence are not a part of the nurse's training-
The point at issue seems to be — how, where, and when is the nurse going
to acquire tliis broader knowledge that will fit her for social work? There are
special qualifications requisite to the visiting nurse; she must be of rugged
health, free from racial and religious prejudices, and she must have vocation;
Not every one who enters the profession is fitted to become a visiting nurse,
but 1 am fiure were the opportunity given the pupil and graduate to come
in contact with social nursing, many would find their vocation.
As the medical priest is the greatest power in the mission fields so the
woman with a hospital training plus vocation plus a social education may
become the ideal social w^orker.
The present method of sending the pupil nurse into the homes from the
dispensaries of our hospitals, where she is instructed in home nursing by the
nurses of established visiting nurse associations, affords her a splendid oppor-
tunity to see future possibilities and to determine if she has the qualifications
necessary to the work*
Because of these temperamental qualiti^ demanded by the work, the
course must be an elective one, open to ^aduates.
It may be that the social service departments, so rapidly becoming a
Deoeasary part of our hospitals, will supply this very need, or the solution may
be found in special courses given in the schools for social workers.
Find the solution we surely must, for until we realize the almost inestima-
ble scope in social work and are ready to make some effort to fit ourselves
for it, we are in danger of its passing out of our reach and becoming the sole
don of the enthusiastic and able social worker.
538
SIXTH INTEHNATIONAL COSfGKESa ON TITBERCULOSIS,
In closing, I would like to say a word about tbe nursing work of the Out-
patient Department of the Boston Consumptives' Ho^ital. We have a staff
of nine visiting nurses (only graduates of general hospitals are eligible).
The question of material relief in the homes ia considered in conference
with the Associated Charities Organization. Through the courtesy of its
secretary and assistant treasurer, Miss Higgins, each nurse is a member of the
conference of her district.
At these weekly meetings she not only discusses her own cases and formu-
lates a course of action, but she becomes familiar with ways and means of
helping those where calamities^ other than sickness, have given need of private
aid. In turn, when the nurse is known to a family, she is often asked to act
in a double capacity, and become friendly visitor in the home.
Every fortnight the nurses meet in conference, reports are made of the
various organizations visited and used in their constructive case work. To
these conferences the leaders and representatives of other philanthropies are
invited, who give illustrations and explain the problems peculiar to their
particular interest. General discussion follows.
When the schools are again in session, two of our nurses will take a special
oouTBC in the Boston School for Social Workers. This course requires six
hours' work a week, involving two three-hour sessions.
To accomplish this social side of a nurse's work necessarily takes her often
from the homes of her district; but all who are interested in the development
of the nurse along social lines are ready to grant these privileges.
Since the campaign against tuberculosis means all that mil in any way
improve the physical and social condition of the patient anci prevent the
spread of disease^ the visiting nurse ia recognized as one especially fitted to
take part in the campaign.
How can we best stimulate the profession to a wide and strong beUef in
the important part it has to fill in the antituberculosis crusade?
To know the work is to be interested in it.
Perhaps an appeal made by the various tuberculosis associations and
dispensaries to the local nurses' homes, registeries, and alumnse assocLations,
asking a few days' volunteer service of the nuraes off duty, would prove
valuable both to the associations and to the nurses.
Until our training-school curriculum includes the care of the poor in their
homes, the work must be met and carried on by pioneers. To-day the situ-
ation demands the very best women the profession can offer to do this pioneer
work.
<
HOME TEACHING IN TUBERCULOSIS CASES.
By Edna L. Foley, R.N.,
Boston, Mam.
Though all ranks are depleted by its ravages, tuberculosis is preeminently
a house dise^ise of the very poor; therefore home care and instruction will aid
largely in the vexing problem of it« extermination. All sorts of places^
from the private dwellings of the humbler type through the gamut of cheap
lodging-houseSp poor tenements, all kinds of workrooms and basements unfit
for habitation, shelter the unfortunate tuberculous patient. By the initiated
few he has been regarded as the modem leper, to be quarantined out of sight
and hearing, but the vast proportion of mankind still has a lingering senti-
ment in its dealings with the phyaically unfit; therefore many of the patienta
are found unwisely protected and cared for by sympathetic friends. The
nurse's task is more complicated for both reasons, as but a small percentage
of these cases can be or care to be treated in hospitals or sanatoriuma. She
may, by her efforts, so adjust the proportaons of sentiment and apprehensjon
in the community that the tuberculous patient is given a chance to live, with-
out being killed by kindly ignorance or crushed by the unjust restrictions and
criticisms of his timorous neighbors. To make the patient see that his own
conduct in certain respects ^ill do much to allay their fears and suspicions
is part of the nurse's teaching, and she must aways endeavor to Inculcate a
wholesome respect for the rights of others, as well as for ci^dc law, by letting
unruly or careless patients know that the officers of the board of health have
the power to remove them from the community by force if necessary.
The homes in wliich the t^^achlng is done, may, for descriptive purposea^
be divided into the ideal, the poor, and the impossible. The last are hardly
deserving the name; they are really the temporary abiding-plaoes of tran-
sients who are oft-en in the second or third stages. Under this head come
cheap hotels and mission lod^ngs, where the dormitory system is in vogue,
hall-rooins in second-class lodging-houses, dark rooms used in many instances
by day and night sleepers alternately, and basements in which the patients
often take refuge as a last resort. The home instruction in these cases is
brief* It consists, usually, in nemoving the patient^ if hopelessly advanced, to
a hospital or almshouse, for by his aimless wandering infection is spread
broadcast* Patients whose prognoses are rather naore cheerful, but tc whom
530
640
IS^TH INTERNATIONAL CONGRESS ON TUBERCULOSIS,
fortune has proved fickle, are giveo a fresh start in a day camp or sanatorium,
through the cooperation of some interested philanthropic aociety. The
keepers of these places are interviewed and told what precautions to take
after the removal of the patient^ and the room is fumigated by the board of
health, hut it is ao difficult to enforce thorough cleaosing after fumigation
that many of these places must remain nests of infection.
Ideal homeSj too^ rarely come into our district, for where housing condi-
tions are excellent, the income is sufficiently elastic to permit home medical
advice or sanatorium treatment. But it sometimes happens that the chief
wage-earner becomes the patient^ and then our assistance is sought. One
great difficulty here is in overcoming an inborn repugnance to fresh air and
sunlight. The latter fades carpets^ and the former^ taken in large doses at
night, is believed to be fatal. Nevertheless, these barriers are not innur-
mountable^ and once broken down^ the rest is plain sailing, for the patient is
generally sensible, and it is not difficult to arrange a separate room or out-
door sleeping place, special dishes, linen, and the other paraphernalia that
accompany home fresh-air treatment. Once patient and family are duly
instructed^ if the patient reports regularly, only infrequent calls^ perhaps
once a month, need be made, for iatelUgent patients, placed amid favorable
BurroundingSj seldom require much watching.
Poor homes are legion — in fact, the perpetuation of tuberculosis is insured
by their existence. Cleansing by fire alone would regenerate some of them,
but as cremation of profitable real estate is not in general favor with property-
holders, less strenuous methods must be employed.
While commissions or boards of health are framing or looking up laws on
the subject of tenement^house sanitation, the nurse goes boldly in, to make
her apparently strawless bricks, with sometimes surprisingly good results.
It is neetUess to dwell here on the causes of the vicious activity of the bacillus
among the ver>' poor. Lack of air and sunlight, overcrowding, insufficient
nourishment, defective plumbing, and inconceivable slovenliness all help to
supply breeding-places. Such homes require most careful attention, for
the surroundings are not conducive to invention on the tenant's part, but
imitation ir his forte, so that when the doctor's orders are supplemented by
the nurse's instruction, an obedient patient ydU do his best to take the treat-
ment faithfully. Equally important, too, is the watching of careless patients,
who, inconsiderate of themselves and others alike, are a menace to public
health, and should be reported and forcibly removed, when necessary.
In al! these homes even the most carefully explained directions are as Greek
to the patient receiving them, and the nurse's advent is usually the signal for a
volley of questions . Parti cularly i s this true among the foreign ele ment, for they
invariably seem, at the dispensary, to understand more than they really do,
and are hopelessly muddled when they reach home^ — so much so that it is
I
HOME TEACHINO IN TUBERCULOSIS CASES. — FOLEY.
541
hardly safe to trust them with medicine unless there is an interpreter with
them. Such a person can be founds easily enough^ in the neighborhood, and
the patient must be taught by pantomime and through the interpreter what
he must do if he would get well
A little family or neighborhood instruction on the communicability and
curability of tuberculosis is a good introduction for a first call. The danger
should not be minimized for sentimental reasons, nor emphasized in such a
way as to frighten everyone from the house, but the truth should be told, and
the family taught that their safety lies largely in their own hands. Constant
emphasis must be laid upon the dangers lurking in the sputum, and the pa-
tient taught how to disinfect his flask or to cany clean paper napkins in one
pocket and a small paper bag to receive the soiled ones in an opposite one.
In many cases napkins and bags, if they are changed frequently and promptly
bumed,are muchmorebygtenicthan flasks. One patient laboriously cleansed
his flask at the kitchen sink, afterward poured in a little weak carbolic,
andthenput itonashelf in the china closet* Henever useditinthedxiytime —
the stoveor window was nearer, and didn't require cleansing I A sputum flask
in such a patient's hands is more than dangerous^ and the man was given
paper napkins, which he really did burn.
In homes where the onJy running water is at the kitchen sink, and the only
available basin may be also the dish-pan, a flask is a difficult thing to dis-
infect. Special dishes for the patient may be marked while the nurse is there,
and the housewife taught to wash these with boiHng water and to wipe them
on a separate towel. In hotiseholds of limited equipment, to ask for perfect
sterilization by boiling is to encourage untruthfulness* A separate room is,
of course, best, but when this is impossible, and the removal of the patient
inadvisable, a single bed near the window must be provided, the carpet and
superfluous funxilure removed, and the patient kept as far as possible away
from the other inmates.
If a roof, pia23a, or yard that is not too damp is available, and a tent, cot,
and lounging-chair can be obtained through friends or by cooperation with
some charitable organization, a good outdoor sleeping room is easily ngged
up* Bedding and diet are important items, too, for to sleep in cold air does
not mean to invite insomnia by shivering all night, nor is it wise to do every-
thing to promote the appetite unless food is forthcoming. Through a diet-
kitchen the much-needed nourishment is obtiuned, and when the cot is asked
for, the blankets may be included. Last, but not least, the patientsare taught
by endless reiteration that the bacillus loves dirt and darkness, so that to
fight it effectively they must tlu-ow back the blinds, wash the windows, and
scrub everj'thing, family included. In spite of its odor, the use of sulpho-
naphthol for drains and floors is encouraged, and the nurse teaches disinfection
of hands by washing her own, very carefully, each time she makes a call on a
542
8IXTH INTERN ATIONAI. CONGBBSS ON TUBERCULOSIS,
positive case. Few of these many details can be brought out at a clinic^ nor
can the patients be made to feel that the nurse is theif friend, advisor, and
private detective until she has seen them in their homes. Then they leam
that they are being closely watched, both for their own good and lest, by
their carelessnesa, they jeopardize the health of otheis*
Advanced cases in these hotnea are the most difficult to managep for
some reasons, for their Btck-room too often becomes the family sitting-room,
and the patient's increasing weakness and more prolonged attacks of cough-
ing double the risk to the remainder of the family, A daily visit is needed
here, and instruction in the care of a bed-patient is ^vcn the housekoe|>er.
She has so many other duties to perform in addition to those of the sick-
room that she is apt to forget that eternal vigilance is the price of her own
safety unless the nurse reminds her of it often. A nice ethical problem Is
presented here, and in the near future, when more hospitals for advanced
cases are established^ the present handling of these patients in their homes,
by the nurses, will help greatly in deciding the vexing question a.s to the
need of home or institutional care. If, without becoming rank sentimental*
ists, we can listen to the pleadings of natural affection and let the patient
die at home, cared for by his own people, without exposing them unduly,
we shall serve an economic as well as humane purpose, for proportionately
few of these home cases are a tax on the State's resources.
Except in advanced cases, the amount of bedside work done by a tuber-
culosis nurse is small, but, accordingly, the number of her visits is larger
and her educational influence is widespread. This new movement in
tuberculosis work is so largely one of education for the laity that the nurse,
by her personal contact with so many people, can enlist innumerable vol-
unteers in the cause, regardless of whether they are children who caution
their mates against expectorating in the playground, or adults who have
ceased to view with favor public tlrinking-cups. A command of simple
English and a knowledge of household hygiene are invaluable assets in her
district, but, best of all, is her ability and willingness to go in and demon-
strate what she recommends, whether the patient is ambulatory or bed-
ridden. By making the condition of the consumptive understood, she has
cleared away much of the stigma attached to hia disease, but, at the same
time, she has made hygienic living the price of hia comfort and his neighbor's
immunity. Cures in tuberculosis are, as yet, few and far between, but as
this preventive work goes on, and the numl^er of cases becomes less each
year, the tuberculosis nurse may gage her usefulness by this annual decrease,
for her success will depend largely on her ability to teach her patients how
to live up to the very excellent ad%ice which it is so easy to give them.
I
HOSPITAL CARE FOR THE ADVANCED AND INCUR-
ABLE CASES OF CONSUMPTION.
By S. H. Cabaxiss, R.N.,
Riehmood, Virslnia.
After almost a decade of experience in Visiting Nursing, one feeb that the
imperative need for hospital care of the consumptive of very limited means
and the indigent consumptive cannot be lost sight of, for if this warfare
against the awful scourge is to be victorious, this seems one of the most
important points upon which to concentrate attention, and provide without
delay the scientific and financial wherewithal essential to establish and
equips first of all, hospitals for the incurable consumptives of the poorer
classes. Not only should these institutions be provided, but such legation,
both State and mimicipal, must be enacted as may be required to compel
every case of tuberculosis who is unable to secure suitable care in his own
home (or who either cannot or will not use such precautions as will prevent
his being a menace to the health of the family or of others) to enter the
hospital.
From a financial standpoint this is in every way a wise and profitable
investment.
Consider, for instance, the incurable or careless consumptive in a home
where laundry or needlework is the main source of income, or has been
adopted as such because the chief bread-winner in the home, since the
consumptive became an invalid, must have home occupation, in order to
care for the patient at all. In winter there must be only one fire, that
usually in the kitchen, and often we find the bed of the patient moved into
this room, especially if clothing and bed-clothing be insufficient. The family
launder clothes, which are often placed upon this bed before being put into
the baskets or parcels to be returned to the owners, who in turn place them
for some hours on their own beds, or at all events in their bedrooms.
The family of the patient eat their meals in the kitchen, and if equal to
the exertion, the consumptive aids in the preparation of the food. The
result of such conditions requires no explanation. Suffice it to say that
perhaps in nine out of ten such instances the patient's family and the families
whose laundry is thus contaminated, do not escape infection. Even with
instruction and the help of the visiting nurse, beside such further aid, in
543
544
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
the way of food and clothings as the charity organization^ diet kitchen,
church guildsj or generous individuals may contributej msuiy cases cannot
apply what they know to be right methods of care and prevention.
One of the pathetic cases that recently came to my notice was that of
a mother of five or six children, the youngest an infant of a few months;
the husband was employed in a machine shop, had to leave home at six
o'clock in the morning, to be absent all day. None of the children was old
enough to keep the home in order or to attend to the mother. A neighbor
each morning prepared food for the day and made the toilet of the mother
and baby, All day long the children played in and alx>ut the room, climbing
on the bed, kissing and caressing their mother, devouring eagerly the bits
of food or drink left in her plate or in her cup. "When weary of pla}% they
would go to sleep aa close to her pillow as possible. When the danger was
explained to the mother, she said, *'AhI yes, when I was first taken, we had
a doctor, but he said I could never get rid of the cough, but I must do all I
could to keep ^ip ray strength. Told me what to eat, and said always take
Bs much as I could swallow; that the cough was catching, and I must not
have the children around. But you know. Miss, I don't believe I am going
to be here long, and my man and I tried to plan the best way about it all.
He wants to pay the lady, our neighbor, something for coming to fix us
up and get the meals cooked. So he keeps on at work to get house-rent
and the things to eat, but it hns kept cold so late this spring we had to let
the association give us coal and wood. So he works every day, and the
children are pretty good here with me — not much trouble. We cannot
send thera away, because they are so little ; they would forgot all about me,
so we will keep them until I go; then they must live with his people and
mine. It can't be much longer, I am sure, Miss." Here a little lad of less
than four years ran in from the street— just to be loved a little. The nurse
tried to make Mm understand that it was best not to kiss or touch sick
people. But the Uttle fellow looked up so earnestly at her and said^
'^Wouldn't you want to kisa yoiir mamma every time you could and if
she was sick you ought to want to all the more/'
Could this woman have ent-ered a hospital, the danger to the family
would have been greatly lessened, and the expense of the household, perhaps,
would have been smaller. Surely, then, the chances for preventing the
husband contracting the disease imd becoming himself a dependent, and
leaving the children also without support, would have been lessened.
Tuberculosis, like other ills, must be fought in the home. But there
are instances where suitable provision cannot readily be had or made in the
home.
During the past year our aympathies were aroused in behalf of a young
Austpo-Hungarian girl of eighteen, who spent a little more than two yeara
HOSPITAL CAHE FOR ADVANCED CASES, — CABANISS,
545
in America, absolutely alone as to family connection in this country. Her
case wafi quite promptly diagnosed, and with earo, seemed in every way to
be curable. She was intelligent, and did all in her power to aid our efforts
in her behalf. In a short while her means were exhausted, and she waa
dependent itixin a Hungarian family for food and shelter. It was soon
found that she had little food excepting the milk and eggs which the nurse
provided. Funds were raiaed to place her in the sanatorium in the moun-
tmns of Virginia, She improved steadily, but slowly. Being very energetic
an<l industrious, the enforced idleness was most trying to her. The physician-
in-chai*ge, also an Austrian, knowing the expense was hea\y upon us, and
noting the restlessness, which increased with her improvement, advised that
we send her to her home in Austro-Hungaiy, where her parents were living
in a most healthful section of the country. Moreover, since her conva-
lescence was sure to be protracted, it would be cheaper.
This brings out yet another poLnt^imlesa light employment can be
provided for these improved cases, or their support guaranteed, nothing
whatever of material gain is derived from a short stay in a sanatorium.
The patient learns to take care of his case and to protect others, but he has
not sufficient means to apply the education he has obtained. With sufficient
and proper food, favorable environment, and not too arduous work, the
consumptives who have manifested improvement in the sanatorium may
earn a ii\ing and jierhapa aid others.
Yet, the percentage of cases able to provide such conditions ia extremely
small, and the majority must be aided, and usually this assistance can
mean only enough for paJhative treatment^nothing better I
Some years ago, when my professional career as eui)erintendent of a
hospital began, having no special ward or provbion for tuberculosis, no
modem methods of fumigation and eterili2ation, consumptives were admitted
promiscuously to the hospitals. At my urgent request our board of
directors began to refuse all cases of consumption and intestinal tuber-
culosis ^ and within three years not a hospital in the city excepting the
almshouse would admit such cases. In the past four years the insane
hospitals provide special and up-to-date care for their consumptive
patients. We have also a few private sanatoriums for consumptives,
but to the great masses of white and colored poor only the almshousea are
ojjened. These merely provide shelter and simple food, and little if any
uistruction and scientific care.
The State, public health boards, relij^ous organisations, and wealthy
men and women must accept the expense and responsibility of providing
these hospitals, if the scattering broadcast of tuberculous infection is to be
restricted and stamped out.
VOL. til— 18
THE IMPORTANCE OF NURSING AND SUPERVISION
OF ADVANCED CASES OF TUBERCULOSIS.
By Harriet Fulmer,
ChieaiCO-
In the care and supervision of the advanced case three thing3 are to
be thought of. Preenunent is the prevention of contagion; gecond, the
humane side; and third, and not least, is the economic value to the com-
munity.
The writer does not wish to criticize any method, but rather to voice a
plea in behaJf of these helpless outcasts, as well as to advance the truth
that the care and supervision of these cases are the very media whereby
nur&es may help finally to eradicate t!ie disease.
If we stop for a moment to consider the real situation, so far as the
advanced case of tul>erculosts is concerned, we will find that a degree of
indifference in regard to him exists that is overwhelming. Education of
the healthy populace and sanatoriums and dispensaries for the cure and
care of incipient cases are not enough, for they do not reach the root of the
matter, os would the rigid and constant care and supervision of the advanced
consumptive, whether in the home or in an institution.
What are associations and nurses doing to-day for these hopeleas ones?
Just scratching the surface and letting them go on spreading disease, in-
fecting and reinfecting lodging-house, tenements, shops, and leaving in
their wake twenty infected people, who will be forced in time to become
beneficiaries of dispensaries and sanatoriums. Speaking from an experience
of ten years, it seems to me that our short-sighted policy toward the advanoed
case is an expensive proposition* With far le^ expenditure can we care
for our 100 a*lvanced cases, than afterward to care for those whom they
will, in all probability, infect. From a pereonal experience in a commuojty,
I should say that two incipient cases come from the infection spread by
the one ailvanced case, which, if properly and adequately cared for until
death, would probably have infected no one. Then we have in a community,
we will flay, three incapacitated persona to support instead of one. Of
course, the percentage of infection is much greater than that stated, but
I have used the figures merely as an illustration, I firmly believe that if
the State would, for one year, turn its attention to the bousing, instruction,
546
NUHBINQ AND SUPERVISINa ADVANCED CASES-— FULMBR,
547
care, and supervision, either in their own homes or in institutions, of the
advanced cases, the appropriations for dispensaries and sanatoriuEos for
cures would be decreased by 20 per cent.
In my capacity as a nurse Ln the homes of the less fortunate I have seen
the handling of this class of cases, and I earnestly believe that our best
means for prevention is lost because of the lack of supervision and nursing
care, simply because the case is hopeless, and a prospect of cure no longer
exists. This apparent indifference to the advanced consumptive and his
needs does not arise from a lack of sympathy^ but in our zeal to make records
of cures, to have so many cases examined, so many visits for instruction
pmd, and acquire an outward evidence of large returns, we have forgotten
the hopeless case, who, in the mean time, with no one to encourage, instruct,
and control him, becomea the great^t possible menace to the community.
The situation is pathetic and deplorable — deplorable because unnecessary.
In correspondence with various tuberculosis dispensaries and committees
for the prevention of tuberculosis throughout the country, I found, with
few exceptions, that it was on the examination of suspects and instruction
to incipient cases that each exercised its largest effort. The advanced case
was a secondary consideration, both as to actual nursing care and further
following up.
Without desiring to depreciate the splendid work that is being done
everywhere along educational and curative lines, I feel, with many of my
coworkers, that so long as the advanced case does not receive our first
attention, the service is inadequate.
Perhaps the following may serve as an illustration of the many instances
that have made the tUre results of inattention to the advanced case;
A young man in the last stage of the disease came to a tuberculosis
clinic for advice. He was told by the physician in attendance that
nothing could be done for him. The man was young, a gmduato
of a well-known coUegej and the county poorhouse seemed the only resort*
Ho went back to his lodgings, a little three-roomed cottage in the rear of
a tenement. Several weeks after the doctor at this dispensary called a
visiting nurse and gave her the man^s name and address, sayiug that he
had come to the clinic some time before and that they had wondered what
had become of hira. The visiting nurse found the man bedridden. The
bedding, toweb, and body clothing, saturated with expectoration, were
being taken to a well-known laundry, and the several sets of workers who
bandied it had no knowledge of the infectious nature of the clothing. The
milk bottles — dozens of them in the ank — were also soiled with the sputa,
and these were returned through the hands of two sets of workmen to the
milk station near by. The man died in a few days. If this man, when he
left the tuberculosis clinic, had been followed to his home and nursed and
BIXTU INTERN ATtON A J> CONQREBS ON TUBEECUUMnB.
cared for, it is fair to presume that nmay peraonfi wouH at least, have been
spared exposure to the disease*
A teacher in a large city school appi^uled to a vituting nurse in behiilf d
a little boy of eleven years who wa^s pale and listleas. The boy was advised
to go to the playground or the small park near by every day after schocd,
and to he out as much as possible. Asked if she knew anything of the boy'a
hume, the teacher replied that uhe had heaixl that hia father was ilh On
visiting the family the nurse found the father in the last stages of consump-
Uon, lying in a dark, windowless room, and his boy sleeping with him.
The father had gone, many weeks before, to a tuberculosis dispensary^ and
hft<I been pronounced a hopeless case. Playgrountls and breathing spaces
may fortify Uatlcas children against the ravages of this diseaae, but no argu-
ment is needed to convince one that this little chap had a pretty uneven
chance with the odds in favor of the dark bedroom and the father in the
tost stages of disease*
When onoe we find the hopelessly incurable case, let us bribe him in
ecVftiy way possible, as we would a child with the longiest stick of candy
possibte. Coddle and pet him and win him, as we coddle and pet our lepers.
Then we shall have no unteachable consumptive^ and we shall give lezs
concern to inforcod rules for preventing contagion. Our lepers are nursed
and cared for, not alUigether out of sympathy, but because they con^tute
a menace to the community.
In conclusion I would say that we will do well to gjve more attentioD
the world over to the advanced consumptive, and, in the mean time, while
the magnificent groups of scientists from every nation under the sun pve
their labor and study to the cure of this great scourge, we, as the lield workers,
uhall have given our service to its prevention by a more humane and closer
supervision of the advanced case.
THE DAY CAMP.
By Suban Forrest Robbinb,
Heir Smnmy Buiatariiim for Tuberenloiu DiaMaao, CUaa Oardoer, N. J.
The day camp scheme, in common with much of the tuberculoffls work|
had it8 origin in Germany, the first camp being established near Berlin in
1900. During the following four years up to 1904 the success was so great
as to lead to the forming of six camps in the vicinity of Berlin alone, several
in other localities in Germany, while England, Austria, and Belgium could
boast of one each, making an aggregate of over 133,000 nursing days in the
year 1904.
Noting this success, and realizing the opportunity for educational work,
the Boston Association for the Relief and Control of Tuberculosis opened
the pioneer camp in this country in July, 1905, at Parker EEill, in Roxbury,
two miles from the business center of Boston. That this association was
justified in its belief in this method of work has been proved by the gratifying
results of the past three years.
In order to be as helpful as possible to any organization wishing to estab-
lish a camp we will consider briefly: (1) Location. (2) Equipment. (3)
Staff. (4) Daily regime. (5) Results. (6) Cost.
Location. — On Car Line, — ^The type of cases are such that going to
and from their homes on the cars is as much exercise as, and often at first
more than, they are able to take. Special cars are not necessary. Divide
the patients into groups, going at specified times, thus avoiding the over-
crowding of cars or inconvenience to the public. If your patients are careful,
they are not a menace to other passengers, and may prove a factor in public
education.
On Grounds of Hospital. — Camps located on hospital grounds and run
in conjunction with other institutions can be conducted at reduced expense.
This would include merely the cost of raw material for food, the salaries of
a nurse and one maid, and the purchase of chairs, blankets, etc. Moreover,
one has the support of the established institution in matters of discipline.
Protection, — From east winds if near the shore; from iu>rth and west
winds for use during winter. The camp should be maintained the entire
year. This can be done with very little additional equipment and but
slight discomfort to either patients or staff, as was demonstrated by the
549
550
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
last year of the Mattapan camp, before the city of Boston made it an im-
portant factor in its battle with tuberculosis,
ElevatioTu — This does not seem to be iniportant* The Parker Hill
camp waa mtuated at an elevation of 220 feet, while that at Mattapan was
at 66 feet, yet the latter seemed aa satisfactory as the former. Moreover,
the higher elevation ia moitJ difficult for patients to reach each day.
Woods, — As much woodland as will give protection from sun and make
the grounds attractive is advantageous. Everything that can serve to
give pleasure and uplift the mental condition is most desirable. Flowers
and vines over rocks and ahacka prove a delight to those coming from con-
gested districts. Also animals are a source of pleasure and amusement,
and give opportunity for lessons in their care ami kindJy treatment,
EQurpM£KT, — Since fifty patients are probably as large a number as
can be cared for at the commencement of any camp colony, the equipment
necessary for that number will be considered. Shacks or tents may be used,
and while the latter cost least at the beginning, the shacks need less repairing
and are more desirable for a permanent plant. If tents are used, there
should l.>e one large one, 20 by 50 feet, with raised floor, to be used as a dining-
room; it should contain movable tables, so that the space may be utilized
as a shelter in stormy weather. There should be five smaller tents, 10 by
12 feet, with floors: one ia used for administration, and should contain
matron's desk and staff dining-lable; one ia required for physicians* use in
examining and weighing patients and doing laboratory work; one is fur-
nished for the caretaker, usually a patient, who rBmains on the grounds at
night; and one is used for storage of chairs and as an emergency or rest
tent. The kitchen may be a '*lcan-to," open in front, with curtains to drop
in stormy weather. This includes kitchen and locked store-room^ the former
containing two sinks (one deep and large) ^ range, boiler, serving table, and
shelves for cooking and kitchen utensils, while the store-room has shelves
for groceries and space for refrigerators and milk-cooler. The kitchen and
dining tent should be as near each other as possible, and connected by a floored
and covered passageway. A smaller addition contains a eoal-shed and
laimdry with stationary tubs.
Lavatories should be provided, and should be large enough to permit of
divisioUj one part to contain water-closets with the simplest open plumbing,
and the other stationary bfwdns, for the washing of hands before each meal.
There should be shelves on which to place a box for each patient, which
is to contain soap and a towel, the latter to be changed each day. These
towels should be boiled each night after the patients leave. An incinerator
ia easily made from a cast-iron ash-can having square holes in the sides
near the bottom, to create a fine draft. Paper and a few bits of wood
Baturated with kerosene are placed in the bottom. During the day all
THE DAT CAMP-— BOBBINS.
«51
Hputum-bflgs and waste of any idnd are thrown in the can, which should
have a solid cover, to be replaced by wire netting while the contents are
being bumedp
In the Parker Hill camp reclining chairs and blankets are provided.
The dining-tablea are covered with white enameled cloth, and green decora-
tion was chosen for the dishes; nickel-plated knives, forks, and spoons and
white paper napkins are used. The staff had separate table and dishes.
In winter were added two small wood stoves for dining-room, coal-
atoves for physicians' and adnunlstration tents, and for the lavatories. The
wood-stoves were used only for a short time (one-half hour) before each
meal. During the winter a large surface of ground was covered with boards,
which could easily l^e cleared of snow, and the front of the *' lean-to" kitchen
was boarded. Heaters were needed, and the ordinary seltzer bottles were
obtained without cost from varioua clubs,
Shacks. — If a shack is preferred, it should have, on the first floor, in
addition to the dining-rooms, kitchen, store-room, laundry, and servants'
rooms, a phyaician's ofTice, matron's office^ examining room, throat room,
Btore-room for medical and office supplies, coat-rooms for men and women,
and toilet-rooms. The second floor may contain the staff quarters. There
should be a broad porch, with southern exposure, covered, so as to be avail-
able during a storm. A porch on the east and west sides of the shack, as
well as the souths is of great advantage during the summer. The interior
finish should l>e of plain, smooth, washable material. The floors of the
porch should be so laid as to permit of their being hosed. Stained sheathing
or shingles make an attractive outside finish.
Staff, — ^The staff for a camp of fifty should consist of: A consulting
staff; a throat specialist; a physician in charge; an assistant physician;
a superintendent or matron who is a graduate nurse; an assistant nurse,
also a graduate; and volunteer workers.
In addition there are needed a cookj two helpers for kitchen and laundry,
and a caretaker^ — usually a patient. All except the consulting staff, the
assistant physician, and the caretaker receive salaries. The physician in
charge ahould devote his entire time to this work, and should, therefore,
receive a remuneration.
Daily RtciME.— At the Parker Hill camp patients may arrive as early
as seven o'dock in the morning in summer, and never later than nine o'clock
throughout the year.
Each patient is provided with a paper bag and paper napkins for sputum,
to be replaced as often as necea&ary through the day, and provision is made
for a supply to be taken home for night use.
Temperature and pulse are recorded on arrival, and again in the after-
noQUt At 9t30 a. m. a luncheon of bread, butter, and milk is given, with.
I
BS2
SIXTH INTEKi^ATlOXAL C0NQBE3S ON TUBERCULOSIS,
on pby^cian'a order. At 12,30 a hearty dinner is partaken of, conastin^
of m&at, fowl, or fiah, potatoes, one other vegetable^ bread and butter ruilk,
and a wholesome dessert, preferably one made of milk and eggs* At 4 P* ii.
another luncheoap similar to that given in the monung, is served.^ In
winter hot milk, broth^ and cocoa are given at luncheons.
Between Eve and dx o'clock, after taking the temperature and pulse,
patients leave, reaching home in time for the night meal. Patients, who
were able, were allowed and encouraged to do light work, but no patient
worked over one-half hour, as the effort required in going to and from their
hotnea was connidered enough exercise. The time may be spent in reclining
chairs or in hammocks at rest, or in simple amusements, reading^ sewing,
and games.
All patients were expected to wash their hands and care for teeth and
mouth before each meal. Examinations of chests were made once each
month, and patients were weighed each week. As the aim of the camp was
educational, addresses were given on tuberculosis, hygiene, care of the teeth,
etc.
The assistant nurse visits in the homes, secures proper sleeping arrange-
ments, supervises the food, and teaches the family the necessary precautions
to be observed in order to avoid infection. In this ade of the work we
become closely allied with organized charities, settlements, churches, labor
unions, various clubs, and sources from which we might expect aid for our
patients.
One of the most important points of our work, and one that will be
amply repaid by marked results, is to relieve ail mental strain. The matron
can spend her time in no more advantageous way than by doing daily
individual work among the patients, showing her willingness to become
their friend and helper.
RESDLTs.^The Parker Hill day camp cares for patients not accepted at
the State sanatorium, and not ill enough to go to a hospital for advanced
cases. There are a large number of just such ambulatory cases, who, with-
out instruction, prove a constant menace to their neighbors and family.
No patient was refused who was iible to reach the camp. All were allowed
to pn>ve for themselves the extent of their weakness, and then they were
more willing to accept the alternative — the advanced hospital The exam-
ination of members of the family and friends of the patients resulted in
removing sources of infection previously unsuspected.
The relief of despondency and anxiety, caused by the separation of
families for an indefinite period, proved of grsat value, and became an im-
portant factor in helping patients to recover.
In the report of the Mattapan Camp for eight months I find the follofwing
figures, which should gratify and encourage alike both patients and tubercu-
THE DAT CAMP. — ^BOBBINS. 553
losis workers. During eight months, 252 patients were admitted. Of these,
209 roomed and slept alone; 16 were sent to the State sanatorium, having
been refused shortly before coming to camp; 30 were discharged arrested;
153 improved; 40 grew worse; 29 died; 132 friends of patients were
examined, and 34 were found to have the disease. Forty, or one-third
of the patients admitted in 1905, the first year of the camp, after four
months' treatment have been, to a great extent, self-supporting for two
years, being able to work all or part of each day.
There are ten camps for adults and two for children in Massachusetts.
Germany has sixty-seven camps in operation at the present time.
Such a camp as that described cannot be compared with a well-r^ulated
sanatorium, where a patient is under supervimon the entire twenty-four
hours, but is of value as a supplement to di^)ensaTy work and to care
given by private phyeicians.
Day camps are of value: (1) In detecting disease in other members of
family. (2) As a means of educating patients and the public. (3) In
obviating the necessity of the breaking up of homes. (4) In caring for a
large niunber of cases unable to go elsewhere. (5) In completing the cure of
those discharged from sanatoriums. (6) In that their comparative cheapness
makes their existence possible in nearly every community.
Cost. — ^The cost of building and equipment for the tent system is from
$1000 to $1500, according to the distance from eewers, and the amount of
plumbing. The shack with equipment for seventy-five patients is estimated
to cost between $5000 and $6000. The cost per patient varies between
40 cents and 50 cents a day. The food and ooal cost 31 cents. Patients
may be charged a small sum, 25 cents a day, or smy fraction of that they
feel able to pay. The camp need not furnish carfare; if the patients are
unable to pay this, di£ferent oiganisatkms should do their lAiaie in this
important work.
THE NURSB IN THE DISPENSART- — LEB.
5SS
in their homes, go over the rules of the dispensary with them, and make
certain that they understand thera in every detail as pertaining to persona!
hygiene and home sanitation. She must investigate the sleeping room, see
that every provision is made for ventilation during the hours of sleep, and,
not less important, for the admission of sunlight during the day; see that
no one occupies the same bed, or, if avoidable, the same room, with the patient.
Insist on their taldng the proper food at the proper hours; insist on a certwn.
amount of rest, and in every possible way oppose the heresy that what the
patient neetls is exercise; instruct the well members of the family as to the
danger to them of the presence of a case of tuberculosis, and as to the precau-
tions the patient should take as regards the disposal of the sputum, the
indiscriminate use of table furniture, and the sterilization of euch articles
after qse, and the boiling of all washable clothing and bed-clothing apart
from the family wash.
As the nurse gradually becomes familiar with the family and they become
accustomed to her visits, they will make her a confidant, and if she finds
another member of the family who exhibits suspicioua symptoms, she will
advise such person to consult the dispensary physician and have the question
of the presence or absence of the disease decided.
She will examine the house and its environment for evidences of dampness,
and use her influence to have the cause of such conditions removed. The
places where patients work will also be visited, and advice given for the im-
provement of unhygienic surroundings. If the occupation be such as is gener-
ally considered prejudicial to a consumptive, she will report the same to the
physician, in order that he may give such advice as he deems proper under
the circumstances. The financial condition of the family will also be noted.
Subsequent to her first visitj a written report on the conditions found is
rendered to the physician in charge of the dispensary. It will be her duty
to note especially the ciirectiona given the patient by the physician in each
caae, and keep in mind those of an unusual nature, such as apply to that par-
ticular patient. She ^vltl attend to the distribution of milk and ^gs, receive
any complaints of quality or irregularity of furnishing them, and especially
assure herself that the food is used by the patient, and not by other members
of the family or by neighbors. In this way alone caJi the results of the treat-
ment be secured and the State guarded from a misapplication of its funds-
It will thus be seen that the requisites for a tuberculosis tli^spensjiry nurse
are of a somewhat more exacting character than those of an ordinary nurse;
that the position deraamls, over and above the usual qualifications, first of
all, tact, in order that she may be able to overcome the natural repugnance,
especially marked in persons of moderate circumstances, to what they may
consider an intrusion into their family circle. She must be good tempered
and not ready to take offense or resent insult. In short, she must be " wise
as a serpent and harmless as a dove/^
THE DISCHARGED SANATORIUM PATIENT.
By M. Alice Gallagher,
Discharged saQatorium patients present so many different phi
their home life, financial and physical eonditionSj that I will divide them into
classes, and endeavor to give a brief history of each type as he appears to me.
First Cluss. — ^The "arrested" case who has meanB, resource, and ability,
whose home surroundings are good or are made good^ who either obtains
suitable employment or who can wait for it, whose family is not sacrificed to
his needs, and who is relieved of all worry. Well equipped for the fight,
he has the heart to keep it up, and be is usually a good missionairy to his.
fellow-men. He is proud of his sanatorium and grateful and loyal to it.
Second Class, — The "Mrested" case who has spent hia savings in paying
his board, providing for his family, and keeping up his insurance. This
class usually have been prudent enough to prepare for sickness, and if the
cure could be pronounced complete, the sacrifice would be well worth while.
But when, after a few months* work at either hia old employment or whatever
he can find to do, he fails again in health, the outlook for him is discouraging,
and, as he belongs to the class who have not become inured to charity, he
is likely to struggle along until he is too ill to work, and the family becomes
exposed through privation and bad living.
Third Class.— The "arrested'* case who perhaps has been in the country
long enough to become an American citizen, but not long enough to become
thoroughly imbued with the idea that ten children cannot sleep in two
rooms and be healthy, and that the dirty little shop in the cellar by which
he makes his living is poor soil in which to complete hia cure. If it happens
to be the ^ife or daughter who returns to these surrountlings, he cannot
understand why she does not remain well, and heaps scorn upon the sana-
torium and all connected with it, and bewmls the money he has thrown away.
He will never have any member of h^ family examined until sickness la
^parent, and then under protest.
Fourth Class. — The "arrested'' case, supported in the sanatorium for
months probably by private or public charity, who returns to pooraurround-
inga. He has always been handicapped by habits, inheritance, or environ-
meiDi; his sojourn in the sanatorium has been perhape his first chance to
66a
TUB BISCHARGBD fiAi^ATORIUM PATIENT. — GALLAGRllR.
557
know what a regular life means, and when be returns to his old environment
without the props that supported him in the sanatorium he is helpless.
He has obeyed literally the commands given. He has worked faithfully
the regulation hours at the eanatorium, if he has worked at all. If he has
not worked, then he haa either forgotten how, or he must be helped to find
suitable employment. He must be fed, clothed, and his family provided for-
Fifth Class, — The "improved" case who feels that a change of climate
will do for him what the sanatorium has fouled to do, and is i>erhaps advised
by a physician to go west or south for his health. If he belongs to the elaas
who can afford to go without seeking aid, he goes. If he needs a little help,
he can, perhaps, be held back. If he hadn't any funds, he cannot go, of
course, but will feel sure to the day of his death that he has lost his chance.
It is pitiful to see the efforts made to Tme enough to get away, with no
thought of how he will live when there, and, awful to contemplate, the
menace he is to the traveling public.
Si^iih Class. — ^The "improved" case who oomee back to drift along
aimlessly, working a week or two, idle a month or two^ who either thinks
he has nothing more to learn, or who drifts from day camp to chrome hospital,
and from hospital to the grave.
Boston has a good many tents on roofs just now. The prejudice of
landlords and tenants has l^ccn overcome, but I trust I will not be accused
of pessimism if I doubt if these tents are always used faithfully. I base my
doitbts upon some evening visits matle last fall, when I found a patient
tucked snugly in bed in a room with closed windows and the baby in his
crib fdongside of him. This man had reoeived all the aid that charitably
disposed individuals could give, all the training that the sanatorium, the
tuberculosis class, and the camp could give him, and yet he was doing just
what any ignorant patient would do. Unless we can awaken a sense of
responsibility and honesty, and impress upon this class a knowlettge of
what is due from them, as well as to them, we would better isolate them
entirely as hope to save them from being a menace to the community.
The tendency to permanent idleness is very great, especially among men;
the public parks are full of loafeiHj and among them can be found many of
our discharged patients taking the cure in their own way, with no restric-
tions, no supervision, some with perfect honesty of purpose. About one-
third of the discharged patients are never located; these are principally
single men in lodging-houses, or servants who leave homed where they have
been employed and to which they never return. It is practically im-
poBMble for the Rutland Sanatorium to give correct addresses when these
patients leave, as the patient himself does not always know where he can
find a room or how long he will keep it. This makes one think seriously
of the problem of proi>erly dLsiMecting after the transient lodger, m he may
668
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
not be known to be tuberculous. Disinfection after every reraovai, whether
the tenant is known to be eick or not, by the proprietor seems the only
Bolution^ This is very frequently done voluntarily in houses of the better
class. The one-night stands one! cheap lodging-houses must be Ene soil
for infection, since the lodgers are usually poor and intemperate, and natur-
ally ill-nourished and careless.
The supervision of the discharged sanatorium patients is, for the most
part, the work of one nurse, and cornea after the urgent daily cases are
attended to. On this account the patient is not visited as quickly as he
should be. The visit is made for the purpose of learning home conditions,
occupations, etc, A oomparison is made with former and present surround-
ings, and the future plans of the patient are discussed. It has been my
observation that the patient who has changed his occupation has secured
his own employment, and that those who waited to be helped to make the
change received very little aid. The occupations, to which several patients
have turned, are driving teams and running automobiles, pa3'ing, in the latter
case, for tuition. A few have been helped by private organizations to such
positions as switch tenders, and a few have taken up farming, but there is
no definite place where a patient can receive the chance that he should have
to reinstate himself in the ranks of the self^upporting, with a prospect of
remaining so.
A man who gets work with sufficient pay to support his family b obliged
to do the work as satisfactorily and in the same length of time that a per-
fectly well man would do it. He leaves the sanatorium with definite in-
structions as to after-care; he has worked very little^ if at all; he has been
well fed, and, in fully 50 per cent, of the cases discharged, he returns to a
small tenement, in a dirty house, in a crowded quarter of the city, where
he becomes a part of an element that it will take years to teach right living,
and where more and more emigrants are constantly being permitted to come
when they land in this city. He uses the kitchen sink in the famiEy living
room, perhaps; at least he finds it simpler than it would be to clean out the
bath-tub in order to take his daily sponge.
The lessons taught can be repeated glibly enough; the daily assertion
that the patient rooms and sleeps alone is maintained, in spite of the fact
that it would be an impossibility, with the number in family and the number
of beds or cots, by actual count. On an income of sbc dollars a week, many
will assert that they take two quarts of milk and from two to six eggs a day.
When one considers the number in family, rent, and family income, with em-
I^oyment only two or three days a week, and deducts the amount actually le-
oeived from what would be a full wreck's wag(^^ one must either think that
Boston has a remarkable set of landlords and storekeepers, inasmuch as these
patients remain in the same tenements and do not die of stiw^ationj or
THE DISCHABGED SANATORIUM PATIENT. — GALLAGHER. 559
else one must fear that the tuberculous campaign has made the class who
seek aid very unreliable. We are getting more and more of the once self-
respecting, self-supporting individual. He may be afrud, with the prospect
of a long illness before him, to acknowledge his savings. After he has told his
history to four or five different people, he repeats it mechanically, and with an
increasing loss of self-respect at each recital. In the end, the aid he gets is
totally inadequate to his needs, if they are genuine, and too much if he is
not truthful. He cannot be ranked with the pauper class. Idleness and
consequent poverty are often, compulsory, and the discharged patient must
be studied from a different standpoint.
Summary and Conclusions.
In summing up the results of my investigation I would like to emphasize
the great need of more thorough supervision of the patient who does not
come in touch with a dispensary, where he will receive home supervision,
day-camp treatment, or hospital care, according to hb need. This can best
be done by making use of the knowledge, gained before his entrance to the
sanatorium, to improve existing conditions before his return, to enlist the
cooperation of charity organizations or tuberculosis associations in cities or
towns outside of Boston, to work with the same end in view, and also to en-
deavor to come in touch with employers who will interest themselves in
helping the patient who is fit to return to work, even if he is not able to work
a full day.
In conclusion, I wish to reiterate my firm belief in the loyal patient as a
powerful good in the factory or shop. This question of work is one of vital
importance where there is a question of family support, and the treatment
in the sanatorium should be productive of something more than education,
unless we are prepared to support large numbers of patients for life.
THE HENRY PHIPPS INSTITUTE TRAINING SCHOOL
FOR NURSES.
By Anke K. SirrroN,
Pbit&ddphiiL
To minister to human life, to protect and defend the human system ag^uost
disease, to relieve suffering, t^ help nttture fulfil its purpose, is, indeed, a
moet honorable vocation,
The Training Srhool for Nurses at the Henry Phipps Institute was
opened in 1904. Suitable young women in whom the disease has been ar-
rested were enrolled as candidates. Preceding this, graduate nurses had
been employed, but they hicked sympathy for their tuberculous patients,
and seemed to be in fear lest the disease make them its victims.
The rouTse of study covers two years. Applicants for admission to the
Training School for Nurses are required to pass an examination in arithmetir
penmanship, spelling, compoeition^ history, antl geography, and are judged
upon their work during probation. The course of study eomprises leeturcs
given by the members of the staff each week on the following subjects:
Embryology and histology.
Anatomy of the skeleton.
Anatomy of the muscles.
Anatomy of the blood and blood-vessels,
Anatttmy of the digestion and genito-urinary tract.
Anatomy of the respiratory organs, brain, and nerves.
Physiology of circulation and respiration.
Physiology of digestion and excretion.
Physiology of locomotion.
Materia medica.
General bacteriology.
Bacteria and disease.
Hygiene.
Bandaging demonstration.
Nursing in medical diseases—care of patients; emergencies.
Observation and recording of medical casea^temperatui^e, respiration,
cliills, sweats, hemorrhages^ convulsions, pain, swellings.
Inflammation, suppuration, abscess, fistula, sinus, ulcer, septicemia.
Surgery — operations; preparation of patients, instniraents, cane during
and after operation.
no
HENRY PHXPP8 INSTITUTB TRAININO 6CH00L FOB NUBSKB.— flUTTON. 561
Surgical emergencies: bums, sprains, bruises, eontusbns, fractures,
dislocations.
Tuberculosis.
Diseases of the lungs, pleurae, and bronchi.
Diseases of the gastro-intestinal tract.
Diseases of the circulatory system, heart, pmcardium, and blood-
vessels.
Diseases of the nervous system.
Diseases of the nose, throat, and ear.
Testing sputum and urine.
Diseases of the skin — effect of baths.
Diseases of the eye — anatomy and physiology of eye.
Infections generally^-conta^ous diseases : small-pox, scarlet fever,
measles, chicken-pox, mumps, diphtheria, rheumatism, pneumonia, typhoid
fever, and malaria.
Electrotherapeutics.
Malignant growths, cancer, sarcoma, syphilis, sites, course, etc.
Diseases of the genito-urinary system.
Class work from September 15lh urUil June 1st by the Superintendent of the
Training ^cAoo/.^Demonstrations on practical nursing are £^ven through-
out the term. Each senior nurse is required to see two autopsies. A course
of invalid cooking is given in the senior term at the Drexel Institute. Ap-
pointment to duty is as follows:
Probation Two months.
Wards, day duty Seven months.
Laboratory One month.
Inspecting uptown Two months.
Inspecting downtown Two months.
Wards, night duty Four months.
Dispensary Foiu* months.
Vacation One month.
Examinations are held at the end of junior and senior years. On gradua-
tion a diploma of proficiency in the nursing of tuberculous cases is given.
Ward work consists of general routine hospital duties. The nursing of
an advanced case of tuberculosis is similar to the care of a very sick t3rphoid
case. Temperature, 100° F. or over — ^placed on rest (bed patient). If
temperature is 101° F., sponge between blankets, using Lo&-cap. Care of
mouth: use listerine solution, and alwa3rs bum swab.
Avoidance of Infection, — In coughing, patients are directed to hold p^>er
napkins over mouth to avoid spraying of sputum. Napkins are placed in
paper bags and then burned.
Care of sputum: Inside paper boxes are burned in incinerator; tin hold-
ers ore boiled and formalized.
Care of stools and urine — chlorid of lime and lye.
Care of hospital appliances — formalize and boil.
562
SIXTH mTERNATIONAL CONORESS ON TUBERCTTLOSBp
Care of beds — formalize.
Care of dishes^boil.
Care of bedding— formalize and boi!.
Care of patients' clothing — formalize.
Care must be taken as to the nmnner in which the lids fit down on the
linings of the sputum boxes. In order to prevent the spread of gerins there
must be no open space.
The patients must be given kindly words of cheer, and need constant
reminders of discipline in the avoidance of infection; the discipline in this
respect must be most rigid.
Diet in TuBERcmxaaiB.
6 A, M.: Milk,
7.30 A. u.: Breakfast: Cere&l, bread and butter, egg^, mUk.
10 A. M.: Lunch: Milk and eg^.
12,30 p. M,i Dinner: JSoup, meat, three vegietables, dessert, milk, and bread,
3 E". M.i Milk BJid e^,
6 P. M.: Supper: Muk, egga^ bread and btitter, fruit.
S F. M.: Milk.
Each patient takes daily from two to three quarts of milk and ai% eggs.
Dispensary Work,
New Cases.^Preliminary facts are recorded on history chart and card
given with history number, which is presented at each visit. When the
patient has been examined for the first time by the physician and diagnosed
as tuberculous, the nurse gives the patient preventive supplies done up In
packages, suificient for two weeks, also a set of rules. On later viaits the
history is taken out of the file, ready for the physician, with patient's tem-
perature, pulae, and respiration recorded; this simplifies the work for the
physician.
Patients are examined, milk ia ordered, and they are weighed every two
weeks by physicians {unless some new symptom appears).
Tuberculin ia sometimes given in the dispensary, and the patient receiv-
ing it comes to the dispensary at more frequent intervals, in order that he
may be watched more closely.
Inspectreases visit the homes of dispensary patients, make careful re-
ports of the conditions found there, and ask the following questions, the
answers to which are recorded and filed with the history:
Date
No ...... Name ,^,*. ..... *
AddrBBS....... .>.....,...> ,.
Amount of milk received
Is oiilk uaed by patientT * - . . .
Is patient working?
Doee p&tieot iske cure out-of-doors?
HENBT PHIFFS INSTTTUTB TRAININQ SCHOOL FOR NtTBSES. — SUTTON. 663
Does patient sleep with windows open?
Does patient sit in kitchen?
Does patient use spit^-cup?
Does patient use paper napkins?
Does patient bum spit-«ups and napkins?
Does patient spit on pavement when on street?
Does patient use hanokerehiefs or rags?
Are premises of patient clean?
Is there a back yard, and what is its condition?
How many people are there in the house?
Is the house an apartment house?
How many windows in the house?
Are any other inmates of house sick?
Does patient use stimulants?
Have the rules of the institute been hung up in the house?
Have you instructed patient in observance of rules?
Income
Rent
Name of inspectress
From the standpoint of nurses, inspecting is interesting; it ^ves them an
opportunity to open the eyes of their souls. Having suffered with the
disease, their knowledge, sympathy, and courage give them an uplifting
power, for having crossed the Rubicon, they can guide suffering humanity
into the realms of health.
To the question, Is there a field for tuberculosis nurses? the answer
is that the demands are increasing both in sanatorium and private duty.
We are unable at times to meet these demands.
Since the year 1905 we have had twenty-two graduates. Of these, two
are still in the institute, two have died, and the remaining eighteen are doing
sanatoriiun work — ^in charge of tuberculosis sanatoriums, nursing in sana-
toriums, on dispensary duty, on private duty, in tuberculous work only.
They are all happy in their work, supporting themselves at a higher salary
than they were earning previous to their breakdown.
It has been suggested that possibly our niu-ses may by degrees attempt
to do general work. In answer to this I will say that so far there has been
no tendency in that direction. Our graduates nurse tuberculous cases only,
and if they desire general work, we then suggest a general hospital training.
HOME OCCUPATIONS IN FAMILIES OF CONSUMP-
TIVES AND POSSIBLE DANGERS TO
THE PUBLIC
By Mabel Jacques,
Philadelphia.
One might almost make a sweeping assertion and say thatj in the home
of every poor consumptivej there is work of some kind going on that will
carry out into the world the destructive tubercle germ. Until it becomes
possible to abolish work done in these unsanitary homes, and to find safe
occupation for this class of people, it seems impossible that much progress
can be made toward successfully stamping out the disease. Being most
familiar with the homes and industries of Philadelphia, my statements have
reference to the conditions existing in that city.
Before we go into any detailed account of the dangers incurred thereby,
let ua hmt consider the different forms of work that are likely to be done in
these homos.
Statistical reports indicate that the greatest amount of tuberculosis is
found among the negro race* The chief occupation in their homes is laundry
work. Occasionally we find dressmakers, restaurant keepers, barbers, and
now and then a tailor among them.
Among the Italians we find finishers of ready-made clothing, such as
trousers, men's coats, shirts, and caps. Women's collars and neckwear
generally are also made. Small manufacturers of macaroni, ice-cream, and
candy; buttonhole makers^ custom tailors, rag-strippera, paper-flower mAk-
erSf barbers, and cigar-makers are found among them.
In the Jewish homes we find nearly the same occupationSj excepting the
macaroni, ice*cream, and candy makers.
The English and Americans do probably less work at home, but we find
among them finishera of aprons, children's dresses, neckties, paper-box
makers, stocking seconders, base-ball stitchers, makers of paper candle-
shades, bread-makers, washwomen, and the small store-keeper that we find
among all nationaUties.
There are, of course, people from many other nations living in our dtieSi
in whom tuberculosis is more or less prevalent, and who are likewise doing
£64
HOME OCCUPATIONS AND PUBLIC DANGEB.— JACQUES.
505
work in their homes, but I should like to speak more particularly about
those that I have mentioned.
It has already been stated that the homes in which tuberculous appeaiH
most frequently seem to be those of the negroes, that increasing race of
people who are not only forming a large part of the population of many of
our citteSf but who also do about half of our household work. Most colored
people, who are not living out at service, are taking laundry work into their
homes.
The family of the congumptive is generally a very poor one, and all those
who are able to work must do so; even the one member of the family, who
stays at home to care for the sick one, must do her share toward augmenting
the general fund, and she will ask you what can be more easily done in the
few spare moments she has than a small wash?
The question as to whether any precautions are being taken about hand-
ling these clothes after waiting on the patient is met with surprise, and you
doubtless discover, after further questioning, that they are being washed
with those of the patient^s. Later they are taken home, apparently clean
and white, to their owner, who wears them without a suspicion of what they
have been through.
To illustrate the conditions described a recent case might be cited.
Upon visiting a child, who for three years had been confined to her bed owing
to a discharging tuberculous abscess, I inquired into the manner in which
the wound was being dressed, and found that the mother was accustomed to
dress it once a day, using warm water and old linen. Questioning her as to
the disposal of these dressings, she repUed that they were washed and used
again, I cautioned her about this, suggesting possible infection to herself,
and promised to keep her supplied with old linen enough to enable her to
bum the dressings after they had been used onoe.
The family appeared to be a very poor one, and upon making inquiry
as to the source of income, I found that the father was the janitor of an or-
phanage, and that the mother did laundry work at home. Ag^n referring
to the dressings^ I asked if by any chance they were washed in the same tub
that was used for the outside laundry, and received an affirnmtive response,
together with the remark that there was nothing ebe to wash them in. It
also developed that the dressings that were not very badly soiled were rinsed
off under the hydrant, and then washed, not only in the tub used for the
outside laundry, but actually at the same time. When asked if she had ever
told the people she worked for what was the trouble with the child, she re-
plied quite indignantly, **No, it ain't smalJ-poxl"
We who are working among this class of people meet similar incidents
every day- We find baskets of snowy linen standing b^de the l:ted of a
patient in the last stages of the disease^ exposed to the spray flying from his
566
SIXTH INTERNATIONAL CONGRESS ON TU13ERCUL08IS,
mouth as he coughs. We find seamstresses in the advanced stage striving
to work aa long as their strength will allow them, stifling the cough with the
hand with wliich they work
The average negro shuts himself in a closed room having no ventilation.
Such rooms are veritable incubators for the tuberculosis genn, and it is in
rooms such as these that much of our laundry work h being done.
The Italians, coming from a warm climate, also house themselves closely
in cold weather^ and it is then that most of the housework is lieing carried on.
During the summer many of the factories and mills from wliich they get their
work are closed, or the work grows slack, and we find whole famihes going
out into the country to pick berries and vegetables. But in the fall and
winter every Italian home is a busy one, and in almost everj' house you will
find piioa of unfinished garments of every description.
If one of our well-dressed men, priding himself upon having his clothes
made by one of the best tailors in town, would follow one of his suits ia the
making, he might be more than stu'prised. He would find that it was cut
and fitted in the well-appointed shop that he was familiar with, but that when
it reached a certain stage it was sent to the It^dian or Jewish quarter, very
likely to a small, dirty home, where the finishing was done and the button-
holes made* In this very home there is perhaps a consumptive who, more
than likely, is helping with the work, for whole fa-niilies are oft-en engaged in
the finishing.
Going through the Italian quarter, not many weeks ago, I noticed a girl
sewing lieside a window. Knowing the family, I stopped to inquire how
they were, and noticed, while talking to her, that she had a persistent cough,
though she hardly raised her eyes from the buttonholes she was making.
When 1 spoke to her about it, she shrugged her shoulders, apparently in-
different to the spray from her mouth, which flew over her work- Her only
ans^ver was that it would all pass away in the spring, when they went to the
country to pick berries. Picking berries a8 a cure for a tuberculous cough,
with no idea ol the thousands that would be endangered from the contami-
nated berries I
Again and again I have found macaroni, ice-cream, and candy making
being carried on in the home of a consumptive, and sometimes by the patient
himself, while he explained to me that the work was easy- The ice-cream
that our school-children buy daily from the "hokey-pokey" man is not in-
frequently made by a patient suffering from tuberculosis.
The keeping of a small restaurant is another form of occupation likely to
be found among the consumptives and their families. All tWough the poor
sections of the cities one sees the sign, "Restaurant, thirty-cent dinners,"
and a list of the eatables that may be obtained there. These signs are in
almost every langua^, some on fairly nice-looking houses, and others on
home; occupations and public danger. — JACQUES.
567
cellar-doors. If we should happen to enter, we would find that the interiors
are eomethnes clean and sometimea filthyj with dirty table-cloths swarming
with flies, and, above the smell of the cooking, tlie odor characteristic of
the tuberculous,
I visited a case last winter reported to me by the Society for the Preven-
tion of Cruelty to Children, The restaurant sign hung before the door, and
getting no response to my knocking, I entered. I found a large, airy room
with rather simple but neat furnishing, A girl of about fifteen, evidently
a waitress, met mc.
"Does Mrs. B live here?" I asked. She hesitated, and then led the
way to A back room, which proved to be both kitchen and bedroom; before
a table sat an emaciated woman opening oysters. She glanced up at me
in a defiant manner, holding her hand over her mouth to stifle the loose,
racking cough, and between coughs replied to my questions, denying that
she was at all ill, denying even that she had a cough, admitting only that
she ran the restaurant and prepared the food. She really had a good busi-
ness, the place looked clean, and the food apparently tasted good; those who
ate there and knew of her condition were either sorry for her or absolutely
indifferent, not understanding the dangers to which they were subjecting
themselves.
Most of us are fond of good home-made bread, and often we see a card
in the corner of a window reading, " Home-made bread and rolls," Last
winter I noticed one of these signs in the window aa 1 entered a house. The
front door was open, and as I entered, a delicious odor of home-made bread
greeted mej and despite the poor surroundings^ 1 sniffed in the fragrant air*
I was looking for the caretaker of the house, and almost unknowingly I
literally foilowe<l my nose to the door of the room from which the odor was
evidently coming. In response to my knock the door was opened by a very
dirty child, and I found myself in a small room, evidently ori^naliy intended
for the kitchen of the house, but now being used as the caretaker's room.
It contm^ned a huge range, a sink, table, bed, one chair, and a cradle. Tlie
husband and wife, five children, a cat, a dog, and a rooster Uved in this room.
The oven door was open, and the wife was taking out loavea of beauti-
fully baked bread, while in the cradle was a large dish-pan fxill of dough.
The family were poor white Southerners, of the most shiftless type. I
learned that, in return for caring for the house, collecting rents, cleaning
hallways, and evicting undesirable tenants^ they were given, rent free, the
use of this one room, in wluch the entire family slept, ate, and lived, generally
with every door and window closed. They earned a small pittance from the
sale of very good bread, made by the wife and delivered by the husband,
the latter of whom had passed beyond the incipient stage of tuberculosis.
Every loaf of bread that was sold went through his hands, first in packing
568
StXTH INTERNATIONAL CONGBEaS OX TUBERCUXOftlS.
it in the basket, and later in huoding it to its purchaser. For months this
has been going oiij the customers unconscious that the bread they so much
enjoyed was being made under these unsanitary conditions, or, if they knew
of itj were unable to appreciate the danger.
These are, of course, only a few of the unsanitary conditions under which
work is being done in the homes of the consumptives, and there are many
more of equal possible danger to the public^ and they should most assuredly
be prohibited, either by law or by the education of the public. But remove
these various forms of occupation from their reach, or educate them to
recognize the danger to the general pubhc by the continuation of them, and
what will you ^ve the poor consumptive and his family ivho must remain at
home to do, that they and their families may be supported?
Various forms of work have been mentioned, both by physicians and
laymen understanding the disease and interested in it, but few* of them have
proved successful.
It really seems that the only efficient means of obtaining employment
for these people that is harmless both to themselves and to the public would
be in the forming of colonies for them outside of the cities, where, to a cer-
tsm extent, they could be under supervision. It is only when removed from
it that they become negligent.
Gardening and the raiaing of plants might be carried on, the most diffi-
cult part of the work being done by those physically able to do it, and the
lighter work by those whose condition will not permit of heavy work.
If some land company could become interested in the formation of such
a colony, it should in time become not only of great benefit financially to
the consumptive, but also to the company. I realize^ of course, that the draw-
back to this plan h the objection of the consumptive and his family to living
in colonies, but it seems to me that if the houses were made attractive, this
objection could be overcome- If the public can be taught that the diaease
is a curative one, those who are affected will be more willing to recognize
their condition in the incipient stage and to realize the necessity of securing
caro and treatment while in that condition, and this should overcome any
objection that might exist regarding this method of living. These colonies
could be formed near enough to the large cities to be of easy access, and in
this way thousands of infected persons could be removed from the congested
parts of the cities. The gardening and Hower^raising could be carried on by
both men and women, the women doing the lighter work.
There have, so far, been few forms of work that have really appeared
to be successful for the incipient or arrested cases of tuberculosis. For those
women who are known to be particular about observing the rules of personal
by^ene peculiar to the disease plain sewing seems adaptable, if it is not done
too steadily. Canvassing has also appealed to be a good form of occupation,
BOIIE OCCUPATIONB AND FUBUC DANGBB. — ^JAOQUBS, 560
For men, such pomtions as motormen and conductors, driving light wagons,
and various forms of canvassing have proved at times fairly satisfactory.
But few people are really able to support themselves under these forms of
work, and are very apt to grow worse instead of better.
The seamstress soon finds the work necessary to provide her with the
proper nourishment too much for her strength, and a general relapse sets
in; the same result is likely to follow when the canvasser becomes despon-
dent and discouraged firom constant rebuffs, and is imable to afford her milk
and eggs. The motorman, perhaps, is not strong enough to meet an emer-
gency if one occurs, he loses control of his car, and incidentally his position,
and the money grows scarce, and the nourishment decreases little by littlOi
until hope, too, leaves him.
Pressure should most assuredly be brought to bear, by all those interested
in the tuberculosis movement, to influence those infected with the disease to
go out of town and find employment there, but this will never imiversally
be accomplished until there is some general plan to get them out, and some
marked inducement to draw them there, and the formation of consumptive
colonies seems to be the best solution of this very difficult problem.
THE INSTRUCTIVE DISTRICT NURSE.— SMITHWICK.
571
3. Cleanliness as pertaining to the patient and others.
4. Proper selection of nourishing and digestible foods.
5. Appropriate clothing and Ijedding.
These aubjecta should be dealt with separately and at length, so that the
)lute value of each may be conveyed to the patient, for his owti safety
kdfor that of those with whom becomes In contact* In this connection it
must be remarked that a nurse daily deaUng wnth tuberculosis must remember
her duty to herself. Tliis includes the faithful observance of the same rules
that she preaches to others. She may then become a living example to them,
and thereby use the very best means to protect herself.
Tuberculosis nui'ses may do much to advance the value of registration
of those coses \vith the departments of health. This need cannot lie over-
estimated. Here again can the modem nurse bring this about in a tactful
manner, enlisting in her service the afflicted ones themselves, by assuring
them that registration is not intended for publicity Dor for the idle or
curious, but to bring to themselves and to the cause a epirit of univeiBal
helpfulness.
For the West, a spirit of enlightennietit is needed along these lineSj where
the conditions are peculiar, and where the field of labor is> indeedj great.
An important question that arises after the fiist months of instruction is
that of securing desirable employment for these patients. Outdoor life
being necessarj^ cari^entry, metal work, canvassing^ light expressage or
teaming^ junk^peddling, or collecting seem to be most favorable. In the West
it has been found that the consumptive is often forced to accept such reduced
wages that his living cooditions greatly counteract the beneficial influence
of the climate. Societies have been formed to meet this condition. For
instance, patient*? leaving the Jewish National Hospital are looked aft^,
and suitable employment is found when possible; a movement has also
been started to teach them trades,
A young woman leaving a sanatorium found her progress retarded by
the carrying of heavy trays while engagp^l as a waitress, Occupations foimd
to be undesirable by visiting nurses are cooking, fruit-peelingj tailoring,
mining, butchering, saleslady, and school-teaching. All work relating to the
consumption of food, and in this connection truck gardening must be men-
tioned, should also be heartily condemned. A patient suffering from tuber-
culosis of the hip was found by a Ck>lorado visiting nurse in a very unhygienic
home. Remodeling of the house was not possible, so, with the aid of a
sanitary couch, heavy oil-clothj and several yards of mosquito netting the
front porch was converted into a sleeping roam. The oil-cloth was tacked
part way up upon the outside, insuring privacy from the public highway;
the mosquito netting was placed over a barrel hoop aad attached to the
572 BIXTH INTERNATIONAL CONORBBB ON TUBEBCUL06IB.
ceiling, and formed a protection from flies- This patient became so bjccuB'
tomed to the fresh air that she was unwilling to return under a roof on rainy
daySj but had an extra oi! doth fastened to the upper portions of the sJeepiug
porch until the warm Colorado sunshine was again available.
Lastly, nurses engaged in district and tuberculoais work in eafftem
States can cooperate largely with phyeiclans by using their good inEuence
in the selection of patients sent to the West. Here the most pathetic
scenes of want and self-denial are witnessed daily by charity workers dealing
with incurable cases. Nor do we believe that persona suffering should be
denied the benefits of this wonderful climatej but rather that these things
might be carefully and scientifically reaervetl for those who may surely
profit by them, that becoming cured they may become, as humlreds are
to-day, a credit to the State of Colorado and to themselves. For the success
of this movetnent are needed social cooperation of all workers^ North,
South; Ea^t, and West, a raJlying together of all forces, a thorough knowl-
edge of what each one is doing, complete B>"stematii:ed reports of each case,
and a firm belief in the hnportance and necessity of the great work ia which
we are engaged*
TUBERCULOSIS IN TOKYO AND VICINITY.
By Iyo Ahaki San,
Judging from statistics, the prevalence of ttiberculoais b J&pan is much
greater pro rata to the population than in America or Europe. Reports
from Government and reliable private institutions place the ratio, exclusive
of special classes, at from 25 to 40 per cent.
Araong factory workers, milling hantls, and those leading a laborious
and exposed life, such as "rickshaw pullere/* street peddlers, etc., the figures
range from 55 to 70 per cent. Pleural and peritoneal infections are unques-
tionably more common in Japan than in the United States.
The bone and joint infections are also very common, and in almost every
instance the disease^ whatever the seat, seems more resistant to treatment
than in America, As a general proposition, it seems correct to state that
the Japanese have decidedly less resistance to tuberculous infection than the
average European or American. There are several good reasons for this.
Before gixing them, it is well to state that practically the whole population
is well informed of the infectious nature of tuberculosis, and fear and general
dread of the disease are more apparent than among the general public in
the United States.
In spite of this fact the measures taken for its prevention and modem
ideas of fresh air and dietetic trei^^ment pjy woefully lacking.
Nowhere in Japan is Ib^- climate especialiy unfaVorsble, and on this,
the main island, it is soJJiewhat better than in many countries where tuber-^
culosis is not so pre;vsient> Climate would not, therefore, seem to play any
very definite rftig '^ ^^^ causation of the disease. The food of the Japanese
is poor in^^aiity^ ^j^ anemia,— a very common disease after thirty,—
^^^^^diseases, and faulty nutrition are prevalent.
fc Japanese method of building houses mak^ ventilation easy, but,
igc to say, no advantage is taken of this fact, and the houses at
_ight are wretchedly ventilated. This lack of fresh air at night and on cold
days, when houses are closely shut up, plays an important part in the prev-
alence of tuberculosis in Japan. The density of the population makes
infection easy, and the general poverty of the people prevents adequate
curative measures from being taken by the individuals infected*
Although the public conscience is well arousetl as to the dangers of
tuberculosis, no adequate instruction is ^ven as to the proper modem
measures for prevention and cure.
573
TUBERCULOSIS AMONG THE INfDIANS.
By Lucy Nelson Carter,
White Roak, Utah,
In the olden time^ when the IndiaBs lived the altogether wild life out of
doors, winter and summer, and fed only upon flesh, they were said to be
hearty and strong. As he becomes more civilized he gets a house, — a
very poor one, — with few windows that probably are not made to open, he
has aatove, he k improperly clad, and he keeps a hot fire as long as the wood
laata. He understaada neither the importance of ventilation nor how it
should be accomplished. They huddle together, ever so many, diseased
and well, io one room. They are euperstitious and afraid of the night,
and so they cover up their heads to shut out the darkness. Could any more
favorable conditions for foateriiig lung diseases be imaged? They are like
children^ and possess no judgment; they buy cheap candy, stale crackers,
and nuts, which they eat at irregular times^ instead of having a wholesome
meal. Their ignorance and immorality must tend to weaken the body,
but that was the same in the olden time. No, it comes to me that they had
not then borrowed the white man's vices, drunkenness, and what follows in
its wake. _
Wtien I first came out here to live I heard a physician say that no matter
what disea^ an Indian had, it always ended in tuberculosis, and in my
eleven years* residence here I have observed the^*^e thing. Severe
illnesses have occurred among the school-children, and r^U^ig^ ^^^Y ^'^^"^
carefully tended and convalesceti, in every case they afterwaJ(^eveloped
tuberculosis and died. ^S^
Their superstition stands them in good stead in connection with a^?^''"
culous patient, for any very sick person is isolated in a tent, and after d(^
everything is either buried with the patient or burned; at no time, however
do they get the necessary nourishment or medicine.
The Government Indian boarding-schools should train and forcibly
impress on the children facts regarding physiology and hygiene, — always
with tuberculosis io mind^^so that they will carry the knowledge into the
camps and through life. In the first place, the schools themselves should be
hygienic in every way, which is not the case here; in this school there is not
room for the children in the dornutories, if the number required to keep up
674
^
TUBERCULOSIS AMONG THE INDIANS. — CABTER. 675
the school is mmtained. No especial attention, if any, is ^ven to physi-
ology or to hygiene in the school-room. Even very small children will take
an interest in the construction of their bodies, the organs, etc. The Govern-
ment physician should devote a good deal of his time to giving lectures
to the older children, and to making friends with the little ones, so that they
will grow to feel his influence, and to consult him, and be advised by him
in sickness. If these rules were carried out, the school would necessarily
become healthy. The lack of healthful conditions has always been] the chief
grievance of the relatives and older Indians against the school. Improve-
ment along these lines must influence the camp Indians to some extent,
and the next generation should show remarkable benefit. If the school can
be made what it should be, what an influence for good it would become I
A sanatorium for Indians should be established. The Government has
buildings here, — an abandoned school plant, for example, — ^that could be
made suitable for the purpose at comparatively small expense. When the
school-children become infected, they must be sent out. But where? To
the camps, when they have not suflicient nourishment for well children?
So they linger on and then die, having no aid to recovery but fine air, and
that is not suflicientl Many poor creatures might be saved prolonged
suffering and death if they could be ^ven a little care and sufficient food.
There is so much room, — acres and acres of it, — sunshine, and pure health-
^ving lur, and even the buildings and the doctor. Just the furnishing, equip-
ment, a nurse, an assistant, and afew employees could do it. The project was
discussed. It was provided for by the United States Government, but seems
to have been dropped.
THE TRUE FUNCTIONS OF THE TUBERCULOSIS
NURSE.
Bv Mary E, Lent,
QrbdiiKta of Johnj Hopkini Hoapitali Head Niim of the iDBtruotiva Viaitins Mutih
At present the campaign agaiaat tuherculoaifi is almost entirely an
educational one. People are l>eing taught by twq different methods, brought
to bear on two tlifferent social classes.
In the first place, there is the instruction of groups or communities by
means of lectures, exhibits, and the press. The people reached by this
method are well above the poverty line; their habits and circumstances of
living prot'ect them, aa a rule, against tuberculosis, which is found among
them only incidentally, tuberculosis being essentially a disease of poverty.
This instruction, nevertheless, is extremely important^ for it enables people
of this class to protect themselves from incidental infection. It is impor-
tant also because of the fact that it is largely the feelings and opinions of
this class that constitute what is known as public sentiment, and in the
rousing of which lies the only hope of stamping out the disease for aH
members of the body social. It is becoming clearer and clearer that the
suppression of tuberculosis demands the segregation of all who are centers of
Mifection, and the only way of bringing this about is by educating popular
opinion to the point of expressing itself in legislation that shall deal with
tuberculosis in this radical way.
The second method is the instruction of individuals, themselves tuber-
culous, belonging to the class that this disease claims as peculiarly its
own— namely, the poor. In order to demonstrate clearly the conditions
and the results attained by this method I will give a brief description of
the history of its development in Baltimore. A few years ago, when the
tuberculosis problem came up for the first time, its solution was thought
to lie in teaching the class especially subject to the disease; showing them
how to deal with it in their own homes when once contracted, how to pre-
vent its spread, and how to guard themselves by hygienic and careful liv-
ing, AH of this seemed feasible at the time. The best means of conveying
this instruction seemed to be by the appointment of nurses who should
visit tuberculosis patients and teach them according to their needs. I
576
TRUE FDNCrnONS OF THE TUBERCULOSIS KURSE.^LENT.
577
think that Baltimore was the first city that undertook to support a nurse
for this purpose.
When the first tuberculosis exposition ever held was opened in Baltimore
in January, 1904, so great was the interest awakened^ and so much waa
hoped for by the teaching of the poor by nurses, that Mrs, William Oaier
undertook to raise a fund to support a special nurse to do this work. At
the same time, through the genero^ty of Victor Bloede, the dispensary of
the Johns Hopkins Hospital was given a special tuberculosis nurse whose
work should include visits to the homes of the patients* These two nursea,
one under the super\'ision of the Instructive Visiting Nurse Association, the
other attached to the Hopkins dispensary, covered the city between them,
\isiting all consumptives whose cases were reported to them. To-day the
Hopkins dispensary has two and the association has four special tuberculo-
sis nurses. The association nurses visit advanced and hopeless cases, where
the patients are on or below the poverty line, while the dispensary nurses
give class instruction to selected cases taken from those whose financial as
well as physical condition hold out some prospect of cure* Both sets of
nurses are engaged primarily in the education of these people, and the people
are learning — the few who can and will apply the teaching to their daily
lives, and the many who cannot and will not.
It is my belief that the nurm is the person best qualified to act as teacher.
The doctor can only diagnose; he has neither the time nor the opportunity
to be a teacher — even to carry out his own work he must use the nurse as
his interpreter and go-between. It has been contended that recovered
tuberculosis patients make good teachers, but not even a patient who has
been cured can carry the sense of conviction that comes with a capable
and experienced trained nurse.
A woman of this sort, when she has entered a home, includes in her care
the patient's family, aa well as the patient himself. Of course^ her atten-
tion is directed primarily toward the comfort and needs of the latter, but
at the same time she instructs the family how to administer to those needs,
thus giving them valuable practical knowledge, while developing in them a
tease of responsibility that they would not feel if she shouldered the whole
burden, She studies the moral as well as the physical condition of the
whole family, and diagnoses their requirements, calling in other agencies for
help and relief when necessary* She assists with the marketing, adviaea
as to kinds and qualities of food and as to the method of preparing it;
reports unsanitary conditions and defective plumbing to the proper authori-
ties. All this means possibilities for the education of the people and the
reconstruction of their home lives which, in the hands of an energetic and
well-trained nurse, far exceed those of any other agent. The conclusion ia,
therefore, justifiable that if the suppression of tuberculosis could be effected
roL. m—19
678
SIXTH XNIXRNATIOMAL CONGHEBS ON TCBERCUZX:i6IB.
at all through the education of the people tnost concerned, the visiting
nurse is the one who must \xi employed to attain this end. In the (jegin-
ning it was t-onftdentiy expected that her teaching might bear fruit, if not in
cures, at any rate in preventing the spread of tuberculosis, thus solving the
moflt important part of the problem.
The question now arisen whether or not this expectation has been ful*
filled. As a matter of fact, four years* continuous experience in the homes
of tuberculous patients of the class under eonsideration has demonstrated
to me that the results hoped for have not been attained, and^ moreover,
are not obtainable by this method. There is now no portion of Baitimore
in which instruction concerning tubercuiosiB has not been given. The people
are aware of what it means, and of the meOioda of treatment and of pre-
vention* Those who have not had it in their own families, have learned
from friends or neighbors who have been visited and taught by nurses.
They are always interested in their neighbors' affairs, and fond of talking
about their own; moreover, they are, as a rule, willing to tell all they know^
and to listen to all they can hear in the way of general information. They
recognize the district nurse by her uniform, and it is a daily occurrence for
some one to ask the nurse as she passes through an alley, to see some con-
sumptive whose existence she had not known. Many of the better class
have attended lectures and exhibits, but few of them grasp the aignifieance of
what they have heard and seen^ unless the nurse explains it to them and
shows them how to apply it to their own lives.
Yet in spite of all the information that has been disseminatedj and with all
the practical aid that has been given to help them in their application of it,
tuberculosis in Baltimore shows no sign of decreasing. The failure of educa-
tion aa a method of suppressing the disease is due to the fact that, even with
the help they receive, these people are unable to apply what they have learned
consistently and unflaggingly to their daily lives, an inability due, in the
first place, to lack of sufficient mora! strength; and, in the second place, to
lack of the material necessities and requisite surroundings. It is only under
the most careful supervision that they fan be brought to practise what they
have been taught, much less carry it on aa a systematic and permanent
routine. On the other hand, it taxes the nurse^s ingenuity to the utmost
to find in their houses the means by which they can follow even one or
two of the simplest rules of hygiene and prophylaxis.
During the past four years the association nurses have visited 3000
patients, of whom 50 per cent, were recipients of charitable aid. Such
people who are on or below the poverty line have notj in the nature of
things, the means for carrying out the principles of hygiene, nor do their
Burroundingg permit of it. Thus, even where patients have the mental and
I
I
I
TRUE FUNCTIONS OF THE TUBKRCUlX>ai8 NUR6E. — LENT.
579
moral capacity to benefit by their instmction, they are prevented from
doing BO by force of circumstances.
It follows, then, that the most that the nura© can do for these patients
and their families, by direct methods, is to mitigate somewhat the evils of the
diaease for the individual sufferers. As concerns the primar}' object, that
of coQtrolUng and ultimately suppressing the disease, her work is a failure;
in other words, education of the class of people concerned is not an effective
method of fighting tuberculosis.
Thia docs not mean, however, that the visiting nurse is not one of the
most vtiiuable and indispensable factors in the workj but only that the real
service that she renders to the cause has taken a somewhat different shape
from that wliich was originally planned. The reallocation of this fact ought
to renew the courage of those tuberculosis nurses who are disheartened by the
seeming lack of results attained in their work, and should enable them to
direct their future efforts with clearer sight, and greater efficiency.
The true function of the tuberculosis nurse at present, as it appears to
me, is of a twofold nature. On the one hand, she can put the factsso strongly
before the public that the State will finally be obliged to take measui"es to
accomplish what she herself has been unable to do. She is able to unearth,
and expose to the public, conditions whose existence no one else could suspect*
Her opportunities in this line are unlimited. She cannot stamp out tuber-
culosis by teaching her patients, but she can do an enormously important
work toward the same end by enlightening the general public in regard to
the facts of the case, and interpreting for them the conditions that render
futile the present efforts to eliminate the disease.
The logical outcome of the present effort, to suppress tuberculosis is the
segregation of patients who are unable to take care of themselves and to
avoid spreading infection, and whose families are equally incapable of doing
it for them* When the community has become sufficiently aroused to take
action in the matter, it will provide for this segregation by building
lioapitals and compeUing patients of this class to enter them.
This brings us to the second part of the nurse's function, namely, leaching
the people to submit to this demand from the State; to forestall antagonism
and hostility, to show how and why the measure is necessary, to create in
alley and tenement an appreciation of what removal to a comfortable and
attractive hospital would mean for the patient himself and for the protection
of his family. It is not enough that the general public should be educated
to the point of seeing the necessity of building hospitals, and of acting upon
this necessity. The people must be educated to appreciate their value and
to use them; otherwise it will be difficult or impossible to get patients to
enter. In the case of segregation, made eompulsi:>ry by the State, unless the
process of education la steadily carried on, the hospitals vriil fail in efficiency
tn
aCCTB DTTERXATIONAl* OONOIIE98 ON TTTBEBCtTLOSIS.
because of tbe antagomam Ui&t will be aroused. The possibilities of this
part of tbe tuberculosis Durse*^ work have already begun to be demonstrated
Id BalUmore. When tbe Jewish Hospital for Advanced Caaes of Tuberculceis
waa opened in this dty recently, there were not only enough patients taken
from the visiting lista of tbe nuraes to filJ it on tbe first day, but waiting lUts
of four or five times the number the hospital could aceommodate were filed
with tbe president of the admission committee. Here we have volunuur
segregation, with no feeling of shock or outrage on tbe part of the people
involved. This state of affairs would have been impossibJe a few ^^ears
ago, and the fact that it now exbta is due to tbe work of the nuisea ia
teaching the patients and theu* famili^ the true meaning and use of such
inatttutionsj and creating in them tbe desire to take advantage of them*
If the State of Maryland would provide a well-managed, attractive^
comfortable boapital for advanced caaes, witliin easy reach of the patiaat3'
friends, those who could not take advantage of the Jewish hospital would,
under the influence of the tuberculosis nurses, be equally eager to enter that
of the State.
DISCUSSION,
De. J. S. Fulton (Baltimore) : It is not unusual that those who go in1<>
a new task with great enthusiasm, show signs of depression when they find
that their results are less than they expected, or very different from thorn
expected. It is an interesting phase of every well-fought campaign,
that the best combatants have a sense of rather exclusive responsi-
bility for the outcome- Apparently the instructive nurses began in the belief
that tuberculosis could be quite eradicated by instructing the people how
to avoid infection. In a sense they were nght; for certain it is that tuber-
culosis can never be suppressed without this popular education. Moreover,
tliis sort of education is best conducted by the tuberculosis nurse. The
nurses have not thought too highly of their function^ and their performance
doea not justify the *' weeps " of Itiss Lent and Miss LaJIotte about tbe
unteachable consumptive and the futility of systematic teaching in the homes
of consumptives. In order to find their way out of this twilight of des-
pondency, they have but to turn their attention, for a moment, away from
the things which they have not done^ and consider the things which they
have done. They have, in Maryland at least, greatly improved the selec-
tion of cases for admission to sanatoriums^ pointing the way to cure much
better than was possible formerly, and at the same time jugulating that
power, which all infectious diseases have^ to compound their infectiousness
while they remain undiscovered* They have shown that the medical pro-
fession, which is supposed to know at all times how much there is of every
sort of sickness, and where is it located, has, in fact, very imperfect knowledge.
Ihe nurses are constantly discovering tuberculosis where its presence was
TRtTE FXmcriONB OF THt TXTBERCtJLOSIS NtmSE. — LENT*
581
not only unknown, but unsuspected. They have attacked the prevalent
ignorance, and, after four years, they say that there is no longer in Balti-
more any class which is ignorant of the iiifectiouB nature of tuberculosis,
or ignorant of the means of avoiding infection. They have, however,
discovered the careless and unteachable consumptive^ who seems to be an
insuperable barrier to further progress along the lines of popular education.
Truly, this is the note of melancholy — the accent of despair. How could
the unteachable consumptive be discovered while people remained untaught?
All of the untaught are necessarily as dangerous as the unteachable. Having
cleared away the movable ignorance, one may count the unteachables,
and I suppose the careless can also be counted. At alt events^ the Instruc-
tive Visiting Nurses' Association of Baltimore has made a numerical state-
ment, and has placed it on exhibition here in graphic form, wherein one may
see four brilliantly colored squares of different sizes: a small one repre-
senting the class of tnily instructed and careful consumptives, a larger one
representing the insufficiently careful class, a very large square representing
the grossly careless, and a small one representing the unteachable or per-
versely careless. A shocking thing is that large green square; but it^
dimensions, four years ago^ would have been equivalent to the sum of the
areas of all the squares* I am quite sure that this graphic statement, even
if it fairly presents the situation at this time, signifies a far more hopeful
situation than that of four years earlier, when no numerical statement could
have been made. Moreover, I am not sure that Miss LaMotte's distinctions
between the careful and the careless are quite just. The degree of careful-
ness which she regards as adequate, I suspect, conforms to very exact tech-
nical standards. Her '^careless" group includes^ 1 fancy, not a few persons
who are a great deal less dangerous than they were — less dangerous in a
degree that may easily mean safety to their family associates. Certainly
the slow to understand, the apathetic, and the hostiles cannot inereaae in
number against currents of enlightenment. They must, on the contrary,
diminish in number.
What has happened in this case seems to me altogether encouraging.
The nurses have successfully negotiated their first problem, that of ignorance,
and behind it they have encountered new problems. One of them is the
unteachable consumptive. Miss Lent has very clearly stated the solution of
this problem. It consbts in the segregation of this dangerous class. To
be able to demonstrate the necessity of segregation and to indicate its scope
is, to my mind, a great merit of this kind of social investigation. Behind
each new problem^ one must expect to find another, and at last you come
to the reddual problems which always remain securely bidden so long as
the main causes are unrestrained. No one can tell yet what the residual
problem in tuberculosis will be, but there are analogies in the history of
BIXTH II4TERNATIONAL CONGRESS ON 'n7BEBCinjOSI&
other difleagea In Germany & residual problem has been uncovered in
typhoid fever. Outbreaks have been traced to some healthy carrier of
typhoid hacilluSf or to some one hardly sick at all, though having a typhoid
infection. Koch has found it necessary to study carefully the apparently
well and the trivially sick, who, as far as manifest sigas go^ have no relatioii
whatever to typhoid fever* This situation could not come to light save in a
country where typhoid fever has been suceesafully repressed to the point
where the manifestly sick are very few, their infecliousnesa perfectly con-
trolled, and the ordinary vehicles of typhoid perfectly guarded. Where
typhoid fever has no longer any allies,— carelesa doctors, negligent nuraes,
dirty milkmen, perverse and incompetent officiala^ — when the conspirao'
of ignorance, greed, and apathy is broken up, — then the tj'phoid bacillus
makes its last stand, in places unsearched and unsuspected* To this extrem-
ity has typhoid been driven in some parts of Germany, so that Professor
Koch, in order to explain the typhoid of a very few sick people, has been
obliged to search the bodies of very many well people.
In some such way we shall^ at length, get down to a residue of tul^ei^
culosis. Before that happens, repeated conquests over successive phases of
the tuljcrculoais problem will have enriched the nation so vastly that no
economist will complain of the inevitable cost of keeping tuberculosis
repressed to that small residue*
Such success as I have suggested is, I believe, attainable, and we shall
have examples of it in thirty years, perhaps.
There will surely be a residue, Man has never quite extinguished any
species, and cannot wholly prevail against the subtle tul^ercle bacillus.
Probably we shall succeed so far that men will forget the pit whence they
were digged^ and take chancy as communities sometimes do with smallpox.
But they will recover wisdom very quickly,
I look upon the performance of the viating nurses as mjccessful in no
small degi-eOj in that they have defined, in a convincing way, that part ol
the problem which is to be solved by segregation, and not otherwise.
gation is an extreme measure; hitherto we have been able to talk about it
in a general way, with much doubt whether it ought to be applied to the
whole class of careless and ignorant consumptives. Here we have the
question narrowed dowTi to a subdivision about which it would be difHeidt
to raise a doubt — the per\'ersely careless, the "unteachable" consumptive-
It seems to me that substantial advance has been made, and I look to the
same source for other clear definitions of next steps.
Dr. H. Lincoln Chase (Brookline, Mass.); All will admit that it ia
absolutely necessary that the local health authorities should know all the
time where the most unaanitary and most poverty-stricken homes are.
The instructive sanitary inspector,^a womaUi — whether a qualified
^
JS^ M-
TRUE FUKCTIOXS OF THE TUBERCm^OSIS NTHSE.— LENT.
583
social inspector or nurse, has the best opportunity, in my opinion, to teach
the women in these unsanitary homes the nature of tuberculosisj and all the
other infectious and therefore preventable diseases. Her work in no way
interferes with that of the school nurse^ or of the regular cUstnct nurse.
Yonkers, N. Y., after Chicago^ was among the first municipalitiea in
thiA country to establish instructive sanitaiy inspection of tenements,
though a few cities in Great Britain were the first that we know of. This
forni of inspection was introduced in Yonkers by the Health League, and
after a few years the health department regularly appointed the same
inspector, Mrs. Joanna von Wagner, and has each year since reappointed her.
My own town, Brookline, with a population of 26,000, and adjacent to
Boston, has organized its antituberculosis aociety, and its executive com-
mittee has recently made a tuberculosis canvass, and taken other necesaary
steps to ap|)oint a woman sanitary inspector of tenementa I feel sure that
in a short time our Board of Health will appoint a qualified instructive
sanitary inspector.
Just a woixl about the pioneer tlay camp for tubercular children in this
country. In July of this year Brookline opened such a camp on the l>eauti-
ful and extensive grounds of our Board of Health Hospital, to receive children
in the incipient stage and pretubereular stage of the disease. The camp
was organized by a joint committee from the Brookline Antituberculosis
Society, the BiMxikline Friendly Society, and the Brookline Health Com-
mittee, Miss Roprs, a nurse from the House of the Good Samaritan,
Boston, was in immediate charge throughout the session* Like the similar
day camp for children of the Boston Antituberculosis Society, it has been a
great success, and will surely be reopened next year.
Miss Butler (Yonkers) : I feel that I ought to make a correction in Dr.
Chase's very complimentary statement in regard to Yonkera, Chicago had
the pnority in putting the inspectors in the field, although they were not
nurses, but whether Clucago has continued to do so in later years I do not
know. I may say that the city of Glasgow was the inspiration for Yonkera.
Dr, White (Pittsburg) : I wish to call especially to your attention the
educational work in the schools. No one can do municipal work without
being convinced that it cannot be done without a trained nurse, but her
duty is that of an educator^ and there is no one who can enter the home aa
readily as the nurse can do, and as a woman can do. We must take the
impressionable age, and that is childhood. You must accomplish results
by repetition; results will come in time. Remember that unless we have
systematic efforts in education they will not be of much value. We must
continue year after year to do this work if we are to obtain results.
Remember the centralization idea^-that there must not be a dispersion
of energy, so that there are half a dozen tiying to take care of a few patients.
BDCTH INTERNATIONAL CONCinEaS ON TUBERCULOSIS.
I rauRt say that the educational work in the school depends entirely upon
the character of the teacher* She must reach not oaly the inteJligent student,
but all the pupils.
Dr. Thomas F. Hahrington (Boston, Maas.): My first word should be
one of congratulation* Aa one of the pioneera in antituberculosia work
in this coimtry, and one who has been foremost in advocating the educational
method of fighting this disease, I wish to say that thia Section deserves
special mention. First., because it ia the only Section presided over by a
layman ; and, second, because I believe that the keynote expressed here to-day
is one of the most important results of this great International Congress.
I refer to the special papers and the general trend of all the papers read
to-day that the greatest hope of the future in fighting tuberculosis lies in
the care of the advanced, the incurable, the house-ridden patient. While
not wishing to minimize in the least the great value of the factors and
agencies already at work, yet the results must be more or less limited until
the many foci of disease in the homes are found and removed to hospitals
or cared for in their homes. This is one of the greatest works the nurse i^
capable of doing. It lacks the stimulation and the glamour of statistics;
nevertheless, it is of a far greater importance than any one work being done
by the nurses in the care of the tuberculous.
It was for this reason that I advocated last year that nurses should form
an essential part in the organization of a department of school hygiene at
Boston, Mass. The school nurse has opportunities to find the chrxinically
ill which are not offered to the district nurse, to the dispensary nurse, nor
to the social worker. All of these enter the homes after the case of tubercu-
losis has been discovered or reported. The school nurse, on the other hand,
enters the home as the friend of the children^ and there finds often the
advanced case of tuberculosis, which otherwise would have gone unrecognized
and unreported until death. When I tell you that the thirty school nurses
in the Department of School Hygiene at Boston have visited 22,000 homes
of school children during the past year, some magnitude of the opportunities
offered in this line may be imagined. 1 would urge that the greater part of
our efforts against the spread of tuberculosis be directed toward the finding
and the segregation of the advanced and the incurable cases of this disease.
Here lies, I believe, the greatest hope for the future.
I
I
I
Mrs. Townsend, Miss Burleigh, Mr. Magruder, Miss Dock, Misa Hobtnson,
and Mrs. Lee also participated in the discusaiaa.
2.
SECTION V.
Hygienic, Social, Industrial, and Economic Aspects
of Tuberculosis {Continued).
SIXTH SESSION.
Thursday afternoon, October 1, 1908, at half past two o'clock.
ELEMENTARY AND POPULAR EDUCATION: METHODS AND
AGENCIES.
Special lAteraiure for General DislnbiUion; Exhibits and Lectures; the Press;
Educational Work of the Nurse; Labor Organvsations; Instruction in
Schools of all Grades.
The sixth session of Section V. was called to order by the President,
Mr. Edward T. Devine, on Thursday afternoon, at half past two o'clock.
ELEMENTARY INSTRUCTION AS TO TUBERCULOSIS,
By A. E. WiNSHip,
Editor "Journal of Education," Boston.
When tuberculosis does its perfect, or imperfect, work, there b an end
to the fruits of mental training. The best of training, scientific, artistic,
and pedagogical, comes to naught when tuberculosis is vmhindered in its
ravaging career in any system. To devote time and energy to the kinder-
garten, elementary, preparatory, and higher education of a child, and offer no
remonstrance to the onslaught of tuberculosis, is too ridiculous for any
characterization.
What does it signify that methods of instruction have been modem,
and the principles of teaching sound, if the mind that could profit therefrom
is ^ven over to a body whose mission is soon to end?
585
m^
BIXTH IZ^EENATIONAt- CONGRESS OM TUBERCULOSIS.
Is there any conceivable function of the school greater than to fortify
the body against cLnnibilatioa at the bjaads of an insidious enemy?
Putting new wine into old bottles is the height of wisdom in coinpajiaozi
with the fatal neglect of the body for the sake of a scientific quickening of
the mind that is soon to tease all human activity. It is like glorying in
the flight of a kite a moment before the line is cut near the hand that holds
it. The glory of education, like the pride in a kite, is in a taut line from
the earth upwaril,
The public, that invests tax funds in education, owes it aa a primal duty
to the taxpayers that everything possible shall be done to extend the years
of activity, lengthen the time of usefulness of the mind that is trained.
Any carelessness or neglect that tends to shorten the life of the educated
child is criminal.
What would be thought of a public movement for providing ao abundant
and pure water-supply, but provided for its retention a weak reservoir that
would give way when the first strain came? Is not that precisely what we
have been doing educationally? We often provide a cle:ir mind with
efficient activities^ and store it in a physical reservoir that will collapse at
the first insidious attack of disease germa.
We educate teachers to treat skilfully and pedago^cally the activities
of the mind, and then, through culpable ignorance, they place the result of
their training in a casing that will easily explode at the first exposure.
The school might be held solely responsible, if it were possible, for the
most complete protection of the physical health of every child whose educa-
tion it undertakes. This, at leasts is eminently necessary — that the school
shall regard it as its first duty^ by theory and practice, to do ever\i;hing in
its power to prolong the activity of the miud it trains; and the lugher the
trained efficiency, the greater the demand for extending its activity-
The teacher ia responsible for fifty children, while a parent rarely has
more than two or three; the teacher has the children while prevention is
possible, while the physician rarely comes into the case in season to do more
than rescue the patient. The teacher has children in the mass, whore
contagion is inevitable without the greatest precautions.
How ridiculous to train teachers in fantastic ways of teaching processes
in number, fashion in speech, and tricks in science, and let them go forth
ignorant of the most modem revelation as to the ways and means of main-
taining the best possible physical condition!
Not only should the teacher know, but he should see to it that the children
know. The schools are the only way of carrying the latest and best knowl-
edge of life to the homes as a whole. Whatever goes into every school,
virtually goes into every home, if it pertfuns to life.
One of the best testa of the value of anything taught is the extent to
4
ELEMENTARY tNSTHtJCTION AS TO TtTBERCULOSlS. — ^WINSHIP.
587
which it is taken home by the children. Give a fantastic explanation of
some process in percentage, and it dies with the teaching; but give some
really valuable information, and it is told in the home and talked over in
the store and stabJes^
No information has more of genuine projectile force than that which
pertains to the promotion of health and the prolongation of life* Every-
thing that is known, and as soon aa it ie known, should be instilled into
the minds of the teachers in the best way and by thera injected into the
community.
If the teacher and pupils in the grades are so overworked that there is
not time to save human lives by si>ecific instruction aa to the prevention of
tuberculosis, a most important need of the present time is to see if any
part of the work can be eliminated to advant;^,
I have never seen an elementary school program from which much
could not be eliminated without perceptible loss to any child. There is
always much of rubbish in processes and in methods. There is no pretense
on the part of any teacher that all of the teaching is of direct value to the
children, and the excuse offered for taking so much time with it is that
it is good discipline. The disciplinary value may be conceded, and then it
can be shown that neither arithmetic nor grammar, spelling nor geography^
discipline the mind more than the earnest study of so much physiolog)^ and
biography, chemistry and physics, geography and civics, domestic science
and architecture^ as are needed for the elimination of tuberculosis.
A teacher or superintendent who will deliberately say that the disci-
plinary value of any subject now taught is greater than that which could
be gained from teaching about tuberculosis is wanting in a knowledge of
educational values.
Instruccido Elementaria acerca de la Ttiberculosis. — (Wixbhif.)
Si i los maestros y los & discfpulos se les da en los cursoa escolares un
exceso tal de trabajo, que no les queda tiempo para las instrucciones especi-
ales acerca de la prevencion de la tuberculosis^ una de las cosas mas im-
portantes del present*, es ver si alguna parte de dichos cursos pueden
ser eliminatla con ventajas.
Yo no he visto todavfa^ un programa elemental de escuela del cual no
se pueda eliminar mucho sin perseptible p^rdida para el alumno, por en-
contrarsea en ellos mucho de sui>i5rfluo en los procedimientos y en los m^todos,
Tampoco existe la pretenci6n entre los maestros de quo todo es de un valor
directo para el alunmo y la excusa que se da para tomar tanto tiempo en
ciertos ramos, es creerse que ^tos forraan parte de la disciplina. Si e! valor
disciplinario es propiamente coneedidoj entoncea ae vera demostrado que,
£88
SIXTH mTERNATIONAL CONGRESS ON TtTBEKCUXOSia.
ni la Aritm^tica ni la Gramitica^ ni el Silabario, ni la GeagraHa; mstruyeo
la mente tanto como el eatudio cie la Fisiologfa y Biologfa^ Qafmica y Flaica,
GeografSa 6 Instruccidn civica, Ciencias Domfesticas y Arquitectura, en la
eliminacion de la tuberculosis.
Un maestro 6 superintendente que sostenga que el valor disciplmario
de algunaa materias, en curao at presente en las escuelas, es superior al
valor que pudiera alcanzaree de la mgtrucci6n sobre la tuberculosis, puede
conciderarse extraviado ea loa oonociraientos del valor educative.
Instruction £l€mentaire en ce qui conceme la tuberculose.^ — (Winship.)
S'il est vrai que lea maitrea et les ^l^vea dana les ^colea publiquea sont
surraen^s au point qu'il leur manque le tempa n^cessaire pour sauver des
vies humaines par I'instruction ep^aiale dans la prophylaxie de la tubercu-
lose, un bescun Important du moment esft de s*inlormer ^ une portion du
travail dans les ^colea ne pourrait pas ^tre avantageusement supprim^.
Je n'ai jamais vu de plan d'^tude d'^cole priniaire dont on ne pourrait
^liminer beaucoup de choses Bans perte r^elle aux enfanta. H y a toujours
un tas de inatitea inutiles dana les coura et un gAchage de temps h cause de
mauvaisea m^thodes. Personne ne pretend que touts Tinstniction detinue
^t une valeur directs pour lea enfants, et le pr^texte qu'on donne pour
y consacrer tant de temps est que c*est une bonne discipline. On peut
en adraettre la valeur disciplinairej et puis on pent d^montrer que ni Tarith-
m^tique ni la grammaire, ni I'orthographe ni la g4ographie ne disoipHnent
Tesprit plus que ne ie ferait I'^tude s6rieuse d'un Equivalent de physiologic
et de biologiej de chimie et de physique, de g^ograpliie et de sociologie,
d'architecture et de science domeatique— assea pour aupprimer k jamais la
tuberculose.
Un pr^cepteur ou un principal qui pretend que la valeur disciplinaire
des sujets qu'on enseigne ^ ce moment dans nos Ecoles est sup^rieure k
celle que pr^senterait un coura d'^tude sur la tubercuIoaCj ignore la valeur
relative des diff^rents sujets au point de vue de T^ucation.
TRAINING TEACHERS FOR EDUCATION AGAINST
TUBERCULOSIS.
- Bt David S. Snedden,
Tfluben^ CoU«c«. Columbia UniTwrity, N«w York.
In all modem movements of social economy there is a persistent tendency
to utilize the period of childhood as suitable for fundamental protective
measiu*es, on the one hand, and educative, on the other. It is felt that
during this time may be laid the foundations for physical and moral welfare,
in the shape not merely of physical soimdness, but also in the way of habits,
standards, ideas, and ide^ that will be operative all through life. And
responsibility for this education is held increasingly to be the function of
the school, rather than of the home, church, and other traditional agendes.
Naturally, then, in the campaign against tuberculosis we look to the schools
to propagate the ideas and to kindle the ideals which, if generally operative
for a generation, we believe will result in the banishment of this form of
communicable disease. But we must also realize that modem social econ-
omy, in its increasing efforts to utilize the plastic period of childhood for
the accomplishment of its reforms, is throwing a constantly increaong
responsibility upon the schools, their directors, and their teachers. We
are asking them greatly to modify and add to their traditional functions,
and we do not always perceive the perplexity into which they have already
fallen in their efforts to meet the new social missions that have been partly
delegated to them and partly developed within the schools themselves.
In all education the teacher is the central figure, and the problem of
equipping the teacher to meet increasing responsibilities in modem sodal
education is in many respects the greatest that educators must face. Teach-
ing is yet a practical, in some respects a fine, art; only slowly are we able
here to avail ourselves of the scientific principles which in less complex fields
have served to simplify and economize human effort. It should be evident
that at present the great masses of our public school teachers are most
imperfectly equipped to carry on effective education against tuberculosis,
but we cannot doubt that in time teachers may, by appropriate means, bo
made ready for that work, and that suitable machinery of education will
be devised whereby effective results may be achieved. It is the purpose of
590
SIXTH INTERN ATI ON Al. CON^GHESS ON TUBERCULOSIS.
this paper to indicate what seem to be some of the fundamental conditions
to be kept in view at present, and to suggest a program of practical action
that American educators may use.
At the outset we shall assume as undisputed: (a) That in combating
tuberculosis the American public elementary school, and in some degree the
high school, is the most available and one of the most promising fields for
the dissemination of knowledge, the formation of habits, and the stimulatioa
of ideals of physical and sanitary action, since it does or soon will retain
all children until the age of fourteen or longer; (b) that with the lengthening
of the school year and the enforcement of adequate attendance it should not
prove difficult to find time for such special education; (c) that it has been
abundantly demonstrated that, under right pedagogic methods, children
of fourteen or under may be quite fully educated along hygienic lines as
regards tuberculosis; and (d) that educational authorities, lay and expert,
are not indisposed to accept responsibility for this form of education if
its desirability and feasibility can be shown.
But it must be realized that at present many limiting conditions exist
that will tend to prevent the adoption of the new matter of instruction or
that will render it ineffective once it haa nominally been made part of the
course of study. These limitations should be recognized, and, so far as
possible, workable expedients should be recommended by those who are
engaged in pushing the propaganda for the use of the schools as agencies ia
the dissemination of knowledge regarding the prevention and cure of tuber-
culosis. Elspecially should this be done where a comparatively new department
of education is delegated to the schools, requiring peculiar forma of fitness,
and often calling for modifications in the traditional portions of school carrio-
ula. It cannot be r^arded as a credit to the medical profession that during
recent decades, when efforts from various quarters have been made to utilize
the public schools for education in various aspects of hygiene, and when
teachers and educators, not specially equipped for the work, have been doing
their utmost to execute the task imposed on them, the scientific leaders in
medicine have acted largely the part of destructive critics, and have given
little of constructive suggestion and tangible aid. Only recently have
medical men of acknowledged standing contributed text-books to aid
struggling teachers in their work. It has not always been recognized that
the elementary school-teacher, while presumably well equipped, so far as
circumstances pern^t, in the arts of teaching of children, cannot be in
any degree informed like the specialist in the different departments of
knowleilge,— language, art, mathematics^ various sciences, etc., — the
rudiments of wJiich she attempts to impart. For the organization of these
she has a right to look to the specialists, and she has also a right to insiat
TEACHING THE TEACHERS- — SNEDDEN.
SOI
that these, in fitting their materials for her use, shall somewhat acquaint
themselves with the conditions under which she works. It seems to the
writer that, under present educational conditions in America, the fol-
lowing limitations must be accepted in preparing any program of in-
struction :
(fl) The vast majority of American teachers are women, and, outside of
the large cities, these are mostly young, inexperienced, and destined, on the
average, to serve but four years in the profession. While successful in
the ordinary routine of teaching, these young persons frequently do not
have wide professional interests or capacity for study and original work*
They accomplish the best results along routine linea and under fairly im-
mediate direction.
(6) On the average, these teachers do not represent the equivalent of
two years' professioiial training beyond high-school graduation, and this
training, owing to the immaturity of the candidates, the multiplicity of
subjects which they are expected to study, and the necessities of practical
teaching, is adequate only to a very limited amount of preparation in the
special subject of hygiene here under consideration. They have little
ecientific instructloOj and, owing to the fact that their work is not specialized,
time is not available to ^ve them full preparation in any line. It must
also be remembered that three-fourths of the teachers of America do not
have even the two years of professional education spoken of above, but enter
the work directly from the secondary schools.
(c) During the last two decads an increasing number of subjects have
been forced on the elementary school program. Ordinarily, the newer
subjects are not well taught, but in cities it has been the tendency to have
special supervisors or directors who should instruct teachers from time to
time in the new work and oversee its execution. But the extent to which
this has gone has produced a reaction, and there is a wide-spread feeling
that the curriculum is overcrowded, and the resulting work, therefore,
superficial. But it is agreed that, in so far as the newer subjects are well
taught, this is due to the presence of specially trained supervisors who
organize and direct the work, and assist the regular teachers at difficult
points,
(rf) Theoretically, it is possible greatly to eoonomize time and energy
and improve teaching, notwithstanding the multiplicity of subjects, by
systematic correiation or related topics, by improved programs of study,
and by more effective presentation, but, owing to various limitations in
educational practice, Uttle progress has so far been made in these directions.
Consequently, courses of instruction are crowded^ and excessive demands
eeem to be made upon the time and energy of teachers-
SIXTH INTERNATIONAL CONGRESS ON TUBERCtTLOSlS-
(e) Supervision of instruction ia one of the most effective means ci
improving its quality and reducing waste, but supervision has hardly
become a special study in American education, and we are far from
realizing in practice Ws possibilities. Similarly, the aiter-traimng of
teachers, — L e., training after they be^n professional work, — is not yet
well developed*
These limitations in educational administration must not be regarded
as discouraging, because, in spite of them, American educatioa is making
rapid progress. In spite of them elementary education is daily becoming
wider and more generous in its outlook, and is improving in its methods.
But they do indicate that the principles of division of labor, specialization,
and cooperation are greatly needed, and that the introduction of new sub-
jects must follow along these lines. No longer can it be assumed that the
regular grade teacher b a beast of burden, uiJcn whom all sorts of demands
can be imposed, without regard to the total situation in which she works.
Thisj it seems to the writer, is the keynote of the new education, or at least
of the educational administration that must suffice until we can de\'elop
a new type of trained professional teacher.
From the standpoint of immediate feasibility, then, the effective program
for organizing instruction regarding tuberculosis would be the following:
(a) In each city or other area contmning a considerable number of teachers —
a few hundred— there should be a specialist who will combine special medical
knowledge and experience with competency to direct teachers and teaching —
a combination at present rarely found; (b) this specialist should arrange to
give instruction to candidates preparing for teachers' positions regarding the
known facta of tuberculosis, and the effective means of teaching these to
children; (c) after teachers have begun their work, he should organize their
programs of instruction in his special subjects, aid in the selection of ma^
terials, and occasionally, at least, give lectures to large audiences of cliildren
and possibly their parents; {d) from time to time he should assemble teachers
engaged in carrying out his program of studies, and give them concrete
BUggestions and instruction as to means of rendering their teaching more
effective; and (e) he should, so far as practicable, supervise the actual
instruction offered. It will be evident, therefore, that we contemplate the
trmning of teachers primarily by the means of a specialist in medicine and
pedagogy introduced into the system of public education. The assumption
is that this first-hand and immediate training, under present conditions,
will accomplish the maximum of result so far as educational effect is con-
cerned.
It may be observed, b passing, that in teaching and training of thia
Bort we have by no means solved the problem of program. Ordinarily, such
TEACHING THE TEACHERS,— SNEDDON,
593
Bpecial teaching is diluted through the year, b fragmentaiy, and often fails
to make an impression. It is entirely probable that, under the influence of
the kind of specialist here described, it might greatly profit to have, in
successive schools, periods of some day^ or weeks in which the teaching
would be intensive, mth abundant means of illustration and objectificatton
similar to exhibits already familiar to this audience. Teachers and pupils
could alike, for perhaps three-quarters of an hour each day, come under
the influence of the specialist himself and his means of teaching^ and thus
impressions be left that are impossible under desultory teaching.
The foregoing program » however, in its narrow aspects, would generally
be regarded as tending to isolate school subjects, to oppose correlation, and
to make for excessive specialisation. A much more practicable procedure,
and one more in consonance with current educational tendencies, would
be to place under expert direction the entire domain of the physical education
of the child, which includes not merely the matter of conser\ing his physical
well-being, but of imparting the knowledge that will make that well-being a
permanent and social matter. In other words, there should be, under the
education department of any eonsiderable area, a spGcial department of
hy^ene in the broadest sense of that word. Such depajtments now find
their begbiningB in some American cities , and at least in one State. This
department of hygiene, under the general direction of the board of education
and superintendent of schoolap must be officered by men who combine
medical knowledge and experience with pedagogic insight, and who devote
themselves primarily to the study of the schools. To such a department
naturally fall guch matters as: (a) The medical inspection and examination
of school-cliildren, with powers to inforce remedies for defects found; (b)
supervision of the hygienic aspects of instruction, school environmentp the
conditions of home study, etc.; (c) the administration of means tending
directly to promote physical well-being, as playgrounds, gj^mnasiums,
calisthenics, games^ etc.j and finally (d), the organization and direction of
all instruction in hygiene, including preliminary and after-training of
teachers to accomplish most efi'ectively such instruction.
Under these circumstances we should have correlation within one of the
four great departments of elementary education; teachers would, at all
times, be under the immediate direction of specialists, who could themselves
atlminister some of the instruction by general lectures and exliibits; and
definite place could be ^ven in the work of each school year for the entire
range of instruction in hygiene and the carrying out of measures designed
to promote health. In time it might be found desirable somewhat to
departmentalize the work of physical education, as where, for example,
the gymnasium instructors might also be called upon to ^ve the necessary
694
BJXrS INTERNATIONAL CONGRESS ON TUBERCUlOStS-
instruction in hygiene, this being presumably one of their special fields,
The teacher of the academic subjects would then, m her retum, be somewhat
of a speclaliBt in the remaining £^eld3; thus increasing the effectiveness of
her range of work. In very large cities, with growing conceptions of the
Importance of social sanitation, it is conceivable that the hy^ene department
might have within it a specialist who would give much time to the devel-
opment of adequate instruction regarding tuberculosis. But in smaller
communities it would be necessary to correlate under simple management
the entire range of instruction in hy^ene.
It 13 more and more evident that it is to aome such organization as this
that we must look for the development of the new side of public education.
We have already found this to be the case in the matter of vocational educa-
tion; the ordinary machinery of instruction mast be supplemented by
another department, specialized for this particular purpose. It should also
be noted that, at present, there are hardly anywhere available men and
women who can be put in charge of this work of educational hygiene^
for men skilled in medical science alone cannot do it, nor can men who are
only teachers: it requires a combination of the results of both kinds of
training — in fact^ a new field of applied science. But if the demand is
once created, gradually a supply of trainetl workers will be available, for
the field offered is certainly attractive to all who incline toward sanltatioo
and preventive medical practice-
Not until some such department ta developed can we discover the means
of solving many of the problems that even now confront us in the teaching
of by^ene. The art of teaching hygiene of all sorts, like that of moral
instructioOj is yet very imperfectly understood i for, though it is not difficult
to communicate the known facts in either of these fields, it is a very different
matter to stimulate motive and t-o have knowledge lead to action. Ped-
agogically, we know it is possible so to teach as to evoke corresponding
action; but how to do it in particular cases yet taxes the wisdom of those
who see far enough into education to realize that the development of motive
ia no less important than the communication of knowledge.
In carrying on the campaign ag£dnst tuberculosis, if those who desire
to utilize the machinery of public education will take account of the fore-
going conditions and lend their influence to the development of the program
described, and will not expect that the mere nominal inclusion in the course
of study of sections of instruction in hygiene i-elating to tuberculosis will
be more than a suggestion of what should be accomplished, then we may
look for important results in the comparatively near futiire, for there is
now a wide-spread interest in physical education that may, and generally
will, lead to the development of the departments described, and these should
TEACHINO THE TEACHERS. — BNEDDEN. 595
find a large program of work mapped out for them, and it is to be hoped that
social demands will impose upon these departments no mere program of
temporary and partial procedures, but that they will be expected satis-
factorily to account, within the limits of their powers, for the present welfare
of all children in the school system, sad to a large extent for their future
physical efficiency. The school is ready to fulfil its mission of being the
great socializing agent, but it must look to other lines of learning for intel-
ligent demands and direction. Notwithstanding many limitations, no
teaching force in the world is more devoted than that of America, but the
public has not yet sufficiently taught the lessons of cooperation, of the
pursuit of large social ends in tiie immediate environment, and the advan-
tages of division of labor. In social reconstruction there seems to be little
limit to the possibilities of our vast school system if that is guided by science
and is kept in intimate touch with the modem life and its social demands.
EDUCATIONAL PROPAGANDA THROUGH LOCAL
LAY AGENCIES;
ESPECIALLY IN SCHOOLS, SETTLEMENTS, AND CHARITY
ORGANIZATIONS
By Henry B. Ward,
Liaooln. Nebraska.
It is evident that this paper must be limited primarily to conditions
existing in the United States. Posdbly m«cli will be said which will apply,
mutalis mutandis, to other lands, but in order to avoid serious errors the
application must be made by those thoroughly familiar with conditions in.
A given nation, I caimot presume to speak of any other than my own
country. Nevertheless I am convinced that the same needs exist elsewhere,
the same unemployed agencies are available, and the same effective results
can be obtained.
The campaign against tuberculosis has been, from the start, largely a
problem of educating the people, and yet up to the present time little effort
has been made to use governmental agencies in the movement. As a factor
of fundamental importance, nearly eveiy section of the Congress has Listed
for discussion some phase of the educational question. In this paper it
proposed to limit the consideration to the strictly official aspect of the case,
id to deal not with methods of presentation, the pedagogical side, but
rather with channels already existing in organized society through which
the propaganda can be effectively and properly conducted. This may be
designated the governmental or official side of the problem.
No one can doubt the power, or question the propriety, of official regula-
tions concerning the presentation of this subject under gorernmental aus-
pices. Sanitary surveillance over travelers and workmen, as well as all
sorts of buildings and places, is well recognized and thoroughly approved as
a function of government. The law limits the actions of the sick for their
own betterment as well as for the protection of the well. It should also
direct the instruction of the child so that the coming generation may avoid
the penalties of ignomnce under which the nation suffers to-day.
In the struggle against disease, the only profitable method consiata in
making use of existing educational agencies, To create new systems, or
596
1
LOCAL EDUCATIONAL PROPAQANDA,— WARD, M7
even to add new machinery for educational purposes under the auspices of
existing agencies, such aa national, State, or local boards of health, is neither
economical nor effective. Such organizations have other work to do which
demands the full extent of their powers. They are not well adapted to
reach the general public in an educational campaign. For them to create
and operate the necessary machinery involves an undue expenditure of
energy, while it is also apt to distract attention from their primary work
and to hamper them in its execution. Some great educational campaigns
have been organized and carried out with marked success by such boards, and
yet these instances are distinctly exceptlonaL As a rule, other agencies are
better adapted for such a campaign; most effective are those which are
primarily educational bodies and appeal to the public as such. Consequently
they can do the work naturally and require little or no change from normal
activities to adapt their systems to the desired purpose.
Finally the enlistment of educational agencies under governmental
auspices will distinctly add force to the movement* Unfortunately, too
many of the people regard this crusade to-day aa primarily medical, and
evaluate it largely according to their attitude toward medical matters.
When the problem is presented by another factor in organized society^
and when the presentation has governmental support, the movement will
assume far greater importance in the eyes of the general public. No one
can have failed to note the tremendous influence exerted in recent yeara
through the legal incorporation into our educational systems of specific
instruction concerning the effects of alcoholic beverages and narcotics* Spe-
cial legislation was enacted to insure the presentation of that subject as its
advocates desired. In our own movement any such particular enactment
would seem unnecessarj^, and the introduction of the topic in proper form
could be provided for without the delay incident to special legislation.
At least one important consideration favors the easier introduction of
instruction concerning tuberculosis. A considerable portion of the commu-
nity has already been convinced of the seriousness of the problem by direct
personal observation. There is not a town or a hamlet into which the
*'white plague" has not penetrated; its results are not masked by compli-
cated features, and the educational campaign under private auspices has
found practically even^vhere a warm welcome and a ready response.
Every civilized nation has an organized school system, and probably
every course of study includes somewhere a consideration of hygiene. So
far as the United States is concerned, this subject is studied at several points
in the course from the kindergarten to the high school, while both secondary
achool and college courses include again, as a rule, the same study. Un-
fortunately, the consideration given the subject is often trivial, and the pre-
vention of disease is especially superficially touched upon. There is evident
I
SIXTH INTERXATlONAt COKOREBS OW TtJBEECtJLOSIS-
opportunity for improvement, and material advaoce would be m^e by tfai
insertion of already existing material oa the tubereulosi^ problem. It e
highly important that this be done in the beat possible maimer, both to eo-
lift and to retain the support of the educated portioD of the commuutj,
and also to achieve the best results in the future.
The influence of school-teaching and text-book illustrations or discus-
sions ia by no meana limited to the scholars reciting upon any portion d s
given subject. Booka are carried home and fail into the hands of older
members of the family; new ideas received at school are repeated at thefaaailj
dinner*table and attract the attention of others; chance remarks lead to
further inquiry, and discussion or consultation of the text-books ev
spreads the knowledge among many outsiders. The power of su
transmitted in this fashion, is often greater than of such as emanate directlf
from more technical sources. Even the professional man may no lon^
deliver hia dicta unquestioned; the achoola arc still regarded as fountains
of pure knowledge.
Let it not be forgotten that our school system is immediately concerned
In the tuberculosis problem. Infected teacliers arc a peculiar menace to
their charges. In close, hot, badly ventilated, and overcrowded rooms,
among pupils of susceptible ages, and^ unfortunately, sometimes ill nurtui^T
the seed falls on fallow gi-ound as the bacilli are projected by coughing to the
furthest comer of the room. Equally unfortunate results follow the intro-
duction into a school-room of a single tubercular pupih Adequate medieal
inspection must be required by school boards even in rurnJ communitiKV
and should be demanded through governmental auspices. Its general jfi-
troduction will require considerable time, alas! and meanwhile the edufi-
tional campaign which can be promptly inaugurated will aid teachers ami
local authorities to see the dangers and avoid them in part at least. E^'cn
disinfection of infected school premises can be carried out without profes-
sional assiatonce if the people are aroused to appreciate its need, and super-
vising agencies have at their command adequate information regarding the
methods to be employed.
The crucial point, in my opinion^ is the proper preparation of the noaterial
to be used. This should be intrusted to a commission pos3<^sing both energy
and ability- Such a commission might properly be appointed by the
United States Bureau of Education, acting in cooperation with the National
Association for the Study and Prevention of Tuberculosis. An impetus to
this movement might appropriately be given by the adoption of suitable
resolutions at this Congress. Such action would lend great moral support
to the movement. The commission should be strong enough to cx)miniind
unqualified support in both scientific an<i educational circles. The out-
lines prepared by it might be printed separately or incorporated into exist
I
I
LOCA.L EDUCATIONAL PROPAGANDA. — WARD.
599
ing texts for school use. The former plan would involve less complications
aiid call more direct attention to the subject. The pamphlets should then
be sold at cost, and their introduction and use provided for by official in-
structions emanating from the ranking officials in national, State^ county,
and city school systems. The distinctly favorable attitude of the public
mind at present would aid markedly in securing a willing response to the
officiai instructions regarding their use* In our country such a movement,
to be most successfulj should start at the top. Through the bureau of educa-
tion the State superintendents of public instruction , county superintendents,
and city superintendents, all teachers of all grades can be reached, and the
movement will inevitably gather force as it goes.
The numerous teachers' institutes, which are held under State and county
auspices a^ vacation schools for the instruction of groups of teachers, are
splendid places in which to present the dangers of tuberculosis and the means
for its suppression. Such synopses as I have mentioned should be laid
before teachers in these institutes in a way to fit them for presenting the
matter later to their pupils, I am confident that voluntary organizations of
teachers, such as State and county associations, schoolmasters' clubs, etc.,
will welcome the presentation of tliLs subject in an adequate manner, and will
cooperate powerfully in achieving the results desired. These private socie-
ties Ue, strictly speaking, without the pale of government control, and hence
outsitle the proposed limits of my subject. Yet a discussion of govem-
mentaj agencies would be incomplete without mention of the assistance
which will be given promptly to legal requirements by these auxiliary socie-
ties.
The other lay agencies which the government may exi>ect to enlist in the
campaign are distinctly secondary', and possibly are to be regarded as vol-
untary rather than formal adjuncts. There is no need to emphasise the in-
timate relations of poverty and disease, or the primary importance of tubercu-
losis in this connection, But charity organisjation societies are sometimes of
a semi-ofBcial character, receiving cash subsidies or quarters from the city^
and they often assume official duties toward some class in the community
or enter into other relations to the municipal government. All this obli'
gates them to receive definite instructions from the municipality and to
follow these mandates. They already exert a real educational influence;
often they originate, and always are closely associated, with college settle-
ments, houses, clubs, and other organized efforts to reach and teach in various
fashion the less fortunate portion of the community. In some such move-
ments the cause and prevention of disea^ form an occasional topic of dis-
cussion* But they have apparently no constant or consistent plan to edu-
cate the i>eople against these diseases in all places. Clearly it falls to the
lot of the governmental authorities to syEtematize and formulate plans
600
BDCTH IN-TEKKATIONAL CONGOESS ON TUBSBCUTiOSfS.
for such instruction. The perforniaace o/ this duty might be j»
required by the municipality wluch subaidizes the chaxity o
ns a fair return for favors given. But such a requirement will be
6uous. These organizations appreciate both the assistaooe tbey recei
from the city and the meaoing of such a movement for the class t
stri\-ing t^ help. The most aerious obstacle to their work on this
the lack of suitable literature. Without outlines for the work, and boob
or even Jeaflets for study, such societies often find themselves stopped froiB
carrying on the campaign. It is not always possible to secure adequatt
assistance from the medical profession in a given locality* Once a de^te
program for geueral hygienic education is formulated under government
auspices and transmitted with appropriate suggestions for use to the sub-
ordinate agencies, the educational influences will gladly accept this addi-
tional duty. They see plainly even now the burden laid upon the nation,
the financial and social lo^, the sorrow and suS'ering accompanying it,
and will seek eagerly the relief which is ofFered. It would be a great
service to this nation if^ out of this conference, should come not only nit
impulse to educational propaganda nation-wide in its scope, but also a
carefully formulated educational plan which should give educational
workers the means to conduct their campaign in schools and slums, among
all ages and classes of 'society, not merely to arrest the disease in crip-
pled humanitVj but to educate the coming generation so that it shall
avoid the dangers of the past and attain in great measure to physical
perfection.
Erziehungspropaganda durch lokale Laien-Organisationen, besonders in
Schulen, Fortbildungsschulea und Wohltatigkeits-
Anstaiten. — (W.ykd.)
Die Regierung hat die Kontrolle iiber die Quarantine und Sanit^its-
zufitande mit grossem Vorteil fiir das Volk im allgemeinen ausgeubt. Solche
Bemiihungen, eine Situation, welche schon enist geworden ist, zu heilen,
ist eigentlich secundar den Verhiitungsmassregeln. Von alien diesea ist
die Erziehungspropaganda die vorteilhafteste, und doch ist fide bisher am
seltensten gebraucht worden. Das organisierte Schulsystem des Landes ist
die natiirliche Erziehungshilfstelle, und dieselbe ist bei weitem mehr au^
gedehnt und wirksam, aU irgend eine andere Sonderorganisation, die ge-
schopft werden konnte. Jeder Schulkurs tragt fiir das Studium der Hygiene
Sorge. In diesem sollte die Verhtitung von Krankheiten, besonders von
Tuberkulose, mit grosserer Betonung behandelt werden* Die Tuberkulose
ist in vielen Wegen eine besondere Gefahr fur unsere Schule, Eine starke
nationale Kommiasion aoUte von dem United States Bureau of Education
LOCAL EDUCATIONAL PROPAGANDA. — WADD. 601
und der National Association for the Study and Prevention of Tuberculosis
emannt werden, um fur den Schulgebrauch geeignete Kompendien vorzu-
bereiten, um in dieser Weise allgemeine Achtung zu sichem und den grOss-
ten Einfluss auszuuben. ESn solches Material kdnnte all den Lehrem in
Staats- und Bezirksanstalten vorgelegt werden, und auch durch die Mit-
wirkung von Lehrervereinigungen und diversen Schulvereinen und Shnlichen
freiwilligen Organisationen. Die Lehrerwelt ist sich der Gefahren bewusst,
und wird von denjenigen, die mit Autoritfit zu sprechen berechtigt aind,
geme die Unterstiitzung bewillkommnen.
Fortbildungsschulen, gesellschaftliche Vereine und organisierte Wohl-
tatigkeitsanstalten sind semi-offiziell, da sie h&ufig von der Gemeinde
unterstiitzt werden. Folglich kann man von ihnen mit Recht verlangen,
dass sie eine bestimmte Arbeit in dem Erziehungsfeldzug der Stadt tun.
Sie sind sich der Bediirfnisse der Lage bewusst imd werden wirksam imd
rasch mitarbeiten. Sie gebrauchen bestimmte Plane fiir das Erziehungs-
werk; so ist auch hier genaue Formulierung eines geeigneten Programms der
bedeutendste Faktor.
THE COLLEGES OF THE UNITED STATES AND THE
CAMPAIGN AGAINST TUBERCULOSIS.
By Wiluam Harmon Norton,
The function of the indirect helper has long since been shown by Darwin
in the struggle for existence and the stirvival of the fittest. In the struggle
for the lives of others, abo» and in that twentieth century phase of it, the
war against tuberculosis^ there are indirect helpers, who^ work, though
unofficial and even incidental, is real and practical, and in the aggregate
bulks large. It is the purpose of this paper to indicate some of the various
ways in which the colleges and universities of the United States are helping
in the war. Our data, gathered chiefly by a qnestionaire sent to the presi-
dents of 200 representative schools, are shown in detail in an appended table.
First in value among the services of our collegiate allies we may reckon
the investigation of fundamental problemSi In this section of the Congress
it is not in place to discuss the large work done in research in the pathology
of tuberculosis by the universities in their biological laboratories and schools
of medicine. But the problems that come undex our own cognizance —
problems of hygiene and sanitation, of economics and sociology — are being
worked out, as we are all aware, largely in the colleges and universities, and
it is here that students are being trained in methods of research.. As ex-
amples of various lines of investigation carried on in our higher schoob I
may mention the advanced course in social economy at Columbia ITniver-
sity, under Dr. Edward T. Devine, where in 1907-1908 an entire term was
devoted to lecture and class work on the social aspects and control of the
disease; the investigatioas of Fisher, Bailey, and Famam, of Yale, as to
diet and housing in sanatoriums, and the relation of tuberculous to labor
and tenement conditions; the sociological work at the University of Chicago^
where students? accompany patients of the college dispensary to their homes,
together with viHiting nurses and physicians, and study local conditions atid
eurroundingSf and the methods employed in improving the environment;
and the similar work done by the University of Wisconsin, where classes from
the departments of political economy and sociology visit the city of Mil-
waukee to study the social and industrial aspects of the disease. In several
colleges students are Becuring valuable data in the local fields of the college
602
4
THE COLLEGES AND THE CABCPAIGN. — ^NORTOW-
603
or home town^ or counties as to some of the simpler problems^ such sls the
number and proportion of deaths from tubercuIoaiSj the recurrence of the
dise^Lse in infected houses, the average length of the disease, and lU economic
loss* In investigative work in tuberculosis 33 schools of the country are
reported as engaged.
The higher schools of the country may be expected to furnish from their
faculties not a few men of knowledge and conviction as leaders in the cam-
paign* The lists of officera of this Congress, of the National Association,
of the State Leagiiea^ and State Boards of Health, show that the colleges are
supplying at least their full quota for this purpose* Fifty colleges and uni-
versities report membera of their faculties engaged as active aaaistauts in
the propaganda.
In the campaign of education the colleges are at work in two fields, that
without the college walls and that ^^-ithin them. Where the commonwealth
does not furnish Jecturers on tuberculosis, — and only two States, Iowa and
Minnesota, do so at present, — the work of arousing and teaching the people
from the platform must fall largely on the colleges. Univeraty Extension
courses, summer Chautauquas, now hekl in almost every county of some
States, as well as less formal occasions, furnish a means of reaching the people
that PhilUps and Garrison might have coveted in their campaign against
slavery. The subject of public health, with its issues as practical as hfe and
death, will everywhere receive an interested hearing. The college teacher
speaks upon such subjects ^ith an influence and authority enhanced by hia
official relation, And to college men the educational campaign makes a
specially strong appeal. We cannot see the people perish for lack of knowl-
edge— knowledge that it happens to be our good fortune to possess, and not
be stirred by some nussionar)" zeal to go forth and preach the gospel of sani-
tation and the salvation that it offers from disease and too early death.
As an ejcample of the educational work done by our more interested uni-
versities may l>e mentione^l that of the University of Wisconsin. The de-
partment of bacteriology of tliis school has organized a tuberculosis exhibit
that has been shown in many cities of the State, the University Extension
department in many cases pajing the exj^enses of demonstrators and special
lecturers. Extended plans are laid for the more general use of tliis exhibi-
tion through the State, and the University stands reatly to furnish at any
time demonstrations and lecturers in the campaign- The other schools
of the United States that give lectures on tuljerculoais in University Ex-
ten^on are the Universties of Michigan, Pennsylvania, Chicago^ Indiana,
Oklahoma, and North Dakota^ the University of Cincinnati, Harvard,
Miami, Purdue, Northwestern and New York Universities, Dickinson College,
the Massachusetts Institute of Technology, and the Michigan College of
Agriculture.
604
SIXTH TNTERNATIONAIi CONGRESS ON TUBERCTTLOSIS.
The field within the college walla b more generally tilled than that wit!
out, and is no doubt more fruitful* In our students we find an exccptioniil
receptivity to new truth. The inertia of long-fbted habits of thought and
will, the stolidity of ignorance, unable to comprehend fundamental principles,
the prejudiee of financial interests imperiled — ^none of these obstacles is
met with in the college. Surely that warm-hearted enthusaasm of youth,
easily stirred to noble ends, which in our Civil War sent forth to battle the
oollego boyis of North and South aLike^ may be aroused to serve in this cam-
pftigHf whose purpose is not to destroy life, but to save it,
A si>ecitd advantage in the appeal to college students is that we may
take for grant-ed the foundations, the knowledge of basal facts, which ebe-
where must first be laid and always incompletely. The familiar use, in the
laboratory, of the culture, the stain, and the microscope^ gives a vital knowl-
edge of microdrgaaisnis and their efiFects. To collie students the tubercle
bacillus 13 neither an empty phrase nor a terrifying banshee announcing an
inevitable death> It is a real foe, though invisible to the unaided eye^ but
one that may be met and conquered by scientific weapons.
I may mention also the indirect educational influence of the bacteriologi-
cal laboratory when it is made to serve the sanitation of the college commu-
nity. Dartmouth may be cited as an example^ where, as Dr. Kijigsford, the
medical director, writes: **The class rooms, dormitories, and chapel are
ex:imined every two weeks by exposing gelatin plates for ten minutes, and
when the number of bacteria that fall upon the plat-es during the ten minutes
exceeds forty, the rooms are thoroughly disinfected with formaJdehyd.
Since the adoption of the wholesale method of disinfection, dckness among
the students has been very markedly reduced, especially those mild forms of
diseasCf such as pharyngitis, tonsillitis, and ordinary colds," And we m&y
easily believe that the indirect benefit of such bacterial cleanliness in ©ducat--
ing tlie students in the principles of modem sanitation is as great aa the im-
mettiate benefits to their health.
Education by example is also offered by such colleges as Bryn Mawr and
Bowdoin, where cases suspicious of incipient tuberculosis are at once exam>
ined, and if the disease is recognised, are isolated and sent home for open-air
treatment.
Another valuable method of education is that of college regulations for-
bidding the rooming of students in infected houses and with families where
cases of tuberculosis are known* Such regulations bring home to students
and townspeople alike the danger of infection, and one of its chief sources.
Nineteen schools are reported to have such regulations, and still others reaeh
the same hygienic, if not the same educational, result by special adminis-
trative action in specific cases. There can be little doubt of the wisdom and
the need of such regulations. Less than one-half of the schools replying to
«
I
THE COI<LEO£S AND THE CAMPAIGN. — NORTON.
605
our questioimire report municipal regulations requiring registration of cases
and disinfection of houses, and in a still smaller number are these regulationB
effectively inforced. Apparently in the large majority of our higher schools
no control is exercised in this vital matter. The young student comes to
the college town a stranger, entirely ignorant of the history and sanitary con-
dition of the houses among which he is to choose his borne. Very pMjssibly,
aJsOj he is equally ignorant of the causes of disease, and sees no danger in join-
ing a family infected with consumption. Yet he is allowed to place bis bfe
in hazard without even a remonstrance from those who are supposed to have
hia physical and mental well-being in their chai-ge.
That the majority of colleges have not as yet adopted such regulations
is probably due to the fact that their attention has not been called to their
educational value* To some, however, the matter has not seemed urgent,
because of the general exemption of their students from serious disease, the
supposed low mortality from tuberculosis of the college town, and the fact
that students room either in dormitories or in the better bouses of the town,
where cases of the disease are most rare. But such reasons can be validated
only by a thorough Investigation of the local field. In almost any community
registration proves tuberculosis far more prevalent than had been supposed*
The in^ance of a college town in the middle West may be cited, a town
rightly considered one of the most healthful in its State^ where an investiga-
tion disclosed in the best residence portion of the city, within a radius of 100
yards^ six houses that had harbored the disease* The investigation should
include the incidence of the disease upon the younger alumni, as well as
upK>n the undergraduate students. A suggestive and by no means exceptional
case is that of a small eastern college two of whose graduates of the class of
1907 are now in tuberculosis sanatoiiums. This college, like the other
colleges of its State, has taken little or no part In the campaign.
Among the things that make for the education of the student is the use
of the tuberculin test with the herds of dairj' cattle kept by agricultural
colleges, and by a number of other schoolsj for the use of their boarding
halls. The regular test of their herds that some colleges report cannot
fail to have a wide educational effect, while the neglect, by the administra-
tion, of such obvious precautions, goes far to neutmlize the most earnest
propaganda of the class-room.
I may suggest also the large educational results that we may rightfully
expect from colleges in the way of prophylaxis. The systematic ventilation
of dormitories and lecture roomg^ with their occasional test for the proportion
of carbon dioxid present, demonstrates the value of fresh air more effectively
than can text-book or teacher. And the colleges whose aim is not the mak-
ing of a few overspeciaUzed athletes and the advertisement of their victories
in intercoUegiate games, but rather the physical well-beingi the majcimum
606
SIXTH INTERNATIONAI^ CONCRSSS ON TUBERCULOSIS,
mental and phyaical efficiency, of all their atudenta — such coUegea inspire
an ideal of vigorous health that becomes the best possible prophylaxis
against tuberculosis, as well aa against disease of every sort.
The colleges of the United States are using the most direct me^ns of en-
listing their students in the fight against the great white plague. LocaJ
antituberculosis societies are being organized, as at Radeliffe, Special
lectures or cout^es of lectures are given before student assemblies. At the
Rose Polytechnic Institute and at Br>Ti Mawr such addresses are given by
the president. At Cornell C-ollege, Iowa, the Science Club has provided
open evening lectures for student-s and townspeople for four condecutive
years, securing for this purpose the State bacteriologist, a United States
meat inspector, local physicians, and in 1908 the recently appointed State
lecturer on tuljerculosis. In 47 colleges and universities such iecturra are
now given before student assemblies.
A still larger number of schools give special attention to the subject in
the class-room. At Dartmouth the physical director gives two or three
lectures on the disease to the freshman class in a course on hygiene. In-
diana State University provides instruction on tuberculosis, its causes, re-
sults, and methods of prevention and cure, in a course of lectures on hygiene
g;iven in the Assembly Hall by diffei*ent members of the faculties, and re-
quired of all candidates for graduation in the college of liberal arts. Pur-
due University introduces the subject in a series of lectures on ** Health and
Efficiency." Carleton College provides for the same in a course on " Social
Problema/' In colleges too numerous for mention the disease in its various
aspects is studied by classes in the biological sciences, in hygiene, domestic
science, sanitaiy engineering, sociology, and economics. The University of
Wisconsin for several years has given lectures on tuberculosis in farmers'
courses and before various meetings of t-eachers. The University of Minne*
sota makes such lectures an integral part of the program of its College of
Education, an example worthy of being ividely followed. The recent organ-
ization of schools of education in the colleger and universities opens one of
the most fruitful fields for the propaganda. The colleges and universities
now supply the large majority of the teachers of the high schools. To teach
the facts as to tuberculosis to these schools of education is to diaaeminate
them throughout the secondaiy schools. By enlisting college men and
women in the great crusade we are drawing to the same banner the hundreds
of thousands of high-school boys and girb who^ in the immediate years^ are
to be under their instruction.
The circular is another effective agency in the educational campaign.
The students of the University of Minnesota were recently thoroughly circu-
larized under the auspices of the Antituberculosis Committee of the Associ-
ated Charities of Minneapolis, a committee of which a number of the univeradty
THE COLLEGES AND THE CAMPAIGN, — NORTON.
607
professors are members. At Syracuse the students of the univer^ty have
circularized the city by distributing cardboard circulars printed in five Ian-
guagea to its 25,000 homes. The entire expense of more than SlOO wae
borne by one of the university professors. It would seem that in any
college the driving force in the propaganda may be found in one man or
a amall group of men, and that to rally all the colleges of the country
to the standard needs but to enti^ the interest of one or two men in each
faculty.
About one-third of the colleges and universities to which our questionaire
was sent have made no answer^ and about one-Mth admit that no active
part is being taken in the propaganda. Ix>oking at the matter on its brighter
aide, we may believe that, at least, nearly one-half of the higher schools
of the United States have been aroused to some interest and cooperation
in the cause- A few repUes, limited to statements of the healthfulness of
the college town and the general care taken of the students' health, evinced
a singular misunderstanding of the scope of the inquiiy* After such a rela-
tion a western college president writes: "Our experiences have therefore
been such that we have never been stimulated to examine into the causes or
other manifestations of the disease." Several eastern college presidents
state that their local conditions are so entirely free from the possibility of
tuberculosis that the matter is of no practical interest. Other replies are
most encouraging in their promise for the future, although they admit an
entire lack of cooperation at present. *' It is high time, however/' writes the
president of a college of the middle west, " that we devoted some attention
to a matter of such vital importance." And this from the pre.sident of one
of the State universities: "I have to say in humiliation that practically
nothing has yet been done in this State and in our institution as to tul>ercu-
losis. ... I am going to take up the matter in the university next year.
I regard the movement as one of supreme importance, and hope to bear my
share in the beneficent cause.*'
What results may we reasonably expect from the general cooperation of
the colleges when it is once secured? We shall gain each year the help of
hundreds of thousands of the best young men and women of the country.
Through them we shall obtain the cooperation of the secondary schools,
whose teachers they are to supply. And, still more, as our college students
go out into every city and town and village of the land, to take their places
as citizens of exceptional influence in their communitieS| we shall secure the
assistance of the social leaders of the future. The harvest sowm in the col-
leges may be some years Ln ripening, but it in no less sure.
The facta which we have stated suggest the privilege, if not the duty, of
the colleges of the United States, to help in the twentieth century campaign
against tuberculosis along the following lines;
608
BIXTH INTEHNATIOKAL C0KQRE3B ON TUBERCULOSIS.
1. Exemplar}/ sanitation — (a) of college biiildiDgs; (6) in the test of collie
herds, in the care of students' health; (c) by examination of siispicious cases
of the disease; and (d) by regulations securing immunity from house infec-
tion.
2. Instruction on iuh€Tculosis~{a) in general lectures before student as-
semblies; (b) in specific instruction of classes in the biologic, social, and eco-
nomic sciences*
3. Efficient influence — (a) in bringing about model sanitary conditions
in the college town^ and (&) in promoting in all possible ways the propaganda
throughout the State and nation.
DATA ON THE WORK OF THE COLLEGES OF THE UNITED STATES IN
THE CAMPAIGN AGAINST TUBERCULOSIS.
t. Lectures on tubcrculosEa before student aasembtics.
2. Special altentfoa to the Bubject in the class-rootus-
3. Investigation of local conditions.
4. Investigation of any hygienic, social, or economic aspects of the subject.
5. Universjity Extension work.
6. Teachers actively asabting in the propaganda.
7. Faculty regulations (ofbiaiding the rooming of etutJcnta in infected houaes.
8. Municipal regulations as to registration, disinfection, and expectoration.
Q. Enforcement of such tnunlcipa! or State regulations.
No reply.
&tATU.
I SWriTVTlON 1
1
2
3
4
5
6
.
8 0
A]^haTn^, . , , . ,
UniveiBity of Alabama
Arizona ..........
University of Arizona .... *
Univeraity of Arkauf^os
X
Arkansas
' ' *
Cftlifomia, .
* University of California , .
Pomnna College ............ . .
OocidentflJ CoUegc
*-
■-
• --
Univewily of Southern Catifomia
University of the Pacific .,...,.
3C
X
■ ■
X
♦ Lcland Stanford, Jr., University.
Colorado
* University of Colorado *...,,
* Colorado College ...
••
•■
Oonaecticut
Colorado School of Mines ....,,
• University of Denver ,,....
Trinity Colle^ ,
X
X
X
..,
E X
Wesleyan Umversity
Yale tfnivi?raity , ,.,,,. ..,.,.,.
* Agricultural CkiUege ,
X
X
X
X
X
X
X
X
. . J
t X
I X
District of Colum-
bia
Washington Univeraity ,
HowardT University ^ ....... . . . .......
X
X
X
..
. , 31
Florida
Stetson University * . .
X
Umversity of Ftoridii ..,..,.,
Geoneia . .....
Georgia School of Technology * .
X .
X 3
Idaho
University of Idaho
I
* .\fBrmative answers checked x. Negative answers left blank,
answers to No. 9 arc in almost every inBtonce qualified.
AfErmalire
THE COLLEOEB AND THE CAMPAIGN. — ^NORTON.
Data or the Work op thb Colleges of the United States in tbb Campaiqn
AoAiNST Tuberculosis. — {ConUnued.)
State.
1
2
3
4
&
B
7
s
9
lUinoia
* Heddinff Colleee ,.,...
llUnob Wealoyan University
AnnoLir Institute
■■
■ •
..
,.
X
X
X
X
X
X
X
X
X
Xtcwia Infitilute , , * * . . . , ,
X
X
X
X
5;
University of Chica^p , .
* MiiUkoD UniveiBitv^ , ,
X
X
X
Northwestern Umveruity . . ...
X
X
X
X
X
X
X
X
X
Kdox College ■ . ■ ■
* lADibajLl Utijveraily . 4
Lake Forest University ...... .,.,,.
£
.,
..
'•
..
McKendree College
* Monujouth Caliege. , , .,...,,.
AtiEtiBtana Colleire . . ^ . . . . .
,.
X
y
* Shurtleff CoU™
Univeraity of IllinoU -■,,,...,,
X
'■
X
X
X
Wbeaton "College , . , , . .
Indiana State Univeraity
WabiLsh CoUea« . ,
X
V
■■
X
X
X
UePauw Lrnivofsitv ....>.
Purdue University *
Moor^ Hill College , , ...,,,,..,
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Univemity of Notre Dome. *
Earlbara CoUege
Rojte Polvtefihnic iDstitute..
X
X
X
X
low&i . * .
Invr^i AcriculliirflJ College.. .
X
* Coe College
C^nwU Collece ,„.,..,■.,--■-.,
X
X
X
X
X
X
* Charles City College
* LutLer Colfpee
DesMiunes Collsre ^ .,...,.
Drake Univeraity
Pareon* CoUfflra
X
X
X
-
X
X
* Upper Iowa UniveP*ity ...............
* Iowa College , ,
Simpson CoDege
Iowa State Univereitv*. . . ...
%
X
X
X
X
X
X
X
X
X
X
* Iowa Wesleyan Univereity
Fenn College .
X
X
..
X
X
X
X
X
X
X
Cetitl^ UnJversity ...........
X
MumingBidc College ,..,... ,..,,.
X
Buena V lata College . - r
X
X
■ ■
Tabor CoUeee
* Clark Collene
Kaasas
Saker University .,.,..* ,
X
X
X
Kansas State University
• Kanjsas Aericultuml College
Kansas Westeyan University. ,,,......
X
X
X
X
X
X
Southweat Kansas College . . *
Kentucky ,,......
* Berea College *.....
* Kentueky Agricultural Cotte^
Tulflne UnivefHiti? ^ ^ ......... .
X
X
X
X
*Affinnative answers checked x. Negative answers left blank.
Bwers to No. 9 are in almost evety instance qualified.
vol. in— 20
Affirmative an-
SIXTH INTERNATIONAL CONGRESS ON TUBERCULOSIS.
Data on thk Work of the Colleges op tub Uniteid State* m the Caupaion
AoAri4ST TDBBUOULoais. — {CorUinved.)
V
StATfc
1
2
3
4
6
e 7
a «
Maine
l3owdoin College
Bated; College ,
X . .
Univereitv of Maine, , » ,*.!... .
.
Colby College .....,..,,.. ^ ,
X . .
Morylatid .......
Johns Hopkina University
X
* Amherst College •
MattuachuBettfl ....
MassachuseLtfi Agricultural College.. ...
X
X
X
* Boston Univerflity
Lasalle Seniiiiary . , , ►
X
X
X
X
X
X . .
X . .
X X
. . X
X X
^^_
Harvard University ...
X X
^^H
Mt. Holyoke College
^^1
Tuft.s Cttllege
X X
^^H
Rftddiffe College
TL
^^^B
Smith College"
X
. • ■ »
V T
■
• WiUiama College
• Clark University ........ ,,.....
Wellesley C-olIege
X
^^1
* Worcester Polytechnic
MttHS, Institute of Technology ,.,,,.,,..
• Adrian College
X
I
X
X
■-
X X
X X
Michigftn . . . ^ . ,
* Michigan Agricultural College
^ Albion College . , ,
University of Michigan . . . >
X
X
X
X
X . .
X , .
X X
Hillsdale Colleee
V X
* Miohif;a.n College of Mines, .,.,..,,
L
Kiedamiazoo Coflcge «.. .......*.
X . .
X . .
X , .
'
1
OUvet College
University of Minnesota
X
X
X
X
X X
Mimiesota . . < ~ . , . ■
Carlton doltege. .
* Hamliue Univerflity ,
MacAtlister College ..................
X X
Agricultural College .
X
Miseiasippi .......
* Univeraity of Mississippi
'
Missouri Weslevon University ....*,*,. .
University of iSiaaouri ,
X
X
Misaouri
X
X
•*
X X
X X
Wa.shington University »
* Drury College ,♦.♦.».,.......«........
X X
Tarkio Ctdleee
X
Central Weafeyaji College
* Univeraity of ^tonata ...,,.,.
X
"
. . X
Montana
University of Nebraska .*»,.......,...< .
Nebraska , „
• Creighton University
* Nebraska Wettleyan University .,,,,.,..
••
. . ..
AgrieuJtural College , , .
'
New Hamt»b)re. .
DaHmouth College..,.
Stevens Institute. , .,.,..... .
X
..
.. . .
X X
New Jersey
* Rutgers College
Princeton University . .
*
* University of Ncsw Mexico ,, , , , . . .
" "
New Mexico
State Srhool of Mitiiis
•
X X
Polytechnic Institute of Bmnklyii , . . , ■ ■
Hamilton College ,,.,.,.........
X
X X
New York
Hobart College
X . .
'
♦ Affirmative answ*n^ checked x. Negative answers left blank,
awers to No. d ore iu almoiit every InataDoe qualified.
Affinnative «i%-
THE COLLEGES AND THE CAMPAIGN. — NORTON.
611
Data on thu Work of thb Colleoes of thb United States
Against Tubebculosis.— (CotUtnued.)
IN THE
GAlfPAiaN
Btatv.
iNvnrtmoM.
1
a
3
4
a
9
7
8
»
• Colgate University .... . . ,
Cornell UnJvereity < ... ^^ »,....,..... .
X
X
X
X
'■
X
X
X
X
z
X
X
X
X
X.
CoUpge of thu Citjr of New York
Cotumbia UniverBity * < #..
X
V
Ehnira C'oUege . . , ,
Massuf^hurietts Institute; of Technology ,
Rensselaer PolytecJinic
"
"
X
X
. ,
T
New York University ,._.., , , . .
X
X
X
* Rocheater University , ,
* Union Cullege
Syracuse Univeraity ,.,..,,,,
Vassar GolteEc ....» ^ .,,. .**
X
X
X
X
X
X
X
X
X
X
X
X
X
North Carolina . , ,
University of North Carolina. -
* Trinity GolIeKe
North Dakota ....
* Stat* Agricltftural College
University ol North Dacota...*
X
X
z
X
X
X
X
Ohio
Bnchtell CoUeee .
If
Mt. Union Coflege
Ohio UniveTBity * * ,...,,,»...,,
University of Cincinnati . ^,
X
X
::
X
X
::
X
X
X
If
Cadc School of Science ................
Western lloiservB University , . ■>
X
X
X
* Ohio State Univeraity
Ohio Wesleyan Uaivereity
KeiiyoD Cofiege , , , ,
-
-
X
'■
X
X
Demson College ,.,,,........-. . , . .
Marietta College . . * . ^ . . , *
X
,.
X
X
X
X
Oberlin College, .,.,,,, ,,.,.,,.
X
X
X
X
Miami University,
X.
T
* Otterbein Univereity
Wooeter University , ,,.,... .
Okl&faoma
Univorsity of Oklahoma ....,..*.
X
-
..
Peonsylvanim ,,*..
Lebanon Valley Collie » ,
Dickinson College . ..,...,..,,.,..
.,
z
T
• Lafayettft College * *
Haverford CoUes^
X
"
■'
■■
* BuLcknetL University , , , . .
Allegheny College
X
--
X
-
X
IT
* Temple Colle£^ , »
University of PennHylvania ,, , . , . ,
X
X
-■
X
■-
X
T
* LfChigh University + ,
* Pennsylvania State College , , , , .
* Swarlnmore CoUegc
Bryn Mawr College »
X
X
X
X
X
X
X
■•
X
X
X
Western University ...... ...^.....^r....
T
Rhodp Island
State Agricultufal College .... ^ * . *
Y
Brown Univeraitv , , , . .
'
X
X
TC
Scjuth Carolina
* Cleftison College ^ . . . . + +
* Univrfsity of South CaroUnft.
South Dakota
State Agricultural College , , ,
3C
X
X
..
Dakota Wesleyan Univeraity
University of South Dakota , , . .
X
-
Yankton College *,....,...
'
* AfHrmative answers checked x. Negative answers left blank. Affinnative an-
swers to No. 9 are in almost every instance qualified.
ei2
SIXTH INTERNATIONAL OONQEZeS ON TUBERCm-OSlS,
Data on tbe Wook or -tbk CoU'Sasa of tub XJtrrmu States uv t^e CiMni
AoAmsT TuBERCULORTS^^Conc/udW.)
Btatb.
TeaineaiH)
Texas,
iMPTtrunON.
Vermont
Vifjfmift,
Wnsbin^n
Weal VirglJlia
WifitJoimiti . , . .
WyominB
Vftnderbilt University. . , , . , ,
• University of the Bouth
* University of Texas . ,
♦ Fort Worth University ............
Fort Worth Polytechnic *
Uuiveraily of V^rraont ,
Middicbury Cbllege
Randolph Macon College
Randolph MiHXjn College for Woniflti
• University of Virgirda .,,..,,...,....
* William and Mary College , . . . *
* Hampden Sidney College
Wasliington and Lee University . , . . ,
Whitwnrlh College
• Whitman Collejj^e , , .
* Htttic Univemity
♦ Heloit College
Carrol College , , ♦ . . .
Uit>on College
UniverBity of Wisconsin ,
State Univeratty
13 3
5. a 7 t
X X
'Affiniintiv* itnDweni checked x. Ne^tive answers left blank. Affinoatire
to No, 0 are In »liDo«t every tnfltance qualified.
Lof Coleglos de los Estados Unidos j la Campafia Contra la Tuberculosis.-
(NORTON.)
LfiM McaolikH su|M'riorc.^ de los Estados Unidos estiln dando auxilio efcctivi
de Vttrii>s inodoH. De ncuenlo con las contestaciones d un cuestionario envi
ndo A 200 pscucijifl de repreaentaci6n, treinta y trea estdn empeiiadas actual-
mente en la investigacidn de probleraas sociales y econ6mjco9 relacionadoS
d la ciifermedad; cincuenta, informan que mienabros de sub respectivaa
facultiidea son auxjiiares activos en la propaganda; quince dan coaferenciaa
Bobre la tubercuJosiH, durante la prolongaci6n de los cursos univemtarios y
setenta y dos prove^n instruccifiri especfQca por medio de conferencias ante
laa corporacionea &studiantiles y prestando atenci6n especial k la materia ea
los varies cursos de ciencias socialea^ biolAgicas y econ^^micas, Algunas d*
ellas dan instrucci6a indirecta por medio de la aanitaci6n ejemplar de lot
ed!Hd6a de colegio, inspecci6n de los rebafSoa lecheros^ de los colegioa, 1
inve6tigaci6n immediata de loa ca30s sospechoaos de enferraedad incipienle y
la publicaci6n de reglamentoa que prohiben ^ loa estudiantea habitar
infertadas 6 vivir con familiaa en que existe la enfcrmedad.
Con la ayuda de los eolegioa deberemoa ganar terreno sobre las escuelftfl
iwjundarias cuyos maestros son suplidos por los primeroa; enlistaremos par*
THE COLLEGES AND THE CAUPAIGN. — NOBTON. 613
la campafia centenares de miles *de j6venes de ambos sexos que salen de los
colegios i ser ciudadanos de influencia excepcional en bus comunidades. La
cosecha sembrada en los colegios puede tardar algunos aQos en madurar pero
no es menos s^ura.
Die akademischen Schulen der Veremigten Staatea tind der Fddzug gegaa
die Tuberkulose. — (Norton.)
Die hdheren Schulen in den Vereinigten Staaten gew&hren wirksame Hilfe
in verschiedenen Weisen. Nach den Antworten auf einen Fragebogen, der
an zweihundert tonangebende Schulen geschickt woiden ist, and drdund-
dreisfflg mit der Untersuchung der sozialdkonomischen Probleme in Bezug auf
dieKrankheitbeschaftigt; berichten funfzig,dassMitglieder ihrer Fakult&ten
aktive As^stenten in der Propaganda sind; bietenfunfzehnVorlesungen iiber
die Tuberkulose in den Eursen der Univerait&ts-Fortbildung, und liefem
zweiundsiebzig specifischen Unteriicht durch Vorlesungen gehalten vor den
Studentenversammlungen und indem ede die besondere Aufmerksamkeit
auf diesen Gegenstand- in den verschiedenen Kursen in den biolo^schen und
sozialokonomischen Wissenschaften lenken. Einige geben indirekten Un-
terricht durch die exemplarische Sanierung der Collegiengeb&ude, durch die
Besichtigung von der den Collegien gehdrenden, milch-gebenden Herden,
durch die unmittelbare Priifung von verd&chligen F&Uen der beginnenden
Krankheit, und durch Verdffentlichung von Ordnungsregeln, welche das
Wohnen von Studenten in infizierten H&usem und in Familien in welchen
die Krankheit existiert, verbietet.
Mit der Unterstutzimg der Akademien werden wir die Mittelschulen ge-
winnen, deren Lehrer sie liefem, und wir werden fur den Feldzug hundert-
tausende von jungen MSnnem und Frauen anwerben, die hinausgehen von
der akademischen Schule, urn Burger von ausserordentlichem Einflusse
in ihren Gemeinden zu werden. Die in der Akademie ges&te Emte wird
Jahre nehmen, urn reif zu werden, aber nichtsdestoweniger wird siesicher sein.
THE BODY OR THE BACILLUS-^WHICH SHALL
EMPHASIZED IN THE HYGIENIC EDUCA-
TION OF THE PUBLIC?
BE
By Howard S, Andkrs, A.M., M,D.,
PnfuaDr of PhyaJoil TXnfinoaLfl, Medtcc^Cblnircinl CoUojm. Philoddpliim, P».
In the prophylaxis of tuberculosis the educational principb is, after all,
the essential, basa.1, universal, and ultimate one. From first to last, from
the time when preventive efforts were initiated until their successful culmina-
tion in the annihilation of the disease shall have l:»ecn attained, Icnowledge of
the facts, means, and methods^ and their S3^tematic, broadcast promulgation
have constituted, do now and will ever constitute, the center and circumfer-
ence of the whole jiroblem; the pith and bark of vitality and groT\i.li of the
movement; the bed-rock feature of the complete sanitary and sociological
structure.
The instruction of the public in the causes and control of tuberculosis;
the intelligent awakening of an aggressive and active, yet rational and practi-
cal, sentiment and service in the prevention of this plague; and the arousing
of a spirit of adaptation and prompt willingness to organize and cooperate in
the work of attack — all are dependent ui>on the educational principle and
procedure for their substantial and successful outcome. Hence the impor-
tance of right instruction of the laity; of discrimination in the emphasis placed
upon the topics presented by talk, lecture, circular, pamplilet, or book:
recent histoiy abundantly and eminently proves this to be so.
The leading hygienic and sanitary points that sustain special relations
to the prevention of tuberculosis are not sufficiently dwelt and stressed upon
in our public schools, our academies, and our colleges. They should receive
nearly, if not quite, as much space and time as, and better balanced presen-
tation than, is now given to antialcohol instruction. But I would not mini-
mize the temperance principle: I would not teach theimportanceof temperance
less, but the prevalence and preventability of tuberculosis more; not leas the
dangers of fiery alcohol, but more those of foul air; not less the menace to
health of intoxicating drink, but more that of infecting dust and incubating
dirt, dampness, and darkness; not in the least cease to discourage the formation
of the saloon habit, but also to encourage the prevention and emdication of
the spitting habit.
614
THE BODY OB THE BACILLUS.— ANDERS.
615
It is upon a consideration of the relative values of the two fundamental
conditions of causatioa of pulmoQary tuberculosis, and their bearing upon
popular education, that this essay has been directed. There are the many
pre\'alent and persistent predisposing causes that render the body susceptible,
feeble, with tissues almost inviting infection and defeat by the ubiquitous
angle exciting cause — the gemi.
In the tremendous Vjatlle between the tender and tired body and the
tubercle bacilhis, which element needs the greater emphasis in teaching the
public the ways and means of preventing the disease? Shall we lay the major,
if not the exclusive, stress upon the menace of the microbe — its sputal habitat,
the abominations of promiscuous spitting, and the alUetidust evil, and risk
the production of morbid fears and tuberculophobia? Or shall we make
mere incidental reference to the seed and its implantation possibilities and
probabihties, but rather expound the receptivities of the soil, and show forth
and wain against the various eneiTating agencies of domestic, industrial, and
social life, which so readily induce the bacillaty insemination of that soil?
That the predisposing factors concerned in the etiology of tul)erculo^
are numerous, wide-spread, and often obscure is well known. For that very
reason those that are definitely determined need every publicity and emphasis.
Environment, with all its subtle influences, not only acts and reacts upon the
individuara physical constitution directly to produce tuberculous suscep-
tibility, but, despite certain evolutionary theories to the contrary, establishes
a debilitated ancestry and a weakened filler and force that are transmitted to
one or more children and genenitiona. This fact— or opinion if you like —
gives justifiable ground for belief in the heredity of the tuberculous predis-
position; and likewise indicates to the people the definite* place and distinct
value of the microbic factor in the production of the fUsciise, by dispelling the
popular fallacy that tuberculosis, with its bacterial content, is inherited.
It is well for the laity to know and realize that the bacillary infection of
the lungs may largely be prevented or miiumized when either the inherited
or predisposing factors are avoided or ameliorated. Such knowletlge and
reaUzation give cheer, courage, and hope in the struggle for prevention, as
well as in that for the cure or arrest of actual disease.
The discoveiy of the tubercle bacillus by Koch, in 1882, and the effect
which that had subsequently upon the prophylaxis and titatment of tuber-
culosis, is a splendid demonstration of the usual pentiulum-like swing of
mentalattitudeain relation toquestions of interest and moment. Before that
discovery the disease was looked u[x>n as a dire, almost mysterious, family
aflSiction, or one due solely to an amalgamation of heredity, debility, and ex-
posure to atmospheric inclemency. Later, with the opening of the era of
bacteriology, the contagiousness of the malady and its microblc ori^n and
816
8IXTH INTEHNATIONAL C0NGBE88 ON TUBERCUIiOSIS.
BpTBad were so strongly dwelt upoa that fear and phthifiiophobia de^'e!
almost to the point of panic in many places.
It might seeoi that, in the last fifteeti years especially, the doctrine of
communicability of tuberculosis, the dangers of dried tuberculous
and of infectious domestic and public conditions generally, had
and widely instilled into the popular mind bj^ antituberculosis
health boards, and the like, that this aspect of the question of prophyti
would need no further emphasis. And, doubtless, there is a rapidly gro*
tread in the direction of emphasizing the greater need of building up ba
health, stren^h» vigor, and endurance, which, when attained by tnost i
vidualB, practically abolishes tlie menace of bacterial invasion.
It in with this as with other important problems having two compUci
phases — the truth is usually found midway, and j udgraent dictates prepond
ant and most potential expression at times and in places according to
ditions as they exist and arise.
A critical and comprehensive study of recent expressions of opinion
be summarized as indicating^ nevertheless, the momentous and predomin
ting value of the body in the prevention of tuberculosis, the preservation
its health, and the cultivation of a balanced functional and organic vigor ai
vita! resistance and endurance. The mastery over tuberculosis is not to i
gained so much by the at present obviously fruitless and almost impaaah
attempt to eradicate the bacilli by sanitary laws, rules, and regulations, but I
fortifying, to the point of impregnability and invulnerability, the tisdiiMM
and chemicophydological forces of the body by carrying out daily the ^^||
practices of an invigorating hy^ene.
Admitting that tuberculosis b truly a genu disease, and one that is spret
directly by intliscriminate spitting, disgusting and irritating dust, dir^
dwellings and working-places, and unsanitary conditions and environmen
generally, nevertheless it is the lowered resistance of the body to infectiiM
due to these very external factors that tuberculosis is dependent on. Indeei
Aflcher, in a statistical study of tuberculosis in Prussia, points out that th
decline in the death-rate had begun before the tubercle baeillus had bea
discovered, and was greater in regions where no special efforts had been madi
to combat the disease on bacteriological lines of prevention and sanitatioa^
A curious, almost paradoxical, statement matle by Jenkins shows agaii
the vital importance of the body a;; relatetl to racial and individual resistanci
to tuberculous infection. Thus, North American Indians and other out
door races, when exposed to civilization, are unable to re^t the diseaai
(observed earlier also by Flick), On the other hand, while indoor life ma;
cause tuberculosis in the individual, it may tend to immunize the rao©
Jews and other indoor rac^ have a marked resistauce to consumptioa
Indoor races in centuries of environment favorable to tuberculoma bavi
THE BODY OR THE BACILLUS. — ^ANDEKS.
617
probably acquired special resistance . Outdoor raoea in their natural
environment probably escape tuberculosis without special resbtance, which
indoor people require in order to survive coutact with the diBcase in indoor
life. This writer thinks that race isolation, eonnnon in outdoor peoples,
may be the chief cauae of racial tuberculosia.
Of especial interest are the investigations recently made by Karl Pearson,
in England, which appear to show that the inheritance of a tuberculous
predisposition is increasing in families having but one or two children;
and that the earlier (elder) children of larger families — that is, the first or
second chDd — seem to have the pathological heritage of weak constitutions.
The obvious lesson is that large fanulles are needed to perpetuate the \igor
and resistance of the race, hut the astounding fact is that large families are
getting rarer.
It has been said over and over again that tubercle bacilli and tubercles
are not the proximate causes of tuberculosis, but that the primal cause lies
in a receptivity acquired by ancestral or personal sins against the laws of
being and health* There are many and varied etiologic factors — economical,
sociolo^calp meteorolo^cal, individual, and governmental — that enter into
our complex modern, especially municipal, civilization beeidea the one
essential microbic cause.
The significance of teaching the public the importance of the vital
resistance of the body is seen in the small mortality-rate from tul>erculosis
as compared with the probably enormously large percentage of the people
who become infected with the tubercle bacillus. This shows that the human
organism, imder even ordinary conditions and exigencies of Ii\'ing, is wcD
able to protect itself and jugulate the invading microorganisms in the
majority of instances. One may not be considered too dogmatic in saying
that tuberculosis is a disease whose symptoms are virtually never produced
by the tubercle bacillus alone.
The social and industrial causes of tuberculosis — those that make for
the physical susceptibility — are really those that most directly concern the
pubhc. If the conditions and environment of housing, working, hving,
traveling, and recreation can be rectified and improved; if every one can
have pure air in abundance for the full twenty-four hours of each day, and
have a sufficient and steady quantity of the right sort of food regularly and
serenely eaten, and if overwork, dissipation, and the most grinding and
nagging anxieties and worries can be avoided, the germ, its "social history/'
and antitubercidous sanitation may take decidedly the lesser place in the
solution of the problem of wiping the white plsigue off the face of the earth
in & generation or two. Lilian Brandt says: "The mobilization of social
forces is a phrase which merits adoption.*^
However, in considering the great prevalence and persistence of the
618
BIXTH INTERNATIONAL CONGRESS ON TUBERCtTLOStS.
tubercle ba^illtts, and the facta and conditions of Uving as they actually
exist, it does not yet appear that we can neglect the beaiing that tliis genn
has on infection and immunity, upon a sustained or even increased mor-
bidity, if decreased mortality. It is still an open question whether, if the
immunization of man is ever attaineil by hy^enic means, the tubercle
bacillus would die and disappear finally for lack of soil upon which to grow
and multiply. Is it more likely that, as one writer has urgqd, if the bacillus
be permitted to continue among ug^ as we increase our resistance it will
probably grow in virulence. Increased resbtance may save the indi\idual,
but to save the race we should destroy all tuL>erde germs^ and knowing how
they find access to the human Ixxly and how they leave it, this do^ not seem
an impossible task, except so far as its early consummation is concerned.
Nevertheless, for the reafions already stated, — tlie multiplicity and variety
and complexity of the factors entering into the enervation of the mtli\'idual,
—it yet remains that the preponderance of modem and future educational
activity and energy should be directed along the lines of bodily health,
heredity, and susceptibility, rather than along those of bacterial communicar
bility.
An editorial writer in the "Journal of the American Medical AssociatJon "
says: "The successful prevention of tuberculosis depends not on mere
quarantine measures, but on a genuine hygienic and social reform."
It is the firm opinion of the present writer that the International Congress
on Tuberculosis has a critical reajjonsibility in the attitude it assumes toward
the educational, economical, and sociolo^cal aspects of the prophyla^icis
of tuljerculosisj and that one of the most serious aspects calling for clear,
decisive, and djuamic consideration is this one of where the emphasis should
be placed In popularizing the principles of prevention — on the body or on
the bacillus. My vote is for the body.
El Cuerpo 6 el Bacilo; Cual de los dos l>eberd Conciderai^ con
Enfasis en la Educacidn Higienica del Pueblo? — (Ander:^.)
El principio etlucativo, vital y fundamental, en la profilaxis de la tuber-
culosis. Gran responsabilidad y distinci6n requerida en cuanto a Ifis
^nfaais en la instruccibn del pueblo acerca de las causos, modos y probabili-
dades de la prevencion. La instruccidn antl-tuberculosa, bien fundada, debe
recibir tanta atencion tal como recibe la instruccion anli-alooh6Uca en las
escuelas piiblicoa, en las academias, en loa colegios y otros centros de ensefi-
aD2a.
Consideraci6n de este artfculo basado eobre el valor relative de dos
cotidiciones fundamentales en cuanto d la causa: el cuerpo y el bacilo;
importancia de estos en la educaci6n ]>opular del prcsente. Referenda
I
THE BODY OR THE BACILLUS. — ANDERS.
619
liist6nca eomprendlendo las ideas remotaa de la herencia y debilidad fisica
como CAUSOS de la mfecci6n y la amenaza del microbio del presente, con-
sideraeion de varias causas predisponentes mas racionales 6 Impoiiantea
tales como eondiciones domesticas, sociaiea, Indiiatrialea y comerciales.
No hay raz6n ni es dabte tampoco, menoaprecior el microbio en relaci^a
con el sane.amiento, peligro del polvo y desaseo^ del habito de escupir, etc.,
pero probablemente se obtendran mayores ventajae do la inslniccion del
pueblo sobre la raanera de preservar Las resistencias vitalea 6 la preservacion
do ^Was por medio de los mejoramientos de vida, del trabajo y \b8 condiciooea
de transporte.
La educaci6n de los jovenes y adultos bacia el mantenimlonto y aumento
del vigor del cuerfK*, tiebe pre|x>nderar A estd debido A la multipUcidad y
complexidad de los medics deteriur^tes.
Lequel du coips bumala on du bacille doit avoir la pr^pondemnce dons
I'^ucation hygi^nique du public? — (Andkks.)
Le principe d'^acation est vital et foadamcntol dans la propbylaxie
de la tuberculoae. Une grande attention et uu grand discemement sont
n^cesaairea pour donuer danB rinstntction publiquc une juste importance
aux moyena de prevention. L'instruetion anti-tubereuleuse devrait recevoir
dans nos ^coles publiques, \yc6es et colleges le m6me temps et les mSmes
soins que rinatruction anti-alcoolique.
Etude de cet article bas^ sur la valeur relative de deux causes fonda-
mentales de la maladie, T^tat du corps et le bacille, et sur leur port^ dans
]'€ducation populaire aetuclle. Allusion eat faite aux Jiff^rents degr&
d'importance, attach^ durant difFdrentes ^poques, soit h, V\d6e de Thdrddit^
et de la d^bilit^, soit au danger provenant du gpnne; de nos jours revenant
k Tappr^ciation plus rationelle de la grande importance dea causes directes
ou prfidisposantes, de suaceptibilitfe corporelles dans la vie dotnestique,
sociale, industrielle et commerciale.
Ce n'est m raisonnable m prudent de nfigliger le facteur microbique en
relation avec la sanitation (jjoussiSres, crachats, habitudes malsaines, etc.),
mais il vaut mieux probablemcnt de souUgner TLmportance de pr6scrver
la r&istance vitale ou de la fortifier, en amSlLorant les conditions de la vice,
du travail et dea voyages.
La preponderance dans I'^ducation de la jeunesse et des addtes devrait
porter surtout sur les m^thodes de soutemr et d*augmenter la vigueur et
sant^ corporelles fi, cause de la complexity et multiplicity des facteurs d4-
teriorants.
ffiO
BIXTB INTERNATIONAL CONGRESS ON Tl7BERC0IiQSia.
Per K5rper oder der Bcuillus. Welches soil bei der hjgienlschen Erziehun
des Publikums mit Nachdruck betoat werden ? — (Andbb&J
Der vitale and fundamental Grundsatz in der Prophylaxe der Taha
kuloae. Groaae Verantwortlichkeit und Unterscbeidung notig im rich
ligen Vcrteilen des Nachdruckea in der Belehmng der Oifentljchkeit mi
Bexug auf die Ursachen, Wege und MitteJ der Verhinderuug, Anti-tubeP
kulOsG Instruktion von gut ausgeaxbeiteter Art BoUte ebensoviel Zeit uim
Sorgfalt erhalten, aJfl antl-alkoholische Belehrung in ofTentlicbcQ Schula^
AkadcmiGD und b6heren LebransteJteni
Der bibalt dieses Vortrages stiitzt sich auf die relativen Wert«
fundtunentaler Verursachungs-Bedingungen, die kdrperliche und
und wie diese gegenwartig in die offenttiche Erziehung gebracht
Keine Ursache, den tnikrobiscben Faktor in Beziehung aiif Gesundbeite^
crbaltung zu vemacblasaigen (Staubplage, Spuckangewohnheiten, etc.);
aber vielleicht ial es besser, mit grSsserem Nachdruck die Wichtigkeit der
lebenden Wideratandakraft oder ihrer StSrkung zu betonenj durch Ver-
bessenmg der Lebeiis-, Arbeits- und Reise-Verhaltni^e.
Sanitare Propbylaxe daher noch ein wertvoUer Teil der Erziebui^
be^onders durch Gesundheltfi-Amter ; aber der uberwiegeiide Teil der
Erziehung der Jugend und der ErwachaeneQ BoUte sich in der Erhaltung
und Vermehrung korperlicher Ge-sundheit und Starke bewegen» wegen der
VieUS.ltigkeit und Maonlgfaltigkeit der gefahrbringenden Faktorea.
HYGIENIC INSTRUCTION IN SCHOOLS,
By Dr. Henby Barton Jacobs,
Baltimore, M<L
It is universally granted that the great result for which we of this Congress
are all working, namely, the eventual suppression of tuberculosis, can only be
att£uned through education.
Associations, dispensaries, sanatoriums, hospitals, while doing inestima-
ble good in relieving and curing afflicted patients, exert their greatest
influence toward the final solution of the tuberculosis problem by educating
people in the nature of the disease, and in the manner of life necessary to
avoid it. These institutions extend their beneficence, for the most part,
only to the adult population of the community in which they may have
their activity, and such part of the whole adult population as has had
brought to its attention one or another of these instnmients of good, through
the necessity of using them because of some afflicted friend or relative.
The entirely well portion of the town or village may look with indifference,
and so not become the recipients of the beneficent influence imtil too late
for prophylactic instruction.
Moreover, an adult population is notoriously slower in receiving instruc-
tion than the youthful popidation, and yet, in this great educational crusade
agmst tuberculosis, we have almost entirely lost eight of those thousands
of young receptive minds who could at half the expense of time and money
become proficient in its principles, if only our energy were directed to them
rather than to their parents.
The battle against tuberculosis is not to be won in any single generation;
therefore why not concentrate upon those who are to become the next
generation? It is the children of to-day who are soon to be doing the world's
work, bearing the world's burden, and producing a succeeding generation.
Instead, therefore, of putting all our efforts forward to care for and instruct
a generation notably slow in learning, which is passing away, how much
more certain of final results if we turn our attention to the quick-witted
yoimg, the school child of the day, the generation which is coming and is
now devoting itself to learning those things which are to be useful for it
when it shall have become grown! And what subject so useful as that which
enables the individual to escape the disease pitfaUs of life I What use is
621
622
SIXTH INTERNATIONAL C0NGHES3 ON TUBERCtTLOSIS.
>wledge of even the mere elements of education if soon after leaving
Bchool the pupil shall be carried away by typhoid, cholera, consumption, or
any one of the infectious diseases which may by proper precaution be avoidedr
That the raind of the child is not sufficiently mature to grasp the real
nature of such subtle disea^s as those mentioned is not true; neither is
it true that the child's proverbial carelessness and inattention to matters
of personal hygiene are so great that he could not be made to imdeRtanJ
or appreciate their real significance. Is it hard to teach a chaJd that fire
burns and so must be avoi<lect7 Is it hard to teach that the waters of rivers
or the sea are deep and dangerous, or that he may jump from the third-
story window with impunity? Such dangers as the^ are appreciated at a
very early age; they are learned quickly and become automatic qualities
of the growing intelligence. Might it not then be as feasible to teach that
flies and mosquitos and rats and dust and filth are equally as dangprous,
if only parents and teachers would turn their attention to such instructions?
One of the arguments against childhood instruction in the nature of con-
sumption has always been that pulmonary tuberculosis was so rare in child-
hood that there was little cause for the child to think about it. But this is
entirely fallacious reasoning. Never has there been any question about tte
prevalence of other forms of tuberculosis in childhood which, while perhaps
less serious in its results than pulmonary tuberculosis, yet were sufficiently
fatal to carry off every year a certain percentage of the children of the com-
munity. And the later and more careful statistics upon city school children
reveal that the proportion of those already infected with the pulmonar}'
foim of tuberculosis is larger than heretofore supposed,
The recent studies of Barbior and Boudon in Paris are extremely inter-
esting, flfl they confirm previous studies in regard to the incidence of tuber-
culosis in early life, and particularly in regard to the high percentage of
mortality in these years. These authors found that 31 per cent, of all
children from under one year to fifteen years of age in hospitals or crSches
of Paris were ill of tuberculosis, and that 43 per cent, of all deaths during these
years was due to the same disease, thus indicating that tliere was a larger
relative proportion of mortality from tuberculosis than morbidity from
that disease* The statistics covered the period of eighteen months, from
January^ 1905, to July, 1907, and during this time there were 525 boys,
58S girls, and 151 nurslingSf or a total of 1264 children, under fifteen years
of age, under treatment in the hospitals of Paris, of whom 31 out of every
hundred were ill of tuberculosis ; and of those dying, 43 out of every hundred
died of that disease. These figures agree with those from other countries.
But the argument is made that even were children instructed in all the
methods of prevention of infectious diseases, yet are these matters outside
their own control ; that, after all, it is upou parents and neighbors and othera
HYGIENIC mSTRUCnON m SCHOOLS.— ^JACOBS,
623
that the responsibility of the infection rests. This undoubtedly may be
true^ but tt does not cover the point that I would make, namely, that while
the education of athool children may do little for them in the earlier years of
school life^ say, to the age of ten, it wil! do a great amount of good in the later
years, and in all the remainder of their life, and wil! enable them to apply
the principles denied them by their parents when they shall become parents
in their turn.
Just as a twig is bent, so is the tree inclined. If, for generation after
generation of school children, no effort is made to teaeh the elementary, but
fundamental principles of hygiene and the prevention of tuberculosia, then
these principles ivill be less well leanied and with greater difficulty in adult
life, when habits and character are formed. But if the principles are incid-
cat^d with their writing, their reading, and their arithmetic, the bent of
their minds will be so fa-sloioned that ever after in life they will incline to the
methods likely to insure health and freedom from infectious disease.
There can l^e no doubt that much effort is already being expended in our
schools in the way of teaching hygiene, but I cannot feel that it is teaching
of a convincing sort, or that the principles inculcated have any lasting effect
upon the manner of life of the pupil either while at school or in the years
following. What, then, la wrong in the present methotls, and how can they
be improved or augmented so that results may be obtained which will in-
fluence pupils to a higher and more hygienic plane of Ufe?
At present almost the sole instruction received by pupils in public
schools upon subjects connected with health is conJined to a short chapter
in the book upon physiology, upon the evils of alcohol, and in some instances
a few paragraplia upon the nature of tul>erculoais — instruction well in its way,
but so inconspicuous that no lasting impression is made. Many schools have
adopted playgrounds, school-gardens, and such other means as will keep the
pupils out of doors, and to this extent they are surely improving the health
of the scholars, but I doubt that any particular stress is laitl by the teacher
upon the reason why these grounds and gardens are established; if I am
mistaken, I am glad to acknowledge it, and to congratulate the teacher
who has so grasped the essential idea of these institutions that he or she
makes clear their meaning to those under his care,
I feel convinced that our present corps of teachers, the world over, have
not yet themselves bad this subject brought to their attention in such a man-
ner that they realize the great work which may be possible for them, and
eo 1 am glad to see that the Board of Education of London is considering
methods by which teachers may be offened instruction in the broad principles
of hygiene. Certainly no author, so far as I have seen, of any school text-
book has begun to realize what needs to \ye written. I make these comments
in no censorious spirit, but rather to bring the matter to the attention of
HlXm INTKRNATIONAL
Aiithoni. 1 yfouUl lluit my tUM^gut^ooB oiigfat be
crit.if'ftl.
j Ttu! i^nyii,i iWiVmiUy IIrm in finding metbodt wfaidi
L ^fl wilt rmvk» an iioprcHMion upon their minds. No
PW>riiprrthr^iiMivn ha Ui nrnbudy all necessary (onoB of
inuHt U; l(!ft Uy Uh? ingenuity tind the devices of tcadien. Ik tte temAy
ttl t)m mt\nVH lifn InacUIn^ by r>.xiiinp]e rather than preeepC, by
pi4rbtiri*H, nioilf^h iin<l fjtlicr ft»rnis of exhibitftf is adYi^iHc; «
tfVi'.ry HvUfHti-dny in mm\(* form of hyp:iene adapted to the M^ and
of iUf \ni[n\ nUtinUl \m tm much a puri of the school cuiriciilBm
hi Hi|K<niiiK or roiidhi^. \u imprirtancc cannot be overestiiiuiled,
rnn lifr orfylunnlion rnonn without hculth? ar, as RahHuw puto ^
hc/dlfi life tH no lift^/' To the ^rcat group of preventable diaeaae
ti't riiitcovor tbfl CitUNC of illru^KH and death in the first five rln^lM- ci fie^
timt JM, in ihn y«5urn of frr(>fLt(^t UBefulness and pmdiifliwnfiw, md tke
itvoidiiTirn of ilinw? fliHCOM^ lim almost completely in the power of every
Individuiil. proviflrd h(^ jh instructed in their nature and the mens of
tlu'ir prcvi^iilJon.
frj viHtiiitK th» iufx^rcukijun exhibits, which are now such potent ^ttftiFff
in IIm) ivjuntition of ihv. puhYw, in tbn nuture of that diseaae, I have been atruefc
witjt thn ^r(»u(. itiUirettt iind uniloratanding taken by children* It ia not aS
atJ Mi«:otr)mon to find Dttlo boyn mid girls of ten to fourteen yeai^ of age
px[»hiijunK to thi^ir purontH the mf^aning of the various models and devieea,
atid ovon wlion ili'.^v, tlio [mrvjiU, could read as well as the children the
r!XpfjiJintir*MH. It wH*ni(Hl to l* that the child's more acdve and peteeptrre
liiitjd icnuiiMid LJic nxplunjUioii of the oxhibit more quickly than that of the
purcnt, J Umi^h wluillu^r Jus roaliaation of its full signiticance was so oocnplede
\h mtotfirT 4|it(;riticjii. Hut tbo illUMlration shows that children are not a>*erae
to thoHo niut,tJ!T'H; on the contrary, they show not only an interest in them,
but art? tjuick In coinprehond, to a limiteil extent at least, their important
ni^nificruia^
The Dxperlenoe of the Now York Committee on the Prevention of Tu-
IjorruhmiH in difitrilniting uttrantive, highly colored pictures of Venice,
. bciLriug irwlruction iilxjut consumption, among the Itdian population^ id
extremely inU^rftnting. ThciM) pictures have been delivered, house by house,
by a young woman who Hpeaka Engliah and Italian, and who^ having recov-
ered from consumption, ifj enthusiastic in aiding others to avoid it. The
pictures have been well received, and apparently are going to become a
potent factor of t'cjucation in the homes. The words of instruction were
printed in ICiigliHh mther than in Italian, inasmuch jis it was realized that
few of the elder j^eoptc could read either language, and all of the children
HTQUWIC INBTRUcnON IK BCHO0L6. — JACOBSi
625
could read English, and they would interpret and instruct the elder membeiB
of the family.
May not our school authorities take hints from this, not only in the form
in which their instruction in hygiene and the nature of infectious diseaaes
is presented, but also in the results that may be hoped for from such instruc-
tion^ namely, that it will not stop tvith the pupil Mmself, but, if made so clear
and so much a part of his automatic life as is reading and writing, then he
will carry the instruction home into the use of the family, as he does his
spelling and arithmetic?
The gro%i,h of the knowleiige of the nature of infectious diseases is
remarkable, considering the few years since Pasteur and Koch gave us the
key to this knowledge, but there are many of us who are disappointed at the
slowness with which the morbidity and mortality, from consumption espe-
cially, is being lessened. I find the dif^culty arising in the fact that there is
always coming on a new generation of individuals, at an age most susceptible
to the disease, who are ignorant of the facts in regard to tuberculosis^ and
whase lives are sacrificed before they come to an understanding of those
things which might liave been avoided — alas! too late instruction to save
them from an undeserved fate.
With the ad\'ent of the playground, the garden, the open-air school,
the "preventorium" of William Ewart; cities with wider streets and more
parks, and a complete system of instruction in the schools of hygiene in its
broadest sense, embracing, as it will, an elementary and practical knowledge
of physiological function, of the dangers of poisons, of which alcohol may be
considered onCj and in the nature of the infectious diseases, the parts played
by insects, microbes, dust^ filth, directly and indirectly through foods,
water, and milkj and, further, the influence of fresh air, sunshine, and
cleanliness, then may we expect that the preventable diseases will be pre-
vented. When these things can be considered as necessarily a part of every
school child's education, may we not hope for a generation of people strong
in knowledge of infection and in physique to resist it?
La lastniccion Hig^emca en las EscueUs, — (Jacobs.)
Los HospitaleSj Sanatorios, Dispensarios, Campamentoe, et^., pueden
tener gran influencia restringir y prevenir la diseminacidn de la tuberculoma
por la educacidn sobre las precaucionea necesarias y loa habitos propios de
vida. Estas instituciones por lo tanto hacen las veces de una e^cuela en
la cual se enseilan los principios de higiene, Por lo general esta instrucci6Q
ee hace a las personas que estan ya infectadas, pero esto no quita que la
influencia educativa se extienda 4 loa amigos y a las visitas y de este modo
llegue al alcance de las personas sana$. EUoa pertenecen a una generacion
626
SIXTH INTERNATIONAL CONGRESS ON TVBERCULOSXS.
que esta ya pasantio y per cata razon estas instituciones son tnenos efectiv«
en la aoluci6n del problema final de la tuterciiloais serfa mas efectivo instniip
a los jfivenea Iom cuales constituyea la generacoln venidera de labradoros j
Los escuelas pdblica&j licademiaa y colegios, son capaces de moldar ka
inteligeacias nacientes del pals; lo8 discipulos de hoy seran loa hombres deJ
manaaa, y si i etloa se lea pudlem instruir en los principios prdcticos r
efectivoa de la higiene, tal como Be hace en los sanatorios, laa escuelas
llegarian a reali;5ar la laudable tarea de formar hombres listos contra laa
emergencies de la vitla y experios en el raodo de evitar y prevenir [as en-
ferniedadcs. Mlentras las e^uelaa no hagan provision para esta clase de
Liistrucct6ti, no podr4 esperarse el ^xlto en la lucha contra la tubercoJosg
y otras enfermedades infecciosas. La instnicci^n de los ninos 6 chaeA
deberd cousistir, en gran parte, en la fornmci6n de hAbitos autom^tieae de
Ixi^ene, amor A la limpieaa, la vida al aire Ubre, etc Nuevos Iibros de texto
dcben escribirse y confiar la in5trucci6n en manos de maestros y autoridades
versados en las nuevas ideas,
Instructions Hygi^nique dans les Ecoles, — (Jacobs.)
Les hopitauXf sanatoria^ dispensaires, camps, peuvent avoir une grandi
influence pour arr^ter le progr&s de cette maladie par moyens de I'^ducatlon
qu'ils donnent sur les precautions niScessairea et su un genre de vie con-
venable. Ces institutions par consequent deviennent des 6ooles dans
lesquelles on enseigne Thygi^ne aux personnes qui s' y trouvent, Cos per-
soiines, pour la plupart, sont d6yX atteintes du mal, bien que cette influence
Educative g' dtende auasli leursamisqui sont encoreenbonne sant^. Maisoes
deux classes, lee maladea et leui-s amis, appartiennent a la population ndulte,
k ceux dont les conceptions et les habitudes sont d^ih formes, lis appartien-
nent h. une generation qui passe plut6t qu' k une generation qui vient, et
ces Institutions ont moina d'effet sur la solution finale du problSme que si
leur influence pouvait etre dirigees sur les gargons et les filles d'aujoupd*-
hui qui constituent la generation prochaine des travailleurs et des parents
Les ecoles publiquos, les penaionnats et les coUdges eont en train de
former rintelligencc grandissante du pays, et leurs ei^vea d*aujourd'hui
seront les hommes et lea femmes de demain, et si on pouvait leur Inculque
d*une maoifere pratique, efifective et convaincante la m6me sorte d'instnjction
en hygiene que I'on donne aux malades dans les Sanatoria, ces institutions
enverraient dans le monde une jeuneaae prtSparee pour leg evSnements de ta
vie, et conoaissant les moyens d/eviter lea maladies qui peuvent ^tre evit^cs
Jusqu^ &. ce que les ecoles aientdonnd place A un cnseignement dece genre, 08
ne aaurait esperer enrayer avec succds la marche de la tuberculose et
4
i
HYGIENIC INSTRTTCriON IN SCHOOLS. — JACOBS.
627
Butres maladies contagieusea L'en^ignemcnt pour les classes d'^j^ves
plus jeunes devrait conaisteF en gnmde partie h leur apprendre h contracter
dea habitudes automatiquea d*hygi^ne, Tamour de la propret6, de I'orde et
de la vie au grand air* II faut <5crire de nouveaux livres et trouver dea
instituteurs et dea autorit^s Bcolaires qui soletit en faveur de ces id6ea aou-
velles.
Hygieoischer Unterricht in Scbulen. — (Jacobs.)
Hoapitaler, Sanatorien, Ambulatorien, Landaufenthalte mogen grossen
Einduss haben^ die Verbreitung dieser Krankheit hintanzuhalten, aber der
EinBuss muss in der Erziehung zu den notigen Vorlieugungs-Massregelu
und der richtig^n Art zu leben, gefunden werden. Diese Institutionen
werden daher Schulen, in welchen ihren Besuchern Hyg^ienc Iwigebracht
wird, sein miissen. Dieae aind zum grSssten Teile bereits infiaiert« Leute,
jedoch erstreckt sich dicser erzieherische Einfluss auf ihre Freunde, die
Doch gesund sind. Aber beide Klassen, die Bewohner und ihre Freunde,
gehoren zu der erwachsenen Bevolkerung, deren Ideen und Gewohnheiten
bereits eine feste Form angenommen haben. Sie gehdren eher zn einer
gehenden als zu einer kommenden Generation, und deawegen haben diase
Institutionen weniger Wtrkung auf die schliessliche Losung de^* Problems,
als wenn ihr Einflusa gerichtet wurde auf die Knaben und Madchen von
heute, welche^ die kommende Generation von Arbeitem und Eltem bilden.
In den oflfentlichen Schulen, Akademicn und Collegien wird die wachaende
Intelligenz des Landes herangehildet; ihre Schuler von heute werden die
Manner und Frauen von morgen sein, und wenn in ihnen dieselbe Art
hygienischen Unterrichtes in einer praktischen^ wirkungsvollen und uber^
zeugenden Art, wie er den Paticnten in Sanatorien gegeben, ju Tcil
wird, dann wurden sie eine IjereJts fiir die dringenden Notwendigkeiten des
Lebens und niit Verstandnias wie die vermeidbaren Krankheiten vermieden
werden konnen, vorberoitete Jugend ia die Welt schicken. So lange njubt
die Schulen fiir dieae Art des Unterrichta Soj^ tragen, kaun man nicht
hoffen, erfolgreich niit Tuberkulose und anderen Infektionskrankheiten fertig
werden zu k5nnen. Der Unterrieht fiir die jiingcren Klaaaen sollte datun
gerichtet sein, daas die hy^enischen Ideen in Fleiscb und Blut iibergebcn,
das3 eine Vorliebc fiir Rcinlichkeit und Nettigkeit hervorgcrufcn werde,
ebemio wie diis Leben im Freien. Es miiaaen neuo Bficber geschrieben
werden, und Lehrer und Schulautoritaten diesen neuen Ideen nahegebracht
werden.
A PROPOSITION TO INTRODUCE A PUBLIC HEALTH
WEEK INTO THE PUBLIC SCHOOLS.
By Ch* Ward ell Stiles^ Ph.D.,
Uikited Stiitea PutiUa Hulth mnd MvuM-HuptUl fiM^rt«»» WnmtnugUm.
Certain of our States have a law to the effect that physiology must be
taught in tbe public schools. In mquinng into tlie practical resuJts d
thia law, I find the impression rather wide^spreod in some localitied thst
this "physiolog)'" consists largely of a study of the effects of alcohol aad
of tobacco. I also find tbe cooviction exiting among certain teachers that
it is often difficult to obtaki for u^ in schools satisfactory and reliable texir
books upon the subjects involved.
During ray investigations, more particularly in the aouthem States, tbe
important point has been seriously pressed upon cne by practical IllustraUoas
that there is great need of elementary instruction in the fundamental
principlea of hygiene, and therefore in the prevention of disease. For the
southern States, three great principles, eapeciaflyi come into oonsideration,
naaiety;
(''irst: Do not epU on the floor, for this habit spreads tuberculoeid and
diphtheria.
Second: Do not poUule the soil, for this habit spreads typhoid fever,
and ground-itch, with its resulting hookworm disease.
Third: Protect against mosquiioa, for moaquitoa spread malaria, yellow
fevefj dengue, and elephant foot.
Recognizing the important fact that it is easier to teach children than
adults^ I have in several addresses made the suggestion that one week each
winter be agreed upon as Public Health Week in the public schoola, and
that the physiology class be utilized during that week in order to teach to
the southern school children these three great principles just mentioned.
This proposition has met with approval on every occasion that I have brought
it forward, and I have received so much encouragement from both teachers
and physicians that I am trying to put the plan into active operation. The
superintendents of education in two States have expressed hearty aj^
proval of the plan, and one of these men is especially enthusiastic on the
subject. Arrangements have not yet reached the point where I feel justi-
fied in ^ving names, but it is hoped before long the gentlemen in question
A "public health week" in the public schools. — STILES. 629
will be in poBition to make the aonouncement that their two States have
adopted the plaa.
In discussing the subject with southern educators, the difficulty of
providing a proper text-book was immediately brought forward, and to
meet this difficulty I have suggested the following plan, which is now under
consideration as to its feasibility and legality.
As the United States Department of Agriculture is now authorized to
issue that excellent series of popular circulars known as " Farmers Bulletins/*
telling the farmer how to save the lives of his swine, and how otherwise to
improve his livestock and his crops, it woxUd appear reasonable to authori^
the United States Public Health and Marine-Hospital Service to issue a
similar series of circulars on "Public Health Facts for Public School Chil-
dren," telling how to save the lives of children. Such a series of circulars,
each written by a specialist on the particular subject in question (as tuber-
culosis, typhoid, malaria, hookworm diaeaaCy smallpox, etc.), could be used
in lieu of a text-book, and would have the great advantage that the newest
facts could be brought promptly to the attention of the public in the frequent
editions which would be requured. These circulars should, in my opinion, be
written in the form of ''quia compends," giving the questions and answers
on all the points involved which everybody should know.
If such a series of popular circulars can be issued, I have no doubt but
that the entire plan will be practicable, and can easily be carried out in the
southern States. That the State boards will co6perate need hardly be
questioned. For instance, a very prominent official in a certain southern
State heard that I had discuaaetl the subject with two States^ and the next
time I met him he took me to task for not having proposed it to his office
also.
If the plan in question materializea^ it is further proposed that I shall
give popular illustrated lectures on hookworm disease before any ooUegeSp
normal schools, and teachers' conventions as may be designated by the
secretary of the State boards of health and the State superintendents of
education, and thus give in wholesale to the public school-teachers the
material which they will retail to their classes,
A further point under discussion as to its feasibility is to try to require
of the pupils to bring a certificate from home to the eiTect that, before coming
to school, they have recited to their parents the lessons contained in the
circulara. By this plan we hope to reach the parents.
It will be noticed that the plan suggested presenta the following advan-
tages:
1. The issuance of the circulars by the Federal Government would insure
reliable, conservative information.
2, The introduction of a Public Health Week into the public schools
630 SIXTH X^TTERNATIOXAL COSOaXBB ON tXTBSBCVUOBn,
would insure our reachio^ nearly all fotmtles in the States which adopt Uv
ptiui.
3. An extensive, veU-OT^ganLsed body — the public schools — ca& \x oti-
lixed for Lbe propttgandn.
4* It tcarhes the children, namely, people at the most tearhable age*
5. It wuuld insure our reaching a greater proportion of the populatioo
thmi wp coultJ reach by any other plan,
6. Tlie (Expense is redu<^ to a minimum , because of printing the ax-
culars in large editions and because nf the postal franking srstem of tbe
Federal Government.
7. Tt requirea no rearrangement of the present school curriculum, bat
simply utilizes hours (already provitled (or by law in certain States) deroted
to a line of study under which this work can legitimately be cla£Bi5ed.
S, The good accomplialied accrue to tbe entire public, and the expense
ia distributed over the entire public beneBted.
It is well to understand that it will take a little time to put this plan into
active motion. But if certain Icgisbtion is passed which has alr^^y passed
the Heiiftte and haa been reported on favorably by committee to the House
of RcpresBntativee, there is no reason apparent why the work should not
he started this coming winter*
Una Semana de Salud Puhlica ea las Escuelas PubUcas.— <Sttles. )
, A conHGCuencia de una investigaci6n en el Sur, Doctor Stiles propone
la intnxlucion de una seraana de Salud Publica en las escuelas publicas,
a fin dc eTisetmrle a lo3 ninos tres grandes prineipios de Higiene, a saber.
IVimero. — No cscupir en el suelo, por que este habito propaga la tuber-
culosis y la difteria.
fctegundo, — No se ensurie el suelo, por que este habito propaga la tifoidca
y las enfermedfttJe^ de origen paraaitario en los intestinos (imcinaria).
Tercero.— Protdgerse contra log mosquitos, por que estos insectoe
propHgrin la malaria^ fiebre amarilla, dengue, y elefantiasis.
ICsta propoaicidn ha side acogtda muy favorablemente, y si ciertos
puntos de ley llegan A arreglaree, el plan serJt puesto en ejepuci6n el ano
proximo. El plan envuelve la distribuci6n de circulares populares por
medio del Serv^cio del Hospital de la ftlarina y Salud I^ublica de los Kfitudus
Unitioa, que los superintendentea de instruccion de los Estados pueden
adoptarlai* cmno libros de texto en laa escuelas y ser^ usadoa en las clasee
de fieiologfa durante ta Semaaa de Salud Publica.
4
A "PUBUC HEALTH WEEK" IN THE PUBUC SCHOOLS. — BTILES. 631
Une Semaine de Sant^ Publique dans les Ecoles publiques. — (Stiles.)
Comme r^sultat de ses recherches dans le sud, le docteur Stiles a propose
rintroduction d'une "Semaine de Sant^" dans les Ecoles publiques, pour
enseigner les trois grands principes hy^^niques suivants aux enfants:
1. Ne crachez pas par terre, car oette habitude r^pand la tuberculoee
et la dipht^rie.
2. Ne souillez pas le sol, ear cette habitude r^pand la fi^vre typhoide
et le ground-itch (maladie du ver unciforme duodenal).
3. Prot^gez vous contre les moustiques, car les moustlques impendent
la malaria, la iidvre jaime, la dengue, et T^Mphantiasb.
La proposition a ^t6 bien accueillie, et u certuns points 16gaux peuvent
€tre arrangds, le projet sera ex^ut4 cette ann^ m. Ge projet comprend
la distribution de circulaires populaires, par le Service de la Sant6
Publique et de rHdpital-Maritime des Etats-Ums, que les Surinten-
dants d'Etat de rinstruction pourront adopter come livres de classe pour
Itre utilise dans les classes de physiologie pendant les "Semaines de Sant6
Publique."
EDUCATIONAL VALUE AND SOCIAL SIGNIFICANCE
OF THE TRAINED NURSE IN THE TU-
BERCULOSIS CAMPAIGN.
By Lilian D. Wai^d,
New York.
The systematic utilization of the tinned nurse in tbe f^usade against
tuberciilosis in the homes of the consumptives is recent.
The trained nurses of America represent a large number of women, and
a sraaller number of men, vho have been carefully educated in the hospitals
of the countn' for the purpose of carrying out the treatment that physicians
ftnd other scientific authorities have found to be of prophylactic or curative
value-
At first these were almost exclusively engaged for the benefit of the
patients in the hospitals and for those individuals vho were rich enough to
secure for themselves the advantages of the material and scientific resourtes
of the world. But along with the larger social and humanitarian conception
of the latter half of the past century this product of training and education —
the hospital nurse — has been called into the field of the general campaign, and
her services are dematided now not only for the individuaJ of wealth, but for
the protection of the public health and for the welfare of the community
and of those individuals whose circumstances would not permit their
Becuring her.
In other meetings of this Congress the details of work of the tuberculosis
nurse will be reported in full. It will be shown that her skill has been
available for those who are ill and bedridden, but primarily for the teaching
of the people who, because of excessive labor^ undernourishment^ and
unfavorable conditions of both home and shop, are most susceptible to the
disease — in a word, for the poor. Her instruction has been not only to
the individuals affected, but to whole families, to whom she has carried
with plain, direct method the results of laboratory research and study.
She has taken education to simple people unaccustomed to student habits
and not readers of scientific treatises — to people who w*ould not have ac-
corded a hearing to an instructor l^s personal and sympathetic than
herself.
The first organisations of visiting or district nursing asBociations in
632
VALUE OF THE NUBflE IN THE CAMPAIGN.— W^ALD-
633
America were the New York City Mission^ 1877; the Ethical Culture Society
(N. Y.), 1879; the Boston and Philadelphia District Nursing Associations,
1886; and since then numerous other aaaocialions have been established in
dty and country districts. Their staffs — practically all women — have
cared for patienta Buffering from tuberculosis who came to them in the or-
dinary routine of their daily service. When the Henry Street (Nur9es)
Settlement was organized in 1893, the first definite plan (as far as the speaker
can learn) for the instruction of tul^rculosis patients by nurses was under-
taken by its founders^ who, realizing the danger to the community from
ignorance, began a systematic visitation to the homes of the patients whom
they encountered, and also secured the names and addresses of those who
had applied for admission to the tuberculosis hospitals, as well as of those
who were known to be attending the general clinics. These were visited and
revisited in their homes. Sputum cups and disinfectants were left, with
careful instructions for the patient and family as to the danger of the
careless disposal of sputum, and advice regarding diet, fresh air, etc., was
given.
A little later the Department of Health of New York city, then in the
initial stage of its honorable and intelligent campaign against the disease,
provided the Settlement with sputum cups and literature of instruction in
various language-s, to be left at the homes. However, it seemed to the nurses
of the Settlement that there was Uttle general realization of the actual
conditions in the tenement-house population, and they lost no opix)rtunity
to report to proper authorities, and to public-spirited people whose knowl-
edge concerning these facta was important, the conditions seen in the routine
of their daily experiences. In the first year of the organization of the New
York School of Pliilantliropy one of the nurses, in a lecture to the students,
alluded to the difhculty of getting hospital beds for tuberculosis cases.
A public ofhcial in the audience^a recognized authority on institutional
provision for the poor— was skeptical as to this, and confidently promised
to get hospital accommodations for any and all such patients as the nurses
could find, little realizing the inadequacy of the hospital and sanatorium
provisions of the city, and his inability to '*make gpod/'
In 1899 systematic work in the homes under medical and hospital
direction was initiated in Baltimore by Dr. William Osier, who appointed a
third-year medical student (a woman) to follow up and visit the consump-
tives who came to the Johns Hopkins Hospital Dispensary* She distributed
printed circulars of information and taught rules for disposing of the sputum,
but from lack of time revisited only ocCEisionally* The msulta and insight
gained were impressive enough, even from this small venture^ to lead to
the appointment of a second medical student the next year.
634
BIXTH INTERNATIONAL COKQRESa ON TtTBERCTTtOftlS.
In 1901 ft nurse in Baltimore, in an admirable article published in **Tbe
American Journal of Nursing," urged the appointment of nurses who could
give ftll their time to the work. This was one of the first definite calls to
nurses to devote themselves exclusively to tuberculosis cases, because of
the generfll social significance of combating the disease, and two years later
a nurse was platred in the field in Baltimore,
In 11)02-03 the Charity OrgAnization Society of New York provided
nurses for carrying out some of the measures of its newly appointed Tubef-
culosis Committee. That same year, in March, the New York City Dep*rt»
ment of Health organised a staff of nurses to visit in the homes all the cases
of tuberculosis reported to them» In 1903, 2950 inspections vrere inotieT
and this number increased until, in 1907, 44*025 inspections were made.
This was done in cooperation with other associations who were using the
services of the nurses, and later some system was established, anc^ ^aduallr
perfected, whereby the patients were saved from the possibility of visitation
for instruction and treatment fmm all the agencies of the city — an error of
overlapping that is not unnatural in the first enthusiasm of a work, and >f i
in this case serious, not only because of waste of time and money, but be-
cause of obvious confusion among the people.
The foregoing were the first organizations, private and municipalf that
utilized trained nurses in the campaign. Since then, of the forty-four St^ites
of this country, thirty-three — Alabama^ California, Colorado^ Coanecticut.
Delaware, District of Columbia, Georgia, Illinois, Indiana, Iowa, Iventucky^
Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska,
New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon,
Pennsylvania, Rliode Island, South Carolina, Tennessee, Vermont, \lrgjnia,
Wtwhington State, West Virginia, and Wisconsin— have seen the promise
of usefulness in tliis plan^ and have placed graduate nurses at work; but
in these tliirty-three States only fifty-nine cities are aa yet represented.
The whole number of nurses' associations working solely in the tuberctiloas
campaign is now 70, with a total staff of 128, while there are 276 general
visiting nurses' aasociations, with 6S5 women on their staffs^ who take
tuberculosijs cases in their general work, making, in all, 813 trained nuraeo
known to be enlisted.
That in these thirty-three States only fifty-nine cities are as yet repre-
sented simply indicates that we are only in the beginning of an assault
against tuberculasis, vast beyond our present imagination, the ultimate
development of which is clearly indicated by the establishment of municijial
staffs of nurses, such as under the Department of Health in New York City
(created by Dr. Herman Biggs and Dr* Billings) and by the comprehensive
plan of Pennsylvania, where, under the State Commissioner of Health
.
4
4
VALUE OF THE NURSE IN THE CAUPAIQN. WALD.
635
(Dn Dixon), nurses are already at work in county dispensaries and State
sanatoriums as a part of the prophylactic network which ia designed to
cover the entire State, An exteoiyve field of responsible pubUc duty is
thu3 opened to members of the nursing profession, since in the near future
every city may have its official force and every State its anny of nuraea
engaged in preventive work under the direction of State boards of health*
When we consider in addition to this the probable development of special
care and special teaching of the children in public schools, now in an experi-
mental stage, it will be perc^ivctl that the possibilities are unlimited.
Some difficulty has been experienced in securing sufficient numbers of
educated women, who, apart from their technical training in the hospitalsj
have quick perceptions and social resourcefulness — in other words, who
possess a special aptitude for this service. The rapid extension of the
tuberculosis campaign has doubtless made unexpected demands on the
nurses, and also their full usefulness has perhaps not yet been universally
understood by them. But a demonstration of their value as teachers and
instructors in the hygiene and prophylaxis of tuberculosis has, beyond a
doubt, b^n made. Such demonstration has proved the necessity of selecting
these nurses from a cultured, highly intelligent, and technically prepared
class of workers, refuting, in the minds of some who were in doubt, the claim
that "a httle knowledge" can succ^sfuUy fight in the forefront of this
battle. Elementary instruction to the patient in the management of sputum
and sleeping out of doors is very easy, and might be undertaken by even the
amateur teacher. If nothing niore were necessary, one naight hope for the
speedy elimination of the disease. But the personality of the nurse should
be such as to enable her to establish a relationship that will lead to accepting
directions, to give advice, and to have intelligent judgment upon the multiple
factors that enter into the circumgtances of the patients and their families
and the community. Her educational propaganda is not limited to what
she is able to give to simple minds, but she acts as an interpreter, not only
of the individual physician or association, municipal or private, that she
represents, but also brings into comprehension the lecture and the stere-
opticon so largely used in the campaign. Where the nurse has been utilii^
for "follow-up" work of hospital and dispensary patients, not only must she
be capable of assisting the patient and family to the best method of living
within their control, but she must direct the feeding and Icnow how to prepare
the food, and must have authority to bring to the people the various re-
sources that the good-will in the community has created for them. The
greatest tax upon her ingenuity and intelligence is to secure, or to assist in
securing, for the patients occupations suitable to their condition.
In the settlement of which the speaker is a member, a system of district
eaCTB INTERNATIONAL CONGRESS ON TtTBERCULOSlS.
nursing is mamtained which covers the boroughs of Maahattan and the
Bronx, and includes among its patients practically all the aatiooalitias of
the earth. Much care is given to '* following-up" the patients, sending
them to convalescent homes, etc.; and wherever possible suitable employ-
ment has been obtained for those no longer able to cany on the work in
which, while in health, they had been engaged. We have succeeded in
placing men who have been under treatment for tuberculoata, as gnards
upon the elevated railroad stations, as "ticket-choppers," car conductors,
drivers of light delivery wagons, peddlers of small wares, keepers of news-
paper stands, employees in the post-office (civil service), etc., and women bb
haiT shampooers and manicurists (going to customers in their homes),
attendants for children in parks and playgrounds, etc* It must be assumed
that patients who have been discharged from sanatoriums or who are no
longer under active treatment, are educated and can be trusted not only
to care for themselves, but to protect the community from the careless
disposal of their sputum. Any outdoor work has been eagerly seized upon,
but it has not seemed to us that suitable employment is limited to such
positions if the conditions of work within are good — work-rooms that are
well ventilated and not congested might be safe. On the other hand, some
of the outdoor work that would seem so eminently suited to the discharged
patient, such as on farms and in nurseries, has not seemed dearable because
of the excessive hours, and also, in the ordinary farmers' families, because
of the certainty of improper food* For the educated patient forestry,
horticultural, and similar positions have been recommended, and have
proved eminently desirable, but the general confidence in work on the farmr
chicken-raisingj etc, would seem not to be justified, unless under unusual
circumstances.
Agricultural colonies for the discharged patients, under superviaon and
direction, would be ideal, and if the families of the discharged were included
among the beneficiaries of this system, the permanency of the good results
would be so great that a community would^ it seems to me, be justified in
establishing such^ even though the colonies were not wholly self-supporting.
The nursing of tuberculosis patients by " cured cases " has been discussed,
and in one institution at least (Pliipps) seems to have met with assurance of
good results. It seems reasonable that intelligent men or women who would
ibe mentally fit to take the responaibihty and training could very well, after
[being cured of incipient tuljerculosis, be specially prepared to work as nurses
outr-of'door sanatoriunis, day-camps, Wald-Schule, etc.j their own exper-
inoe making them qualified missionaries, and also opening up a new field
them to earn their own living. But nursing by them should be allowed
in open-air places only, and when the policy of such sanatoriuma hm been
VALUE OF THE NURSE IN THE CAUFAJON. — ^WALD. 637
fully developed, it will doubtless be possible to furnish sufficient employment
to the discharged patients who have been found to have the requisite ability,
and who cannot return to the city and their former environment. The send-
ing of "cured cases" into general tuberculosis work as visiting nurses, or
for indoor hospital work, should not be encouraged. Such work is too la-
borious to be considered suitable for discharged patients. Those who have
been engaged in it can testify to this. Moreover, a general training and
experience are needed in this specialty, and the possession of these abilities
where time and education have not been given to secure them is not likely.
Education through lectures, stereopticons, leaflets, and general pubUcity
has been well worked up, and in these measures the nurses have played an
independent part, giving simple talks at mothers' meetings, working girls'
clubs, etc., and serving on the general tuberculous committees in their com-
munities— ^in some places, notably Chicago and Cleveland, the nurses'
associations taking the initiative in organizing such coounittees for active
work. But the nurse has been more generally accepted as the conveyer of
education to the individual, the interpreter of the movement to the people,
the guardian of the patients, and, indirectly, through her supervision of
them, the policeman for the community.
The educational value of the technically trained and socially aroused
nurse is of great importance, but her best social value lies not primarily in
her office as carrier of education, but in the clearness and force with which
she may make known and understood the consiunptive's accompanying
disease of poverty. Teaching individual hy^ene, impressing upon the poor
consumptive the last word of science upon the healing value of sunshine,
importance of limited hours of labor, good food, etc., would many times
appear to be cruelly sardonic were it not for the confidence that she (the nurse)
is playing her part to urge on the regeneration of living, housing, child-pro-
tective, and wage conditions. No one sees as well as she — not even the phy-
sician— all the misery, the heroic struggles, the ignorance, and superstition
in the double struggle against poverty and illness. Her force must be
tested by her clearness in making these conditions known, as well as by her
intelligence in caring for her patients and by her value as teacher.
This teacher, this social reporter, must be trained for the work. The
schools of the hospitals prepare, morally and technically, through the two or
three years of education and discipline. If from the graduates of these
schools selection can be made of those with enthusiasm and culture broad
enough to comprehend and serve the need of the individual and of the com-
munity too, the generals in this campaign can command soldiers doubly
armed for the struggle. Such nxu-ses are at work all over these United States,
and more are being prepared.
Statistics of nurses obtained from Miss Y. G. Waters, Henxy Street Settlement.
SIXTH INTHRNATIOTfAL COTmRE&S ON
RBFEIUEJifCB TO AsmCLBB,
"BA]tiinore Work in TuberculoerLs/ ' Ruth BrewsC«r SbennAO — Amerieao JovuimI
of Numing, June, 1001, p. 626.
"The VieitiDg Nurse for Tuberculona,'* Adelaide Nuttmg^-Cbarities aod tbeCoto-
roonfl, AprU 7, 1906, p. 5L
I
La Signification Sociate y el Valor Educativo de la Enfennera en el Trabajo
de la Tuberculosis*— (Wald.)
1877. Primeni orgamzaci6ii en America del Distrito 6 Asociadon de
Enfermeras profcwionales.
1803. VisitaB de iTistrucci6n hechas en las casaa de los pacientes por las
primeras (io.H enfermeraa del Henry Street (nurses) SettlemeciU &cupi-
deras y ^iofiinfectiintea se dejaban en las casas.
1900. El trabajo es continuado y organizado por el doctor Osier en loe
diapensariofl del Hospital Johna Hopkins en coopcracion con "The Chanty
Organisation Society,"
1902-1903* Las enfermeras eon empleadas por e! Comite sobne Tuber-
culosis de " New York Charity Orgaiiiisation Society,"
Orgaiiizacion del cuerpo de enfermeras en el Departamento de Salud,
de la eiijtlud de New York por el Dr. Biggs y el Dr. Billings.
Conpronsiva organization del trabajo sobre tuberculosis en el Eetado
de Pennsylvania bajo la direccion del Dr. Dixon, Comisionado del Estado,
con oiLrernieraf^, como adjuntat^, en los oentroa del campo y en los sanaton'od
del eatado.
El trabajo de boapitales y dispensarios ea continuado incluyendo en ^:
iastnic'cionj interpretaci6n, el envio de los enfermos a los dispensarios y
hoApitale^ convcmentes al caso, el procuramiento de ocupaciones y enipleoa
apropiados, etc.
EI trabajo educativo por medio de conferencias, ojas sueltaa etc.; con-
sejoa a la^ nuKlroa, el club de las j6venes obreras, y cosas por el estilo. Aten-
Ci4^n so1>re el cuidudo especial de tos nino}^ en las escuelas pilblicaa.
E3 atlie^traniietito de las enfermeras en lo.s hospitales, durante dos 6
tree aRos lea da una excolentc preparaci6n i^ciiica y moral.
El cuitio de loa soldados en el campamento y la 3elecci6n de enfermeras
expertas.
La 6ignificaci6n social depende de la abilidad de "Los Soldados** de
cuidar por las vfctimas individuales, de arrojar un rayo de luz sobre el tema
7 Bobre los multiples asuntoa encueltos en la question social.
VALX7E OF THE NXmSE IN THE CAMPAIGN. — ^WALD. 639
La signification sociale et Timportance, pour reducation, de rinfirmier
dans le travail contre la tuberculose. — (Wald.)
1877. Premiere organisation en Am^rique de TAssociation des infirmiers
de district ou visiteurs.
1893. Visites d'^tude ffdtes aux maisons de malades par les deux pre-
miers infirmiers du Henry Street (Nurses^ settlement. Crachoiis et d^n-
fectants distribu^.
1900, Travfdl de continuation organist k Baltimore sous la direction
du docteur Osier, du dispensaire de TEdpital Johns Hopkins, en coopera-
tion avec la Soci^t^ d'Organisation de Charity.
1902-3. Infirmiers employes par le Comity de tubercxilose de la Soci6t6
d'Organisation de Charity de New York.
Organisation d'un corps d'infirmiers dans le bureau de Sant6, h, New
York, par le docteur Biggs et le docteur Billings.
Organisation comprehensive du Soin de la tuberculose par I'Etat, en
Pensylvanie, sous la direction du docteur Dixon, chef du Bureau de Sante,
avec des infirmiers pour adjoints dans les centres de Comt^s et les Sana-
toriums d'Etat.
Trav^ de contintuUion pour les malades d'H6pitaux et de Dispensaires,
comprenant Tinstruction, ^interpretation, I'envoi k im hdpital et h un dis-
pensaire convenables, Tobtention d'un emploi oonvenable, etc.
Travful d'education par conferences, vues, stereoscopiques, brochures,
etc.; causeries aux reunions de Societes Matemelles, de clubs d'ouvrieres
et organisations semblables; — le developpement des soins speciaux des
enfants dans les ecoles communales.
Les ecoles d'infirmiers dans les hdpitaux donnent deux ou trois annees
d'enseignement technique et moral, une preparation excellente.
Manoeuvre des **Soldat3 en Campagne" et selection soigneuse des gradues.
La signification sociale se trouve dans Thabilete deces"«o^/5"^soigner
les victimes individuelles et k jeter de la lumi5re sur le sujet entier et les
nombreuses questions sociaies qu'il comporte.
Die soziale Erscheinung und der erzieherische Wert der Krankenwftxter-
innen bei der BeschiLftigiing mit Tuberktdose.— (Wald.)
1877. Erste Organisation in Amerika von besuchenden oder Distrikta-
krankenwarterinnen-Vereinigungen.
1893. Besuche zum Unterricht in den Heimstatten von Patienten ge-
macht, von den ersten zwei WSrterinnen des Henry Street (Nurses) Set-
tlement. Spuckn&pfe und Desinfiziermittel zuriickg^lassen.
1900. Weitere Ausarbeitung organisiert in Baltimore unter Dr. Osier
640
BIXTH INTKRNATIOMAL CONGRESS ON TUBEBCtTLOSlS.
von der Johns Hopkina Hospital DiApensary, in Mitarbeit mit der Ckiaritj
Organization Sccioty.
1902-3. Wiirteriimen angestellt durch das Tuberkulose Komit^ der Siw
York Charity Organiiatioo Society.
Organisntion eines Warteriimen-Personals unter dem Gesundheits de-
partment der Stadt New York durch Dr. Biggs und Dr. Billings.
Veratandlich© OrganiBation der staatUchen Tuberku J ooe- Arbeit in Penn-
sylvanien luitcr Dr. Dixon, Staatscommissar mit Warterinnen als HilE*-
personen in den (jrrafachafts-hauptorten und Staatasanatorten.
Weiter folgende Arbeit von Hospitals- und Ambulatoriums Patienten
emschUessUch Unterricht und Erklarung, mdero man sle nach pa^endeo
Hospitalern und Ambulatorien schickt, die Fursorhe fiir richtige AmMA-
dung, etc.
Erzieheriflche Arbeit durch Vortrage, Lichtbilder, FlughlAtter, etc.;
Reden in Multerversanimkingen, VepeirLigungen arbeitender ^fadchen imd
ahnliches; die Entwicklung besonUerer Kinderfiirsorge in fiffentlichra
Schulen. Trednierschulen in Hospitalern fiir Warterinnen, ura durcb xm
Oder drei Jabre techaische und moralische Erziehung zu gebea. Eine
ausgezeichnete Vorbereitung. Einiibung von *'FeldsoIdaten" und die sorg-
faltige AuswaU dor Graduirtcn.
Es liegt eine soziale bemerkenswertc Erscheinung in der F^higkeit dieser
'*SoIdaten'* fur die einzelnen Opfer Sorge au tragen und Licht auf dea
ganzen Gegenstand und die vielfachen in Betracht kommenden aonakn
FiagE^n ^u werfen.
.^^ ^-
LA LUTTE CONTRE LA TUBERCULOSE A LYON.
Par M. Paul Courmont,
Lswo.
La lutte oontre la tuberculose s'exerce k Lyon comme dans toutes les
grandes villes par les armes les plus varices. Sans le savoir, ou du moins
sans avoir ce but direct, ce sont les oeuvres charitables et philanthropiques
si nombreuses dans notre ville qui ont 6t€ les premieres barri^res opposto
au fi^au (Soci^t^ protectrice de Tenfanoe: OBuvre des enfants abandonn^,
Colonie de vacances du Serverin, etc.).
Puis est venue la phase scientifique; le combat s'est engage avec des
armes plus precises et plus sp^cialis^es: hdpitaux, sanatoriums, dispen-
saires. Lyon a Thonneur d'avoir cr^ k Hauteville, en 1897, le premier
sanatorium frangais pour adultes avec I'GBuvre des tuberculeux indigents.
Actuellement, c'est la phase de generalisation oil les oeuvres philanthropiques
specialis^es se multiplient sous Pimpulsion des donn€es scientifiques et de la
campagne d'hygi^ne sociale qui marche de conqu^tes en conqutdes. Chaque
ann6e les oeuvres de prophylaxie directe ou indiiecte se multiplient, et par
exemple Lyon compte plus de quinze oeuvres diff^rentes pour Tenvoi des
enfants k la montagne.
Le tableau un peu sch^matique que nous allons donner de T^tat de la
question sera divis^ d'apr^ les id^es directrices etablies plus haut: oeuvres
de traitement, oeuvres de prophylaxie directe ou indirecte.
1° (EUVRES DE TRAITEMENT.
EUes s'adressent aux tuberculeux av^r^s; le traitement et la gu^rison
sont leur premier but, la prophylaxie n'est qu'un r^sultat indirect.
1° CEUVRE LYONNAISE DES TUBERCULEUX INDIGENTS (1) ET SANATORIUM
Felix Mangini d'Hauteville. C*est en 1897 que, sur Tinitiative du Dr.
Dumarest et sous Timpulsion de M. Mangini, principal fondateur, fut cr^ee
rCEuvre lyonnaise des tuberculeux indigenta pour 6difier un sanatorium
regional. Celui-ci fut ouvert en 1900, k Hauteville (Ain), k 900 metres
d'altitude.
Depuis cette 6poque jusqu'en 1905, il a traits en quatre ans 1, 184 malades.
Le s^jour est de quatre mois (minimum) k six; Tetablissement contient
118 malades. Le prix de la joumee est d'environ quatre francs; chaque
VOL. m— 21 641
642
BIXTO INTEItNATIONAI* CONQREBS ON TOBERCULOSIS.
malade verse (1^*'i^^'^i^< ^^ ^i^Q ^^ eommune^ ou bien rmstitutlon qui
I'envoie) la sorame joumalidre de 2 fr. 50.
I^e budget du sanatorium est (Jquilibr^ par les dons des acMiscripteun
el le revenu (iu legs de 1,800,000 francs de Mme. Ferret. Certains liis "<t
fondaiion ** soni T^mrv^, moyennant le paiement integral de la joum^d*
roviont, ^ ccrtmncs communes et soci^tfe. Vne '* Oaisse de secaur.s" ep^diJ*
fonctlonne pour aider les famillea des pensionnaires les plus n^cessiteux.
L*a*imission des malades et la tlirection mi^diraJe est confix au m<d^
cin directeur; la dLreption administrative est sous Ja di^pendance d'ufl
conseil d' administration ; un ^conome^ un auin6nier et le personnel (parue
laique, partie reli^eux) assurent le fonctionnement de Tceuvre. La «irt
d*air, de repos et de sural i mentation avec adjuvants therapeutiques <xA
dt6 appliques k Hautevitle pour la premiere foia en France aux adults
d'une fa<jon m^thodique sur une large ^chelle.
L'hy^^ae prophylactique est, dans r^tablissement, I'objet d'une t^^
mentation s^v&re. Pour ^carter tout risque de contamination aucune me^
ure n'eat n^glig^e: defense absolue de cracher k terre sous peine de renvoi
imm^diat; pr^t;autions prises au moment de la toux, separation des ccm-
tagieux et des non-conta^eux sur la galerie de cure, & la salle k manger et
dans les chambres; dfemfeclion des cx>uvert3 aprfes usage, de la literieapr^
chaque depart; sti^rilisation des cracholrs, cette derni^re fatte par le pro-
cM^ physique (cbaleur) iVexclusion de la disinfection chimique que nous
consid^rons comme inefficace et dangereuse dans un grand ^tablissement
En ce qui les conceme les malades, loin d'etre rebelles aux preseriptjoiB
qui leur stint faites^ lea ex(?cutent avec une ponctualit^ irr^prochable.
Sur ce point, celui qui 6tait le plus r^fractaire a. Thygi^ne, avajit son entree,
acquiert sans s^en douter une Education complete, par le seul fait de I'eii-
tralnement et de la suggestion qu'il subit de la part du milieu ambiant.
Lieu de traitement, ^cole d'hygi^ne^ ceuvrc d'assistance par excellence,
le sanatorium F^Iix Mangini, qui est le premier en date des sxinatoriunas
populaires en France, a servi de modftle aux ^tablissements similaires qui
sc sont £ond<js apr^s lui et dont certains se sont inspires de son organisa-
tion et de ses r^glements. Sea quatre premieres annfes d'existenc^ onC
H6 f6condes en r^sultats, les chiffrea suivanta, que nous communique le
docteur Dumarest, permettent d'en juger. Du ddbut de son fonctionae-
ment au 31 d^cembre 1904, 1,184 malades en cont sortls, dont 910 aprds un
edjour miniraum de trois raois* 175, soit plus de 19% des malades class^
ont quitt4 I'^tablissement sans aucun symptome morbide; 189, environ 21%^
l*ont quitt^ gu^ris en apparence maia conaervaat encore de lagers signes
d'auscultation ; 284, tr^s am^lior^s au point de vue local et g^n^ral ; 164,
am<$lior6s seulement au point de vue gdn^ral ; 48, avec une amelioration in-
Eignifiante; 60, stationnaires ou aggrav^s.
I
LA LIHTE CONTRB LA TUBEECULOSE k LYON. — COURMONT.
643
Sur S9S malades bacilUferes k I'eatr^, 115 avaient perdu leuia bacilles
pendant leur s^jour,
Des enqu^tes trimestrielles faites aupr^^ des Emcieos pensionn aires,
aix k neuf mois^ puis 5. nouveau dix-huit k vingt-et-un moiB apr^s leur
deport, ont affirm^ le maintien des ameliorations ou des gu^risons obtenues
chez 84% des maladea tourhds par I'enqu^te dans le premier cas, chez
80% dans le duexi^me,
2° HApital maritime deGienb (ou bApital REKtE-SAORAN). Fondfi
en 1889, grdce k 200,000 franca de dons volontaires, 120,000 fr. dus aiL\
Hospices chrils de Lyon dont il depend, et bAti sur un terrain de la presqu'Ile
de Giens, donn^ par M, H. Sabran, cet h6pital maritime pour enfants fut
inaugur^ en 189h 11 ne s'adrease pas uniquement comme le sanatorium
aux tuberculeiix pulmonaires, mais aux enfants scrofuleux, d^biles, an^mi-
qiies, convalescents des h6pitaux de Lyon. Les bAtiments, tout au bord de
la mer, pres de forMs de pins, se composent de trois pavilions de 50 lits charun,
d'un pavilion d'isolement, d'un hall couvert, d'une chapelle et d'une maison
d'administration, Quatre piscines ferm^s (eau douce, eau sa!^, eau de mer
chaude ou froide) pennettent Tapplication de Thydroth^rapie marine,
Une ^tuve k dfeinfection y est annex^. Un wagon special transporte lea
penaionnaires de Lyon k Giens, A part le m^decin en chef, un interne dea
hdpitaux de Lyon assure, en permanence, le service medical.
Les enfanta sont regua jusqu'ii 12 (garQons) et 16 ana (filles),
Un nouveau pavilion va permettre de recevoir les filles de 16 k 25 ans La
nombre total dea iits eat 150; la durde moyenne de s^jour est de 167 jours.
De 1892 k 1904, 3,310 enfants ont ^t^ hospitalism. R^sultats: 36,3%
de gu^ris, 50,8% d'amfiliorfo, 11,5% de stationnaires, 1,20% seuiement de
morta,
Les heureux effets de cette cure d'air, de repaa et d'hydroth^rapie
marine ont fait de cet hdpital un ^tablissement modMe pour les ceuvPBB
fiimiiaires.
3^ Service AyTrruBERcuLEux i>u Dispensairb g^n^ral de Lyon
(me Moli^re)» Fond^ en 1818^ le Dispenaaire g^a^ral est une tBU\Te pnvfe
ayant pour but de soigner les malades indigents, k domicile ou k des oonsul-
tattons ap^cialef^.
En 1003, fut inaugur^ le service antituberculeitx, sous la direction du
dodeur Levrat. Le local se compose d*une salle d'attente, d'un cabinet
d'examen et d'un lahoratoire commun aux autrea sections. Le budget
est de 1,800 francs par an. Les malades viennent trois fois par semaine
aux consultations (S heures du matin et 1 1 heures du soir). La th^rapeuti-
que constste en pointes de feu, huile de foie de morue et injections de cacody^
iftte de sonde; deux fois par semaine, distHbution de viande de bceuf. En
deux ans, 345 malades sont veuus aux consultations, Ufeultats (Dr. Levrat):
ft44 BlXm INTERNATIONAL CONGRIS5 ON TCrBKRCULOaiS,
18% tie gudrid en apparmce, 18% d'am^lior^ k tous pouite de vue, U^i
d'am^liorfe sculemeot au point de vue de T^tat g6n6rBif 20% sUtionBiins
La piiri-ie pmphylaclique de Tceuvre conaiste en in^niction d'hy^i^
ortdvs et Writes (instructions imprim6c6 domi^cs au sujet) en dons de crachou
de pochc ct distributions ubondantes de lyswl. L'ceuvre ne fait ni en*T*'*'j'
tu dfoinfection donijciliaire comme dana le synt^me Calraette, et si;
seulement «ii Bureau t^hygi^^c municipal les logements insalubres. C'ts;
en somme une consultation gratuite pour tuliercuJeiut indigent.-* ^^ '
installfe dans dee locaux d^ih existants peut fonctionner avec im l
trfes modeste.
4^ H6pitaux spfec'XAUX pour TtTB&RCUL&ux. Nous dcrivions en l....
'*Nou3 n'inscrivons ici ce titre que pour signaler les clivers projcte qui ont
vu le jour depuis deux ans sans etre malheureusement encore r^lisds. Alon
que Lyon eat k la l^te du tnouvement pour l^ autrea institutions antituber-
culeudes, ni radiniuistration des Hoepicea civila, ni Tinittative priv6e n'ont
encore rien fait pour isoler les phtisjquca contagieux qui encxnubrent tous
nos h6pitaux dana la proportion d'au mohis 30% et qui trop souvent <i^
bordent in&me (fait inoui tol&r4 par la routine), dans les hfipitaox de con^'ai-
esoents (Ijongcheue) d*o{i ils devraient ^tre soigneusement exclus."
Depuis 1905, rien n'a 4t4 fait dans lea divers hopitaux de Lyon.
En juillet 1906, un vceu de la Soci6t^ mdtUcale des h6pitaux, ^mia sur
la proposition de M. I^^pine, demandait la creation au Perron d'une scvrte
de sanatorium d'essai pour hospitaltser les tuberculeux et decharger d*autaiii
les services des hApitaux centraux : rien n'a encore ^tfi tent^ dana oe aens^
Seule, V(Euvre lyonnam des hospices pour ttihercitl^iLt^ de caract^
priv^, a organist en 1006, un premier asile^ i\ la campagne dans la commune
de Francheville, Cet a&ile ne comporte encore que 50 Hts et ne re^oit qwe
des femmes. D'excellentea inatallatlons hygi^niques pour la disinfection
du linge, pour I'dpuration des matins des fosses d'aiaances, assurenl U
destruction des germes contagieux. Cette raaison ne regoit que les tubercu-
loses ouvert«s, eontagieusesp graves; les tuberculeux curablea sont tlirigfe
sur une autre maison de cure sur laquelle nous manquons de renseignementa.
{Ljfon m£dical^ 21 mars, 1907.)
2* (EuvREs DE PROPirruixiB*
La prophylaxie, ou prfeervation de la tuberculose a'est exerc^ ^ Lyon
suivant les principee expos^Ss plus haut, aoit direcimnent (en s'adressant)
de propos d^lib^r^ aux foyers de cont^on pour les rendre inoffenaifs)
soit indireciefnent (en am^Iiorant la sant^, la condition, le logement, etc
de ceux que leur ^tuatioa ou leur misdre prklispose plus parti culidrero^it
It la tubercuioae).
LA LUTTB CONTHE LA TUBERCUW5SB X LYON ,^-COUH MONT,
645
A. — Propkytaxie directe-
La prophylajde directe s'exerce de trois faQons: P en isolantle tuber-
culeux contagieux; 2* en detruisant la mati^re infe<;t4Mite, la graine, par
tout oii elle se trouve; 3° en enlevant le sujet le plus prMspos^, Teofant de
tuberculeuXj au milieu familial oCi il doit s^infecter.
La destruction de la gratne m fait k Lyon par le LHspenaaire antUxtberculeux
et le Bureau d^hygihne.
Lea cEuvrea concemant les nourriasons et faisant pratiquer la sterili-
sation du lait, font aussi de la prophylaxie directe, mais leur r61e est plus
^tendu et elles trouveront place avec les institutions de prophylaxie indirecte.
Quant fl. la preservation de Tenfant de parents tuberculeux en s^parant
oelui'Ci du milieu infects, elle commence ^ 6tre assur6e depuia 1906 par la
section lyonnaise do VCEm^re de 'preservation de Venjance contre la tuberculose,
1* DisPENSAiRE ANTiTUBEHcuLEux DE Lyon (pue Chevrcul)* Cct ^tab-
Ussement orgamsfi aur le tyj)e ColtneUe est desUnd surtout h. ThygiSne et k
la prophylaxie* H est un des services de Vin&liiui bacl^riologique de Lyon,
et a ^t6 conatruit et organist en 1904j sous la direction de MM. S. Arloinget
J. Counnont. II a une administration autonome et a 6t^ cr^ grdce k des
dons particulierg et ^ une subvention de 59,000 fr. du Conseil municipal.
Les bdtiments se eomposent d'un rez-de-chauss6e et de deux stages,
Le premier 6tage comprend une vaste salle d'attente avec affiches anti-
alcooliques et brochures de propagande; deux vestiaires avec lavaboa et
crachoirs, salle de consultation, cabinet mMical, laboratoires bact^riolo^-
ques, salle de radioscopie, logement de Tenqu^teur et du concierge. Au
rez-de-chauss^ se trouve la buanderie module et un fitablissement hydro-
th^rapique complet : bains, douchesj pulverisations. Les murs sont en faience
ou lavables" il y a des crachoirs partout, etc.
Les raalades sont envoy^ par lea m^decins du Bureau de bienfaisance
qui, se d^chargeant ainsi de ses tul^erculeux, peut subventionner le EHs-
pensaire au prorata du nombre de ceux-ci* Certainea mutual! tds doivent
suivre I'exemple du Bureau de bienfaisance.
Chaque malade est interrogS et cisit^ par un enqu^teur special comme
k Lille. Le service m^<iical est assure par deux medeeins sous la surveil-
lance du directeur, le professeur Jules Courmont*
La th^rapeutique proprement dite ne se fait pas au Dispensaire; c'est
le Bureau de bienfaisance qui s'en charge, et qui distribue ^alement aur
Tordonnance des ra^decins du dispensaire la viande, le lait^ le pain et le
charbon* Pour chaque raalade une observation m6dicale est prise, les
crachata sont examines, le logement visits. Le tuberculeux lui ra^rae
fitant attir^ par le c6t4 th^rapeutique et assistance, la prophylaxie, viti-
table but de Tceuvrej ae fait: {° en donnant au malade crachoir et in*
structions d'hygi^ne; 2° en d6sinfectaDt le logement avec Taidc du Bureau
646
SIXTH iMTERXATtOMAL CONGRBBS ON TUBKBCVlJOSiB,
d'hygi^ne et sous la surveillance de Tenqu^teur; 3° en disinfectant le linge
de la famille (buandene, orgamsation comme daDS le dispetiBaire Calmette);
4° Eq donnant &ux maUdes tcutes fodlitds de soins de propt^t^ par V^tMb-
liBseaient hydroth^rapiqua
C'est le dispenaaire ayst^me fran^ais, oomme Tappelait dcvant moi mi
ED^decin de Chicago, par opposition au systdme allemand du saaatohunL
Ualliance dea dispensaires avec les services dea bureaux de bleofaisance et
des mutuality par laquelle ceux-ci assurent le traitement de leurs tubcrea-
leu3C et subventionnent le Dispensaire est un des c6t& les plus int^reasants
de cette organisation.
2* R6lf. du Bureau d'hygiIixe municipal. Le Bureau d'hygitee oouiu-
cipal joue un rote dea plus actifs dans la lutte antituberculeuse.
Outre les subventions pour le placement des enfants k la campagne
(20,000 fr. en 1905), I'entrctien de colonies scolaires de vacances (voir plus
loin), la viUe de Lyon a engag6 la lutte centre la tuberculose par son r^gle-
ment aanitaire et son Bureau d'hygi^ne (directeur, M. G. Roux),
Le Ttqlenierd aanilaiTe (titre ler, art* 12 k 16j titre H, art. 1 k 7 et 20
k 24) interpr^tant la loi de 1902j est extr^mement s^v^re pour tout oe qui
toucbe aux poussi^res^ crachats, v6hicules, by^^ne de rhabitatioa. Son
application fera faii^ un paa dnorme k la lutte antituberculeu3e.
Au point de vue sp6cial qui nous int^resse^ le Bureau d'fiyffiknc f^t
pratiquer: P la tknnfectwn des habitations et v^tements deg tubercu-
leux, aur d^darationa des ra^ciecins ou des dispensaires ; 2* Vimtpeciion
m&dicaU des ^olcs^ r6organis^ avec trois m6decins depuis 1904^ le gou-
dronnage dea planchers d'^coles; 3° La distribiUion de laii stdrilisi; 4* les
enquik^ $ur ks logemenis insalubres: 1,000 enqu^tes en 1905 (m^decmB
et architectea). Une commission des logemenis ijisalidtres fonctionne pour
Tinspection et ram^lioration des locaux antlhy^^niques (voir plus lotn).
DISINFECTION DES LOCAUX OCCUP^ia PAR DES TUBEHCULEUX ET DB
LEURS vfeTEMENTs,^3elle-ci est op^§rte, soit k la suite d'une d^claratioD de
maladie contagieuse faite par un m^decin, en execution de la loi du 15 f6-
vrier 1002, ou par le Dispensaire antituberculeux de Lyon (Tnstitut bae-
t<^riologique)r soit apr^a d^c^, sur la demonde de la famitle ou des int4res6^.
Kn 1900, 71 d^nfections de logemenis de tuberculeux ont ^t^ op€r6es;
en 1901, 96; en 1902, 131; en 1903, 1S2; en 1904, 157.
Le Bureau d'hygi&ne d&infecte pour tous les cas de tuberculose toutes
tes fois qu'il ne lui est pas oppos^ par la famille un refus absoJu, auquel
cas, la tuberculose ne faisant malheureusement pas partie des maladies
obligatoirement d^darables et dfeiufectables, il ae voit dans Tobligation
de a'abstenir, mais non sans avoir au pr^alable, par les moyens les plus
persuasifs^ chercb6 l\ convaincre les plus recalcitrants.
LA LUTTE CONTRE LA TtTBERClTLOSE 1 LYON, — COXTIUtONT.
647
Prophylark indirecte. S'adressant tnoiDB aux tuberculeux mfimes
qu^aux conditions ^tiologiques et k la protection des sujets pr^diapoa^a,
oes cEuvres ne sont pas lea moina efficaces et ce mouvement toumant sera
peut-fitre celui qui assurera la victoire centre le fi^au.
Beaucoup de ces demi&rea ont fait de la prophylaxie antituberculeuse
BBns le savoir, ayant, au premier plan, un humanitaire ou religieux. Pour
i'hy^^nistef ce sont ces r^sultats qui doivent 6tre pris en consideration ©t
mis en Evidence,
Nous nous ^tendrons moins aur ces oeuvres que aur telle de prophy-
laxie directe, car d'autrea rapports de ce Congr^j? s'occupent pr(5cis6ment
de la Qiteslion du hit, de VHyrfitne d^ Vhnbiiation et des Logcments ouiTiirM,
de I'Alcoolisme, et enfin du R6l€ des mni'u^listes dans la campagne d'hygi^e.
Nous parlerons done aeulement des Hospii^es de contKUescence, des (Euvres
d^enfants d. la campagne^ dea Jardins aumers et des (Euvrcs de protection du
noitrrissons.
1* Hospices de convalescence. Rien n'est plus eificace centre la
tuberculisation des indigents que la protection du convalescent ; la euro de
repos i la campagne doit I'isoler du milieu contagieux hospitaller et aurtout
le preserver du surmenage trop hdtif de ralcooUsme*
Lgs Hospices civils de Lyon poss^dent trois ^tablissementa de conva-
leaoence (sans parler de TH^pital maritime de Giens oil vont nombre d'en-
fants convalescents non tuberculeux).
VAsik Sainic-Euginie a 6t<S fond^ en 1S67, par un don de 200,000 fr.
de i'imp^ratrioe, pour les convalescents aduttes hommes des hdpitaux de
Lyon. Le nombre des lita eat de 100 environ, r^partis en petits dortoiis.
La dur6e de s^jour de un mois k six semainea. On y re<joit 1,200 convales-
cents environ par an (1,228 en 1906)* Mais par une singuli^re ironie, grdoe
k la routine de T administration et des mMecins, un grand nombre de tuber-
culeux contagieux ont, jusqu'ici, profit<5 de cet asile (80% envifon), malgr^
i'article formel interdisant i'entr^ des contagieux. De sorte que cet asile
est trop souvent une source de contagioa pour les autres convalescents, au
lieu d'etre un sejour de prophylaxie!
L'Asilc dea femmes conixilesccntes est I'anaiogue du pr^c^fident, mais
pour lefl femmeS' II a H6 fond^ en 1903^ gr^ce aux dons de M™' Bouniols
et de M. Livet. II revolt les femmes convalesce ntes des h6piiaux (50 lits:
549 malades en 1904; 59S en 1905 et 663 en 1906). Les tuberculeuses ne
doivent pas y ^tre admisB8>
UAsxle P. M, Ferret a ^t4 fond4 en I895j avec les dons et mir les inten-
tions de M*" veuve Ferret. II regoit les enfants convalescents des hdpi-
taux (50 lits de gardens et 54 Mia de filles), au nombre de 550 en moyenne par
an (558 en 1906) et n*admet pas les tuberculeux pulmonaires. Situfi en pteme
il r^od left phn ffiti
tr^ diveraes d'ori^
hmcoiantB d^nks^MsiBok
XI* quelques seniaiDea de pmd
I colonies de Yweum,
m BBS partiftuis; le pR-
ngD*iieti9e dea cooditions ihj'
de vie pfus procbesdt
k qui Us aoot ooafi^ ne soot {oi
chez des pvcBti
I« phts important daos )es oetir-
^^»""t« <ies enfiuUM aaut b
cm autres) et eboiar
wtour, pour ooostsler ks foo-
A5<^fe des {Mi^otB ad(^pti£s, qui doivait
^ s»at<, dlijgitee et ds morality
ranrrovoiDa bu remarqusble
de Ljon (1906) de rav«oo»zieDt del
de cea ceu\Tes avec Seurs
de leiir 6UbIi^ement.
(2, me Sainte-H^ldiie) a pour but de
psvfis de leuxs soutieoa famitiaux, Elle
i la me et 4 ta tuberculcee
SO i 110 plac«s diex des cultirateuis qui re^tvent sa
it fmfma (std^e aodalp 42, me Sala).— ^tte soci^
todd* «ft t80ftk i^orap* la prend^, depiu3 18S9, de Tenvoi d'eofants i
la MMIt^w; Mais ca b'M que oe» demi^res ann^es que te service a pna 6t
rmaaiWl (1€0 «^Mti on i9QS, 73 no 1904, 82 en 1906), et a'est adjoint
Taide d^un m^deoa pour ***■*"**' fes enfanta au d^pflrt et k Tarnv^e et
anp^her Vexportatw© des eonta^eux. Le cfit^ ori^al de rorganisation
«•! que TtiFUvie siikqiuHe da placer ces enfanU cbez les parents plus ou
ttOittS fijoigiafrr qu'ib peuvent avoir k la c&mpagae, d*oii meilleur adaptation
si soiitt pltti d&VYMiis. Dur^e du s^jour: deux mois.
U(Smt ilfpMai>i>r d^ mfanis d 2a aimpo^nc, foad^ e^ 1S93 par le
pastcur Louis ComUi, a M la premiere et la plus importante de notre r6-
LA LUTTE CONTRE LA TUBERCXTL08E k LYON. — COURMONT.
649
gion. Elle donne 45 jours de vacanccs dans la Haute-Loire k un trds grand
nombre d'enfants (1;411 enfants en 1902). La section lyonnaue, transform^e
depuiB 1904 en ueuvre ind^pendante sous le nom de : Les EnJaTils it la monlagne
(si&ge me LanternCf 10), a envoys 124 enfants dans la Haute-Loire» en 1905
(1^105 enfants depiiis sa fondation).
En 1895, VCEuwe protcstanU des colonies rfe vatances (Eglise r^form^)
a coramencd b. envoyer 74 gardens h la montagne; elle a envoyfi en 1905 140
enfants (gardens et filles)^ et en tout, de 1S05 h 1905: 1,101 enfants; le
B^jour est de 42 jours, la d^pense moyenne de 30 francs par enfant.
La Colonic munici}xil£ scolaire du Serverin a 6i6 organist en 1905, dans
une propri^t^ de M, Fisch, bous la direction du Bureau d*hygi^ne de Lyon.
Depuis 1898j le Serverin revolt en juUlet et ao(kt deux groupea de 150 fillettes,
et en septembre 1.50 gardens; les enfant^ sont r^unis en intemat; le prix
rooyen du s^jour quotidian de chaque enfant est de 1 fr. 95,
La Ligue fraknielle des Enjanh d^ Fixtnce commenga en 1899 A envoyer
& la campagne quelques enfants d^biles. En 1902, elle s'est transform^ en une
autre soci^t^: V Assistance fraiemeUe de VEnjance par la jeunesse, Celle-ci
ft pratiqu^ le placement familial par un ou deux enfants chez dea cultiva-
teurs TAin (193 enfants en 1904, 195 en 1905; dur^ du s^jour; 31 joura
iV 2 mois; prix de revient: environ 20 francs par enfant et par mois), visit©
m^cale avant et apr^.
En outre, elle fail des placements pennanents d'enfants & la campagne
(17 en 1905).
UCEm^re amnicipale hjonnaise des Enfants A la niontagne est la plu.s impor-
tante* Elle date de 1S91 et a ^t4 organisde par le Comitd de la Caisse Ues
^colesj son fonctionnement eat ai5sur^ par des subventions du minist^re,
de la ville, des cotisations amiuelles des membre de U Caisse des ^coles, dee
dons particuliers et le produit d'une f&te annuelle de bienfaisance k I'HAtel
de Ville; les parents versent aussi une petite somme proportionn^e k leur
condition.
Les colonies de vacances de roeuvre sont Stabiles dans TArddche region
Slid de rarrondisscment de Toumon.
Ont 6i6 envoyes :
Ann^ 1901, 100 garganset 60fille6, soit 150 enfants,
1902, 402 *' 233 " ....636 '^
Pour chaque enfant est dreas^ une fiche m^cale (mensuration, ant^e^
dents..,, coefficient de robxiaticit^) suivant le mod^e du D'. Mayetj secrfrtaire
de Toeuvre.
Dans rArd&che, les enfants sont plac^ chez des pay^ans dont le r61e de
nourriclers r^pond k ce qu'il est pennis d*esp6rer de mieux en tdles circon-
stances.
650
SIXTH INTERNATIONAL COWGE3GSS ON TCTBERCCTLOSIS.
La dur^ du s^jour eat de 40 jours, On juillet, ao6t, commencement de
aeptembre.
Lea rdsultats obteiius sont excess! vement encouragesants : augmentation
de la taille, de la circonf6rence thoraciquc, du poids, en moyenne 2,000 k
2f500 grammes, suivant les ^^ries et de toutcs fagons, aitgmentatioa plus
inarqu^ pour les filles, et un air dc robuatesaCf de sant^ recouvr^e, qui frappe
toua oeux qui voient les eofants au retour, leurs p&rents surtout.
Ann^
1903,
1904,
1905,
546 gargon^et
637
331 mies.soit 377
405 f' 1,042
1,087
enfaats
Total 2,506 enfanta en
Lb budget des d^penses a ^t^ de :
8,082 frunest en 1901; 33,970 francs en 1902;
33,080 francs en 1903; 41,110 francs en 1904;
Et 44,777 francs en 1905.
L*CEuvre s'occupe avaat tous autres des enfants "candidats i la tubercu-
lose" et raye de sea Ustes tout enfant "tuberculeux av6r6/'
Chaque enfant inscrit pour les coloniea de vacances est Boumis quelques
jours avant !e depart i unc mmie m6dicale irh sirieiisc, Celle-ci a pour but dc
rechercher quelles sont lea tares et maladies dont I'enfant pourrait itre atteiot
et quiseraientdangereusessoitpouj lui-memesoit pour lea autres^au coura dc
sa vie campagnarde. Lea m^decins charges de la visite m^dicale rechercbent
ftvec soin les liSsions tuberculeusea en activity pour ^viter Tenvoi des enfants
qui en sont porteurs aux fermes de TArd^che qui ne sont paa des sanarohunis
et ne doiA'eat pas recevoir de malades. Enfin et surtout, la visite medicate
a pour but d'indiquer aux bureaux de TCEuvre ceux des enfanta auxquels le
B^jour k la montagne paralt devoir etie le plus n^cessaire et le plus pruiitable
k leur sant<^.
Ces enfants^ldi sont le-s premiers inecrits sur les Ustes de depart.
En 1906, les examens m6dlcaux h Lyon out port^ sur 1,S00 enfants et oat
occup^ pour cela 22 m^decins de bonne volont^ pendant troi;? jours.
L'ann^ 1902 vit apparaitre plusieursoeuvrea priv6es d'enfanta k la moo-
tagne.
Solidarity scolaire du deuxikme arrondissement* — Les enfanta envoy^ p^
cette ceuvre ont de 7 ^ 13 ans; ils sont plac^ individueliement dans cles
families de cultivateurs, pendant un mois. Examen medical avant et apr^;
dur^ du s^jour : un mois; cot^t ; 1 franc par t^te et par jour. Augmentation
de poids : 2 kiL 150 en moyenne. Nombie : en 1905, 429 enfants.
LA LtriTE OOKTRE LA TT7BERCUL08E X LYON.— COURMOKT,
651
Lea ressources de TcBUvre: de dona^ cotisations et fStea de bienfaiBOiic^;
aucune cotisation n'eat exig^ dea parents.
Le Groupe d^6Utdes sodales du deuxihrne arrondissemeni a form^ une colonic
d'intemiit dans les monts dti Lyoonais; les eafanis y restent trente-cinq
jours. Service medical local. Codt : 1 fr. 10 par t^te et par jour, Nombre:
186 en 1905 (43 payanta et 143 gratuits).
La Colonie de vacances de Douvainc a ^t^ organis^e par un vieaire de la
paroisae Saint- Augustin en 1902 (40 enfants en 1905)*
En 1903 : (Euvre des enfania ii la montagjic de la sod^l^ de Saini^Vincent-
de^Paul {125 gargons en 1905).
Depuia cette ^poque dix^ auires colonies de i^acanceB ont ^t€ organisge par
les paroiasesou les patronages catholiquea de Lyon ou des environs et fonc-
tionnent sous la direction de rArchev^cb^.
Enfin trois ceuvres diff^rentes k Lyon a'occupent de procurer un s^jour
de campagne ou de convalescence k de jeunes ouvri^rea de la ville.
UEglise rijorinee fonda h. Champagne-au-Mont-d'Or, en 1846, un adle
de 20 lits pour tes jeunes fUles^ et, en 1870, k Oullins, un autre de 20 lits
pour les gardens*
ViUa Chantade, Situ^ dans les montagnes du Puy-de-DfiraCp cet
dtablissement revolt depuis 1893, deux fois par an, pendant un mois, sous la
direction du D'. Bonnard, un groupe d'ouvri^res lyonnaisea an^miques ou
d^bilit^s. Rdsultats durables et tr^a encourageanta. Le e6t6 original de
rinstitution est qu'elle est une d^pendance du Syndicat ouvrier. Seules
les jeunes fillra du Syndicat des employ^ de commerce^ des ouvri^rea de
raiguille et de la sole ont droit k cette cure d'air et de repos,
Le mime SjTidicat s'eat procure la location d'une campagne pr^ de Lyon,
oil les jeunes ouvTi^xes vont faire k volont4 un s^jour de repos^ Cette initiative
d'un SjTitiicat ouvrier est k signaler et peut fitre k inijter,
L'Aliruisme (soci^t^ pour le rel&vement des famiUea malheureuses) a
organist en 1905, VCEui^e des jeunes Jilles a la campagne, pour les predisposes
k la tuberculose (2S jeunes filles en 1905; prix de revient, 1 fr. 75 par jour),
Jardins ouvriers* — En 1891 l'(EuvrB des jardins ouvriers fut fond^
et organist k Sedan, et tanc^ k Paris en 1893 par I'abb^ Lemire et le D'
Lancry. EUe a pour but de c4der k dea ouvriers n^cessiteus de petits
jardins dans la ville ou la banlieue, afin de leur donner te goOt de la terre,
leur permettre de r^colter quelquea (leurs et l*^gumes, et surtout de lea
Eloigner eux et leur famille de la rue et du cabaret. Depuis 1S91 existe
I'CEuvre lyonnaise des jardins ouvriers^ En 1903 celle-ci avait cr6€ sept
sections de jardins, occupant 41,000 mUres rarr^s ripartis en BOl jardinels
attribu^s k 201 faviillea indigentes ayant 850 enfarUs* L'assistance annuelle
de ces 1,860 personnes revient k 1 fr, 75 par t^te. he rapport d'un jardin
est pour roccupant de 90 2k 100 francs; le b^ndfice moral et bygiinique
652
BIXTH INTERNATIONAL CONGRESS ON XtTBBBCUlOBIS.
est encore plus appreciable, point n'est besoin d'in^bter devant de puaU
chiffres.
4° Prophvlaxie chbz lb NouRRisaoN*
Xia SocUU proieclrice de Veiifance fond^ en 1866 a surtout pour but de
diminuer la mortaUuS des nouveau-nSs, Pour cela elle encourage rall&ile-
ment cnatemel (tsecours, recompenses, prix, etc.), vient en aide aux meres
indigentes, en errant des crdches et une consultation de noiirrisdon^
Cette comultaiion de nourrissom est compl^t6e par une viaiteuse k div
micile qui va relancer ohea elles Ics niGres pour les conseiller et diriger ['allaite-
ment (70 4 100 nourrissons par an).
Des consultations de n&urrissons existent d'ailleura dana les maternity
des trois priacipaux hdpitaux de Lyon.
Lea Hospioes civils de Lyon ont organist en 1905 une nourT^serie mod£k|
install^ k la eampagne prhs de Lyon et destin^ k abriter lea nounioes
de Vhospice de la Charity et leura nourrissons, dans des &alles am^nag^
avec tons les progrt^a modemes de I'hy^&ne.
Ooutte de lait de Lyon. — De fondation riScente aus^, cette ceuvre, oi^anis^
sous la direction du profe&seur Fabre, a son ei^ge k la Guilloti^re dans le
quartier le plus populeux et miserable d© Lyon, et occupe trois pikes;
une pour lea nourrissona sains, une pour lea contagieux, une pour le st^rili^ar
tion du lait (^tuve humide chaufi^de au gaz^ module Dandy). Les biberon^
en verre sont st^rilis^s par sept dans des paniera metalliquea avec une t^tine
de caoutchouc; chaque biberon correspond k une tet<5e, on n'k qu'A y placer
la t^tine (un biberon toutes les trois heures). Le lait, toujoura de m^me
provenance est at^rilis^ k 100° pendant une demi-heure; pur ou coup^
d'eau Belon T^ge de I'enfant* Les biberons sont livr^s aux m^res le matin;
celles-ci sont int^ress^a au fonctionnement de TGeuvre par une Idg^re r&
mun^ration qu*on leur demande pour le lait st^rilis^, les amendes, en cas
de pertes des objets confi^g, Les nourrissons sont pes^s et aurveill^ et
une consultation a lieu chaque semaine.
Le budget eat le suivant: mat<5riel d'installation, 1,250 francs, frais
d'entretien annuel^ 1,500 francs^ y compris le loyer; le lait est pay4 par
les m^res*
11 serait h d^sirer que les gouttes de lait s'installassent sur le m^rae mo-
dule dana toua lea quartiers; c'est un des rneilleurs nioyeng de diininuer
la morbidity infantile et la tuberculose, que celle-ci provienne de la d^bilit^
de Tenfant ou du manque de sterilisation d'un lait tuberculigfene.
RSle du Bureau d*hygikne, — Le service municipal de stinlUaiion du lait
a distribu^ du lait st^rilisS en 1904 k 681 enfants (en moyenne: 230 litres
par jour en 6acons de 125 grammes).
Crhches. — Depuis 1902j eept creches autrefois tenuea par la Soci6t€
protectrice de TEnfance^ sont administr^ par la ville et sous la directioa
LA LtOTE CONTRE LA TtTBERCULOSE X LTON. — COURMONT- 658:
du Bureau d'hygi^ne. Les enfants oat de 15 jours ^ 2 ans (298 enfants en
1904) sont surveilMs (visite m^dicale k Tentr^e et toutcs les senminea)
et nourria au lait si^nHs^*
* « * 4
Tel est le tableau trop r6sum6 des oeuvres et institutions qui lutlent h
Lyon, directement ou indirectement contne ta tubercitlose: un sanatorium,
iin h6pital marin, un dispeneaire k consultation gratuite, un dispensaire
type Calnaetie, trois hospices de convalescence, une vingtaine d'tBuvres
de colonies de vacancea et d'enfants k la montagne, une ceuvre tr§s prosp^re
de jarctins ouvriers, plusieurs soci6t^s de logements bygi^niquea ^ bon
march^ et d' alimentation saine et tfconomiqtie, une society centre la mort-alitd
des aouveau-nds, une goutte de lait, plusieurs consultations pour nourriaeons,
line organisation sp^cialement active du Bureau d'hygi^ne, une organisa-
tion des mutualistes pour la propagande antituberculeuse et le traitement
de sea malades au dispensalre, une Mutuality matemeller des ligues aoti-
alcooliques.
Nous en oublions certainement et peut-^tre des meilleurea; mais au total,
k Lyon, plus de trente institutions concourent directement ou indirecte-
ment k la lutte contre le fldau.
Cette lutte est active et g^n^raUs6e surtout depuis quelques ann6es;
Tavenir montrera ^n efficacit^ certaine, par l*abaisyement progresaif de la
mortality et de la morbidity par tuberculoses
Der Kampf gegea die Tuberkulose in Lyon. — (ComiMONT.)
Der Karapf gegen die Tuberkulose in Lyon findet atatt:
1. Durch Aufnahmevon Patienten in das Sanatoiium Mangini in Haute-
ville, in das spezielle Hospital fiir Schwindsiichtige, oder durch Fiirsorgestellen.
2. Durch Vorbeugung von Ansteckung mit Bazillen (directe Prophylaxe):
(a) Durch isolimng ansteckender Tuberkuloaer in an IsoUrungshospital
fur Schwindsuchtige.
(&) Durch Entfcmung der zur Krankheit Veranlagten vom Herd der
Ansteckung: Schutz der Kinder gegen Tuberkulose (Lyoner Abteilung
der wuvre de GraTicher),
(c) Durch Zerstfining der Bazillen; Desinfektion des Auswurfes, der
Kleider, der Wohnungen; der Teil, welcher von dem Amt fiir Hygiene
ausgefiihrt wird; Fiarsorgestellen nach Calmette, Sterilisiren von Kinder-
milch; Stationen fur Milch-verabfolgung; Konsultationen iiber Kinder.
3* Durch versetzen der \'eraulagten uoter bestmdgUche VerhaitnLsse
iur Vcrbesserung Lhrer Widerstandsfahigkeit (indirecte Prophylaxe).
664
aOETH INTEBNATIONAL CONGRESS ON TaBKRCULOSlS.
(a) Arbeiten in friacher Luft: Senden der Kinder ins Gebirge; Wocben-
Landaufenthalt; Garten fiir Arbeiter,
(b) Hiilfesleistiing fiir Genesende; drei Hospitaler und ein Heim fur
Genesende; gemeinschaftliches Vorgeben von den Muttem.
(c) HvilfefurPunderxind Sauglinge: ICrteilung von Ratschl^gen; Stellera
fur Milchverteilung; Kinderschutzgesellschaft.
(d) Hatisliche Hygiene: der Teil, welchen die Stadtische Abteilung
fiir Hygiene unter ibrer Obbut bat; Verein fur billige Wohnungen; Garten
fiir Arbeiter, u, a. w,
(e) Der Kampf gegea den AlcoboUsmus: Zwei Gesellschaften: daa
Blaue Kreuz und das Weiaae Kreuz. Grosser Congress in 1908.
The Fight Against Tuberculosis in Lyons. — (Courmont.)
The fight against tiiberculod^ in Lyons has been carried on:
1. By taking care of tuberculous palienta in the Sanatoiiura Manguu
at Hauteville, in a Special Hospital for Consumptives, and in the dis-
pensary.
2, By preventing contagion by the bacillus (direct propbylajds).
(a) By isolating contagious tuberculous subjects in the Isolating
Hospital for Consumptives.
(&) By removing the predisposed from the focus of contagion : The
protection of children against tuberculosis (Lyonnaise section of the
Grancher enterprise)-
(c) By destroying the bacillus : Disinfoction of sputum, clothings and
dwelling-houses. The part performed by the Bureau of Hygiene. The
Lyons Dispensary after Calmette (Arloing and J. Courmont). Steril-
isation of infants' milk (milk stations; consultations on babies),
3- By placing the predisposed under the best possible conditions to
improve their resistance (indirect prophylaxis),
(a) Fresh-air work: Sending children to the mountiuna (countr)*^
weeks); workmen's gardens.
{b) Convalescent reUef work; Three hospitals and homes for con-
valescents. Cooperation among mothers.
(c) Relief work for infants and children; consultations; milk sta-
tions. Society for the Protection of Children.
(d) Hygiene of the home: Part performed by the Municipal Bureau
of Hy^ene : Society for cheap lodgings^ workmen^s gardens, etc.
(e) Fight against alcoholism: Two societies: the Blue Cross and the
White Cross. Great Congress in 1908.
LA LDTTE CONTRE LA TUBERCUL08B k LYON, — COUBMOKT. 655
Lfr Lucha Contra la Tuberculosis en Lyon.— (Courhont.)
La lucha contra tuberculosis en Lyon se ha hecho del modo siguiente:
1. For medio del cuido de los pacientes tuberculosos en el Sanatorio
Mangini, en Hauteville, en un hospital especial para tlsicos, y en el Dis-
pensario.
2. For medio de la prevenci6n de la infeccidn (profilaxis directa).
(a) For medio del aislamiento de las personas tuberculosas en el Hospi-
tal Aislado para TMcos.
(&) For medio de la eeparaci6n de los predispuestos del foco de la in-
fecci6n: la protecci6n de los nifios contra la tuberculosis (Secci6n lyonesa
de la obra de Grancher).
(c) For medio de la destrucci6n del bacilo: Desinfecci6n del esputo, de
los vestidos y de las babitaciones. La parte i cargo del Departamento de
Higiene. Los Dispensarios de Lyon de acurdo con los principios de Cal-
mette (Arloing y J. Courmont). Esterilizacidn de la leche de los niflos,
Estaciones de leche. Consultaci6n de los nifios.
3. Foniendo & los predispuestos & la enfermedad bajo condiciones favor-
ables para aumentar la resistencia (Profilaxis directa).
(a) Trabajo al aire Ubre. Envio de los nifios a las montafias (Sema-
nas en el campo).
(&) Trabajo de los convalecientes. Tree hospitales y casas para los
convalecientes. Cooperacion entre las madres.
(c) Trabajo de alivio para los niilos. Ck)nsultaciones. Estaciones de
leche. Sociedad para la protecci6n de los nifios.
(d) Higiene del hogar dom6stico. Farte a cargo del Departamento
Municipal de Higiene. Sociedad para los Alojamientos baratos, jardines
para los labradores.
(e) La lucha contra el alcoholismo: Dos sociedades: La Cruz Asul
y la Cruz Blanca. Gran Congreep en 1908.
TUBERCULOSIS AND TWO THOUSAND DOLLARS
A YEAR.
By Helen C. Putnam, A.B,, M,D.,
rhjurmpA of CommkUe to iDvwtisAte tb« Toicbins of Hypcne Ip Pu-bUe Scboola,
Americ&ti Academy of MedicirMS^
Appoialed b^ tte
There is admittedly a large amount of avoidable illne^ stmong people
with moderate incomes, who are not reached by present preventive nieasuiBfly
such aa our model tenements, visiting nurses, philanthropic instruclioA.
More efficient efforts should be directed to the problem of prevention in
comfortable homes, and it demands a wider outlook. A brief sketch of
conditions noted in thirty such homes within four years sugg^s the iises
of effort.
In each of these homes had been, or were at the time of observation,
cases of tuberciilosifl, the patients dead or dyings or holding their own. In
every home "cultural" education, i. e., the curriculum predominating in
our schools and colleges, had been generously taken — nothing less than high
school or Its equivalent, with a goodly number of men and women graduated
from college* The homes were in attractive residential quarters of a city
of a quarter million, with an active department of health; milk, school,
and factory inspectors; organized charity, visiting nurse, and public educa-
tional associations, and a popular antituberculosis crusade; in a State
whose record is poor for illiteracy, criminality, mortality, and political
corruption, but whose per capita wealth is high. Each factor is vitally
related with health problems.
These twenty-two houses were of three to four stories, were from 500 to
100 feet apart, renting for S600 to $1000. Thirteen were single; nine divided
in two flats, each with six or seven rooms. Incomes ranged from $2000 to
S4O00, families from two to five members, except in certain fiats. In one
three families (relatives) had crowded, a household of eight in seven small
rooms; in another, two families of six adult-s; in another, five adults* This
was quite as unfortunate for single families occupying the companion flats,
whose premises necessarily had to receive an overflow of noise, dirt^ and
trespass* The facts of high rents, small incomes^ and overcrowding are Dot
all around the poverty line.
For brevity in discussion conditions of residence are grouped under two
headings:
650
TTTBEBCITLOBIS AND TWO THOUSAND DOLLARS A TEAR. — PUTNAM. 057
1. Construction of houses, including plumbing and ventilation.
2. Practices of inmates concerning (a) garbage, (b) vermin and domtetic
animals, (c) dirt and cellars.
It should be recalled under each beading that tuberculosis, like other
ill health, has both direct and predisposing causes; the latter all such as
depreciate general vitality and nerve force, lessening remstance to microbic
invasion. Of the two^ this is by far the more importantj and deserves
more attention than either curing invalids or killing germs.
1- Construction, Plumbino, and VENrrLATiow,
Nearly half these houses, including all but two of the nine divided in
flats, were erected on made land, a swamp twenty years ago. In spring
and early summer dampness from basements mildewed articles on the ground
floor.
Their construction was so light that in winter thermometers re^stered
several degrees lower on outer walls than on their double-sashed windows;
and while strong heat was coming from registers, heavy currents of cold
air poured down from these outer walls. Severe catarrhal colds occurred
inevitably every winter, even in two *' fresh-air" families. The great
majority for the sake of warmth sealed themselves up with storm-doora,
douljle sashes, and tightly closed cellars,
Flimsiness of stmcture was indicated also by the jarring which occurred
with high winds, passing teams, miming sewing-machines, ironing, slam-
ming doors (one invalid told me his chair shook by count that day from 111
slamming neighbors' doors — not an unusual number); by falling flakes of
kalsomine and rattling gas fixtures under overhead walking, rolling furni-
ture, trotting wailing babies (1); by sounds of domestic and personal details
from bedrooms, water-closets, kitchens, cellars, and parlors; conversation
and "music^' (at least one family in each double house hafl piano, musicv
box, phonograph, or '* vocal culture"); evening social life and night illnesses
or exigencies making it impossible to r^ulate honvB of sleep, with the conse-
quent fatigue. The transmission of odors, from tobacco to frj'ing fat, was
inevitable; soapy and other laundering odors invaded the floors above,
while dampness blistered wall-paper and steamed windows, especially when
tenants on wet or stormy days dried washings in basements. A tenant
sometimes used the common passageway as a closet for dust-cloths and mops,
soiled clothing, etc., or a means of ventilating the kitchen (into the other
tenant's house)*
In several of these two-flat houses was a cheap type of plumbing, requiring
attention from the landlord ten or fifteen times a year, and so arranged that
he intruded on both families in repairing for one. Flooded ceilings and
furnishings below occurred annually* Water-closets were not properly
658
SIXTH INTERN ATIONAI* CONGRESS ON TUBERCUIjOSIS.
ventilated, intestinal odors being perceptible half an hour after use tlirougb
adjacent rooma* Tliia was particularly offensive in basements, which wi
the back-stairs were used in common.
2, Practices op Inmates,
The majority (but not all) of the foregoing items were fundamentally be-
yond tenants^ control. The followini; depend cluefly on tenants' standards.
To make slender incomes go aa far as posable ladic5s frequently do their
own housework, hiring service by the hour when needed, usually for laundrj
work or dinner ptirties. It is customary to depreciate the quality of hired
domestic service. My personal observation has been that back-staiTB and
other retired parts of premises, wliich need routine cleaning, scrubbing, and
sweeping, are in better condition with such help. Hired workers are more
muscular, or freer to put all their energy in the work; while laciles of the
family have quaflruple burdens, not only manual housework, but social,
maternal, esthetic responsibilities — a hea^-y burden often upon elderly
shoulders because of the uselessness of the buxom daughter at the piano,
or the eon ^ith cigar and novel, while the slender mother scrubs or carriee
coal. Idleness in youth and overwork in f^e are of significance in anti-
tuberculosis endeavor.
(a) Garbage, — One family of these thirty dried and bunied its ^lid
garbage and grease, pouring fluid waste into the house drain. One family
had a covered galvanized iron pail sunk in shaded ground* It was cleaned
perhaps twice a year. One family had a large wooden tank fastened to the
fence, directly in the sunhght, from wliich the accumulation was dipped by
the city garbage collectors. It could not be effectively cleaned, Four
familiea used galvanized iron ash-cans, barrel pize. They had covers rapeJy
in place- Each stood in direct sunlight. Perhaps they wet^ cleaned twice
yearly. The remaining twenty-four families used galvaniied iron pails,
all but four in direct sunlight, covers very frequently out of place, three
having none, cleaned perhaps twice yearly, Avith two exceptions, where they
were cleaned monthly. One swung on a wire inside the fence along the
sidewalk, its odor evident to passers-by.
The peculiarly offensive odor of uncleaned garbage pails was distinctly
perceptible through neighbors' open doors and windows, especially when
garbage collectors were filling their carts, and when a tenant kept his pail
by the entrance used also by another, An ailing baby sleeping out of doors
for fresh air was observed within three to twenty-five feet of five uncovered
paits, the carnage and all but one pail in direct sunlight; the carriage^
incidentally, haAdng a white silk ruffled shade shedding its dazzhng, waverisg
light upon the baby's eyes.
FMea swarmed around all such pails, cats and dogs Bpilled their contents,
1
TUBERCULOSIS AND TWO THOUSAND DOLLARS A TEAR, — PUTNAM. 059
and very often bits were scattered by tbe housewife, thus increasing odors,
flies, and other vermin. These back yards might have been wholesome
open-air spots; house fronts were within five feet of dusty streets,
(b) Vermin and Pet Animals. — Pel8 were not kept by seven famili^.
Cats, one, two, or three, were kept by twenty-one; dogs by six, even during a
period when not a week passed without some victim in the city being sent to
the Pasteur Institute,
Three families in a two-flat rented houae had five Angora cats with peri-
odic increase of kittens, which the ladies sold for " pin money," getting much
pleasure out of their antica during growth. It is customary where pets of
financial value are kept in city houses to provide sand-boxes rather than
allow them out of doors with risk of loss. With so many pets this arrange-
ment proved dlMcult, back halls and cement basement serving the purpose^
a cupful of sawdust being poured over spots after removal of feces, with the
idea that it absorbed odors!
It is a well-established fact that Angoras are hosts for the flea puleJC
serralicepSf not so irritating to man (biting thin skins chiefly) as pukx
irriians. Eggs, laid in the long hair, are shed on floors and grass, hatch into
larvae, pass through pupal into adult form, and jump on passing animals
and human&™a cycle of six weeks. The above three households and nine
neighboring for several years had annual ''plagues" of thousands of fleas
from July, the last of them continuing in warm cellars until January, Cats
and kittens (after a few hours of life) were "idive" with fleas^ which the ladies
spent many hours trying to pick oS and drown one by one for the sake of
the health of the cats.
Lamllords of premises of tliis construction, and used li ke this, passed them
on to other tenants; the fleas went with cold winter weather and with the
cats; the characteristic odor is perceptible after two years on hot damp days,
Because of ignorance of methods of prevention, and riddance^ many bouses
had roaches, red ants, or black ants; flies and moaquitos were abundant,
Other insects and mice were l^s numerous. Garbage and animal dejecta
are an item in their prevalence.
(c) Cdlars and DirL — The great majority of these families used cellars
for holding evezy waste or superfluous article. Some accumulated dump
heaps six or seven feet high tlu-ough the winter, containing dry material or
material drying, boxes^ old flowers and greens, papers, including wTappings
from meat and vegetable markets^ hair combings and other toilet wastes,
soiled cloths, sponges, bandages^ cotton, etc. TIus was usually cleaned
out in early summer. Ctellara used for storage, or otherwise, were not
infrequently kept with all windows, or nearly all, tightly shut throxighout
the year. The presence of pathogenic bacteria is not nece?isary to prove
that these conditioiiSi in addition to heating and laundering purpc^es.
660
SIXTH rrn^RNATlONAL CONQEESS ON TUBKRCUL06IS.
injure the tonicity of the ^ in houses where thin floors cannot be air-
tight.
Sweeping house dirt out front and back doora was oommon, and shakinf
or beating rugs and dust-ciotha before neighbors' open windows. In hou3&-
cleaning times masses of fuzzy accutnulations, bits of soiled cloths md
sponges, and similar refuHe were noted on sidewalks; also applicators that
had been used on some lea on were found on eddewalka under windows.
The back halls and stairs used in common by the families, their trades
people, etc*, in the two flats, sometimes went many weeks i^4tbout sweepbgr
even longer without scrubbing. Inspectors of model tenement^houaes do
not allow the conditions of cellars, garbage disposal, and back stairs that were
Been in some of these thirty householda.
Dusty streets and automobiles as well as other vehicles easily cover a
freslily cleaned house with a thick coating of dust. The practice in a few
families of spreading handkerchiefs, table linen, dish-wipera, diapers, etc.,
upon grass "to bleach and dry," which country people eaa often do with
propriety, was noted. Upon this unfenced little city house-plot, dogs, cats,
and humans, including garbage collectors, walked continually, while clouds
of street-dust were constantly settling there.
Direct CAusEe oP Tuberculobis,
Opportunities for direct communication of bacilU-laden sputum were
chiefly through social intercourse, use of door-knobs and other parts of
premises in common^ flies and other vermin, and carelessness suggest^ by
the following: in one instance the wall-paper removed by medical advice
from the room of a patient with open tuberculosis, instead of being destroyed,
was placed in the cellar of the adjoining tenant, who found it aft-er returning
from a few months' absence, iJVhether this was infective or not, it was so
believed by physician, family of the deceased, and landlord; its carelesB
disposal is characteristic of much antituberculosis work.
CoKCLtrsioN.
From these items, selected from a much larger number of imsanitary
blunders^ one cannot logically conclude that all well-to-do families with
tuberculosis and other ill health arc so badly housed and so badly kept,
or that badness of environment always takes these particular forms, Neither
should one conclude that this is an exceptional set of households, even if
certain details sc^m exceptional.
But one can logically conclude that the large, thrifty, well-meaning body
of our population needs industrial and scientific education as well aa the-
hterary of the last half century. These notes indicate fairly a neglected
field of greatest importance for this Congress to cultivate to its utmoit
I
TUBERCULOSIS AND TWO THOUSAND DOLLARS A rEAR. — PUTNAM. 661
capacity — the training of all young people in sanitation; the intelligent
application of biological lawa; an early edueatioHj needed by physiciana,
for all these famili^ had medical advisers and a board of health; needed by
architects, law-makers, and^ especially, by these so-called educated who help
to create public opinion, enforcing buikling laws and landlords' duties.
Fundamentally, we touch here questions of rentals and land-ownerahip.
We cannot rely upon popular lectures, newspapers, and magazines, for,
besides their superficiality, they contain more error than truth; and "cul-
tural education" has not given ability to discriminate between authorities
nor between statements, nor has it ^ven interest in pursuing such subjects.
There is but one way to accomplish lasting results that will tell when this
present new crusade shall have settled into the commonplace and neglected.
It is to redirect the ''tools of life^' that our public schools now sharpen on
academic propositions; to sharpen our reading, writing, arithmetic, which
are only tools, on practice applications of science instead of merely verbal
exercises.
This is a plea for the great class with worthy ambitions and small incomes,
crowded by unscrupulous rich and politicians on one side, by appeals for
help and social agitators on the other, needing, and in all justice deserving,
an education better fitting them for life and health, for usefulness and
happiness.
This Congress and its affiliated societies should have strong, well-balanced
committees of scientific men v,nd women to study and initiate methods of
practical training for schools and colleges in samtation and personal hygiene.
La Tuberculose et S3,ooo par an. — (Ftttkam.)
(1) Beaucoup de maisons occup6ea par des gena inteUigents ayant un
revenu modeste, invitent la tuberculose par teurs locations malsaines et leur
l^gjret^ de construction et cependant les loyera de cea maisona sont 6Iev^.
(2) Dee pratiques communes dons beaucoup de ces maisons en ce qui
conceme les rebuts de cuisine^ la salet-^, la ventilation, la verraine et lea ani-
maux domestiques invitent aussi la maladie ; ces deux ( 1 et 2) causes diminuent
la vitality g^n^rale et T^nergie nerveuse (pouvoir de r&istance i rinvaaion
des microbes), qui sent plus importantes que la gu6rison des invalides ou
la destruction deg germes dans la pr«5vention de la tuberculose.
(3) La seule mdthode effective de parvenir jusqu'i ces gens est par Tentre-
mise des institutions r^guli^res d'^ducation.
(4) Ce Congr^s devrait demander que ?on donnAt dans les ^coles et les
colleges des cours pratiques d'hygi^ne et de sanitation avec des profeaseurs
comp6tenta ; et aussi inslster sur une Education industrielle sufEsante (a) pour
mettre rarchitectupe, les metiers de la construction et la science du manage
«IZTH DTTSBSrATIOXAl. COHORT OX TCBE&CrUkSlS-
de Santd pins cap«blei de remptir leors devoin; ^) poor aia une cpiaiQn
ptMqoe intelli^ate ctemandant et appliqtuuit one tfpHlMinn pour oonfaflier
le« bA^rocnte,lw bysv^ ^ ^^ mesures poiittqvie* dtas ViotMt de U saaK.
(S) Ce Ccmgrte ei ees aasociMioau affilifew devfaient avoir des oomit^
^eotroux pour e^oeeager de I'mstiw^km de Vhy^kat et de 1& ****^*»w^
dim let tolee et dans lee ool]^ge8,et lea meaii^^s de ee comity devnttent toe
dee bommes et dee femmes s&vflnts et bien seosis, avee ime
kr^e et d^&nie dee divefs problS^nee 8oule\'^
r
Die TutierlmlQae imd Sitooo jMhiiich. — (PtmfAU.)
L Vielc H^uacr, die von mtelligenten Lenten mit g&ringem Eankomzoen
bewohnt werden, fur die hobe Miethen verlangt werden, sind durch ungesimde
Lagie UDd maiigelhafte Koostniktion einladead f iir Tuberkulose.
2* Die gew6hnlichen Praktiken in vielen solchen Heimstatten in Berap
ftuf Abfall, Schmutz, Ventilation, Ungeziefer und Lieblingstiere fuhi^n
dhnlirherweise zu schlechter Gesundheit einereeits und andereraeita dadureh,
da«s uie die allgemeine Lebenskraft und die nervdee Energie (Widerstaiid&'
kraft gegpn das Eindringen von Mikrobea)schwacben,welcbe wichtiger stnd
ab Invaliden zu kuriren oder Keime zu toten urn Tuberkulose zu verhindera.
3- Die einzige wirksame Methodej flieae Lente zugewianen (indem man sie
grosBhefzig in uberhand nehmenden ** cuJturetlen Curaen" erziehl), ist durch
rBgelrechte Erziehungsinstitute.
4, Dieser Congress soUte eine praktische AusbUdung in Hygiene und
(jesundheitfllelm; in Schulen und Collegen durch massgebende InstruktoTcn
verlangen und gleicherweise auf wirksaraer industrieiler Ausbildung bestehen
um (fl) eventuell die Architektur, das Bauen von Wohnungen und die Anlage
dcr Haushaitungen zu sanjtaren Werten emporzuheben, Arzte und Gesuxid-
hpitj^bcamte an erhohtcr Wirksarakeit anzuspomen, und (b) eine vemunftige,
6ffcntlicheMeinungzu8chafEen, die von der GesetzgebungconlroUirendeMaa*-
nnlmien im Baucn, der Vermiethung und der Politik im Interease der Gesund-
lieit verlangt und erzwingt.
5. Dieser Congress und die mit ihm in Verbindung gtehenden Vereini-
gungen eollten Zentralcomit^ im Schul- und Hochschulunterrichte iia
Hygiene und Gesundheitslehre haben, desaen Mitglieder wohl ausgcbildete
MAnner un^l Frauen von Wiagen sein solit.en mit ausreichendem und brei-
tcm Verstiindniiise der verschiedenen, in Betraclit kommenden Probleme*
THE POPULAR LECTURE IN THE CRUSADE AGAINST
TUBERCULOSIS.
By S. Adolphub Knopf, M.D.,
Profwaor of Fhtbiaio-Uwrmpy at the New York Post-Oraduftte Uodioal Sohool and H(M|>ital.
Valuable as the distribution of literature alwa3rs has been and will be to
enlighten the people on subjects of hygiene and the prevention of disease,
and although the interesting and instructive leaflets on the prevention of
tuberculosis have proved to be of incalculable benefit, the spoken word, the
verbal instruction to the individual, or the popular lecture to the masses,
has a most important mission to fulfil in this crusade against tuberculosis.
While it is by no means essential that such a lecture should always be
delivered by a physician, in smaller oommimities, where the lecturer is likely
to be personally known to a large number of the audience, the local physician's
words will be listened to, perhaps, with greater attention and respect than
those of a layman. If there is a local antituberculosis committee, the
lecturer should be a member of it; and if, as is of course desirable, several
physicians belong to the association, they should alternate in lecturing.
A public hall or school-house, easily accessible, well lighted, and well
ventilated, is of course the most suitable place for this purpose. It will not
do to lecture on tuberculosis and on the value of light and pure air in a gloomy,
badly ventilated hall. The lecture must be free to all and delivered at a
time when the masses can come to listen. The titles of the lectures should not
be gruesome ; they should be dignified, encouraging, and inviting ; for example,
like the following, which the writer has used with success: "Our Duties
Toward the Consumptive Poor"; "The Tuberculosis Problem and How it
May be Solved"; "The Prevention of Tuberculosis"; "The Joyful Message
of the Preventability and Curability of Tuberculosis " ; " Pulmonary Consiunp-
tion and the Possibilities of its Eradication Through the Combined Action of
a Wise Government, Well-tr^ned Physicians, and an Intelligent People";
"The Victory Over the Great White Plague"; "The Social and Humani-
tarian Aspects of the Tuberculosis Problem"; "TheDutiesof the Govern-
ment and the Individual in the Combat of Tuberculosis;" "The Successful
Warfare Against Tuberculosb."
If the audience is to be composed of women or school-teachers, it is well
to select titles similar to the following: " Women's Duty in the Fight Against
663
664
BIXTH INTERNATIONAL CONGRESS ON TUBERCtTLOSIS,
Tuberculosis " ; " Tlie Teacher's Part in the Antituberculosis Crusade. " Or U
the audience is composed of laborers, it is well to use a title similar to this:
*' What Can Workingmen do to Fight Tuberculosis Among Themselves? "
The handbills^ circulars, or cards inviting a general or a special public to
attend a lecture should be attractive and to the point- If it can be announced
that a prominent officer or a particularly honored citizen or preacher of the
city or State will preside over the meetings it will add to the prestige of the
movement and be likely to attract a larger audience.
1 give here three examples of invitation cards wluch should be issued.
They are a card of invitation issued by the Columbus Board of Trad©, a
handbill inviting the do thing- workers to a lectm*e on the prevention of
tuberculosis^ issued by the United Garment Workers of America and the
Committee on the Prevention of Tuberculosis of the Charity Organization
Society, and an excellent and attractive circular issued by the Newport
Association for the Relief and IVevention of Tuberculosis.
COLUMBUS BOARD OF TRADE
Secretary's Office
In the Board of Trade Auditi^nump on Saturday evening, March
18, 1905, at 8.15 o'clock.
Dr. X X . from N N , will lecture on "The
Duties of the Citiiens, and the Government, in the Combat of
Tuberculosis."
Governor Hcrrick Will Preside
and Introduce the Speaker.
NO ADMISSION CHARGED.
You are cordially invited to attendj and bring yoMT friends,
Veiy respectfully,
John Y. Bassell, R- Grosvenor Hittchins,
Sfcretsry, Prtsident.
POPULAB LSCrURE IN CBX78ADK AGAINST TUBERCULOSIS. — ^KNOPF. 665
ATTENTION V-oIkIH !
If you wish to learn how to guard against the
dreadful disease of consumption, which is
very common among the tailors, and which
can be easily prevented, come to the
MEETING
which will be held on
Sunday Eve, March 13
at 8 P. M.
EDUCATIONAL ALLIANCE HALL
Jefferson St Cor. £. Broadway
Professor Jacobi, Dr. David Blaustein, Mr. Jo-
seph Barondess, Mr. Paul Kennaday, and other
prominent speakers will address the meeting.
Mr. Henry White will preside.
ALL ARE WELCOME I
UNDER THE AUSPICES OF THE
United Garment Workers of America and
The Committee on the Prevention of Tuberculosis.
Do you want to know how consumption is cured ? At-
tend the free illustrated lectures on the subject which will
soon be announced in the papers.
Are you interested but cannot attend the lecture ? Write
for further information to
NEWPORT ASSOCIATION FOR THE RELIEF
AND PREVENTION OF
TUBERCULOSIS
290 THAMES STREET
(Over Aquidneck Bank) Room 5
TELL YOUR FRIENDS TO COME TO THE LECTURES
666 SIXTH INTERNATIONAL CONORB8S ON TUBERCULOBIB.
CONSUMPTION
Will You Help to Drive the
Disease from Our City?
LEARN
WHY?
HOW?
Newport Association for the Relief and Prevention of
TUBERCULOSIS
NEWPORT, RHODE ISLAND
POPULAR LECTURE IN CRUSADE AGAINST TUBERCULOSIS. — KNOPF. 667
It has sometimes been the experience of the writer as an occasional
lecturer before public audiences to be requested by the committee on arrange-
ment to avoid the word tulierculosia or consumption in the title of his lecture.
It was thought by the committee that too suggestive titles might keep a num-
ber of sensitive people away. Such titles as^ for example: "How May the
Health of Our Community be Improved?" "A Health Problem of Interest
to Everybody*'; "Health and Prosperity and How it May be Furthered"
might then be used.
In a public lecture on tuberculosis it is well to point out strongly the eco-
nomicloas accruing to a community which'does not take care of its consump-
tive poor at the right time and at the right place, when there is the best
possible chance for recovery, but waits until it is too late, and then cares
for them at the wrong place (county hospital or poor farm). It is best to
make such calculations with direct reference to the locality in which the lec-
ture ia deUvered. Thus, for example, in my own city and Stat« of New
York I have been in the habit of giving to my lay audience the following
convincing figures: It is estimated that there are in this State about 50,000
tuberculous invalids. Of these, probably one-fifth belong to that class
of patients which sooner or later become a burden to the community. These
10,000 consumptives, absolutely poor, will sooner or later have to be taken
care of by the public general hospitals. While they may not stay in one
hospital twelve months continually, they will certainly occupy a bed in
one or other of the public institutions for that length of time before they die.
According to a recent report by the public charity hospitals of New York
city, the average cost ijer patient per day in the general hospital is SL16.
Thus, the coat to the commonwealth will be $4,234,000 per year for caring for
the 10;000 consumptives. What would be the expense if they were taken
care of in a sanatorium? Experience in tliia country has demonstrated that
the maintenance of incipient cases in well-conducted sanatoriums can easily
be carri^i out for $1,00 per day. If these 10,000 persons could be sent to
a sanatorium in time, at least 6000 of them would be lastingly cured after a
maximum sojourn of two hundred and fifty days, at an average expense
of $250 per capita. Thus, for $1,500,000; 6000 persons would be made again
bread-wianera and useful citiaens. If the remaining 4000 invalids were
kept in the sanatorium one year before they died, it would cost $1,460,000.
Thus, taking away from the tenement district 10,000 consumptives, curing
more than half of them, caring for the other half, and destroying 10,000 foci
of infection will cost f2^1>60,000; when not taking care of them in the earUer
stages of this disease, they will probably all die, since this 10,000 represents
the absolutely poor, who now live under moat unhy^enic conditions; they
will have infecte^l a perhaps equally large or larger number of individuals
Uving with them, but before dying they will have cost the community
$4,234,000.
668
glXTO INTERNATlONAli CONGBESS ON TLTtS KKCUU3SI8.
Another valuable argument which may well be presented in any public
lecture is that reJating to the loas which accrues to a community by faiiiag
to prevent ita peuple from becoming tuberculous. Besides the lQ^saQd sorrow
which are naturally felt by the incUvidual and family, the economic loss from
tuborculuaia flustained by the commonwealth is tremendous. Dr. Thomas
Darlington^ the Health Commissioner of New York city, in speaking of the
cost of tuberculosis in that city, declares in a recent publication: "EstimsU
ing tlie value of a amgle life at 11500 — not necessarily a high estimate—
and taking only the Uves between sixteen and forty-five years, the los of
life in that city alone from tuberculosis amounts to the startling sum of
123,000,000 annually."
It should never be forgotten in a public lecture that much good may ht
accomplished by a dignified protest against the use of patent medicLDes and
the dangeroiia and nefarious trade of quacks who advertise "sure consump-
tion cures," claiming some secret method or remedy. A very valuable
pamphlet has been issued by our Tuberculosis Committee and the New York
Department of Health on so-calletl consumption cures.
I take pleasure in reproducing it here for those who wish to use it U
their propaganda.
CONSUMPTION "CURES.''
The Consumptive tb the Ideal Victim of the Ottack, Charlatak,
AND Vender of Pateiw Medicines. Consumptives spend more money on
patent medicines and special modes of treatment than any other cl&ss of
persons who are really ill. The amount of money thus thrown away is almost
as great as that obtained from fancied or real sufferers from catarrh or
dyspepsia. Every year sees new remedies and methods of treatment ad-
vertised, only to be replaced later by others; and almost all these " cures,"
if well advertised for a timcj pay their originators wclL All such Adveb-
TisED Special "Cures** and Methods of Treatment are practicai*lt
WoRTHLESSj AND Many OF THEM Harmfuu As Saniucl Hopkios Adduns
says in hig article on "The Great American Fraud'* in "Collier's Weekly,"
" Every advertbement of a consumption cure cloaks a swindle. **
There are a number of reasons why the consumptive is such an easy prey
to quacks and charlatans. Consumption is not a disease of rapid progress
as compared to other illnesses; even the cases of '^galloping consumption"
rarely terminate in less than three months, and the average case of con-
sumption lasts at least two or three years. There is ample time for the con-
sumptive to look about him^ to grasp at any stra^n^ in the way of assistance^
The consumptive is, by a wise provision of Providence, hopefid — and this
brings with it credulity. Many consumptives have not the time or money to
undergo sanatorium treatment, or to provide themselves with the special
diet so often necessary, and naturally lend a willing ear to the assertions
of the quack, who promises to cure them rapidly, cheaply, and without
keeping them from their work. In consumption there ia not the prostration
i
POPULAR LfiCrtJRB IN CRUSADE AGAINST TUB URCULOSIS.— KNOPF.
and diilUng of the senace that so frequently accompanies other grave diseases.
The consumptive has time to realise all that life means, and to desire ever
more ai"dently and keenly to live.
Consumptive *' cures " may be classified as follows:
1. Patent Cough Medicines. These almost without exception contain
either considerable amounts of opiura or morphin, or else alcohol. Both
drugs are bad for the consumptive ; they give only temporary relief and leave
him in a worse state than before.
2. Special Remedies for Consumption, These consist of preparations of
vegetable or mineral substances, usually claimed to be very rare or to be
found only in distant parts of the world. They are practically \^*ithout any
effect whatsoever as regards curing the disease.
3. Serum Treatment. Based on the remarkable value of antitoxic serum
for diphtheria, many serums are advertised to cure consumption. So far no
eerum having any curative effect baa been discovered.
4. Special Diet. Curative influence is claimed by some of the quacks for
special kinds of food — all meat or no meat, beef blood, onions, oliveSj etc.
5. Electricity, x-Rays, Light and Cabinet Cures. These various methods
have no special value in consumption. Some of the frauds claim by their
means to render the absorption of specific medicines more rapid and thua
more efficacious.
6. Plasters, Poultice, and Other External Applications. While the
pain of a tuberculous pleurisy may be relieved by the application of a mustard
plaster, yet such prof-edures have no effect on the disease of the lungs. To
produce ulcers of the chest wall by means of blistering plasters is a useless,
brutal mode of treatment, and to claim that the discharge ('* corruption")
from such ulcers comes from the lungs is a deliberate falsehood, uttered
knowingly. Such procedures are harmful^ aa they exhaust the strength of
the patient.
There Is No SPEriFTc Treatment For CoNstnoTioN. A Suffktibnt
Amount of Proper Food, With Plenty of Fresh Am and ResTj Con-
stitute THE Essential Basis of All Successful Methods of Treatment,
Realizing the truth of the above statements, the Committee on the Pre-
vention of Tuberculosis of the Charity Organization Society of the City of
New York has passed the following resolution:
Whebkas. It has come to the knowledge of the Committee on the
Prevention of Tuberculosis of the Chanty Organization Society that many
8o-cailed specific medicines and special methods of cure for pulmonary
Tuberculosis have been and are exploited and widely advertised, and
Whereias, In our opinion there is no specific metiicine for this disease
known and the so-called cures and specific and special methwis of treatment
(by electricity, x-rays, electric light treatment, *'diet" cures, plasters,
serums, etc.) widely advertised in the daily papers are, in the opinion of the
Committee, without value, and do not at all justify the extravagant claims
mode for them, and sen^e chiefly to enrich their promoters at the expense
of the poor and frequently ignorant or credidous consumptive ; therefore,
Rc^wlved, That a public announcement be made that it is the unanimous
opinion of the members of this Comimttee that there exists ao specific medi-
070
SIXTH INTERNATIONAL COtfOHESS ON TUBERCnLOStS.
due for the treatment of pulmonary tuberculosis, and that no cure can beet-
pected from any kind of advertised medicine or aiethod, but only froms
sufficient supply of pure air, nourishing food, needed r^t* attention to the
hygiene of the skin^ and such medication as appears from time to time re-
quired, in the judgment of a physician/'
The above-mentioned Committee is composed of physicians and lajTLen
all of whom are specially interested in the aubject of tuberculosis, lis pre^-ec-
tion and cure.
Such or a similar leaflet should circulate in every community, and tke
names of promment phymciana should be attached to it. I am coovinoftd
that surh a circular would do much toward convincing the people that lU
the so-oailed sum and quick cousimiption cures advertised as such are in^
variably based on false claims.
To say a few words on the abuse of alcohol, to denounce the idea that it is
a valuable preventive in tuberculosis or an estimable nieans to cure, should
be the duty of every physician. In doing so he need not make his lecture &
fanatical temperance talk. Every physician is justified in stating that alco-
hol ig no preventive, that the abuse of it predisposes to tuberculosis, and
that in this disease alcoholic beverages should be considered medicine, aad
not be taken except by order of the physician.
The lecture itself should, of course, be practical and to the point, avoiding
too tedinical and too scientific expressions. It is not always easy to speak
the language of science in the language of the people, but one should strive
to use plain, simple words and make himself well understood- Wliile a ^j
dignified and earnest manner will always appeal to an intelligent audience, ^H
the lecture should be enlivened with some bright, cheerful suggestions, and ^^
even an occasional witty remark may find its place. If the lecturer is able to
speak extemporaneously, it is always the most appealing and successful
way to reach a popular audience. But whether the address is extempora-
neous or read from manuscript, it should not exceed three-quarters of an hcMir
in length. The remaining quarter of an hour should, whenever posstble,
be devoted to showing stereopticon views, illustrating de\'ices for the pre-
vention and treatment of tuberculosis, such as sputum*cups, reclining choirs
window-tents, chair half tents, sleeping tents, sleeping shacks, leaa-tce^
Banatoiiums and special hospitals.
While illustrations of bacilli may be useful and interesting^ it hardly
seems wise to show a popular audience reproductions of patholo^cEil speci-
mens, such as decayed lungs, etc.
No public lecture on tuberculosis is ever complete or will ever fulfil its
mission without an ardent remonstrance against phthisiophobia — that insane,
exaggerated fear of the presence of consumptives, as such. The lecturer
must have, of course, previously explained the simple measures b^' which
4
POPITLAH LECTURE IN CRUSADE AGAISTST TUBERCULOSIS,— KNOPF. 671
^
the consumptive may protect others from infection and himself from rein-
fection, and thus have shown to the au<lienc€ the folly of individual phtliisio-
phobia. In a popular lecture it should be declared emphatically that the
clean, conscientious consumptive who takes care of his expectoration is no
more a danger to his fellow-men than any healthy citizen^ and that he should
be treated with the utmost kindness and consideration.
Those who as official authorities or private citizens oppose the establish-
ment of sanatoriums and sj^ecial hospitals for consumptives must be con-
vinced of their error. They should be shown the great educational value
of a sanatorium for consumptives, and should be told that any patient who
has been in a sanatorium, if even only for a few months, must of necessity,
on account of the training he will have received, become a hygienic factor
in the community to wliich he may return, improved or cured. If this simple
assurance does not suffice to convert them from their unjustified prejudice
agiunst the establishment of a tuberculosis institution, they should be shown
the statistics of this country and Europe, which prove that the mortality
from tuberculosis among the inhabitants of villages and towns where sana-
toriums for the tuberculous are situated has always been considerably reduced
after the establishment of these institutions. The cleanly and sanitary
habits prevalent at the institutions, involuntarily imitated by the villagers,
have resulted in diminishing consumption in their own miilst. Thus the
well-conducted and well-equipped sanatorium for consumptives serves not
only as an institution to cure, but also as an institution t« prevunt the spread
of consumption. It can even be demonstrated that the prosperity of the
community which harbors a sanatorium for the consumptive poor has alwaj-s
been improved thereby. By the cures accompli:3hed in such a sanatorium,
wealth}' invalids are almost invariably attracted to the locality.
But besides this individual orofacial fear of the presence of the consump-
tive on account of his disease there is another prejudice, based on his
alleged difTerent and peculiar mentality (egotism, selfishness, immorality,
etcO' People forget that among the consumptive invalids of the past and
the present there have been and are same of the best types of manhood and
womanhood — useful, noble, and valuable citizens, humanitarians, scientists,
and philanthropists.
Some years ago I had occasion to address a group of physicians and jur-
ists, and chose for my title, "A Plea for Justice to the Consumptives." In
preparing the address I had collected a number of opinions on the moral
standard and mental attitude of the average consumptive. I received re-
pUea to my inquiries from such men as Biggs, Bowditch, Bonney, E. D,
Fischer, Flick, Janeway, Klebs, Osier, Otis, Trudeauj and they all concurred
in the opinion that the moral and mental state of the average tul>erculous
patient is equal to that of any well person or patient afflicted with other
672
SIXTH mrCRNATIONAL CONGREfla ON TC7BERCtrL08l&
diseiisee. Dr. Trudeau, to whom we all look up as the Ameiican pby
who haa, perhaps, the largest individual experience with oonsumpi;
ftl! elames of doctety and in all singes of the disease, wrote to me ti
lowing in direct reply to the statement which a phymcian had made
medical press* to the effect that, in the average consumptive, ps;
thenia, — the loss of self-control and the rise of bru(^ selfishness, — cou-
to distort the clearness of the patient's ethical perception:
ifnva^H
*' I have never noticed any greater tendency to inunorality or crime
consumptives than is to be found in the average of the human race» as (at
it haa come under my observation. On the contrary, I have seen all the fiae?
iraite of human natiue developed to the fullest extent by the burdens whicfa
chronic and fatal illness, often slow in its progress, odds to the ^um totAl of
what men and women usually have to endure in life. I have seen cerUtnlf
more patienccj courage, self-deniali and unselfish devotion to others in ooa-
Bumptives than I have noticed in the majority of healthy bum:in being?.
Indeedj the sanatorium work never could have been carried on were it not
for the self-sacrificing devotion to the suffering of others shown by my as-
BoeiateSj the nurses, and even the employees at the sanatorium, most «f
thera having corae here originally because suffering from tuberculous disease.
History is full of instances which prove that tuberculosis does not interfere
with the development to the highest degree of the intellectualp the moral,
or the ethical sides of man's nature,''
When the lecturer has read to the audience such beautiful lines as these
of Dr. Trudeau, he may be sure of the sympathy of his hearers, and a large
stride toward overcoming phthisiophobia will have been made. If the lec-
ture which is to be delivered has for its purpose to solicit financial help, it is
well, besides presenting the figures above referred to, showing the advantages
of treating the patient at the right time and at the right place, to relate Ode
or two personal experiences from the lecturer's own professional life.
The public press is a most powerful factor, and ijidispensable in our cru-
sade agmnst tuberculosis; but at times there is a tendency among the young
reporters to try to find something sensational in the lectures they are aeat
to report, or they misunderstand the lecturer, and the result is a dlstortioa
of the ideas the lecturer had tried to convey- To guard against this
there are two remedies: either to hand a manuscript or a synopas of ibe
address to the reporter or ask the newspaper to submit to you the proof
before pubUcation. With these precautions you may avoid erroneous and
sensational statements*
Every lecturer will thank his hearers for the close and careful attention
they have given him, even if the attention could have been a little closer.
But when lecturing on tuberculoaia, one should never fail to announce It
*Sftx(j: "Psychical Relation of Tubereiilosb in Fact and Fictioo *' New Yoric
MedJo^ Jdui-Dal, Aug. 1 &ad 8^ 1903.
POPyLAK LECTURE IN CRUSADE AGAINST TUBERCXTLOSIS. — KNOPF, 673
personalty^ or have it announced by the chairmjin, that at the close of the
address the lecturer will be glad to answer questions.
If the lecturer is a physician, he will be almost invariably asked questions
as to the beat methods to pursue in individual cases, what kind of medicine
to take for a certain symptom, and so on. The lecturing physician vnW
then have to use the necessary tact to avoid ansT\'ering directly, and will
refer the patients to their family phyaicianSj or if they have none, to any
physician of their choice.
It is not always a grateful task for a medical man to give a popular lec-
ture, and the pubhc does not always appreciate the tiroe and sacrifice it
involves to the busy practitioner. Some people may even be so ungracious
as to consider it a means of advertising. All this one must forget, and find
his reward in the feehng that he has done his duty, hved up to his calling,
and been a true doctor — which means a teacher.
I
LasConf erencias PopwUres en la Cruzada Contra la TuberctUosis, — ( Kkopf*)
Mieutras que la distribuci6n de literatura para instruir el pueblo es muy
valiosa 6 indispensable en la prevencion de la tuberculosis^ la irxstrucci6n
verbal, las conferencias populares hechas por m6:lico3 competentes. son
igualmente importantes, Iwos lugares para tales conferencias deberan ser
los edificios pubUcos, escuelas 6 iglesias.
EI tema de la confercncia debera ser sobre las p^rdidas econ6micas
consecuentes a la tuberculosis en las comunidades que no dan la debida
atenci6n a los tisicos pobres y que tampoco eduean el pueblo sobre la pre-
venci6n de la enfermedad. El orador dcberA instruir el pueblo contra e! uso
de remedioa secretes, avisos tales como "cura segura de la tisis," etc< El
deberd iiisistir en que la luz del Sol, el aire puro, buena alimentacif5n, iodo
esto hecho bajo la direcci6n de un medico competente, es el mejor medio
para la cura de la tuberculosis. Sin que la conferencia tome un cardcter
fandtico sobre la temperacia, el orador deberi insistir en que el alcohol no
es un medio preventivo contra la tuberculous, y que el exceso de fete pre-
dispone 4 ia enfermedad. La conferencia deberd ser prictica; demasiado
tecnicismo y exjiresionea cientihcas deben evitarse.
A la ayuda de ilu^raciones (escupideras, etc.) el orador deberd demostrar
cuan f Acil es la prevenci6n de la tuberculosis por medio del cuidado apro-
piado con el esputo, Mostrando los tratamientos al aire libre y las foto-
graffas de los sanatorios, el orador debera dar una idea del tratamiento
modemo de la tfaiii, Deberd reclamar conaderaci6n para los tlsicos cuida
dosos en et modo de disponer de las expectoraciones.
La prensa publica del^era invitarse d las confeienciaa, maa seri mejor
dar UD resumen de la conferencia 4 fin de evitar algunos ermrcs en la in-
voL. Ill— 22
eri
SIXTH INTERNATIONAL COKGR£S$ OV TV BEBCUJJOQIS.
terpretacioD del tema. Una conierencia bleu prepamdn es prefenble
vez lie la lectura de un manuscnto, m^ la lectura de tin manasczilo tun
prep:inido es preferible 6d vez de un discurso desconcertado. 1m oOQfe^
ericia no deberS prolo&garae, como regla, mas de tre^ cuartos de boxs: i
la audiencia deber^ pcnmtfrte quince minutes para baoer Biginmt pc^
guntaa.
La Coof^remce Populaire dans la Lutte Coatre U Tuberculose. — (Em>f?.}
Bien que la distrtbution de litt^rature pour ^lalrer le public sor la
meBures h prendre poiir combattre la tuberculose soit d'une grande v&Ieur*
la parole, la conference populaire, par un tn^ecin biea instruit est tout auas
importante. Une telle conference devrait avoir lieu daoa une s&lle publique,
une 6cole ou une ^glLse, d'acc^ facile, bien ^clairfe et ^VBnf^.
La perte ^conomique que subit une communaut^ qui ne soigne pa3 ses
phtiaques indigents au propre moment et en propre lieu, et qui n'insimt
pa3 le public dans la prophylaxic de la tuberculose, de\Tait ^tre pr^ewil^
par le couf^reucier d^une mani^re frappante. II faut qu'il mette son audh
toire sur ses gardes centre Temploi dea remMes aecreta, afficb^ comiDi
"rcm^es infailllbles contre la phtisie/* etc. Le conf^rencier insisteta sur
ce que le soleil, le grand air, la aouniture aLmpIe et bonne, — ^tcut sous k
direction d'un m^decin — eont les meilleurs moyena pour gu^tir la phtlsie.
Sans faire de sa conference un discoura faiiatique contre ralcoolisine, il
faudrait faire reniarquer que I'alcool n'est pas un moyen pri6ser\^ateur contre
la phtisie, et que, au contraire, Temploi excessif de* ralcool dispone k la
maladie. Que la conference soit pratique et que le conf^rencier se garde de
Be ser\'ir de phrases trop techniques et trop scientifiques.
A Taide d*objeta comme crachoirs, etc,, dont il ferait TexpoaUon devant
Faesistancef le conferencier montrera comme on pent facilenient emp^cher
la phtide en soignant les crachata tuberculeiix. Qu'il montre des appareild
employes dans le traitement au grand air et des photographies de aanaioritua,
pour donner k I'auditoire une id^ du traitement modeme des poitrinaires;
II liii faut aus^ en appeler k ta bout^ et k la consideration de Tassistanoe
envers le phtisique soigneux et consciencicux dans la disposition de ses cm-
chats.
On devrait inviter la presse publique k la conference, mais il vaudrait
mieux pour tout le monde de donner un resume du discoui3 aux reporters,
afin d'e\'iter dans les journaux les details faux et mal compris, Un diacout?
bien prepare et sans notes vaut mieux que la lecture d*un manuacrit; m^
une conference bien prfiparee et bien lue vaut mieux qu'un di^oura k rim-
proviste, divagant et desunL Une conference populaire nc doit pas» en gen-
eral, durer plus de trois quarts d^heure. Quince minutes suffi^ni k V\
toire pour poser des questions.
POPULAJl LECTUKfi IK CHUSADE AGAINST TUBERCULOSIS. — KNOPF, 675
Die Bedeutimg allgem«in verstandticher Vortr&ge tm Kampfe gegea die
Tuberculosc. — (Knopf.)
Obzwar die Vertheilung von Ut«ratur Kur Atifklaruag des Volkes in
Beiug auf Vorheugung der Tuberculose ausserordentUch werthvoll und
iinentbehrlich ist, so ist doch das giesprochoae Wort, der allg)emein verstand-
liche Vortrag eines competentea Arztea, von ebenaolcher Wichtigkeit. Ein
fiolcher Vortrag soil stattHnden in emer offentlicheu Halle, eiaem Schul-
hatise oder in einer Kirche; der Ort soil leicht zu erreichen seio, gut beleuch-
tet und gut geliiftet aein*
Der ocoaomische Verlustp den ein Getneinweaen erieidet, welchea tdclit
fiir seine armcn Schvvindsuchtigen zur reehten Zeit und an dafiir geeigneten
Platzen Sorge tragt, und dau Volk nicht iiber Vorbeugung der Tuberculose
belehrt, sollto den Haiiptgegenstand des Vortrages bilden, Der Vortra^
gende soil die Zuhorerfichaft wamen gegen den Gebrauch von Geheinimit>-
te!n, vor angezeigten *'slcheren Schwindauchtskuren/* etc. Er soil nach*
drucklich hervorheben, dass Sonnenlicbt, frische Luft, einfache aber gute
Nahning — allca unter Aufaicht eines Arztes— die besten Mitt«I zur Heilung
der Tiiberculose fiind. Oline aus seinem Vortrage ein fanatischea Enthalt-
samkeitsgespmch stu machen, soil er hervorheben, dass der Genusa von Alco-
hol kein Vorbeugungsmittel gegen Tuberculose ist, und dass ein ubermassiger
GenuHs desseUieu zn der Krankheit veranlagt. Der Vortrag soil practisch
sein; zu technische und zu gelehrte Ausdriicke soUen vermienlen werden,
Der Vortrag^nde soil tnit Hulfe von Illu^itrationen (Spucknapfe, etc.)
zeigcQ, wie leicht die Tuberculose verhiatet werden kann, werni man auf
das tuberculoae Sputum aufpasst. Dufch Vorzeigen von Hiilfiimitteln
zur frischen Luft^Behandlung und Ansichten von Sanatcricn eoU er der
Zuhorerschaft eine Idee von der modemen Behandlung der Schwindaucht
geben. Der Vortragende soil Gute und Aiifmerksamkeit fiir diejenigen
Schwindaiichtigen enipfehlen, wekhe aorgfaltig und gewissenhaft in der
Wegschaffimg ihres AuHwurfes sind.
Vertreter der offentlichen Presse soUen zu den Vortriigen eingeladeu
werden; es iat aber am besten, wenn man den Berichterstattem einen
Auszug des Vortrages giebt und dadurch das Erscheinen von falschen luid
misadeuteten Bebauptungen in den Zeitungen vermeidet. Ein gut vorbe-
reitetcr Vortrag, obnc Benutzung eines Manuscripts, ist einem Ableaen aus
einem Manuscripte vorzu2dehen; aber eine gut abg^lesene, sorgfaltig vor-
bereitete Vorlesung bt doch besser als ein unzusammenhangender. umher-
achweifender und unvorbereiteter Vortrag, Ein popularer Vortrag soUte in
der Regel nicht langer als dreiviertel Slunde danem; fiinfzehn Minutcn
sollten den ZuhOrem zum nachtraglichen Fragestellen zur Verfiigung gestellt
werden-
THE BLUE STAR.
A SBfFLE AND PRACTICAL WAY TO INTEREST PEOPLE
IN TUBERCUIJDSIS AND TO RAISE FUNDS TO
COMBAT THE DISEASE.
Bt Glaha E. Dtar,
Delrait, MichJcfta.
In presenting this subject to a world-congress I am Impelled by the belief
in the efficacy of an emblem the success of which in tuberculosis relief work
seems to justify its introduction to all the countrira of the world. Symbals
have been the inspiration of great movements. From the winged globe of
Elgypt to the star of Bethlehem, forms of flower and fruit, bird and beast,
cloud and star^ have expressed a living thought to man; and of all these
symbols, no one more fully embodies man's hope and aspiration than the
star. Though far above our planet^ its light penetrates jungles and deep
woods, as hope lightens the darkest of human destinies.
The old astrological meaning of the five-point star is man — humanity —
the upper point being the head, the lateral and the lower points the extended
arms and legs, — man dominating the lower elements of his being; and as such
this symbol seems peculiarly appropriate for a movement which aspires to
dominate disease.
In suggesting a star as the emblem for TubercuJoas Charity Day in De-
troit, June 9, 1908, I believed it to express the sentiment of those who inau-
gurated this movement and of others who were to give time and money to
bring it to success. The Executive Committee for Charity Day accepted ray
suggestion, and also that of Dr. William E. Blodgett, to make the star blue,
the eanitary color, which is significant of progress toward better condi-
tions of living. Blue has also its ethical dgnificance of purity and fidelity,
A blue star on a white ground was adopted as the emblem for June 9th.
On "blue star day*' was inaugurated the fir^ general effort for the preTCO-
tion and relief of tuberculosis undert-aken by a voluntaiy association in
Detroit, and as the unusual success of this collection day has been largely
attributed to the use of the blue star, an accMiunt of the work of this volun-
teer association seems of importance, in the hope of interesting other dtks
aod towns, not only of Axnencaf but of all the countries represented in tfas
676
THE BLUE STAH. — DYAR.
677
congress, to adopt theaame meanB of creating general interest in the preven-
tion and relief of tuberculosis*
The voluntary association called the Executive Committee for Tubercu-
losis Charity Day grew from a suggestion made to the Visiting Nurses As-
sociation. The society, being in need of funds to carry on ita tuberculosis
relief work, welcomed the idea of a public donation day to this cause, such
as has been held for various charities in Columbus, Toledo, and other cities.
A meeting of those interested in promoting a public collection known as
"tag-day" was called, and an executive committee appointed to organize
and direct the working forces for Charity Day. This committee, with its
aubcommitteea, included the mayor and many prominent physicians of the
city^ trustees of the Tuberculosis Society, membera of the Tau Beta Society
for the Relief of Tuberculosis, women prominent in social and club life,
young girla and boys, young women and young men, teachers in the schools
and superintendents in the factories, people of all faiths and widely varied
interests working together to save Detroit from the ''white plague." A
remarkably well-conceived organization was set in motion by the chairman,
and the fact that the committee had only three weeks in which to prepare
for blue star day made its results most noteworthy.
In a proclamation Mayor Thompson set forth the aims of the committee
and gave official sanction to June 9th. This manifesto, widespread through
the aid of the press of the city, reached all cliisses and prepared them to con-
tribute to the collection boxes in charge of the committee, each peraon to
receive in return a white pasteboard "tag" printed with a blue star, indica-
tive that he or she had helped the cause and would not be asked to contribute
a second time.
On Alonday, June Sth, the members of the committee assembled on the
steps of the city hall, where the mayor presented the chairman with a
" floral key/' therewith bestowing upon her the complimentary right of office
of mayor for June flth. Directly following these ceremonies, which attracted
much pubUc interest, both at the time and in newspaper reproduction the
next day, a mass-meeting was hehi in the Detroit Opera House, across the
square, at 'which prominent officials, physicians, and religious leaders gave
their hearty endorsement to the movement and enthusiastic commenda-
tion of the organization which was to be put in operation the next day.
On June 0th the marshal of the day assembled her force of fair collectors
and their chaperones and aides, messengers and other officers of the day, at
the Hotel Pontchartrain, which had l»een generously offered by the manage-
ment as headquarters for blue star day, as well as for the preparatory meet-
ings. Stations for recxiiving collections had been assigned in tlie principal
shops, office-buildings, and hotels, and in the schools and factories. Ma-
trons and young women, accompanied by young men as protectors, started
678
SIXTB INTERNATIONAL CONGBESS ON TUBERCULOSIS.
in automobiles from the hotel to their variouB posta, carrying the collection
boxes (white pasteboard cylinders, marked with large blue stars) and wear-
ing blue star badges and arm bands marked with blue stars. The blue star
on the white ground, the emblem of the day, placed on street^cars^ automo-
biles, banners, etc*, gave an air of festival to the principal streets, and a
large blue star on white placed on the city ball showed municipal approval
of "blue star day."
From early morning of this beautlfuJ June day till late evening fair col-
lectors exchanged blue star tagig for contributions to their boxes — ranging
from one penny to several hundred dollars. At intervals during the day the
filled boxes were taken by messengers in automobiles from the various sta-
tions to the People's State Bank and opened by responsible tellers under the
supervision of the president of the bank, who was treasurer for Charity Day.
These boxes, heavy with pennies or light with paper bills, were the evidence
of a widespread sentiment of sympathy and justice to sufferers from tubercu-
losis. Little stories of personal sacrifice, on the part of contributors of
small amounts, gave value to the boxes filled with pennies and small coins.
The motive for giving in many cases was the remembrance of some relative,
friend, or neighbor who had "died of consumption.'*
In all cases the "blue-star tag" seemed to have a peculiar attraction-
Many bought these "stars of hope" to take to sufferers at home, showing
their belief in the suggestive power of the emblem. In the factories there
was enthusiastic exchange of coins for stars, and in the public schools the
children were eager to buy **blue stars" for themselves and parents and
little sisters and brothers at home. Those having charge of this department of
the collection said that the star emblem increased the contributions at least
one-half p for every child wanted a star. On that day few grown people cared
to be seen without one, so general was the sentiment, which one cannot fail
to attribute in part to this emblem of hope for sufferers-
The financial results of June 9th (with the contributions sent on follow-
ing days to the chairmen of the committees by those who were not able to
go to the stations on the collection day) amounted to SHfOOO. Considering
that the committee had only three weeks in which to bring this new idea
before the Detroit public (and the depression in the business world)^ this
amount was most satisfactory.
Not too much can be said in praise of the press of our city, which from the
first gave full notice of the plans for "blue star day,*' and from day to day
followed the action of the committees. In all the papers, for several da)^
before June 9th, stars appeared on every page, accompanied by quotations
from authorities on tuberculosis, such as Dr. S. A. Ivnopf, as well as senti-
ments of local ofHcials and authorities. On June 9th much space was given
to reports from the Pontchartroin and the stations, accompanied by snap*
THE BLUE STAB. — DYAK,
679
shots of the fair workers receiving collections. Editorial comment on tbe
movement was highly commendatory.
The funds were placed in the hands of a finance committee made up of
the representatives of the various Kocioties interested in the prevention and
cure of tuberculosis. The city was divided in four sections, and nurses
were engaged to visit the tuberculosis poor in the north, south, east, and west
districts, these nurses to be under the direction of the Visiting Nurses A»-
flooiation. It is planned to use part of the funds to support patients in the
new shacks which the city is building and for other relief work.
However important the securing of such' an amount of money and the value
of its distribution, the educational results of such a general rousing of public
intorcvst must exceed it. A keener sympathy for tuberculosis victims and a
sentiment in favor of more stringent laws in regard to sanitation— such as
ventilation and spitting— are among the good results of '*blue star day."
Andj still better, a greater freedom in speaking of tuberculasia and the will-
ingness of those afflicted to report their trouble both to doctors and to the
Finance Committee. Police and street railway officials promised to enforce
the laws in regard to ventilation and spitting, and acknowledged their fault
in not having done so before.
However brilliant and efficient the work of organisation and the carrying
out of plans for Charity Day, it is generally conceded that the blue star was
largely responsible for the lasting effect of the movement. To all, it was a
star of hope, and it has become a star of progresa^ and will identify all of our
public effort along these lines. Literature on tuberculosis for general dis-
tribution, issued by the Finance Committee, bears the blue star, and the
placards in street^cars, to be used later, will attract by this well-known
emblem.
From the first I believed in the value of this star emblem, and of the im-
portance of securing it for tuberculosis work. With that end in view, I
attended the State meeting of the Michigan Association for the Study and
Prevention of Tuberculosis, which met in Grand Rapids, June 23d, in order
to introduce their emblem to the State. The blue star was adopted by the
Association, and any future work of this character undertaken in Michigan
by this organisation will use this emblem.
Already Kalamazoo, one of the smaller cities, has followed the example
of Detroit in holding a successful blue star day, on Friday, July 24th. Other
cities of our State are planning relief work of a similar character, and mil,
of course, use the star. The only fear is that this emblem, if not secured for
tuberculosis relief work throughout the country, will be used by other organi-
zations for the growingly popular "tag-day." Cities in other Stat^ have
written asking to use the star for other chariti^, but it is our hope to secure
it for tuberculosis relief work.
oso
SIXTH tXTERXATlOKAL COXGR£8S ON THBEBCULOfiXa.
of its sucoesB in Michigan, I offer my suggeetioa to the memba»
ot this oongres», made after consultation with eminent authorities on luln^
cuJosiB and diaftinguisbed members of this congress, that the blu&suvbe
univwsaDy adopted as the emblem for fteld-work in the tubemiloos wv-
Because of its universal mgnificaocc as the emblem of hope and peace, it
makes universal appeal. The fact that it is not a novel emblem ism its
favor, for ita meaning is apparent or felt by the most simple. Tbcesvl^
do not entirely understand are, at least, attracted, which is half the effort
The sentiment of hope b the prevailing one in the treatment of all disMKs.
for hope is in itself curative.
The first use that I would suggest for tills emblem wonJd be its adoptioo
by tuberculosis nuraes» or any nurges attending cases of tuberculosis. Tha
need not interfere with tho wearing of the red cross, but siuipJv indicatr »
more hopeful aentiment than that suggested b3- an emblem of suflerioE.
An order of blue star musses might be foun<ied by some great philanthft^
interested in tlie prevention and relief of tuberculosis. Sueh an oiir,
started in America, would, I believe, in time become as universal as tte «d
cross.
If thia star of hope and peace could be placed in every tuberculceis ho^'-
tal and free dispensary in the country, a corresponding sentiment would Se
created and the belief in the fatality of the disease very much lessened- My
ambition for this emblem is not confined to my own country. I should lite
to see the blue star on the while ground the international emblem for tbB
work, but, realizing the sentiment and association attached to the presoit
emblem, the double red cross, I suggest that when the blue star has won stiffi-
eient recognition by general use in this country^ it be embodied with the pre^
ent international emblem.
Let the blue star, emblem of hope antl peace, indicative of man's domins^
tion over disease^ become as significant as the red cross of battle-fields and
great disasters, and the double red cross bearing the blue star become the
standard of a universal effort to combat the white plague.
La Estrella AzuL^Dyah.)
Informe sobre una asociacion voluntaria en Detroit, 5iichiganr 9 de
Junio de I90S; el objeto de la asociacion es de levantar fondos para la
lucha contra la tuberculosis. Hacia tal fin el emblema de la Estrella Axul
ha sido tan efectivo que esto ha sugerido el intoducirla en el Congreso In-
temacional para uso con tal ffn en este y otros pafses 6 adopt aria en coin-
binaci6n con el presente emblema, La Doble Crua Roja como el futuro
emblema intemacional. Colecciones diarias de caridad Si 1 ,000.
Los simbolos han sido la inspiraci6n de los grandes movimientos.
THE BLUE STAR, — DYAK. 681
La popularidad de la estreila se deja ver en el interns de los niiios en
comprar las marcas y tambi^n por la demanda de "Blue Stars" en las
estaciones de colecci6n en las principales oficinas de los talleres, hoteles y
factorlas.
Valor educativo del "Blue Star Day" demostrado en el interes general
y continuado en la prevenci6n y alivio de la tuberculoas.
L'Etoile Bleue.— (Dyar.)
Ck>mpte-rendu de Tactivit^ d'une soci^t^ volontaire de Detroit, Michigan,
le 9 juin, 1908, afin d'obtenir de I'argent pour pr^venir la tuberculose et
pour am^liorer la condition des tuberculeux. L'embl^me de TEtoile Bleue
eut un si bon effet que nous trouvons utile de le proposer au Congr^, pour
qu'il soit employ6 quand on ferait des soci^t^ semblables chez nous ou dans
d'autres pays; proposition d'adopter cet embl^me, qui, combing avec le
signe present, double Croix-Rouge, deviendrait le futur embl^me interna-
tional. R^sultat de la qu^te faite le "jour de la charity/' $11,000. — Les
symboles inspirent toujours de grands mouvements.
La popularity de TemblSme se montra par la h&te des 6coliers d'acheter
les ferrets vendus par notre soci^t^ et par la demande d' "6toiles bleues"
aux stations des quotes situ6es dans les principaux b4timents, magadns,
hdtels et dans les fabriques.
Valeur Educative du "jour de TEtoile Bleue": il a r^veill^ Tint^rfit
g6n6ral k la prophylaxie et au traitement de la tuberculose.
Adoption de "TEtoile Bleue sur un fond blanc circulaire," comme
emblSme du mouvement contie la tuberculose dans T^tat de Michigan.
TUBERCULOSIS AND THE PUBLIC SCHOOLS.
Bt Dr. Iajthkr H. GujjCKf
VitoKUw itf Pbor^CBl Tntnina i« Nvtr Ycrfc CSty.
The importance of attacking this problem throxigh the agency of
public Bcbools is tndieatad by the fact that ten out of eleven of all the child
of the United States come under the juriidiction of the public-achool syal
for approximately seven years of their lives— from seven to fouitcen.
otlker department of our government has so intimate a relation to the «
population as has the public-school system to ite children.
The ultimate attitude of society toward such problems as thia is
determined primarily by the discussions which occur in the daily
but by the attitude which is taken and secured by children during
<rf their school life. If the work is adequately done during t
it means a permanent set of coiivicttona and habits which shall giiid0
both in action and in thought throughout the rest of their lives,
The fact that departments of education are already awakened
their opportunity and their it^ponaibility with reference to mattm
health concerning children^ is indicated by an investigation of the md
recent reports of the superintendents of schools in the largest cities of tl
country. lb these reports there are extensive, useful, and intelligent d
cussions of one or another phase of this topic. Among others there shoxA
be particularly noted the following:
Baltimore, Md-
78th Annual Report of the Board of School CommiasionerB, 190(
Boston, Mass.
Annual report of the Superintendent of PubUc Schools of th
City of Boston, 1907.
Cambridge, Mass.
Annual report of the School Committee, prepared by the Supei
intcndent of Schools, Cambridge, Mass,, 11*07,
Camden, N. J,
Annual report of the Board of Education, 1906*
Cincinnati, Ohio.
78th Annual Report of the Public Schools of CindnDati, Ohic
1907.
TUBERCULOSIS AND THE PUBUC 8CBOOL8. — GUUCK. 683
Geveland, Ohio.
Annual Report of the Superintendent of Schools, Cleveland,
Ohio, 1907.
Fitchburg, Mass.
35th Annual Report of the School Committee of the City of
Fitchburg, 1907.
Hanisburg^ Pa.
Annual Report of the Public Schools of Harrisburg, Pa., 1907.
Los Angeles, Cal.
Annual Report of the Board of Education of the City of Los
Angeles, Cal., 1906-07.
Lowell, Mass.
82d Annual Report of the School Committee of the City of
Lowell, and 44th Annual Report of the Superintendent of Public
Schools, 1907.
Newark, N. J.
51st Annual Report of the Board of Education of the City of
Newark, N. J., 1907.
Newton, Mass.
Annual Report of the School Committee of the City of Newton,
Mass., 1906.
New York, N. Y.
9th Annual Report of the City Superintendent of Schools, City
of New York, 1907.
Syracuse, N. Y.
58th and 59th Annual Report of the Department of Public
Instruction of the City of Syracuse, 1906-07.
The steps necessary to be taken are four:
1. The Detection op Tuberculosis Among the Pupiia.
This is part of medical inspection. Up to the present time the data
which have been secured on this subject in America are of relatively little
value^ for the inspection which has been carried on has been for protection,
from those diseases which are recognized as more immediately contagious,
such as measles, scarlet fever, diphtheria, pediculosis, and the like. Ii&
a large number of cases the medical inspection has been carried on so rapidly
that each child has received but a few seconds' attention. The cases o4
tuberculosis which are sufficiently advanced to be discovered by relatively
rapid examination, without the removal of clothing, are obviously fe-^
For these reasons the data which we now have, as to the extent of tubercxi
losis among school children, are unreliable and inadequate.
2. The Detection of Tuberculosis Among Teachers and PROSPEcrrx'V
Teachers.
A large number of American cities have statutory enactments by ^^1>*-*
persons having this disease are not allowed to be teachers in the p%^^'
684
BIXTH INTERNATIONAL CONGRESS ON TtlBEBCULOaiS.
schools. This has occurred chiefly in the western States, toward which
those having the disease have gone for cure. It depends for it^ efficacy
upon the efficiency of the meclical inspection which precedes the license to
teach. In some places this is performed with faithfulness and ability,
and in otters it is not so performed. The presence of tuberculosis among
teachers must be regaixled as of the utmost danger to the community — of
more danger than is the presence of tuberculosis in any other class of persons,
for they, even with the utmost care as to the disposal of sputum, will cough
in the air, and so expose every pupil in the room to the contagion. Because
of the slowness of the development of tubercle bacilli, the danger of infection
from this source is not appreciated usually, the child having long since
passed from under the jurisdiction of the tuberculous teacher before the
results became evident. We have not as yet instituted in America any
periodic examination of teachers for the detection of those who are the
victims of this disease and tiieir elimuiation from the ranks. Such exami-
nations have been instituted in other countries, and it seems inevitable and
necessary for the protection of the community that they should be earried
on in the United States,
3, The Instruction of Pupils with Reference to the Fundamentai.
Facts REOAHDiNa Tuberculosis.
The iastruction that should be given to children may be divided into
two major headings; that with reference to individual hygiene, and that
which relates to social or community hygiene*
The emphaaia in this kind of instruction in America has already changed
from instruction in physiology as such to inatruction in hygiene. The original
assumption was that a knowledge of physiology was all that was needed
to modify the conduct of the individual so that he would lead a hy^enic
life. The experience of the last few decades has shown the futility of such
hopes. What is needed ia such instruction, example, and illustration as
shall lead the cliikiren to form habits which shall guide tiiem unconscttjusly
into effective living.
The legal requirementa of our several States demand that the Bubject
of physiology' and hygiene shall be taught during practically all the years
of school Ufe, It has been the custom to have series of text-books and
syllabuses which cover the whole subject each year, treating it during the
early years in simpler outlines, and with the advancing years adding tech-
nical details. From the standpoint of pedagog>' tlus is vicious, for it takes
from the subject all that freshness which comes from the approach to a
new topic, and new sets of facts. Accordingly, in the schools of New York,
Cleveland, and a number of other cities, the principle has already beea
adopted of selecting special points of view for emphasis each year.
TUBEBCULOBIB AND THE PUBLIC SCHOOLS. — OXJLICX.
685
During the first three years the instruction is largely by illustration and
Btory, without the use of a text-book. It is therefore exceedingly informal.
Beginning with the fourth year, however^ we find the syllabus demanding
particular attention to good health, as an object in itself. The following
para^aph, taken directly from the New York syllabus, is illustrative of
the objects r
" Pupils should be taught the value of pure air; the causes of impure air ;
the methods of purifj^g the air; the effects of impure air on respiration^
nutrition, feehngs^ and mental power; necessity of cleanliness in and about
the school building. They should be taught the necessity of a proper
ventilation of rooms; the nece^ity of an even temperature, of a change of
mr, and of the avoidance of drafts; the importance of pure air in sleeping-
rooms; the value of rest and sleep, and of a change of activity as related
to rest."
The difference l^etw^n this and the formal teaching of physiology to
these young children can easily be appreciated. The text-books that are
being prepared to meet this new application of the methods of pedagogy
are largely composed of references to facts within the child's knowledge
and experience, and allow a large amount of experimentation.
In the fifth year the point of view taken is tbat of accidents and emer-
gencies. Here the chief facts with reference to any specific subject^ as, for
example, the skin, may be given much as they were in the preceding year,
but this time from the standpoint of blisters, bums, scaldSi and the like,
so that, while the same subject may be covered, it is treated in such a way
as to be novel.
In the sixth year discussion is made of hy^ene from the standpoint of
the community, This, so far as we know, is new as a factor of elementary
school instruction. The following paragraphs indicate the relation of this
to tuberculosis*
"Attention should be given to matters of civic hygiene; to the city
water-supply ; to the diseases frequently incurred by taking drinking-water
from streams, wells, and springs; to the general policy of cities in reference
to water-supply anti water distribution; to the sewage system and the
disposition of waste by cities; to the danger of defective plumbing; to the
fire department, it« organization and use; to the need of clean streets; to
the work and duties of the street-cleaning department; to the danger from
spitting and the law bearing upon this; to the need of sun and air in rooms;
and to the building law relating to the hygiene of buildings.
" Pupils shoukl be taught the nature of contagious diseases; the necessity
of segregation; the treatment of epidemics and the law bearing upon the
subject; the importance of quarantine; the value of hospitals, dijspensaries,
and ambulances; the work and duties of the Board of Health.*'
686
SIXTH INTERNATIONAL CONGRESS ON TTJBERCITLOBIS.
The texts meeting these requirements give illustrations of the effects
of the new biiitding laws with reference to light and air in the tenements;
illustrations of the kinds of rooms in which tuberculosis is most frequent;
the results of overcrowding, and an account of the campaign in New York
city which resulted in the reconstruction of our building laws, the Juvenile
Street-Cleaning League which was started by Colonel Waring, and other
movements which bear directly u\yoTi these topics from the standpoint of
hygiene. Tuberculosis it^lf ie treated as a special topic^ and as one which
is vitally related to the children.
In the seventh year emphasis is laid upon the study of the body it^f,
inclutling the senses and nervous system. Particular point is made of
physical training: how people learn to do gymnastic exercises^ dance, and
the like. The physiology of the subject is given merely in explanation of
the facts themselves, which are brought out in dramatic form.
The eighth and closing year is given to the discussion of the nervous
system. Inasmuch as it bears no direct relation to tuberculosis, I shall
not go further into an elaboration of the subject,
4. The Instructiox of Pkospective Teachers with Referenci: to
THE Fundamental Facts ab to Tuberculosis.
Our daily acts are not predominantly the result of conscious thinking,
"but are and must be largely automatic. C^onduct, then, is the thing at
which we should aim, rather than mere intellectual information.
Because the great white plague constitutes at present one of the few
remaining general <lisea^ perils to mankind, it is necessary that tboae who
are to have charge of the education of chiUIren should have in their posses
sion those facts which are needed for daily conduct with reference to these
matters. Few of the normal schools in American cities have adequate
courses of instruction with reference to matters of health. The reason for
this is to be found in the history of the development of American schools.
Health has not been regarded as an object of education. Other institutions
in the community have l:»een regai'ded a£ being respoiisible for the health
of the children* With the reconstruction of society, due to the development
of machinery, with the development of a democracy which depends upon
the intelligence of all the citizens, the State had to adopt general education,
not primarily because of the elevation of the individual, but as a measure
of self-protection. These are the fundamental reasons why the State mu^st,
through the same agencies, the departments of education, protect itself
from those ravages of disease which are dependent upon ignorance with
reference to the fundamental facts of life. How to so manage the home
organization as to live most effectively, has only recently come to be re-
garded as one of the basal elements in general education. Therefore as
^ifrj
TCBERCSIpOBIS and the P^BUC schools. — QULIOL.
687
yet it is not treated as a prominent topic in the curricula of our normal
Bchoolfi or colleges* In practically no normal school is it ranked yet with
such Sfiences as psychology, education, history, and the like.
This changed attitude of the State toward health, expressing itself
through the schools, does not mean merely, or mainly, the thrusting of
additional burdens with reference to instruction upon the existing force.
It means grafting into the service of departments of education experta
who are qualified from the educational standpoint, whose rank and power
shall be coequal with those who work exclusively from the standpoint of
education. Health and education must go hand in hand. This cannot be
done by making the subject of health a subdivision of some relatively smaller
topic which is not considered as a primary matter with reference to pro-
motions, diplomas, or the granting of licenses. It is a fundamental matter
with reference to the protection of the State, and must so appear in the
education of those individuals who have to do with the education of our
future citizens.
In addition to these, which are direct attacks upon tuberculosis through
instruction or detection of tuberculosis, there is the far larger topic to be
considered of prevention. The following proposed measures are indirect,
but fundamental:
It is a matter of common knowledge that tubercle bacilli are so common
that practically all persons are affected. The development or non-develop-
ment of the disease depends primarily upon one's resistance power. The
time may come when the disease has been sufficiently conquered ao that
this will not be the case^ and that itifection will be the exception rather
than the rule. A great number of autopsies performed in this ns well as
in other countries, of those who have died from other diseases, show that
nearly nil persons do have tuberculosis to a greater or less extent. Hence
the primary factor to be considered in stamping out the disease is the raising
of the level of the general power of resistance; that is, the cultivation of
vitality, the power to live, the same power which enables one to resist
every agency inimical to life.
The specific measures in the conduct of the school which have a direct
bearing upon the prevention of tuberculosis are:
1. Ventilation^ — Upon this there does not remain much to be said that
has not already been adequately said, and adequately carried out in the newer
school buildings, conduct-ed by intelligent officers. Two thousand cubic feet
of air to eat^h person in an hour is not unusual, but is an actually obtained
idool in practically all of the newer buildings which are being erected in
our American cities. This air in most cases is either taken from sources
where it is practically dust*free, or it is filtered. The general impresdon
seems to obtain that the ventilation in all school buildings is a matter of
SnCTB tXTERNATlON'AL CONGB£68 OK TUBSRCT7U06XS.
negject; that none of the systems which purpart to give adequate
resiilta really da so. Th&t this is not the fact is indicated by an inrestigi-
tign conducted by my associate, Dr. C. Ward Oampton, who in a number
of schoob made adequate teets on daya in which the "vnnd varied m diiectiDD
and power, making his tests on all mdes of the buildiogs and under vaned
eoDditioQs. The "pockets" in which the air did not circulate were a neig-
liable quantity, and the wiark done by the apparatus wras genuine and reaUy
did ventilate the rooma in the way in which it waa aupposed to. In ^ite
of this fact, however, in these rooma there was soEnetirnes that odor which
indicates lack of ventilation. Where there are thirty, forty, or fifty chiid^e'X^
many of whom bathe rarely or never during the winter, niony of whom do
not chan^je their underwear from one week's end, or one month's end to
anothefj who do not perform the toilet of the mouth, who eat oniony garlic,
cabbage, and the like — it is impossible to avoid the odor save by such a
Gtonn of air aa 18 impos^ble and undesirable within the school building.
What nceda reformation is the conditions of the childmn or of the famih*.
2. Exercise, — The school system as such cannot, should not, and docs
not pretend to provide sufficient exercise for the growing child- Jt does,
howei'er^ in many cases, and should alwaysj provide sufficient exercise to
correct the more or less baneful portion induced by the school de^sk. Xo
two school periods should be allowed to follow each other without at least
two minutes of ^^ setting up" exercise between them. This exercise should
be done whether it is interesting or not, and should be done in such a way
as to thoroughly ventilate the limgs, increase the circulation, and contract
the muscles of the back which have been taxed in the sitting position.
3. Playgrounds and Playtime.^ln the building of schools and the plan-
ning of cities, it must be remembered that play has been one of the major
activnties of all the children La all the world, and that a school-bouae without
a playground which is adequate to pro\'ide for all the cliildren that attend
the school is as anomalous as a school-house without seats in. which the
children may do their work. The general exercise which is needed as a
fundamental factor in aiding to promote growth must come frooi play
rather than from the fomaal gymnastic exercises of the school-room. The
gymnastic exercises of the school-room have already been indicated under the
discussion of the way to correct the effects of the school desk. The play-
ground is a place in which there should be that large activity which is relative
to growth and de\'elopment. Not only space, but time, is needed for this
purpose. These playgrounds should be open under suitable supervision
after school hourSj and in the congested districts suitably lit by night,
so that those young persons who work by day may have the opportunity
to use them during evening hours. The whole tendency of the tim^ is to
seek amusement; rather than play. To ait still and be amused ia a paatuoe
TUBERCITLOSIS ANU THE PtTBLlC SCHOOLS. — GlTLirK.
having in itself great danger. It fails to arouse the powers of the individual,
fails utterly to arouse that self-activity that is essential to life.
4. School-buildijtgs which are Free from DuM.^lt may at first appear
that the dust which is found in the school-buildings is non-dangerous dust.
When we remember, however, that it is composed of dirt brought into the
building on the children s shoes, of minute particles which are brought from
the homes of the children on their clothings that it is brought in direetly from
the streets through the open windows, it is evident that it is to be oonsidered
as a direct element of danger, and is not to be breathe*!.
Singing while dancing or marching is one of the joys of childhood which
has its place in education^ but where it is carried on under such conditions
that a cloud of dust arises by the activity of the children themselves it b
not only of doubtful value but should be stopped. The emphasis, however,
should be placetl on the removal of the dust^ rather than on stopping the
activity. It is possible to have school-buildings and school-rooms practically
without dust. Even old buildings can have their floors so treated as to be
relatively dust-free. There is no reason why school-buildings should not be
constructed with reference to sanitary principles, as hospitals are — and there
is ju£t the same reason for having schools sanitary places as there is that
hospitals should be sanitary. Children ought to be able to dance and sing,
and to march and sing; but this should not and cannot be done under the
ordinary conditions of the ordinary old school-building.
All that has been said so far implies a new attitude of the State toward
health, America is as yet a young country. When we remember that at the
beginning of the preceding century 96 per cent, of ua lived in communities
of eight thousand or less; that most of the families performed most of the
trades; that the schools were eo few and the number of children that at-
tended each one so small as not to be a factor in the community with refers
8 nee to the spread of contagious disease, we see the reasons why the present
attention to matters of health in schools Is so relatively new with us.
It is only recently that we have been having congestion in our cities and
congestion in our schools. It is only recently that we have begim to appre-
ciate the fact that the State^ in order to protect itself, must bear as definite
a relation to the health of its children as it does to their education. These
two purposes must be administered in the main by a single department of
our government, namely, the public school. Hence it is inevitable that
there should be established as part and parcel of our departments of educar
tion groups of medical experts who shall see not only that the school is
conducted without injury to the health of the school children, but that they
are a positive factor in raising up for our republic that body of citizens
which ia not only intelligent, but which has that background of vitality and
m)
SIXTH INTEBNATIONAL CONaRE8B ON TUBERCinXISIB.
IKiwer without which education, science, philosophy, and art are relativify
valueless.
CONCLUSION.*
In this paper I have endeavored to show, in addition to the alreatfy
genemlly recoguiaed need of hygienic conditions in the schcx)!, together with
a wholesome curriculum embnicing exercbe^ P^^Yr and the like —
1. That school systems need anil are already beginning to assume & new
attitude and sense of responisibility for the health of the children. Health
being regartled as tumtamental to education;
2* That instruction in personal and school hygiene should be given in all
normal schools to the same extent sia are such major subjects of the curri-
culum ail pedikgogy;
3. That all candidates for license to teach in public schools should tie
required to pass s\s severe an examination in school and f^cr^anal hygieoe
&s in any other subject;
4. That all candidates for license to teach in public schools should be
required to pass a strict examination for the detection of conta^ous dieeflse,
and also for such disabilities as would render them undesirable as ^' risks.'"
Such e3tamioation should be given periodically, perhaps once in each Jive
years.
La tuberculosc ct les ^coles publiques. — (GtJucK,)
Uimportance d'attaquer ce probl^me par rinterm^diaire der fete
publiques est indiqu(^ par le fait que dix sur onze de tous les eafants des
Etats-Unis se trouvent sous la juridiction des syst^mes d'instmction pub-
lique pour une dur^ de sept ans environ, c'est-i-dire de 7 ^ 14 ans.
L^attitude finale de la soci<5t^ vis-&-vis de prohlfemes semhtables k eelulna
n'est pas determine, dans le principe, par les discussions qui paraissent
dana la presse quotidienne, mais par Tattitude que prennent et gardent
les enfants pendant les ann6es de Mur vie scolaire.
Nos actes quotidians ne sont pas, dWe mani&re pr^dominante, le r6sultat
d'une conception consciente, mais sont et doivent fitre largement auto-
matlques. La conduite, par consi^quent, est la chose k laquelEe on doit
viser, plutAt que la connaia^nce intellectuelle seule.
Avec la reconstruction de la soci6t6^ due au d^veloppement d'une dtoo-
cratie qui se repose sur Tintelligence de toua les citoyens, T^tat devrait
adopter une Education g^a^rale, — non pas premi^rement pour aasurer
r^l^vation de I'individu, mais surtout comme mesure de protection pour
lui-m6me. Cea raisons sont Identiquement les m^mes raisons pour lea-
quelles T^tat doit, par 1' intermedial re dea memes agences, se prot4^r
* The concluding paragraphs of thia paper were formally introduced ai raaolatioDfl
by Dr. Guilck.
TUBERCULOSIS AND THfi PUBLIC SCHOOLS. — Gin4lCK.
601
contre ces ravages d'une maladie qui sont causes par I'iguomnoe dea fnita
fotidamentaiut de la vie,
Ce n'est que r^cemment que Ton a commence k regarder la science d*ad-
ministrer Torgamsation familialej de mani^re ^ v\xm le pliia efficac^ment
possible, comnie un dea ^l^menta fondamentaux de I'^lucation g^n^rale,
Aussi cette science n'est>-elle pas^encore tmit§e comme un des topics im-
portants dans les programmes de noa ^colea normalea ou de nos coll^geB.
Cette attitude nouvelJe de I'^lat vis-S^-vis de la sant4 ne signifie paa
seulement ou principakment que Ton va jeter nn fardeau additiormel sur
les ^pauies des professeurs actueb» pour diss^miner cette iostructton. Cela
Bigmfie que Ton doit ajouter, au personnel de TMucation, des experts poss^-
dant 1^ qualifications n^cessalres au point de vue de rinstruction, et qui
devront avoir le inline rang et le mt^me pouvoir que ceux dont le travail
est purement dana le domaine de rinstniction. Santd et education doivent
aller la main dana la main, Ce but ne saurait 6tre accompli si Ton place le
sujet de la sant4 comme subdivision d*un sujet relativement petit et que
Ton consid^re pas comme 6tant d'une importance premiere, quand il a*agit
dea promotions, des dipldme^ ou quand il s'agit d'accorder dea licences.
L'Eiat, \yo\ir ae prot6gerj doit a*occuper de la sant^ de sea enfanta avec
la m§me sollicitude qu'il s*occupe de leur Education, Ces deux objets,
la sant^ et I'^ducation doivent ^tre sous radministration d'une seule branch©
de notre gouvemement, k aavoir, I'Ecole Publique. C'eat pourquoi il
est Evident que Ton devrait ^tablir, comme partle int&gre de notre syat&me
d'6ducation, des groupes d^experts mMicaux dont la mission serait non
seulement de veiller k ce que I'^cole soit conduite sans danger pour la sant6
des enfanta^ mais qui seraient ausai un facteur posltif pour Clever, pour
notre r^publique, une gdn^ration de citoyens qui fussent non seulement
intelligents, mais qui posaMassent en outre un fondement de vitality et de
force, sans lesquelles T^ducation^ la science^ la philosophie et Tart soot
relativement sans valeur.
Tuberkulose und die Volksscbulen. — (Gulick.)
Die Bedeutung, dieses Problems durch die Hilfe fler Volksscbulen anzu-
greifen, Keigt sich in der Tatsache, dass zehn aus olf Kindem in den Vei^
einigten Staaten unter die Gerichtsbarkeit dea Volksacliulsystems ung^fahr
aieben Jahre, niimlicb vora siebenten bis zum vierzolinten Jahre, kommeo.
Die Endatellungnahme der Gesellsciiaft gegen solche Probleme, wie dieses,
wird nicht durch die Erorterungen, welche in den Tagessseitungen gemacht
werden, bestimmt, sondem durch die Stellungnahme, welche von den
Kindem wahrend ihrer Schuljalu« genommen und gesiehert wird. Unsere
tSglichen Handlungen ^nd nicht vorherrschend das Re^ultat bewussten D&i-
692
SIXTH INTERNATIONAL CONGRESS ON T0BERC1JIXJ8IS*
kens, soiidem sind imd miissen grosstenteils automatiach s^, Es ist mehr
die Lebenaweise, auf die wir zielen miissen, als blossea inteliektuelles Lenien*
Mit dem Wiederaufbau der Gesellschaft, abhangig von der Eatwick-
lung der Maschinen, mit der Entwicklung der Demoknitie, die von der In-
teliigenz aller Burger abhangt, bat der Staat die allgemeine Scbulbildung
zu adoptleren^^nicht in erster Absicht, um den Einzelnen ku hebeo^ aon-
dem ats eine Massregel dea Selbstschutsjes, Diese sind die identischeo
Gmnde^ waruin der Staat durch dieselben Hilfsmittel, namlich die Unler-
richtsabteilung, sich von den Verwiistungen von Kranklieitea beschutsea
muss, die von der Unwissenheit in Bezug auf die fundamentalen Tatsochen
des Lebens abhangen. Die Leitung des Heima in einer Weise vim das
beste Leten au fiihren, Ist erst in jiingster Zeit als einea der Hauptele-
mente in der allgemeinen Bildung angesehen worden. Es ist daher noch
nicbt als ein hervorragender Gegenatand in den Lebrplan unserer Nonnal-
schuien iind Kollegien behandelt worden, Eigentlich in keiner Normal-
schule hat es bis jetzt denselbcn Rang erhalten, als die Wissenscbaften,
wie Psychologie, Unterricht, Geachichte und andere mehr.
Dieae veranderte Stellungnahme dea Staatea^ welcbe aich durch die
Sehulen in Bezug auf Hygiene ausdriickt^ bedeutet nicbt bios oder haupt-i
BS^cblich die Aufbiirdung von mehr Lasten auf die vorhandenea Kraft&l
Es bedeutet die Uberpflanzung von Fachmaaaern, welcbe vom Uaterricht*-
standpuiikte aiis tlazu befahigt sind, deren Rang imd Macbtbefugnis die-
selbe sein soli, wie diejenigen^ welche ausschliesslich von dem Erzie-
hungsstandpunkte aug arbeiten, in den Dienst der Unterricbtsabteilung.
Gesundheit und Erziebung miissen Hand in Hand gehen* Dieses kann
nicht gescbehcn, indem man den Gegenatand der Hygiene eine Unterab-
teilung eines verhaltniratnaasig kleineren Gegenstandes macht, welcher nicht
als eine Hauptaache in Bezug von Promotionen, Diploraen und Lizensea;
betrachtet wird. Es iat eine fundaraentale Sache in Bezug auf <len Schuti
des Staates und muss bo auch in dem Unterricht derjenigen erscheineo^
die mit der Ausbildung unserer zukiinftigen Biirger zu tun haben. Um
sich zu scbutzen^ muss der Staat elDenso in einem bestiminten Verhaltnkse
zu der Gesundheit seiner Kinder stehen, als in dem zum Unterricht, Diese
beiden Zwecke miissen in der Hauptsache durch eine einzige AbtetlungJ
unserer Regierung, namlich der Volksschule geleitet Unterrichtsdepartment
Gruppen von arztlichen Fachmamiem eingesetzt werden, die darauf sehea
mussen nicbt nur, daaa ctie Schule ohne Schatlen der Gesundheit der Schul-
kinder geleitet wird, sondem da^ sie ein positiver Faktor sind in der Eraie-
hung von Biirgem fur unsere Republik, welche nicht nur intelligent sind,
sondem auch einen Hintergrund von Lebenskraft und Energie haben,
ohne welche Erziehung, Wisaenschaft und Kunst verhaltnismasaig wertlos
sind.
REPORT ON THE TEACHING OF ELEMENTARY HY-
GIENE IN THE TRAINING COLLEGES AND
ELEMENTARY SCHOOLS OF GREAT
BRITAIN AND IRELAND.
By G. a. Heron, M.D., F.R.C.P.,
IMegat« of the Royal Society <rf HsdioiiMS of London.
1. Ignorance is the chief cause of the prevalence of disease. The great
importance of this truth to the well-being of mankind is brought home,
even to the least imaginative of us, by the story of what has been done to
lessen and to stop the ravages of infective diseases. Much of this story has
first been told in our own times. Cholera, t3^hus, rabies, sepsis, smallpox,
Malta fever, malaria, yellow fever, tuberculosis — all these diseases are not
now such scourges of our race as they were even within living memory.
Those named by no means complete the list of diseases which knowledge
has enabled us either practically to exterminate or greatly to modify both
in their mortality and in the suffering they cause. The list, however, suffices
to impress upon us the great truth that in the fight with disease knowledge
is our mightiest help.
2. There is but one road which leads to knowledge, and we call it educa-
tion. The International Society for the Prevention of Tuberculosis, being
deeply impressed with the importance of these truths, thought it well to
act on a suggestion I made at its meeting in Paris in 1903, and in Copenhagen
in 1904. The suggestion was that in each country represented in the So-
ciety some one should be asked to do what he could to promote in the schools
of his own country the study of the laws of health. The man entrusted with
this task was to present to each congress and conference of the Society a re-
port in which he was to state the position occupied in the schools by the study
of hy^ene. The Society entrusted me with this task as regards the schools
of the United Kingdom, and so it is that I have to-day the honor to present
this report to the congress held in Washington.
3. If a foreigner seeks to understand the system of education in the
United Kingdom, he will find he has no easy task before him. It is certtdn
that few even among the natives of the British Isles know more than a very
little about the system of education there in use. The State school as it
is to be found in most, if not, indeed, in all other European countries, has no
694 SECTS INTEHNATIONAli CONQRESS ON TUBERCULOSIS, ^^M
existence in the United Kingdom, Local authorities exercise important
control over schools, and the central education authorities will, in the in-
terests of peaceful and easy working, never omit to remember that the local
authorities have to be reckoned with, and will have their say in the manage-
ment of school affairs.
4. In England and Wales a great step has l>een gained in the cause of
school education in hy^ene. On August 1^ lOOS, ended the eviJ system
which, till that date, allowed the study of hygiene to be optionjU with those
who meant to become school-teachers. On that date it was included among
the subjects wliich an "intending teacher" is obliged to study during his
years of special instruction in the training college. In the course of a yoar
or two there should, by this means, be available for this si>ecial teaching a
coi^siderafale and increasing numlxjr of young me-n and women with some
knowledge of the subjecti and of how it should be taught to school children.
5. Here is the syllabus recommended by the Boai*d of Education for
use in the training colleges; but it is not compulsory upon any college to
adopt it. Any other syllabus, modeled on this one, may be subnaitted to
the Board for approval.
LEcnmE L — Ivtroductohy.
The place of man in the animal kingdom.
The cell as unit of tissues and organs of the body. Ita life, growth, and
reproduction (compare ameba).
Structure and function, work and rest. Division of labor.
The ctiild a tleveloping and immature human toeing. Factors influenc-
ing its development; (a) heredity antl antenatal conditions; (6) environ-
ment; (c) nutrition and training (particularly of briun and nervous system
during plastic period of growth).
Lecture II. — ^The Skeleton and Mdscular Svstem.
The skeleton and ita development in the young. Joints. Locomotion.
Importance of attitudes and |K>stures. Spinal curvature.
The muscular system and its relation to the nervous system*
Influenca of proper and sufficient food (rickets)' Alcohol.
Physical exercises, driUing and games.
Lectture III,^The Digestive System.
The alimentary caiiaL
Process of digestion, commencing in mouth. Hygiene of mouth, teeth,
etc.
Dietaries. Amount and sorts of foods for children, us^es and values.
Characteristics of unsound food.
Evil results of wrong feeding, underfeeding^ food poisoning. Dangers of
stimulants, alcohol, tea, etc.
Higns of malnutrition.
I
ELEBfENTARY HTQIENE IN THE SCHOOLS OF GREAT BBTTAIN. — ^HEBON. 695
Lecture IV. — The Respibatobt and CircuIiATOrt Systems.
The purpose of the circulation of the blood. Blood, heart and blood-
vessels. Anemia. The l3anphatic system.
The lungs. Correct breathing. Obstructions to breathing (adenoids).
Purpose and mechanism of respiration. Breathing exercises.
Difference between fresh and expired air.
Relation of respiration and circulation to nervous system. The effects
of exercise, posture, occupation, malnutrition, tight clothing, alcohol, etc.
Advantages of an open-air life.
Lecture V. — ^The Excretory System.
Waste matter — in tissues as result of work, in bowel as undigested and
indigestible food.
Excretory organs and how they work: skin, alimentary canal, kidneys,
lungs.
Evils resulting from delayed or irregular excretion.
Importance of personal cleanliness, regular habits, nutrition, clothing.
The care of the body.
Lecfure VI. — ^The Nervous System.
Brain, spinal cord, motor and sensory nerves.
Reflex action. Brain centers and nerve-cells. The way the brain works.
Codrdination and association.
Requirements of a healthy nervous system (nourishment), regular habits,
physical exercises, manual and intellectual work, periods of rest and change
of occupation. Evil effects of malnutrition, defective senses, overstr^un,
impure air, bad habits, alcohol, etc. Causes of mental dullness, headaches,
neuralgia.
Development of child's mind and nervous system (sensory receptivity,
reflex movement, imitation, attention, self-control; nourishment and educa-
tion of nerve-cells).
Physical and mental fatigue.
Lecture VIL — Sensb-orqans.
Relation of sense to nervous system.
Their training and development.
Sense of Sight, — Structure of the eye. Eye muscles; mechanism of
accommodation.
The visual center in the brain.
Defects of vision and common eye diseases.
Eye-strain, particularly in young children.
Short and long sight, etc., vision testing.
Effect on sight of bad light, long hours, small print, close work, etc.,
especially in childhood.
Lecture VIII. — Sense-organs {Coniinued),
Hearing, — Structure of ear. The auditory center in the brain. Causes
and signs of defective hearing. Tests. Deaf-mutism.
eo6
BIXTn INTERN ATIONAL COW
OK TttBERCtTUJeiS.
Spetch, — yhe Atructum aud uj9q of vocal organs Voice c raining and in-
fective articulivtitiri. Sj>eech center,
Scnac aj S7nelL
iyenae oj ToiuJi. — Co5rdination, temperature, feeling, musculaf senat
Lbctuke IX. — Sanitation of the ScbooLw
llequireineut-3 of the healthy school :
Suitability of sitx*, soil, and construction (various types of school-
buildings).
Water-supply: Collection, storage, and distiibution. Various ioraad
pollution. Methoda of pnevention-
Sanitary conveniencea (viirious types), drainage, refuse removaL Earth
oloseta and their management.
Effects of sewer-gas.
Lecture X. — Sanitation or the School (Caniinufxi),
Ventilation— fubic capacity, amount of fresh air nece:3sary. Impuiv
ties of atmosphere and their effects. Methods of ventilation.
Warming and lighting,
Equipment, (('lass rooms, desks* blackboards, cJoak-rooms, tavatoiie^
etc.) The hygiene of infant departments.
Cleanliness: Clas8-room as an object-lesson in health.
Duties of individual in relation to health of community.
I
LscrtfRE XL — DlSABlUTIES ANB DISEASES OF CutUORRN.
Characteriatics of normal and abnormal children (mental and ph3rsical
defects).
The relation of microorganisms to diaease. Conditions of their life.
Relation of seed (bacteria) and soil (body tissues). Means of resistance.
Inherited tendencies and conditions due to environment (dirt, neglect*
exposure, etcO* Predisposition to disease*
Early signs and symptoma of ill health In children (nervous diseases, in-
fectious diseases^ tuberculosis, parasitical diseases).
Lecture XIL — Medical Ikbpection of Schooi-s, Etc.
The objects and method of medical inspection of schools and school chil-
dren.
Methods of detecting and dealing with physically and mentally defective
children.
Direct and indirect means of cultivating good physical habits in school,
and adapting education to the physical needs of the child.
(Example and health of teacher, games, physical exercises, ventilation^
cleanliness^ absence of near-eye work.)
School closure and exclusion of children on medical grounds. First aid
in minor injuries and common ailments.
Disinfectiom
The duration of each lesson is left in great measure to the discretion of
ra<EMENTART HYGIENE IN THE SCHOOLS OF GREAT BRITAIN. — ^HEEON. 697
the teacher; but the indications are that not less than one hour at a time
should be given to this teaching. The whole course should be comprised'
in twenty-four lectures.
6. An admirable new departure has also been made by the Board of Ed*
ucation in issuing for the first time syllabuses for the teachers of children
who are blind, or deaf, or mentally defective. Here are these syllabuses:
Syllabus No, 4'
Special Syllabus for Teachers of Bund Children.
1. Physiology.
The syllabus of instruction in hygiene should be modified and am-
plified so far as may be necessary.
2. Psychology.
Educational limitations imposed by total or partial blindness.
Cutaneous and muscular senses the main avenues of observation.
Preservation of the tactile sense.
Speech in the training of the blind.
The part played by physical training, music, manual work, and
literature in the training of the blind.
The aim of blind education to secure independence in movement,
industrial aptitude, and refinement.
3. Special Subjects*
Braille reading and writing as used in schools.
The teaching of . practical number and arithmetic to the blind.
The teaching of geography to the blind.
Physical training for the blind. Gait. Attitude.
Manual occupations suited to blind children of various ages (either
kindergarten or senior occupations to be offered by each student).
The training of blind children in personal habits.
Syllabus No, 6.
Special Syllabus for Teachers of Deaf Children.
1. Physiology.
The syllabus of instruction in hygiene should be modified and
amplified so far as may be necessary.
2. Psychology.
The limitations to intelUgent verbal expression imposed by loss of
hearing.
The limitations of the totally deaf, the congenitally deaf, the par-
tially deaf, the semi-deaf, the semi-mute, and the hard of hearing.
Language for the deaf. Modes of commimication. Speech, lip
reading, writing, and finger spelling.
3. Special Subjects,
The oral method. The development of speech among the deaf.
Language. The development of terms, actions, ideas. Verbal
BIXTH INTUBNATIONAL CONaEBBe ON TUBEHCULOSffl.
insertion. Conjunctives. Subject matter for language teaching. Tt^
toacbing tif reiuiing to the deaf,
Tractical number and arithmetin for tlje deaf.
Manual occupations {eitho' kindcrgarteu or senior oceupatioas to
ht offered by each student).
Physical training of the deaf. Gait. Attitude.
Syllabus No. 6,
Special Syllabus for Teachers of Mentally Dkpbctive Chiij>i
1, FhyMology.
The syllabus of inetmctiou ia hygiene should be modiSed and
amplified so far a$ may be necessary.
2. Psychology, i
The mental signs of deficiency; disturi>ance of ethicaJ and reasnn-
ing power, memory, response, volition^ and volitional balance; nen^e
fiabbine^.
Disturbances of excess or defect in the lower faculties.
Spurious mental defect due to de|;>reasing physical conditions.
The effect of traming on mental deficiency, real and spurioiis.
Special Sttbjects,
Speech training. Types of speech defect and how to deaJ with them.
The division of subjects of inatmction into small steps mlapted to
defectives.
Physical training adapted to defectives. !
Manual occupations {either kindergarten or senior oocupationa to
be offered by each student).
Training in pereonal habits.
7, When the students complete their course at the training coll
there is an examination to be passed, and a part of this examination is
special paper in hygiene.
S. An object the Board of Education has in view in giving this course of
speciai instruction and of examination is to avoid even the semblance of turn-
ing out teachers who might imagine themselves to be specialists in hygiene.
The object of it all is to endeavor to secure for the school a teacher who is
"able to appreciate the conditions, lx)th mental and physical, which unfit a
child for school work/' and who Is so trained that he would be likely to pick
out a child who failed to acquit himself creditably, not because he was im-
wilhng to work, but because he suffered from some defect or incapacity^
Here, in the words of the *' Regulations for the Training of Teachers for Ele-
mentary Schools," is a statement of the teacher's fitness as the Board would
like to leave it after he goes through the couree of special training and passes
the examination in hygiene:
9. *' Students on completing their course of training, and taking up the
work of teaching in elementary schools, should know enough elementary
anatomy and physiolog}' to understand the general structure and functions
4
n
ELEMENTARY HYGIENE IN THE 8CHOOL8 OF GREAT BRITAIN- — HERON. 699
of the body. ParticuJar attention should have been given in their course of
training to the nervous system and special senses, in order that signs of
backwardness and overstrain, the consequence of defective sight, hearing,
etc., in the children may be appreciated by the teacher, who should be able
to recognize abo the early signs of the commoner infectious diseases of chil-
dren ; for much can be done to prevent the spread of epidemics by the timely
detection and isolation of suspected cases. Further, the importance of phys-
ical exercise and rest should be clearly understood. The intending teacher
should also have an adequate knowledge of the hygiene of the school, should
understand the general conditions necessary for making a building or room
healthy, and for keeping it so, and he or she should be well ac<}uainted with
the laws of personal health. In the case of women students the nutritive
value of food-stuffs in relation to their cost in the market and to the needs
of young ctuldren should be known in outline^ even though the student may
not be specially qualified in domestic economy. Only thus will they know
how to conduct the school as a whole with the greatest profit to the health
and bodily development of scholars, and how to adapt the Instruction which
they give, either in incidental teaching or by example, to the limitations which
unhappily are not unfrequently imposed by the feeble hefdth of children or
by tlie poverty or neglect of their parents,"
10. In Scotland all the training colleges have courses of instruction in
hygiene. Dr. Leslie Mackenzie, the Medical Member of the Scottish Local
Govermnent Board, in his official report describes the objects of the courue
in these words;
''Objects of the CoimsE in Laws of HiiALTS,
*' Briefly, the object of this twurse is to assist the teacher in discovering
such gross mental or physical defects as may unfit, or tend to unfit, the child
for school work. The teacher is not expected to become a doctor, or to
assume the functions of a doctor. It is intended only that he should be put
in the attitude to observe, that he should know enough of the common
school disea^jes and defects to prevent him from pressing incapable children
or retaining sick children at school, and that he should be trained to appre-
ciate the limits of physical exerciaet and, generally, the conditions that imfit
the child for the one or the other. He is not exf>ected to search out diseases
or defects; but, when placed in charge of a chisa or a school, be should be
able to say whether a child is maintaining his progress in his class and whether
hia failure to do so is due to some special defect or to general incapacity.
Among children at school, many defects necessarily emerge, and the object
of the course on the laws of health is to prepare the teacher for the commoner
defects and ailmenta/'
II. Dr« Leslie Mackenzie's "General Report on the Teaching of School
and Personal Hygiene to Students in Training as Teachers in Scotland"-
TOO
SIXTH rXTERNATIONAL CONGRESS ON TTTSfiRCULOfllfi.
ifl full of very valuable infonnation of a thoroughly practical kin
re|x>rting upon ^* Methods of Instruction," he shows how the teachem
giene have quickly given up the mere systematic lecture, to substitB
it practical trainmg in observation of individual, taken from amoi
children attending school. This demoostratioR from the living ;
must surely appeal strongly for the approval of all who have auffem
that pedagogic atrocity, the merely syst<?matic lecture. It will be {
obvious that the method of teaching the laws of heaJth from the Ilvingi
can best be done by properly qualified medical graduates^ who tal
models from among the Bchool children, and give their demonstradoi
founded by the conditions of real school life. Of what he saw at one ot
demonstratkans, Dr. ^lackenzie givee a description.
12. Here is a descnption by Dr. Mackenzie of how in Scotland pu|
training colleges are required to show to what extent they have profit!
the course of instruction in hygiene:
"The students (both males and females were senior students) wa
quested to proceed to the different classes, to select, each, any chiJd
seemed to suffer from any defect, examine the child witij some car«\
write down the reason given for considering that any defect existed,
was done outside the t-eaching room. Next, the student brought forwaf
selected child, and wag cross-examined on the conditions alleged. Th(
of the class were required to criticiae and supplement. When one sta
came in with a child, another proceeded to the corridor, and, in due
brought in the child selected by him or her. Then the same process w-as
through. In this way practic^dly the whole class had exaiuined at leaa
cluld^andhad the advantage of observing all the children and mticixiit
conclusions come to by the other students. The demonstration was at
general and special. The lecturer brought out^ without loss of time,
leading points, Jn the course of an hour some twenty or thirty children
been presented in such a way that every student was able to ol>ser\-e
accuracy, and to come to a conclusion on, the leading features of the
The same method was followed in the second hour, when the male s
students were present. Among the defects discovered were the follow
mouth-breathing (several cases), defective eyesight, skin diseases,^
eluding scabies, impetigo, eczema, and otherSj— rickets and large g^
deafness, adenoids, cleft palate, malnutrition, anemi&p paralysis, fee
mindedness (cretinoid and mongoloid cases).
*' In my last report on this college I indicated the difficulty of maintaii
the large supply of cases for demonstration, but the difficulties have I
completely surmounted, and, as indicated above, the supply of material
been even greater than last year. The work at this and some other colli
clearly shows that without any serious interruption of school work, h
numbergof suitable children can readily be provided forteaclung purpo
" In the course of the examinations^ every care was taken with the
dren, who were handled sympathetically and tenderly."
13, Still quoting from Dr. Mackenzie's report, we find given then
ELEMENTARY HYOIEN^E IN THE SCHOOLS OF GREAT BRITAIN. — HERON, 701
striking instance of how the method of iastructioii ia carrieci out in the
Scottish training colleges.
''The co6peration of the master of method of the college with the medi*
cal lecturer [L e., the medicaJ graduate who lectures on hygiene] has had a
very happy result. The nature of the demonstration deserve to be recorded
with some detail,
"Although only one hour a week ia required from the lecturer, he has
visited the school very frequently in order to discover children in the prac-
tising school suitable for concrete demonstrations to the students. As the
result, he was able^ in concert with the master of method, to produce some
sixteen cliildren to demonstrate the nature of respiratory obstructions and
their serious coniaequencea both to immediate school work and to the nutri-
tion of the children. But the essentia! novelty of the demonstration arose
out of this, that, instead of being directly examined medically, the children
were exercised in a model lesson in phonetics by the master of method.
Before the entry of the children into the room, the students were instructed
generally in the leading points, and directed to record their observations.
'■The master of method had selected a series of words and expressions to
bring out precisely the results of respiratory obstruction. The leading words
were these;
"Man
may
mug
mat
Imow
noee
gnftt
nut
name
mane
mass
singing
swimming
ringing
beginning,"
14* "Several of the children were mouth-breathers; two or three of them
were slightly deaf; two or three were normal. A child was selected for a
short lesson. He was requested to pronoimce some of the above words after
the teacher. The words were repeated again and again, until the greatest
accuracy of pronunciation that the child was capable of had been attained.
Then the child was requested to read some sentences from his ordinary class-
book. As a contrast^ one of the normal children was required to read the
same or similar passages, and to pronounce the same words. Thecliildren
were a shade more nervous and excited than they probably would have been
in normal conditions, but they were so excellently handled that this waa
hardly apparent. Words like 'man* were not fully pronounced by those suf-
fering from adenoids. Words Hke 'singing/ 'swimming/ etc.^ brought out,
in the most striking way, the existence of tonsillary or ationoid obstructions.
Further^ the halting and 'backward' quality of the reading was very obvious
in the more pronounced cases. The attitudes of the children, the tendency
to stand on one foot, the forward stoop of the head, the flatness of the chest,
the somewhat dull aspect of the face, the open mouth, etc., were all abun-
dantly obvious. But, through the whole demonstration, the susceptibili-
ties of the chiUben were absolutely untouched. They seemed quite to under-
stand that they were being supervised in the customary manner of the prac^
tising school. The lesson was followed by one or two simple breathing ex-
ercises done to the word of command* This brought out the slight lack of
attention in some of the pupils and the alight deafness in others."
702 SIXTH INTERNATIONAL CONG&BB8 OH TVBEttCWO&ia,
15, "When the lesson was over, the children were marched raund the
room sn that ali the students could appreciate at close quarters the waat of
spontaneity and somewhat stunted growth of some, the pallor of o&heis, the
Blight hesitation in others to the word of oommaiid."
10. " When the children had left the room, the lecturer eaUed atteutioo
to the leading facts emerging at the demonstration. He af terw&rd g&ve aocoe
detailed expiaDation^ by models aod diagrams^ of the nasal pAasAges a&d Lfae
back of the mouth. This completed the lesson."
17. "The demonstration was in every respect successful. It fulfilled,
in the most detailed way, the primary purpose of a cour9e In the Uws of
health, namely, the putting of the teacher in the attitude of observiog Ifae
phytiical defects that obstruct his specific work as a teacher. These defJBcts
were all observed as an incident in the course of an ordinary lesson. la-
deed, the demonstration constituted a strong justification for the system-
atic teaching of phonetics. Phonetics, more, perhaps, than any other
discipline, thus becomes, aa it were, a method of functional diagnosis of de-
fective conditiona,".
18, 1 have described above, with considerable detail, the method fol-
lowed in the winter part of the course. The present demonstration was on
somewhat different lines. A number of children were selected from the
practising school, some suffering from defects, others normal. The students
were all assembled. Each child was made to walk in front of them, to do
such actions as brought into prominence any special botlily peculiarity, to
aoBwer questions, or otherwise to display such mental capacity as he had.
The students were instructed to note down their observations and afterward
to write them out in full. The resulting papers were taken into account
in settling a final mark. The precise instructions given to the students are
contained in the paper appended. (See Appendix I.)
APPENDIX I.
"Caseb for Obsebvation/'
" Student's Name
" Note carefully the appearance of the children* Each may be taken
as a type of different classes of children attending an ordinary elementary
echooL State fully what measures you would adopt in carrying out the
ordinary daily work of the school, not only to prevent any aggravation,
but, if possible to secure an alleviation of the specific troubles from which
each child suffers, Special attention must be paid to physic^ exercise,
position in class, amount of standing, or sitting, reading, writing, advied_
(where possible) to the parents or to the children themselves.".
1 and 2. Cases of rickets.
ELEMENTARY HYGIEKE IN THE SCHOOLS OF GREAT BRTFAIN. — HEtlON, 703
3. Anemic.
4. Adenoids.
5. Squint.
6. Defective (mentally).
7. Ill health (dry, fiat hair, iU-nounshed, prominent eyes).
8. Retarded development-
19. Each of these lectures lasts about an hour, and the course ia made
up of from 16 to 30 lectures. In the elementary schools in England and
Wales no syllabus of instruction in hygiene has yet Ijeen issued by the
central authorities. Education in that direction has been hitherto guided
by the independent action of each local education authority* The result
of this is that there are any number of different syllabuses issued to the
schools. To give any idea even in rdsumi? of the course of instruction foU
lowed is, therefore, iinpossible. That all this may speedily be changed must
be the hope of every well-wisher of the cau^ie of this special education.
Under the plan which came into force last month in the trtuning colleges of
England and Wales all this will be altered. In what has gone before in
this reportj I hope I have not failed to indicate what that plan is. Capable
teachers well trained on the new lines will^ by precept and example, soon
impart to children sometlnng of the elements of hygiene, whether the teach-
ing follows the direction of a syllabus or— as in my judgment would be far
better — is the outcome of the teacher's own conviction of bow the subject
should be taught to the particular class of children undergoing instruction.
There can be no doubt that in tr>Hng to impart this knowledge to mere
school children the teacher's example in matters of hygiene will give at
least as much instruction to the pupils as they will get from any other form
of lesson, no matter how ably the lesson may be given.
20. In Scotland no syllabus on inspection or hygiene is issued for use
in training colleges or schools. The reason for this is that in the colleges
the instruction is ^ven by properly qualified lecturers, who, with only tliree
exceptions, are graduates in medicine. The Scottish education authorities
are of the opinion that a free hand should be given to those lecturers, and
therefore no syllabus is issued. In the Scottij^h schools the teachers are
also encouraged to teach hygiene on their own hnes,
21. As a matter of course the work of the lecturers in the training colleges
and of the teachers in the schools is submitted to frequent and elBclent
inspection, and the results of the inspection are t^d in full before the educa-
tion authorities.
22. In the training colleges the teaching and study of hygiene is com-
pulsory; but that is not the case with schools, though a greatly increased
rate of money grant from the central authority in respect of the older scholars
704
SIXTH TSTEKSATIOSAIm CONGBE86 OX TUBEECtJLOSIS^
(i «., &bove the age of trrelve) in pnm&ry schools is dep^ident iqraii m-
SEtructJon being g^ven in ihia and oert&in other special subjects^
23. By kind pennissioii and help of Dr. Starkie, Resident Commiaaiaiier
of National Eklucation in Ireland^ I am able to embody in this report the
foUowing memoraDdum, which deals, in general terms, with the questioo
of hygiene In relation to the national achools of Ireland.
Office of National Edacadoa,
Dublin, July 7, 1908.
In cases where the school premises are grossly lnsamtar>' and dlLapi
the Commisfflonere of National Education in Ireland suspend th^ grants
to the school until the premises are put in proper order, or they may evea
withdraw the graiits permanently.
In May, 1903t the earnest and immediate attention of the miuiB^n wbs
directed, generally, to the extremely unsatisfactory condition of many of
the Dationial schools in regard to repair and cleanliness, and pardcul&rly to
the disgraceful state of the out-of!ices, which in numerous instances had been
reported to be in such a state of filth as to constitute a grave menace to the
health of the children. The Commissioners of National Education in Inland
then expressed the opinion that some organised local eCTort should be ouuie
to cope with the discreditable state of things to which they called, attention,
as the decent maintenance of existing schools can only be satisfactorily
provided for by systematic supervision. They also gave warning that in
the case of any school in which the reporta were not satisfactory as to these
matters they would consider the propriety of ceasing to recogEilxe the
BchooL
In June, 1903^ the Inspectors of schools were strictly enjoined to pay
special attention to the sanitary and hygiemc condition of the schools axid
the outH>fhces, to the cleanline^ and brightness of the school-rooms, azid
to the neatness of the teachers and pupils. The promotions of teachers are
dependent in a degree on the manner in which attention is given to these
matters as well aa to the other portions of the teachers* school duties^
Two of the practical rules for teachers dealing with points of sanitatioiL
are as follows:
"VIL — To promote both by precept and example, deaolineas,
neatness^ &nd decency* To effect this the teachers must set an example
of cleanliness and neatness in their own persons, and in the state and
general appearance of their achools. They must also satisfy themselves,
by personal inspection every morning, that the children have had their
hands and faces washed, their hair combed, and clothes cleaned and,
when necessary mended. The school apartments* too, must be swept
and dusted every evening; and whitewashed at least once a j'ear.
Should the Board of Public Works be engaged in repairing or
improving a vested school, it is the duty of the teacher to facilitate
their action in every way."
"XV. — ^To attend to the ventilation of the school: immediately
after entering the room In the morning; at the time of roll call; and
4
4
ELEMENTARY HYGrBNE IN THE SCHOOLS OF OEEAT BRITAIN. — HEKON* 705
at frequent intervals during the day. The ventila-tion caa beat be
effected by lowering, where practicable, the upper part of the windows,
eo as to admit a thorough passage of air through the room.''
24. All candidates for admission to the training collegea are now examined
in hygiene, including points such as necessity for pure air, food, pure water,
general stnicture of the body, respiration and organs involved, circulatory
and digestive systeniB^ bacteria, health and sickness^ prevention of disease,
nursing the sick, etc., and a more advanced acquaintance with hygienic
■matters is expected at the King's Scholars' final examination. Also, in
some of the Irish training colleges arrangements are made for periodic
lectures to the students in hygiene*
25. On the introduction of the revised program of inatruction for national
schools in 1900, stress was laid upon the great importance of personal cleanU-
neas and attention to hygienic principles in the preparation of food, etc.
In the school programs which have been issued by the Commissioners since
1906 are inrtuded "Simple Lesaona on Health and Habits." These lessons
are compuhory, and are designed to embrace instruction on the following
matters: domestic and personal clcantinesa^ fresh air, pure water, warming
and lighting, food, evils of intem|:ierance, illness, etc. Instruction in
cookery and laundry-work is also provided for in girls' schools and a special
fee is paid for these subjects; but, in order that the full fee may be earned for
cookery or laundry-work, suitable instruction must be given to the children
in hygiene.
26. As regards the frightful ravages of tubercular disease throughout
the country, the Commissioners in April, 1S03, circulated among all the
managers and teachers a little pamphlet called ** Consumption and its
Prevention/* which wa^ prepared by the National Association for the Pre-
vention of Tuberculosis. Again, in December, 1904, a notice was issued to
managers and teachers as to the importance of the adoption of such hygienic
precautions as are calculated to reduce the excessive mortality from tuber-
culosis^ and during the year 1906 another publication of the National Asso-
ciation for the Prevention of Tuberculosis was sent from the Education
Office to be posted in every school (national) throughout the country. It
contains valuable information as to how the disease is contracted, how it
may lie averted, rules for consumptive persons, etc.
27. As regards the prevalence of epidemic disease in the neighborhood
of national schools, the Commissioners accept the certificate of the local
medical officer as to the necessity for closing the school, and allow payment
of the salaries of the teaching staff in fuJl for the period of closing.
28. Before being admitted to the training colleges, candidates who
propose to qualify for the position of a teacher in the schools of Ireland are
required to pass an examination in elementary hygiene, which is based upon
the syllabus of instruction in that subject given below. This is the syllabus
recommended for use in the teaching of the senior school children.
Hygiene— Health and Habits.
Instruction in the laws of health should embrace the following subjects:
vou ni— 23
906
SnCTH INTERN ATIOKAI. CONOR:
I. Cteajiliness: {a) DoTnestic. — The origin
of diaeaae and decay thrive best where tl
aniJ moisture. Importance of sunshinei
Cleaoing of rooms — the best metfa
washing, scrubbing; clcaniag of furnit^
clumneys, sinks and drains, of cookin
portanoc of clean outhouaes, cowshed.
Leaps near house or water-supply,
(6) Personal.— ClQnnWnt^a of skin, hair, teett
Frequent changes of clothes worn iiexl
garments; perspiration, change and airin
The dirty and dangerous habit of sp
the spread of tuberculoBis ; other goodt
dirtiness a sign of want of self-respect ; si
2* FTesh Air. Breathing; importance of e
and of exercise to strengthen the nm&cia
Changes in air when breathed; necessil
freali air. Ventilation and ventilators;
The importance of fresh air as a prevent!
aid in resisting it.
3. Purr Water. — Use of water; dangers of in
contaminated and how it may be made fii
4. Warming and Lighting, — Fires and stova
fire, cleaning the stove- Proper temperi
bui-ning; compare with breathing.
Oil lampfj, gas, coal.
Catching cold; dangers of damp clothes
5. Food.^-Typical food materials — starch, U
eggs, meat, bacon, potatoes and green fo
diet: water and salt as food; air as food;
overfeeding and underfeeding; regular me
Beverages — tea, coffee, cocoa are stimu
value; tea if drunk too strong and in axce
if taken in moderation.
6. Temperance. — Alcohol taken in any but vei^
injurious effects on digestion, breathing,
its use by young people always harmful j
habits if acquired, of using alcohol, expezu
ability and energy, and in many cases the
degradation.
The use and abuse of tobacco; every on
dangerous and poisonous until young peopl
7. Illness. — Minor ailments and accidents^
stingH, fainting, fits — bow dealt with, neces
freedom from excitement in dealing with s
Poisoning, infection^ and disinfection, R|
8. Thrift. — Money earnings, spending, saving,
9. Order. — A place for everything, and evei^'i
ELBHENTABY HYGIENE IN THE SCHOOLS OP GREAT BBITAJN. — HERON. 707
times and regular days for fixed duties; Sflving time by forethought
in arranging one's work properly; finish one task at a time,
10. Con^wci,^PuDctuality— self-control — politeness.
ft
29. After passing through the training colleges, and before being recog-
nized as trained and receiving the diploma, the intending teacher must pass
a still higher examination in hygiene than is required of the candidate for
admission to the training c-ollege,
30. It must be admitted that in England, Wales, and Irelajid the teach-
ing of hygiene in schools has, until to-day, been behind the times. In Scotland
thisis not the case ; for there the teaching of hygiene in the training colleges has
been, for the most part, intrusted to properly qualified medical graduates,
who have done the work well. Why this difference l^etween these four
countries in a matter so important? The answer to this question is not,
in my opinion, hard to find. In England, Wales, and Ireland the subject
of education is intimately mixed up with party politics. In Scotland the
people believe in education to an extent unknown elsewhere in the United
Kingdom. With the Scottish people this belief In education, as a power
for making for the greatest good, amounts almost to reverence, and party
politics would not in Scotland be permitted to injure the cause of education.
The man in the street in England, Wules^ and Ireland, who takes an interest
in politics, knows very \ve]\ that the present Parliament and its predecessor
spent montlxs in the discussion of education bills, and that the cliief out-
come of these endless discussions has been a fierce fight among certain
religious sects. Each sect is striving to secure for itself what it calls fair
treatment, and which the rival sects loudly denounce as a shocking example
of what men will do to secure supremacy in the schools of the country for
their own particular sectarian belief- In Scotland the people will not permit
any question of sectariaii supremacy even to be mooted in connection with
education in the schools.
3L The new departure in England and Wales, which began on August
1st, promises welL The permanent officials of the Board of Ekiucation ate
well aware that the interest taken in the teaching of hygiene is not now, as
it has formerly been, almost confined to a mere handful of doctors. It \s
a real public recognition of the neglect and indifference with which that
important subject has hitherto been treated in the education of our chil-
dren. The party politician who^ until very recent days, had successfully
hidden his convictions on the subject even from himself, begins to show,
by the usual sign, that he ^believes votes are to be kept, or even gained^
by ventilating this topic on suitable occasions; and he now says he is de-
lighted to find that the public voice is beginning — as according to him it
usually does — to attune itself with what he has recently discovered to have
708 SIXTH INTERNATlOKAli CONGRE^ ON Tt?BEBCUM)Sia»
been his life-long conviction on this subject. All this is hopeful, and it
makes for the advancement of this special education, which is so much
needed, not only in the British Isles, but wherever there is a rising genera-
tion to be educated,
32. I know that our International Society for the Prevention of Tuber-
culosia has helped on this good work in the United Kingdom. Through the
use of private influence every Minis^ter of Education who has there held
office since 1900 has had this matter pressed upon his attention. Since 1903
I know that all our Ministers of Education have personally axpressed their
willingness to help on the cause, which in that year at the Paris meeting
received the support of our International Society.
It is mth more than ordinary pleasure that I am able to give here the
names of the distinguished men who, at my suggestion, joined me in 1906
and addressed the following communication to the English Minister for
Education;
To the Right Honble. Augustin Bibrell, M.P., K.C.,
President of the Board o} Ed^Kxition.
Sir: We, the undersigned, desire to press upon the attention of the
Board of Education the following considerations;
It is, in our opinion, of great importance to the public interest that
those who intend to devote themselves to the teaching of the young in our
public elementary schools should be required by the State to give due
attention to the study of elementary hygiene.
Were this done, a knowledge of the laws of health would in course of
time become part of the professional equipment of all school-teachers, with
the result that they would know, better than they now do^ how to safe-
guard the children intrusted to them from the grave dangers of preventable
disease.
Moreover, school-teachers who have thus themselves acquired a sound
knowledge of elementary hygiene would be able, given suitable opportunities,
to impart some of this knowledge to their older scholars. In particular, the
scholars would learn the fact that many disorders, with whose names and
dangers their home life has made them familiar, are in their nature pre-
ventable and by simple means can be prevented*
Children so trainetl wovikl, on reaching maturer years^ be more intelli-
gently alive to questions concerning the preservation of health than is now
the case with the majority of our people.
We believe it is in the power of the Board of Education to further these
ends by suitable changes in the Regulations for the training of Elementary
teachers, such as the following:
1. That elementary hy^ene should be made a compulsory subject of
study in training colleges.
2: That l^efore receiving a certificate of proficiency every teacher should
be required to show a sufficient knowledge of the lawa of health, and in
particular of those relating to the prevention of infectious disorders,
3, That, whenever possible, the instruction in elementary hygiene given
I
ELEMENTARY HYGIENE IN THE SCHOOLS OF GREAT BRITAIN.— HERON, 709
in training colleges should be intrusted to specially qualified medical prac-
titioners.
We are, Sir,
Your obedt- Servants,
T, Clifford Allbutt, M.D., F,R.S.
Regiua Professor of McdiciHef UniwrsUy of Cambridge.
G. L. Bruce.
Laie Scho<U Board for London and London CommitUfe of Education.
G. A. Heron, M.D., F.R.C.P.
Rgpftaeniing the Iniematwnal Association for the Pmeniion of Tubcrculosta.
Donald MacAlister, M.D., F.R.CP.
Principal of tfic Univeriniy of Giasgow and Presuknt of the General Medical
Council.
William Osler, M.D., ¥.RS.
Profeaaor of Medicine, University of Oxford,
John Twekoy, RR.C.S.
LoUl^ Preifident of tfie RoyoX CoUegt of Sur^eont of England.
34. It 13 noteworthy that of the three recommendations made in this
communication to the Minister, two are now adopted in full. The third
recommend H-tion has, I know, not been lost sight of; and it seems likely
that, oa is already the case in Scotland^ the teaching of hygiene in the train-
ing colleges of England, Wales, and Ireland may, in time, be Intrusted to
medical graduates.
35. In Biitain the medical inspection of children is now a feature of
school life. If it be thoroughly done — and there is every reason to believe
that it will be well done — the medical inspection of school children will in
itself^ I venture to predict^ prove one of the most useful means of ^ving
valuable object-lessons in hy^ene, not only to the children, but to the
whole community.
36. The same end will be furthered by the proper teaching of gymnaatics
in schools. This is now much better done than it was until quite lately. The
system of teaching, in this connection, which seems to commend itself most to
the education authorities is that known as Sivedish educational gymnastics.
37. Though it is not easy to overrate the power of education as a force
working, on the whole, for good, still it is possible to fall into that error.
I am^ however, sure of this, that no one who has thought about it will accuse
me of so erring when I venture to assert that education of the kind dealt
wnth in this report will go very far indeed to help us vastly to lessen, and
with increasing frequency to end, the ravages of the diseases which scourge
the human race. For my own part I venture to say that every disease is
preventable, perhaps with only one exception — the disease which shows
itself in extreme old age, and which, because we know not precisely what
It is, we call senile decay. Certainly the work kept in view by our Inter-
nationa! Society can only be achieved by the spread of knowledge; and
710
SIXTH INTERNATIONAL CONGRESS ON TUBERCUIjOBIS.
sound education and hygiene, given both to school children and to adulte, is
the chief means by which we can not only immensely lessen* but practically
end, the existen*^ of tuberculosis.
38* My warm thanks are due, and I heartily offer them, to the chief
Secretary for Ireland for tliis courtesy in putting me into communication
with the Office of National Education in Ireland for the purposes of this
report; also to Dr. Starkie, Resident Commissioner of NatlonaJ Education
in Ireland^ for hie kindness in supplying rae with information.
39. To Mr. Struthers, Secretary to the Committee of Council on Educa-
tion in Scotland, I am deeply indebted for the trouble he took, in response
to my request, to help me to trustworthy information on which is bas^i
what I have reported concerning Scottish education,
40. I have also to acknowledge a debt of gratitude to Sir Robert Morant,
Permanent Secretary to the Board of Education, for the help he has himself
given me and for his kindness in putting me into communication with Dr.
Newman, who has recently been appointed to the new post of Chief Medical
Officer of the Boord of Education, and who spared himself not at all in
taking pjuns to answer in the fullest way the many questions he kindly
allowed me to put to lum.
Rapport sur FEnseignement de I'Hygi&ne ^^mentaire dans les Colleges et
Ecoles £l€mentaires de Grande Bretagne et d'lrlande.^IiEKON,)
En Angleterre et dons le Pays de Oalles, la cause de fenseigncment
de rhygidne dans les dcoles a fait un grand progrds, Le ler Aotlt 190S, on
mit fin ^ ce mauvnis systt^me qui, jusqu'^ cette date, faisast de T^tude de
rhygifene un sujet facult^tif pour ceux qui avaient I'intention de de\-enir
instituteurs*^ A cette date, on ajouta ce sujet k la liste de ceux qu'un futur
instituteur est oblig^ d'^tudler pendant les annte od 11 re^oit son instruction
apiSciale k Tecole normale. Dans una aan^ ou deux, on devrait avoir,
par ce moyen, un nombre considerable et t^ujours gramlissant de jeunes
gens et de jeunes filles poss^dant une oertaine connais&ancc du sujet,
sachant comment Tenseigner aux enfants des toles-
Le Consell dlostruction a aussi pris une initiative tr^ louable en put>^
liaut pour la premi^ iola des Lnstructions pour les instituteurs des enfants
qui soQt aveugles^ ou sourds, ou faibles d'espiit.
Quand les ^tudiants ont terming leur cours ^ t'Ecole Normale, lis dotvent
passer un examen, qui comprend une composition sp^ci^de sur Thygiene,
Une des raisoos pour lesquelles le Conseil d'Instruction doune oe oours
d'instruction sp^ciale et d*examen est d'^viter meme Tapparenoe de former
des instituteurs qui puissent slmaginer ^tre dm sp^ciiilistes en hygidcoe.
maaniNTART hyqikwe in the schools of great britajn. — heron. 71 1
Le but de cette instniction est de t&cher d*obtemr pour I'^eole un insti-
tuteur qui soit ' ' capable de comprendre les conditions, mentales et phj^quea,
qui readent un enfant incapable d'dtudier k F^cole," et qui ait re^u une
^ucation hygifiniquo suffisante pour savior distinguer un enfant qui ne
fait pas de progr^ suffisant, non pas pares qu'ii ne veut pas travailler^ noais
parce qu'i! souffre de quolque dt^fformitd ou incapacity.
En Ecosse toutes les Ecolea Normalea ont dea coura d'instruction d'hy-
gi^ne. On n'a pas publi6 de livrea pour rinatniction de Thygifine dana les
Ecoles NormaleSj parce que Tinstruction est donn^ par des cxjnf^renciera
compi^tents, quij ft part seulement trois exceptions, sont des Docteurs en
m^decine* H faut admettre qu'en Angleterre, dans le Pays de Galles et
en Irelanile Tenseif^nement de I'hygi^ne dans les Ecoles a H6, jusqu'^ main-
tenant, tr&s n^^iig^. Ce n'est pas le cas en Ecosse, oh Tenseignement de
rUygi^ne dans Ics ficote normales a 6t& confix, pour la plupart dea caa, k
des dipldm^s mddicaux comp^tents, qui se fiont tr^ bien acquitt^ de leur
tAche.
Le nouvel ordre de chosea, en Angleterre et dans le Pays de Galles,
inaugur^ le ler Aoflt, est plein de promesses. Lea fonctionnairea permanenta
du Conseil dlnstniction se rendent bieii compte que I'int^r^t pris dans
I'eDseignement de Thygi^ne ne doit plus fitre, comrae autrefois^ limit-d A
un petit nombre de Docteurs, C'est une veritable admigaion pubUque de
la negligence et de Tindiffi^ronce avec laquelle a 6i& traits juaquMci co aujet
si important pour T^ducation de nos enfants.
En Angleterre Vinspection m^dicale des enfanta fait partie du syst&me
scolaire. Si elle est s6rieuse et complt^te — et il y a raison de croire qu'eile
le sera — I'lnspection raMicale des enfants des Ecolea sera, je le pr^diw, un dea
nioyens les plus utiles de donner de prdcieuses legons pratiques d*hygi&ne,
non seulement aux enfants mais k la communaut^ enti&re. Ces rfeultats
seront encore facilit^s par un enseignement rationnel de la gymnastique.
Bien qu'il soit difficile de irop dvaluer le pouvoir de I'instruction fomme
force active pour le bien, on pent cependant tomber dans cette erreur,
Je 8ui3j toutefoiSj convaincu de ceci^ que ceux qui out r^H^chi sur la
question ne m'aecuseront pas de faire cette erreur, quand j'affirme que
I'instruction dont nous parlous ici dans ce rapport contribuera largement h
nous aider k diminuer et enfin k terminer les ravages des maladies qui sont
un flt^au pour la race humaine. Pour ma part j'ose dire que toute maladie
peut ^tre pr<^vcnue, avec une seule exception peut-6tre, la maladie qui
attaquc les per&onnes d^un dge tr^ avanc^, et que. parce que nous ne savona
pas pr^cia5ment ce qu'eile est, nous appelons, la decadence senile, Une
bonne instruction d'hygi^ne, donn^e et aux enfants des 4cole^ et aux adultes,
est le moyen principal par lequel nous pouvons, non aeulemont diminuer
immens^mcnt, oms pratlquement abolir Texistcnce de la tubcrculose*
712
SIXTH INTERNATIONAL CONGRESS ON TnBEKCtn/)flia-
After presenting his report Dr. Heron introduced the foUowiog reso-
lutions :
L That elementary hygiene should be made a compulsory subject of
study for those who intend to qualify as school-teachers*
2. Thnt whenever possible the instruction in elementary hy^ene given
to inteuding te&chera should be intrusted to specially qualified medical
graduates,
DISCUSSION.
Dtt. Robert Koch: I have long felt that in thia generally infecticrtw
disease of tuberculosis, as I have felt in regard to the many infectious diseases
in the study of which I have occupied my life, that every effort must be
taken to prevent the sprend of this contagion, and most important of all
the contamination of human beings by each other. From this point of^
view I have noted and recommentl to you as very important to study the
very complete exhibit of New York on the floor below, of the methods and
appliances to be utilized to prevent the spread of this infection.
But it is not suflacient to see the mean^ and apparatus. One must know
how to ase them. Therefore of most importance in this crusade against i
tuberculosis is tlus campaign of education,
Thus far moat of the educational efforts have been made with addts.
It is well known that adults are much more difficult to teach, slower to
learn, and forget more quickly than children. The youthful age is im-
pressionable* Children, of course beyond the age of babyhood, old enough
and intelligent enough to understand, leam most quickly, and never forget
what they are taught in this period.
The duty imposes itself upon the teachers to instruct their scholars in
all of the sanitaiy measures and precautions to be taken in combatiDg
tuberculosis. And both teachers and scholars must be thoroughly and
competently tjiught. These necessities are so ample and &e]f-e\'ident, the
most important of all antituberculosis measures, that I wish to endorse most
insistently the words of Dr. Heron.
Mr. Max Cohen, Miss Bissell, Dr. A. J, Richer, Miss Sadie American, and
Dr. Abernathy also took part in the discussion.
The following resolution was offered by Mr. Cohen i
**R€Solt'edf That, in order to promote the educational propaganda for
the prevention and cure of tuberculoaie^ the various societies or local brancbea
identified with this International Congress are herevxith respectfully re-
quested to institute measures either for the appointment of a Press Com-
mittee or for securing clerical assistance to its secretaries, as will best enable
such societies or organizations to furnish a brief synopsis of at least the
most important features of its proceedings or addresses to its local news-
papers for publication."
SECTION V.
Hygienic, Social, Industrial, and Economic Aspects
of Tuberculosis (Continued).
SEVENTH SESSION.
Friday morning, October 2, 1908.
PROMOTION OF IMMUNITY.
Development of the Conception of Physical WeUrbeing; Measures far Increasing
Resistance to Diseasej such as Parks and Playgrounds, Outdoor Sports,
Physical Educationf Raising the Standard oj Living in Respect to
Housing, Diet and Cleanliness; Individual Immunity and Social
Conditions Favorable to General Immunity,
The seventh session of Section V was called to order by the President,
Mr. Edward T. Devine, on Friday morning, at half past nine o'clock.
NOTE SUR LE R6LE DES ASSOCIATIONS DE LA
PROPRI^fi BATIE EN FRANCE, AU SUJET DE LA
TUBERCULOSE, ET PARTICULItREMENT DE
LA CHAMBRE SYNDICALE DE PARIS.
Par a. Marc,
PHndeot de U Chambre Sjoidioftle des PropriAAi Immobilite«t d« 1* Viile d« Paris.
(Present^ par M. Talamon.)
Des Associations de propri^taires se sont fondto en France, depuis une
vingtaine d'ann^es, dans le but de s'occuper des int^rSts ^conomiques des
propri6taires adherents.
713
714
SIXTH INTERNATIONAIi COKGRESS ON TtTBEHCUtOSlS-
Cee Associations con3titu6ea sous la forme et sous le litre de Chambres
Syndicales de la Propri^t^ Batie ont en g^n^ral pour objet:
1. L'^tude des questions int^ressant la Pfopri^l^ unmobiH^re,
2. La ddfense des int^r^ts g^n^raus des propri^t-aires.
3. L*organisation au profit des adherents de services pratiques variables
suivant lea besoins de la locality,
Une Union de toutes cca Chambres Syndicales a 6i6 fondde en 1893.
Elle est un lien entre Ics Associations locales de propriSt^iines^ un centre
d'^tudes et d'action pour tout ce qui conceme les int4rets g^n^raux <ie la
proprii4t4 immobili^re en France.
L'Union s^occupe, conime les Chambres s3Tidicaies, d'int^rets 6conom-
iques et non pas de questions politiques.
Constamment pr^ccup^ de poursui\Te ram^Uoration de la propnet45
b4tie, lea Chambres Syndicales de la Propriety B&tle de France ont ^t^
amends 4 s'occuper particuU^rement de Thygi^ne et de la salubrity des
habitatioua.
Daus cet ordre d'id6es, elles n'ont pas h^t6 k reconnaitre qu'il exist©
dana les grandcg villes des immeubles qu'il convient d'aasaiiiir; Elles se sont
efforcdcs de ddmontrer h leurs adherents quo leur devoir comme leur int^r^t
leur commandaient d^aysurer la salubriti^ des habitations, d'y ^tablir un
confort chaque jour plus grand, mats en m^mc t<?mps, elles n'ont cess^ de
protester coiitre les injonctions injustifi^es, vexatoires et souvcot coutra-
dlctoires de certains hj^gicnistes oflQciels.
Aussi, ees Cliaml^res Syndicales do la propri^t^ b6tie de France ontr^Ues
Bpplaudi aux parolee — ^ leur avis — si justes si plelne^ de bon sens, pronon-
c6es h Geneve en Septembre 1906 fiu Congr^ de salubrit<5 et d'assaiidssement
de I'habitation par M. le docteur Bard,
Cet «5minent profcsseur de TUniversit^ disait aux administrateuiB et
aux mddecins de tr6s utiles v^riti^s qu'ou ne saarait trop signaler:
" . . . . il ne a'agit pas de mcttre du noir sur du blanc et de faire des
rfeglementa pour se figurer qu'on a fait avancer Tbygi&ne des habitations,
II faut reformer les moeurs des habitants. 11 faut ausai appliquer les r^
glements et commencer par lea rendre applicables; lb sont souvent fort
beaux sur le papier mais inapplicables; Tapplication en est tout aussi ira-
portant« si ce n*est plus importante que la redaction. . . *
"Les administrateurs aanitairea ont aussi leura defauts. Bs se pr^
occupant trop de Tharmonie des r&glements
"L'Unit^ des formules eat plus funeat*, car les besoins sent forc^ment
diff^rents et lea solutions doi vent 5tre mobiles et changeables comme eux.**
Et plus loin:
" Rassurez-vous, pour avoir gard€ les m^decins pour la fin je ue les oubUe
b6lE DES ASaOCiATIONS DE LA PROPRlfrrt BATTE* — MARC.
715
pas. II faut bien concevoir qu'ik ont aussi leurs d^fauts et je signalerai lea
deux principaux:
"D'abord, ila versent trop dans rid^aiiame en mati^re d'hygi^ne.
" En second lieu, ils exigent dea m^iures dont les bases reposent souvent
sur de simples et biltivea priSsoraptionB, Avant d'imposer au nom de Thy-
gi^ne des entravea aux libert^s populaires, 11 est l^time de demander que
les principes sur lesquels elles s'appuient ne soient pas de simples hypothfeea
deatinfes k se dissii>er aux premieres recherches ult^iieures."
Le easier sauitaire que certains recommandent peut constituer ^videm-
ment un document int^ressant, mais ses donn^ sont n^ceasairement im-
parfaites et quelquefois m^me erron^, il ne doit pas ^uivaloir k une liste
de proscription.
La v^rit^, qu'on ne saurait trop r^p^ter est que la salubrit-^ d*une habita^
tion ne tient pas uniquement aux quality intrins^ques du local: dimensions,
ouvertures, orientation, etc, elle a sa principale cause dans la fa<jon dont se
conaporte Tbabitant qui sait tenir son log^s en parfait 6tat d*a^ration et de
propret^.
Mors m&me que la construction serait d^fectueuse, on y vivra dana de
bonnes conditions d*hygi&ne en y prenant tous les soins n^cessaires. Par
contrej on s'exposera aux plus graves intoxications dans un appartcment
dou^ de tout le confoH nioderne s'il est raalpropre et s*il n'est jamais a^r€.
M. Emile Cheysson a fort bien d^veloppfi ces consid^rationa dans une
Stude panie en 1904 : Des maisons salubres — disail-il^peuvent ^tre rapide-
ment infect^ par leurs occupants; D'autre part, dans des cit^3 insalubreSj
il arrive de trouver c6t^ h c6t4 avec dea logements r^pugnants des logenients
proprea et coquets. Si Ton transportait une mauvaise m^nag^re dans un de
nets plus jolis cottages h. la fois riant et ensoleill^, elle aurait t6t fait de le
convertir en bouge- Comme contre ^preuve, que Ton inst-alle dans certmnes
casernes de chiffonniers des m^nag^res flamandes et Ton verra le parti que
les vaillantes femmes sauront en tirer/'
De ces judicieuses romarques deux conclusions se d^agent:
La premiere, c'est qu'en se bomant k vouloir procurer k tout le monde et
par tons les nioyens des habit-atioiis constriutes hygi^niquement, on ne fera
qu'uue oeuvre superflue si, au pr^alable, on n'a pas iceulqufi aux habitants
Tart de tenir saines leurs denieures.
La seconde — consequence de ce qui pr^cMe — est qu'il est n^cessaire de
d^velopper Tenseignement mdnag^r^ c'est-i-dire d'apprendre les r^<
d'hygi^ne h ceux qui les ignorent et dHnciter tout le tnonde k lea pratiquer
dans I'habitation.
Le d^vcloppement incessant de Tenseignement manager, voili done le
facteur principal de I'assaimssementI
La Chambre S^iidicale des Fropri^taires de Paris et I'union B'est tou-
jours inspire de ces idto.
716
BDCTH TNTERNATlOJfAL CONGRESS ON TTTBEBCULOSIS.
En 1906, eUe institua un concours annuel ayant pour objet lea meilleuraa
dispositions des logements ou appartements.
Le3 motifs invoqu^s par son Conseil d* administration k Tappui de la
©Nation de ce concours sont k noter:
'^Convaincue que de la bonne disposition ties locaiis depend la sant^
physique et morale de leurs habitants la Chambre Syndicale %'eut eocourager
lea propri^tairea k demander k leurs architectes de faire jouir les locataires
de la plus graode sorarae de jour, de soleil et d^air, de eonfortable et d'hy-
giSne en joignant k ces avantages qui contrihueront k leur sant^ une d^
coration int^rieure sobre et r^pondant h la destination de I'immeuble, satis-
faisant ainsi le gofit des habitants, leur faiaant aimer le foyer autour duquel
fie serreront les membres de la famille.
C'est en consideration du grand r6le social que Thabitation humainc^
bien comprise et d^corde avec goiit joue dans la soci^td que la Chambre Syn-
dicale dea Propri^t^ ImmobiUeres de la VilUe de Paris a r<5solu d'ouvrir un
concours tous les ans pour une des cinq cat^ories d^signto ci-apres".
La ni^me anii^ la Chambre Sjiidicale de Paris dficida encore qu'elle
dScemerait des recompenses aux locataires de petils appartements, logement^
ou chambres dont le loyer n'exc^de pas 600 francs par an pour la boone
tenue des locaux occupds par eux et de leurs abords.
Cc8 rdcompensea consistent en une somme ^quivalente k un ou deux
termes de loyer.
L'Union des Chambres Syndicales et la Chambre Syndicale de Paris
envoy^rent des d^Idgufe au Congr^a international de I'habitation de Gen^fve,
au Congrfe national d'hygfine de Marseille, en 1906, au Congr^ de I' Alliance
d'hygi^e sociale h Lyon, en 1907,
A la suite dea discussions les plus courtoises, ces diffSrents Cbngrfe ^mirent
le voeu:
1^ Que rAdministration soit autorisfe k mettre en cause, non plus seuic-
ment lea propri<!taires d'habitations insalubres^ mais encore tous ceux qui
auront nui h la salubrity de rimmeuble;
2** Que rAdministration vienne en aide aux propri^taired dana Tex^cu-
tion de^ travaux d'assaiiiissemeut, par la cr^tion d'une causae d'assainiase-
ment ou par tout autre moyen;
3° Que les pouvoirs publics, k tous les degrfe, favorisent Textetision de
I'enseignement manager; que I'imtiative priv^ encourage la pratique de
rhygidne dans lea habitations;
4° Que, sous peine de nuire aux travaux d'assainissement et d*am^ora-
tion des logements, il ne soit plus proc^dd 4 de nouvelles aggravations d'im*
p6ta sur la propri^t^ bfl.tie servant d'habitation.
Nous demandons la confirmation de cea voeux* Enfin nos Chambres
Syndicales demandent ^galement avec Anergic le tnaintien et m^me Taug-
meiitation dea pares, jardins et espacea libres k I'int^rieur de cettes villes.
THE RELATION BETWEEN INCOME AND TUBER-
CULOSIS.
By Woods Hutchinson^ A,M»i M-D.,
K«w York.
Consumption is the most certain of the numerous blessings of the poor.
That it ia and always has been closely connected with poverty is so painfully
obvious that to fonnally call attention to the fact is about on a parallel
with Mr. Bernard Shaw's recent announcement that, after profound refteo-
tion and careful investigation^ he had discovered that the real trouble with
the poor was — poverty.
It is tuberculosis that keeps the lives of the poor, like th^r annals^ short
And simple. But when one attempts to establish the precise relationship
between these two conditions, the difficuitiea begin- It is^ of course, and baa
rlieen for half a century, a commonplace of vital statistics that the death-rate
from tuberculosis varies precisely with the social position of the individual,
falling moat lightly upon the highest and wealthiest classy, and most heavily
upon the lowest and poorest.
In this sense consumption is the price of civili nation, and, a3 usual, is
paid by the lower two-thirds, for the benefit of the upper third. A tj^ical
statement is that of Korod — ^that of inhabitants of Budapest, there die of
consumption, in every 10,000, well- to-do persons, 40, moderately well- to-do,
62.7, 77,7 poor, and 97 paupers. There is a sound biological basis for our
modem determination to acquire wealth, since those who obtain it reduce
their chances of dying from tuberculosis 50 per cent. Furthermore, there
can be little question that the marked and encouraging decrease in the mor-
tality from tuberculosis which began about sixty years ago, long before the
discovery of the bacillus, and which in England progressed as rapidly before
that time as it has done since, was both the accompaniment and the result of
the superb industrial and scientific developments of the Victorian era — baaed
upon the utilization of steam, electricity, and other forces of nature; and
that this lowering of the death-rate was largely due to the immense improve-
ment in wages, food-supply, housing, and sanitation of the great masses of
the community — the working classes. To-day, those nations which have the
highest rate of wages and the shortest hours have the lowest death-rate from
tuberctilosis*
717
718
Sl%TB tNTERNATIONAL CONGRESS OPT TDBEBjCUIjOSIB.
It 19^ however, of oourae obvious that a number of different factors i
into this relationship. First of all b the self'^videiit fact th^t the L
the income of the inilividual, the better will he be able to supply hii
with the necessities and aoiround himself with the comforts of Ufe^ ini
ing good food, better house accommodations in less densely populated
more healthful districts, better sanitary surroundings, more bath-tubs,
leseened exposure to infection, better and earlier medical attention,
Again, it must be remembered that when you have class]6ed indlvidv
anil even classes, according to their earning capacity and ineome^ you
roughly arranged them in the order of their mental and probably phya
vigor; that an unoonBcious phy^cal selection is continuously goicg o^J
between different industrial classes and ]:»etween the individuals en^^^f
the^ classes of occupations, by which the stronger and more endunng see
the best positions and the highest incomes^ leaving their weaker and
fortunate fellows to fill the lower ranks. So that, to a certain extent,
more restricted and unfavorable surroundings, dependent upon smaller
comes, fall upon a class which is already less vigorous and less resiBting.
Thirdly, it ia urged that inasmuch as consumption runs a couiBe of yet
and in some of its more chronic forms even decades, its existence would te
to lower the physical vigor and earning capacity of its victims, so as to in
pacjtate them from earning the higher rates of wages, and competing in i
more higlily paid and strenuous occupations. Frequent periods of s
leave might cause them to lose their positions in well-paid employinent w
regular hours, and compel them to drop to more poorly paid and less con£t4
positions, or even to change their occupation entirely, for others which hn
lighter work but much poorer pay.
But, frankly, it seems to me that all these explanations practically bri
us back to one natural conclusion: that is, tbat the heavier factor in
production of tuberculosis, and the most unfavorable element in the prospi
of recovery, is lack of income, in the sense of power to provide the ne«
sities of life and of health. If by some means the victim of coasumption
any industrial rank of life could be given an increase of say 10 per cent.
his wages, it would do more to improve his chances of recovery than atmc
any other single remedy. If the rate of wages for a given occupation
by some legitimate means be increased, the percentage of tuberculosia vi
be diminished almost in the same ratio.
In sliort, t^ borrow again from the profound philosophy of George Bi
nard Slmw: ^'Tbe cure for poverty is money," Fortunately the cxperiea
of our open-air sanatoriums furnishes ua with laboratory experiment 1>eanj
upon this question, whose findings are unmistakable and practically unai
moud — and that is^ that patients taken from no matter what rank in 1!
show almost the same percentage rate of recovery, when placed under favi
RELATION BETWEEN INCOME AND TUBERCULOeTS. — HTITCHINSON- 719
able conditions. The difference cornea in when the question is reached of
BeodiDg them back to their previous occupations and social aurroundings^
after they have been cured.
From a practical point of view, there can be no doubt but the question of
income is a most pertinent and painfully important one, Almoat the first
question ttiat the physician has to ask^ after makijig a diagnosis of tuberculo-
sis ia: "What are your circumstances?" "For how long can you afford to
go away? " '* Of, if you cannot go away, what extra food, what shorter hours
of work or confinement are you able to give yourself?" Upon the answer
to this question depends the probable result. And the consumptive can,
roughly speaking, buy as many chances of hving els he is able to afford.
The findings of our splendid system of tuberculosis dispensaries in New
York, under the committee of the Charity Organization Society, are profoundly
instructive in this regard. Of those of their patients who are able to go
awaj^, either to sanatoriuras or to the coimtry for six months or more, some
70 per cent, recovered. Of those who were only al>le to go away for a few
weeks, or could shorten their hours somewliat and improve their food and
suiToundLngs, 50 to 60 per cent, recovered. Of those who were unable to go
away at all, and couJd not shorten their hours of labor^ or improve materiaUy
their food or surroundings except by opening windows and getting milk
and eggs from diet kitchens^ about 30 per cent, recovered.
The second point on clinical experience, where the question of income
comes vividly home to us, is after the consumptive has been cured. Tlie
problem arises how he is to earn bread to support the life that he has saved.
Unless he be possessed of unusual ability or skill, or be fortunate enough to
have saved money, or to have relatives or members of his family upon whom
he can lean, it ia exceedingly difficult — I had almost said impossible— for the
wage-cn.rning "graduate" of a sanatorium to earn a lixing under modern
industrial conditions without relapsing and losing his life in the process.
This is one of the most pathetic and one of the most hopeless phases of our
experience with the scourge of coosuraptiou.
The light that is thrown upon this problem by the death-rate from con-
sumption in different occupations and classes is interesting, but somewhat
confusing. In the first place, the data arc exceedingly defective in this
regard in several ways. Firsts because many occupations and professions
run the whole gamut of wages and incomes, from low to high, from miserably
underpaid to well paid, within the limits of their own class. And we have
no means of determining as yet whether the mortality accorded to the
class comes chiefly from the lowest or from the highest paid. Secondly!
because moat of the records at present available from census reports^ indus-
trial insurance companies, etc., give only the deaths actually occurring
among the workers themselves, without any information as to the conditions
720
SOCra INTERNATIONAL CONGRESS ON TUBBBCUL09IS,
in their wives and children, who have to live upon their wagea^ in the air-
rouDdings made possible by them. Thirdly, because in many of these the
requisite data are aot given for calculating the influence of age on the part
of the workers, as different occupations, of course, vary widely in the per-
centage of workers of different ages, and cortsumption is profoundly affected
by the age relations of the individuals subjected to it. Nevertheless, there
are certain general results and groupings which in the main appear to support
the importance of income as a factor in tuberculosis.
First of all, the findingSj both from the United States Census, the reports
of the English Registrar-Gene ral^ and the data collected by the industrial
insurance companies so ably brought together and presented by Mr. Fred-
crick I. Hoffman, support the same general conclusions in regard to the
relations between tuberculosis and social portion that have already been
discussed. If the difTerent classes be arranged in order of the amount of
their death-rate from tuberculosis, with those having the highest mortality
at the top, and a line be drawn marking the average mortality for the entire
series, every non- wage-earning class and occupation in the community,
Buch as the professions, merchants, business men, etc., will be found below
that line. On the other hand, every class of day laborer, with the exception
of fami laborers, as distinguished from those paid by the month or week,
will be found above it. Secondly, with the exception of certain notoriously
unhealthy occupations, like marble and stone cutters^ compositors aod
printers, etc., the five classes and groups having the highest death-rate from
tuberculosis are those which are among the most poorly paid and having
the least control over their surroundings — headed by servants, and followed
by laborers (non-agricultural), book-keepers, clerks, etc., cigar-makers and
tobacco-workers, cabinet- workers and upholsterers, barbers and hairdressers.
At the other end of the scale we find, as having the lowest rates of all,
with the exception of farm laborers and farmers, five exceedingly well-paid
and light-worked occupations: vhs.^ bankers, brokers, and officials of cor-
porations; miners and quarrymen; steam railroad employees; clergymen,
and policemen. It is peculiarly apropos to our contention that bankers
come at the very foot of the list, with the lowest mortality from tuberculoafl
of all classes.
In fine, whatever may be our attitude in regard to the precise relations
between wages and tuberculosis, we are justified in promoting every honor-
able movement for the raising of wages by legitimate means as a factor of
great importance in our success. Especially is this the case with relation
to the prevention of the disease at what w© are now coming to r^ard as
ita very fountainhead^ viz,, in children and in the small home. The merO'
increase in the income of the head of the family, which would be sufficient
to furnish each child with an additional cup of milk, an extra egg, or a double
RELATION BETWEEN INCOME AND TUBERCULOSIS. — HUTCHINSON. 721
thickness of butter upon the thinly spread bread, might turn the scale in
deciding the question whether that child would succumb to the invasion
of the tuberculosis bacillus or throw it off. The results obtained in our
tuberculosis dispensaries merely by adding a quart of milk and two or three
eggs daily to the diet, and opening the windows, abundantly prove this.
Data bearing precisely upon this question are most difficult to discover,
and their collection would be a colossal task for any single individual. The
main excuse for presenting this paper is the hope that some institution or
organization, working among the tuberculous poor, like our superb dis-
pensaries for tuberculosis, our charity and social workers, or our boards of
health, would be stirred up to collect the requisite data.
Two interesting straws pointing the general relation I have already
secured. One, the admirable study by Dr. Charlton Wallace of 443 children
treated for tuberculosis of the bones at the New York Hospital for Ruptured
and Crippled. The average family income of these cases were found to
be 1542 per year, as compared with the minimum required to keep a family
of five in decent health in New York City, estimated by the Charity Organi-
zation Society at $876— a shortage per family of nearly 40 per cent. In
other words, these little sufferers had been living on about 60 per cent, of
their proper amount of food, air, and light. The other straw is a short
series of the cases in the laboring classes reported in one week to the New
York City Health Department, kindly collected for me by Dr. Shirley
Sprague, showing a subnormal wage.
LE TRAITEMENT DES ETATS PRE-TUBERCULEUX
DANS LES INSTITUTIONS SPECIALES
(PREVENTORIUMS),
Pah le Dr, AHTHim J* Richer.
lie Saaatorium a jou4 le r^le le plus important dans ta croUade Anti-
tuberculeuse durant les quarante ans ^coulfis. Ceci eat un fait concSU6 de
toutes parts, Ces demidres annfeSj plusieurs organisatioca et instilutions
ont prouv^ leur valeur comme adjuvants. Le dispensiure special a 6t^ iiiis
demiercment en grande Evidence, et cela pr^cis^ment parce qu'iJ a ouvert
de nouvelles voies d'investigations et de contr61e aussi bien qu'apport^ de
I'am^lioration et la gu^rison fi. un certain nombre de malades, qui autrement
am^ent succomM et grossi le nombre de ceux, qiii chaque ann^ flonl
nioi6son<5s par "la ffrande faucheuseJ' Calmette a bien expliqu^ le r6Ie du
dispensaire nommd par lui, — Preventorium, parce que par son interm^iaire
de nombreuses meam^a preventives sinmltan^fment sont mises en actioiL
Tous ceux qui ont travaill^ en faveur de la croisade antituberculeuse out
le sentiment qu'actuelleraent notre armement, aussi vari^ qu'il aoit, n*e3t
pourtant pas sufisant. Le sanatorium, le dispensalre, I'asile pour Incur-
ableSj les classes de traitement h. domicile, les institutions sp^eiales, !ۥ.
colonies rurales, les colonies camp^ en plein air, les ligues et les associations,
tous ont des missions particuli&res k remplir, et cependant, en toute sinc^
rit^, noua ne pouvons pas dire qu'avec ce formidable arsenal d*arme5 anti-
tuberculeuses, nous nous soyona rendus les maltres de la situation.
Pourquoi en est-il ainsi?
Parce que nousj comme m^decins, perraettons que la maladie prenntt]
racine avant que nous ne I'attaquions, Comme preuve de ceci, que chacuit
de nous revise h loisir les histoires cliniques de ses patients phtisiquea.
Dans un cas, nous liaons que quelquea mois avant Tapparition du mal,
le patient a eu une fi^vre typhoide, ou une pneumooie, ou une pleur6aie, ou
bien la grippe.
Chez beaucoup d'autreSf nous lisons qu'^ plusieurs reprises, avant la
maladie, ils se sont sentis^puis^s et pour les ouvri6reSj combiende fois n'avons-
nous pas appria qu'ellea ont ^t4 an^mifies et d^bilitte. Aprfe avoir totalia6
tous ces cas, nous trouvons que nos rapports cliniques prouvent qu'environ
723
LB TRAITEMENT DE9 ^ATS PRfe-TUBERCULEUX. — RICHER.
723
90% de nos tuberculoses appartiennent k cette cat^gorie- Pour les autrea
10% dea cfls, noua trouvona que ce eont des rhumes n^gliggs qui tmp tard
ont <St4 diagnostiquds comme tttberculosc. Si Ton examine de pr&3 lea
rapports de tout sanatonum^ Ton y a la preuve que les maladea y ont €t^
envoy^s beaucoup trop tard pour g^n^ralement obtenir de bona rdsultats
du traitement. II y a plusieura ann^s d6j^, comme m^decin-directeur d'uu
Ganatorium. que j*ai ^l^ frapp^ par cg fait ddsolant et je fu8 bientflt convaincu
qu^une raison patent* existait et devait ^tre trouv^. La tiche que je me
6uia assignee a eu sa recompense. J'ai dt^ pteinement pcrsuad6 que si nous
luttions contre les avant-coureura de la tuberculose {pleurtnCj pneumanief
typholdef influemaj dibiliti ct an&mie) en traitant cea convalescents dans dea
institutions sp6ciales ou priventariums, nous prdvieadrions certainement
le ddveioppement ^ventuel de la tul>ereuIose chez ceux ainsi soignds d'apr^
lea regies et m^thodes sanatoriales. Noua donnons k Tappui de ceci, Vex-
p^rienoe de plusieurs ann^ea d'observations. Si Ton avait de suit* recoura
h cette m^thode de traitement pr^coce, noua serions bient6t k m6me de
noua servir de nos sanatoriunis comme preventoriums^ — le diapenaaire
et Taslle pour incurables ne seraient plus nt^cessnirea et lea organisations
aujourd'bui existantes trouveraient un nouveau champ d'action dana lea
mesurea preventives, en am61iorant lea habitations des classes ouvriirea
et les conditions dans lesquetles ellea travalUent.
Tou9 ceux qui s'occupent du c6t4 cUnique de la question doivent n^cea-
siarement etre frapp^s par la fr^[uenpe des prodromes de la tuberculoes
pulmonaire, Parmi les cliniciens les plu3 obaervateurs, cet ^tat pr^tubercu-
leux est reconnu comme un vdritable niasqud Avec toute I'dvidenoe des
laitg recueiilia durant ces demi^rea quarante ann^eg d'eiqierience, nous
devrions ^tre capable de reconnaltre et de traiter la maladie derridre eon
masque. D^pister la maladie et la traiter franchement de suite.
La Preventorium est l*institution qui nous permettra de faire suivre
ce traitement par anticipation,
Au jour qui vcrra cette marche vers le progr&a, dans le traitement de la
tuberculose, nous pourrons en toute siiret^ proclaraer I'ennemi k notre merci.
Die BehandluQg der prStuberkulosen Fiille dutch besoadere Institutiooea.
— (Richer.)
Die Rolle, welche daa Sanatorium wiihrend der verfloasenen vieraig
Jahre gespielt hat, ist unleugbar von solcber Wichtigkett^ dass sic als der
Hebel betrachtet werden muss, der den Kreuzzug gegen die Tuberkulose auf
seinen jetzigpn Standpunkt gebracht hat* Dieee besonderen Bestrebungen
haben breite Wege der Forschung und Kontrolle, die die Tr^ume ihrer
Verfechter iibertreffen, gescbaffen.
724
fiCCTH INTERNATIONAL CONGRESS ON TtTBEBCULOBlS,
Es existieren In alien civilisierten Landem viele Agenturen, tatsachlicb
siiid sie aelir zahlrcich, dennoch ist die Losung des Tuberkuloae-Problemfl
noeh in \\eiter Feme geriickt, Waruni? Well wir als Arzte die BebandJung
veriftgeTO, bis die Krankbeit einen ku festen Halt gewonnen hat.
Mit w^nigen Ausnahmen ist die tuberkulose Erltraukung durcH das
Tragen eiiier Maske verhiillt. Die Maske mag die Form von Asthenie,
AmimiCt Chloruse, Pleuritis, Pneumonie, Typhus oder Grippe annehmen;
die wirkliche Erkrankung kann fur gewohnlich hinter der Maske entdeckt
wurdcn, sie kami daber im vorhinein erkazmt und zur selbeo Zeit beh&odelt
wenlen,
LjiftsGt nie die Maske euch cu einer Verschleppung der Bohandlung
veraiilasseu.
The Treatment of Pretuberculous Coaditions in Special InstituCions,
— (RicesaL)
The rAle played by the sanatorium dtiritig the past forty years is
lindeniably of such importance as to be considered the lever which
brought the antituberculosis crusade to its present position. The
special dispensary has opened avenues of investigation and control
beyond the dreams of its promoters.
Many agencies exist in nearly all civilised countries, in fact, they are
very numerous; yet the solution of the tuberculosis problem is still far
distant^ Why? Because we aa physicians defer treatment until the
disease has taken too Erm a hold.
Wth few exceptions tuberculous disease is ushered in wearing a mask.
The mask may take the form of debility, anemia, chlorosis, pleurisy,
pneumonia, tjjphoid, or grip; the real disease can, as a rule, be discovered
behind its mask. It can thus be anticipated and as such be treated ftt
onoe. Never let the maak cause you to defer treatment*
WOMAN'S RESPONSIBILITY IN THE PREVENTION OF
TUBERCULOSIS.
By Mrs. Isabel Hampton Robb,
(3ev«Und.
As a result of years of study and experience, scientific and practical
physicians now teach that the prevention and cure of tuberculosis must
mainly be sought in hygienic measures, proper houong, nutrition, fresh air,
proper clothing, and cleanliness of home and person. Hence it is clear that
the crucial problems to be solved are these connected with the economic
conditions of the individual home, for, needless to say, a community of
ideal individual homes will foster a civic pride and a civic foresight without
which their existence would be impossible. And when we think of the
individual home-life of the people, there instinctively comes into our minds
some appreciation of the part that women, individually and collectively,
must play in the solution of these important problems. When we consider
that all these hygienic measures are largely imder her control, that she bears
and rears our children, that the finest and greatest work in the world is
hers to make or to mar, that the formative years of our boys and girls are
hers to direct and control, we cannot fail to realize how wise and careful
should be her education to fit her to meet successfully so great a responsi-
bility. But we that have lived in hospitals realize with sorrow that one-
half of the patients would never have needed to seek admission in hospitals
had social conditions been different and better. Those who have spent
years in watching and 8tud3ring the ordinary economical and social con-
ditions of the home and the common methods employed in the rearing of
children have found that system, order, and hygienic conditions, as they
are administered to-day, are, for the most part, impossible in homes, where
all is largely dependent upon the good or bad judgment of some individual
woman, upon whom these responsibilities have been thrust, but to whom
has been offered no opportimity for obtaining the education and training
that might enable her to meet them with some success at least. Can any
one deny that conditions are faulty? The old happy-go-lucky way has been
tried and failed. Are we to sit still or shall we not try to make a fresh
be^nning, however small?
In the lists of members and committees of this conference and of this
725
726
SIXTH INTERNATIONAL CONGRESS ON TDPERCULOSIS.
section, where she properly belongs, the horue-oiaking woman is not repre-
sented, nor has she volanteered or foimd a place in any of the previous five
congresses. The knowledge and teaching disseminated by them do not
seem to have reached her, or^ at aay rate, they have not roused her suffiriently
to render her willing to bear her share in such meetings, although she
forms the liirger eliare of the human race. Her absence forcibly recatla
George Frederick Watts' two great companion pictures: In one & large,
powerful woman is sitting with arms and body lax and inert, the head
dropped over on one shoulder, and the eyes closed in profound sleep, while
on her lap rests a naked infant, its body curved toward her and its head
resting on her breast, but with its eyes, full of wonder, turned toward the
world. This picture is called "The Slumber of the Ages." The second
represents tlie figure of a woman with a bent and drooping head, with eyes
bandagedj and a broken l}Te in her grasp. Huddled up she sits on the edge
of the world, which her feet do not even touch. And this picture the great
painter rightly calls " Hope/' for we are conscious of a stirring in that great
slumbering body during the past fifty years, and as we look at it we become
hopeful for the years to come.
It may seem strange that women as a body should seem so indifferent to
these great vital questions of life and death, to the yearly devastation of
our homes by tuberculosis, and to the terribly high mortality of infants
But this indifference is not real. She suffers, and it is because she does not
understand that she meekly and sorrowfully submits to what she believes
to be inevitable. She does not know her education is such as usually to
keep her in profound ignorance of the subjects that would rouse her interest
and hei*seif to action. The average woman has no practical conception of
the anatomy and physiology of the human body, of its various organs, of their
functions, and of their relation to each other, nor has she any conception
of the fundamental facts connected with food-stuffs and their application
to the best nourishment of the body. She is profoundly ignorant of true
hygienic principles and their application to her own body and that of her
children ; and yet to her, and her alone, is entrusted the rearing of the family.
The hygiene of the home and of its members ia largely under her control.
But let a woman once elect to become a hospital nurse to care for the sick
and restore them to health, and her education in these subjects is at once
taken in hand, and at the outset she is taught the elements of human anatomy
and physiology, bacteriology, hygiene^ and food principles as the foundation
upon which to build her education as a nui-se, N'ow^ however, since pre*
ventiA'e medicine ia so popular, would it not seem logical to train our women
in these subjects, and thus undoubtedly save many a case of illness?
It is astonisMng how many women, even teachers and college graduates^
are absolutely ignorant of these subjects, or have but a superficial knowledge
of them. They are not given the proniineace or importance that should be
4
woman's RESPOKSIBILITY IN PREVEhfTlNO TUBERCOIjOSIS. — BOBB, 727
^ven them in our girb' schools and colleges^ and therein lies one of the
greatest weaknesses of our present-day Uigher education of women. Nor
do the Institutions for domestic science make the study of the human body^
hygiene, and bacteriology the basis upon which to build their scientific
domestic training, nor is this training practically applied to the needs of
the body^in fact, most of the teachers of domestic economy are ignorant
of these subjects themselves.
My plea, therefore, would be to take such steps as will result in educating
and training all women in tlie theory and practice of such hygienic measures
aa are needed in the affairs of the home and in the proper care of the body.
We need, in fact, two kinds of schools for our boys and girls — those we now
have for general education and knowledge, and others for the teaching of
the household arts.
I am aware that our public schools give courses in elementary houae-
keepingj but this is not enough. The subject is too important a one to be
added to an already crowded curriculum. What are needed are buildings
and courses apart in every neighborhood, with a separate staff of teachers
and workers. In the past few years the great development of commerce
has taken out of the home many of the old home industries that kept the
women busy and that afforded the splendid practical training that formerly
gave us so many efficient housewives. With the industries a large class of
'Women have gone from our homes to the factories, and until she is manied
the young woman learns little or nothing of the important duties of home
life. But training in industries in the home and in the factory are two differ-
ent things. In the former, the girl became versatile; in the latter she becomes
a mere machine, knowing but the one thing required of her. When tliis
girl marries and goes back Into the home, she is in no way trained to meet
its responsibilities. It is true that there is another largp class of women
that need not work for their daily bread, but their need for this special knowl-
edge of household affairia and the proper rearing of children is just as great
as is that of thetr working sisters, and were such schools properly established,
they would undoubtedly make good use of them.
The belief has always existed that women are bom housekeepers, just
as they w^re formerly^ before the days of training schools, "born nurses,"
Unquestionably, there are those who are bom with a natural taste and adapta^
bility for such work, and they are the ones who always succeed, but, as a
matter of fact, many housekeepers to-day are *' square f>e^ in round holes/'
and would gladly take up a more congenial occupation. Nor can we shut
our eyes to the fact that many are doing so daily, and we must recognize the
truth that all women can never again ^d full occupation in the home, but
that many are bound to go further a&eld in search of other pursuits^ accord-
ing to thetr individual tastes. Nor can this distaste for housekeeping be
diminished so long as the kitchen and laundry are attached to the household
728
SIXTH INTERN ATlONAIi. CONGRESS ON TTTBEBCUIOSIS.
requirements. About SO per cent, of the luarried womea in the world have
to do their own housework, which includes the duties of cook and lAundreaSy
seumstress, nursemaidj housemaid, and devoted wife, any one of which occtquk
tiona is considered quite enough for one woman in a wealthy, well-r^ulated
family. Then, when tbe children come and the stress of work is too great,
the two things usually first neglected are the children and the proper prepara-
tion of food, with the result that all the members of tbe family become €t
Bubjecta for tuberculosis,
Sincej then, so many of the industries have been taken out of the home,
why not take these two also^^-the kitchen and the laundry — and assign them
to the practical working plant of the household schools in eveiy neighbor-
hood. Each w^d or district should have this kind of a school.
Other economical advantages for this centralization of the kitchen would
be that food for the neighborhood could be bought fresh and in bulk for \ea&
money, and without being exposed to decay and all sorts of conditions in
the little nondescript shops that infest our cities in the smaller streets.
Proper cold storage could also be procured, and the food kept pure and sweety
instead of being stored in the impossible and often badly kept little ice-
boxes to be found in the average home, or, as in the houses of the very poor,
in dark; hot cupboards. Then, again^ think of the enormous saving of
women's time and energ>' in the matter of buying and cooking. Picture to
yourself one small street of 50 homes, and on Saturday morning 50 women
going from them to market to buy 50 family dhrnere, and that only indiffer-
ently welL The matter of delivering hot food to the various homes in a
neighborhood m a detail that would not be difRcult to cany out.
Education of the children in this special school would be given from spring
until autumn J so as not to interfere with their other school work. This
part of the year also could be devoted to their nature studies. The teaching
of anatomy, physiology, and bacteriology should begin as early in a child's
life as he begins to ask questions about his little body; this is at about six
or seven years of age. The teaching should be ^ven in relation to other
nature studies, and in succe^ive years there should be a gradual develop-
ment, untilj at adolescence, the boy or girl is familiar with the work to
done by all parts of the body and with their uses and abuses. Attached to
the general practice kitchen and laundries should be bacteriological and food
laboratories^ where demonstrations of principles should be conducted and
practice work carried on. Classes for women through the day and after-
shop hours should be arranged, with no particular limitations as to courses,
tbe aim being that tbe people in the end should really understand the business
of hygienic home-making. One difficulty might be to find the right kind
of teachers, but if these were not yet in existence, the demand would soon
create a supply, and they could be found and trfuned.
For the staff of workers, each neighborhood is already supplied witb
woman's EESPONSTBILITT in PREVENTTNO TUBERCDTjOSIS. — ROBB, 729
enough and to spare of bright, clever women, practical and capable, with
both minrls and hands, and one of the great points for success is to have the
people feci that the school is theirs and that their wits and work are needed
in it. Such schools should be essentially educational; nothing about them
should be done in the name of philanthropy, nor should the home privileges
of such a school be extended without a certain return. It should be made ao
attractive that to be on its membership roll would be accounted a privilege
to be worked for by every member of the pommunity. In return for mem-
bership certain standards of hy^enic living, of neatnesSj of cleanliness and
order might be required, and cert^n duties for the general good expected from
its members. Prizes for various things that would tend to improve the
appearaJice and health of the neighborhood could also be offered. In Cleve-
land we have already in existence a strong ally in The Home Gardening
Association, an dissociation that, in unison with their nature schools, could
convert a city into a healthful^ beautiful spot.
One final appeal I would make for the general healthy comfort, and con-
venience of the neighborhood. We need the cottage or neighborhood hospi-
tal as opposed to the large city institutions we now have. In the large institu-
tion^ even with our best endeavors, the flavor Is bound to be institutional;
the individual cannot always be all we could wish for, and not infrequently our
young women nurses and young student doctors become infected with tuber-
culosis. Now that we know that the seriously ill can be better cared for
away from home, why not have the neighborhood cottage hospital, where the
necessary isolation, care, and quiet can be provided, but where the patient
is still witliin easy distance of his family, and could still be under the observa-
tion of the nurse, even after returning home?
The social nurse is now lieing developed to follow up convalescent
patients, but she has to work under great disadvantagea^ It could readily
be made possible for her to become a resident of that neighborhood, and do
mcalculable good in preventing tuberculosis by finding out unsuspected
incipient cases. Then, too, we could be certain that proper disinfectant
and hygienic measures are carried out.
To establish such schools may seem an impossible undertaking, but just
lose sight of the fact that we are dealing with large cities— for cities are only
villages repeated over and o%'er again and packed closely together — and try
to establish just one such school in one neighborhood, and see what the results
will be,
La Mujer ea la Prevencion de la Tuberculosis. — (Robb,)
La aplicaci6n prdctica de las lecciones ensenada por las otras aeccionea —
La iiifrecuencia de la mujer como representante del hogar — Ivos atributos
de la mujer y el valor de 6!lo3 en el hogar en la prevencion de la tubercu-
losis— La raz6Q por que ^Ua falta en la apreciacion de )a situacion — 6us
730 SIXTH INTERNATIONAL CONQKE39 ON TTTBTmrtrLOSISL
poabilidades futuras. La necesidad de dos elates de escuelas: (1) las
eacuelas en el Inviemo tal como existen al preaente, (2) La InstaUctidQ
de secuelas de Verano para la ensenanza de las economlas domesticas.
En estds instituciones deberd ensenarse: (Iro.) elementois de Anatomia^
Fisiologia, Higiene y BacteriologSa, (2o.) principios de alimentacidn y so
apiicacion con relaci6ii A las neceaidades del cuerpo, (3ro.) la constnicido
higi^nica del hogar y e! vecindad, (4o,) la centralizaciiin de las eociiuks y In
coQirtruccidn de laboratorios de aliraentoa, cocinas y hospitales nirales.
La femme dans la pi^Tention de la tuberculose, — (Robb.)
L'applicatioQ pratique de5 legona enseignte par les autres sectjons —
Combien il est rare que la femme soit le repr^sentant du foyer — Place et
utility de la femme au foyer pour la prevention de la maladie — Raisons
pourquoi elle ne se rend pas compte du s^rieux de la ^tuation— -Posaibilitea
pour le future. — On a besoin de deux sortea d*6cole: (1) Les ^coles pour
I'hiver comme elles existent k present, (2) Le d^veloppement d*te>les
pour V&t& pour Tenseignement dea sciences du manage. Dans ces Scoles
on devrait enaeigner: pi^emidrement et principalement, Tanatomie, la pbysi-
ologie, rhygi^iie et la bact^riologie; deuiifemement, les principes alimea-
taires ct leur application aux besoinsde notre corps; troi^&mement, oe qui
constitue uiie maison et un voisinage bygieniquesj quatriemement , la oen-
tralisatjon des cuisines et le d^veloppement dans le voisinage de laboratoires
pour la preparation de la nourriture, de cuiaines et de v'illas-h6pitaux«
Die Verantwortllehkeit der Frau in der Verhtitung der Tuberkulose, —
(Robb.)
Die praktische Anwendung der Lekren, die die anderen Sectioneo
erteilt haben, — daa seltene Vorkommen der Frau als Reprasentatiiin des
Heims, — der Platz und Wert der Frau dahelm in der Verhindenu^ dier
Krankheit, — die Ursachen, warum sic es unterlasst, die Situation richtig
xu beurteilea, — ihre zukiinftigen Moglichkeiten, Die Notwendigkeit aweier
Arten von Scbulen: (1) die Winterschulen, vde sie gegenwartig sind; (2)
Eutwicklung von SommerschuJen fiir den Unterricht der Okonomie det
Haushaltung. In diesen Scbulen sollte gelehrt werden, erstens und baupt*
saehllch, Anatomie, Physiologic, Hygiene und Bacteriologie; zweiteus, die
Grundprinzipien der Emabrung und ibre Anwendung in Bezug auf unaere
kdrperlichen Erfordemisse; drittens, Heim und Umgebung hygienlsch
auiszugestalten; viertens^ die Centralisation von Kiichen und die sich ent-
wickelnde Anlage benachbarter NaJmmgslaboratorien, Kiicben und Cottage-
Ho^italer.
SOME USES OF THE IMAGINATION IN THE PREVEN-
TION OF TUBERCULOSIS.
By Sadie American,
Exeeutira Secretary of the Counad of Jewuh Women.
In the days of Haroun-al-Raschid the imagination builded for us tales
whose charm still holds the old and young. To-day we no longer need an
Aladdin's lamp: by touching a button, miracles and marvels surround us,
beside which those of the old tales pale, for science has captured the imagina-
tion and holds it fast to guide the conquest of nature's secrets in the service
of man.
Few strides in human progress have been made without the exercise of
the ima^nation — of that constructive imagination that reveals or creates
that which it has foreseen. So have the causes of tuberculosis become
known, so has the propaganda of prevention been bora — prevention so diffi-
cult of comprehension by the educated, the supposedly enlightened, so in-
finitely more difficult of comprehension and accomplishment by the common
people, the tenement dwellers, among whom are the majority of victims,
for to compass it environment, habit, custom, and superstition must be
changed, transformed, or overcome. To bring about such a change a lively
and widespread exercise of the imagination is essential.
** Put yourself in his place" is easy to say, but very difficult to do. Is it
not true that what we really do in the vast majority of cases is to put him
in our own, for very lack of sympathetic ima^nation?
There must be a much more lively exercise of this sympathetic ima^na-
tion on our own part if we would compass our ends. It must make us fully
realize the environment of those whom we would help — realize the forces,
material and mental, that hold them in thrall. So only can we hope at
last to be able really to put ourselves in their place, and to devise methods
and means more suited and more likely to influence them.
We urge "plenty of good food," "good air," "temperance." I am re-
minded of one of those plumeaux one finds on European beds, which, if you
put it over your feet, leaves the chest exposed, and if you pull it over the
chest, leaves the feet cold and bare. And what if it must suffice for a whole
family? Scanty and poor food, overcrowding, worry, and strain, and in-
temperance, so often but the consequence of these, are but another spelling
731
732
SIXTH DTTERNATtONAL COKOBEea OK TtJBEBCYTLOaia.
of *' underpay." Plenty, even waste, at one end of the social scale
it difficult to realize scarcity at the other; constant overfeeding renders
the thought of coiijstant underfeeding almost incomprebenslble. Modern
life itself prevents such Uke experience at either end of the social scale sa
make for action based on sympathy, t. e., feeling with others. Tlie feeling
are dulled or stunted equally through lack of exercise, in that suffering is
hidden, or through overexerciaej in having it constantly in evidence, and so
taking it as a matter of course* Without the feelings we shall never be
roused to adequate action*
A previona speaker has said that all know and have learned to protect
themselves against the risk of drowning and the danger of falling from &
window^ and that, equally well, all can learn to protect themselves against
tuberculosis. Such happenings are dramatic^ and the results are instant
and acute. If a man falk from a window and breaks his leg, we ^xe roused
to expressions of sympathy and immediate action. But if ^ after being healed,
he remains lame for the remainder of his life, we grow impatient with any
Belf'pity he may show, and consider that he must bear the inevitable with
fortitude.
Tul^erculoaia ia not dramatic- It Is insidious and of long standing.
It, therefore, arousea neither to sympathy nor to action as do the more dra-
matic diseases. The inertia of working-people themselves aeems to me to
be due to the fact that the disease is so common that they take it for granted^
just as they take other inevitable risks in their avocations* Familiaiity
breeds indifference as well as contempt.
Upon the imagination, therefore, we must depend as the only agent power-
ful enough so to present to us all evil conditions, with their causes, that
aroused feeling will force us to a resistless campaign for a living wage, for
shorter hours, for protection against fumes that sear the lungs, and against
all health-breaking conditions of factory and home; that we must realise
the utter futility of a propaganda of prevention that does not aim at the
root causes of that which it would prevent.
And imagination must work not alone through words, through pictures
of suffering In others, through the appeal to selfish interest in legal penalties
inforcible and inforced, but in every group through that strongest penalty,
social condemnation of those who, either consciously or unconsciously, —
for in these days ignorance is unpardonable and special pleading no excuse —
enjoy excess of food and the common necessities of life at the expense of
others who lack them. So only will we be able to minimize evils that will
not disappear until unceasing work shall have wrought a greater industrial
j ustice.
This brings us to the fact that not until imagination concerns itself as
*
I
SOKE USES OP THE IMAGINATION,— AMERICAN.
733
much with human life as it doea with property and all that the possession
of property implies can we expect to stamp out tuberculosis.
The words of the Constitution, " the right to life, liberty, and the pursuit
of happiness," are held up as an obstacle against carrying out the will of the
people as expressed in protective laws. Our forefathers braved wind, wave,
and wilderness, not for life, but for a life. Surely they too would say,
life is of little value unless it be a life; liberty is not indivirtualj but soci^;
and the pursuit of happiness does not mean the pursuit of bread, for "man
does not live by bread alone."
I repeat, therefore, that not until the imagination realizes human Iife»
with all that it implies, as fully as it now realizes property, with all that it
implies, can we have decisions of justice and equity as well as legal decisions.
"Open your windows, day and nighty summer and winter/' we say*
What if there is no window to open, or if it opens on a foul court or a dead
wall? Oh! that owners of such places could be shut up for twenty-four hours
in such a room just after a tuberculous patient has passed out, " Drastic/*
you say; yes, but more hkeJy to be effective, you will agree, than any law.
The imagination would need no stimulant, and might be as effectively in-
fectious as the dread bacillus itself. The "mene-mene-teker' on the wall
would need no interpreter.
"Open your windows, day and night, summer and winter!" Some years
agOi wl\ile at a foreign water-cure, I found, on going to my room in the even-
ing, that my windows were closed. Naturally, I threw them open. Shortly
after the maid appeared, and somewhat bewildered, exclmmed, "I thought
I closed the windows," and at once proceeded to shut them. I asked her to
leave them open, whereupon she said, ** You vdW be ilh Shall I come later
and close them?" "No," said I, ''please never close them." Wide-eyed
she asked, "But you do not leave them open at night?" "Yes," said I, and
then ahe said, "We once had a Frfiulein who did it, but we were sure she waa
crazy." She but expressed what the majority of those whom we would
influence feel — feel, I say, (or reaUy thought or knowledge has Uttle to do
with it.
And who are they whom we would influence? Country dwellers in the
city, from the village hovel, perhaps, they come, scarcely as bad as the city
tenement to which they go. And they bring with them the habit of the
closed %vnndow (scarcely an imported habit, for time is not so long since fresh
air, and even the daily bath, became a fashion among those whom we like
to call the "enlightened classes"). Observe your neighbor's windows any
morning. Tliis habit of the closed window lies in experience or fear of those
ills of the flesh associated with damp and chill, for fuel is costly and covering
scanty and the air is cold; once more, the imaginatioD must show us the
734
SIXTH INTERNATIONAL
ON tubi:rcuw)sis.
empty purse. Or the custom may lie in that other experience, ruiming from
the far distant past, which has crystallized in superstitious fear and dread
of the evil powers of the nighty and has expressed itself in great epics aod tales
of dread dragons creeping up from the swamps on the niists of evening,
aeeking whom they may devour, sucking the life forces of all whom they
encounter, until a Beowulf shall come to the rescue. Mist and mystery,
miasmatic maladies, are the death-dealing dragons of which imaginatioa
no longer speaks in high poetic language, but science coldly names moequito,
malaria^ bacillus.
Experience plus imagination created the epic, the habit, the belief in the
mysterious evil powers of the air, the darkness, and the night. Will our
imagination so put us in the place of those others that we will realize that no
mere dictum or cold instruction wUL serve to break this coEtrol of habit,
imagination, and belief?
Can we not use the same power of imagination to create a belief in the
myst>erioua forces for good dancing in the sunlight, eager to get in, traveling
on the wings of the quiet evening air, waiting in the starlit night to enter, to
protect^ to safeguard, and to heal if only the window is open to them— if
only they are not barred by the glass that, to the mysterious powers for
good, may be made to serve as did water against the evil demons of old?
Can we not transform fear of the mysterious evil into faith in the mysterious
good? Or cannot one create an epic of the mystery of the good, a St. George,
invisible^ yet ever present, the reflection of whose lance is the sunbeam, the
point of whose lance ia the star; St. George, ever watchful^ ever slaying the
dragon. The tale should take different form according to faith, oceupatioa,
the folk lore, the country of origin of the several groups; angels or saints,
tale or mjih, fairies or powers of the air, soldiers ever in battle array against
the enemy^ pictures from old-world life^ what not? — if only it be so presented
as to take hold on the imagination, andj using the old superstition^ create a
new habit in the new world that shall drive out the once protecting, now
destroying, habit of the old.
We are urging the use and value of stoiy-telling in school and playground
for creating interest in the fine and noble — for awakening ideals. Here,
to my mind, is instrument and opportunity to our hand. Use old forms, if
you willj or use new ones, but by all means use the story-teller for young and
old — for all are children in their love for a good story.
Let the story-teller of to-day be dramatic; let him people for us the cir-
cumambient air with beautiful, l^eneficent beings whom liia hero welcomes;
let him, by voice and presence, ^e the imagination of his hearers as did the
story-tellers of old, and dramatic imitation will come, and belief and faith
in the good viill grow from witliin — ^ili replace fear of the evil and itself
create a new protecting habit and tradition*
I
BOIIE DSES or THE IMAGINATION. — AMERICAN.
735
And spitting! we say, "Do not spit" — we, the American people. Can
imagination picture a sputumlesa city hall or court room or other place where
men gatlier? Will it picture the myriad mysterious microscopical demons
loosed on the wings of the wind, menacing every moment of life? Can we
make it picture to the careless spitter, the victim of his selfish carelessness,
perhaps one of his very own, poinling at him with his finger and saying,
"Thou art the man who destroyed mel^'
Time is not so long since the constructive imagination of women saw a
clean-floored street-car, and to-day, by constant vigilance, we have comparjt-
tive cleanliness. Time was when tobacco-chei^ing was considered as re-
spectable aa smoking. If we could utterly discourage it by flagrantly in-
forcing the edict, "No American gentleman chews or spits," imagination
can picture a time not far distant when promiscuous spitting will have
disappeared. For who among us, boy or man^ rich or poor> native or
foreign born, hut aspires to be considered an American gentleman?
The mystery of the bacillus itself, who can fathom? The imagination
may help, but it may haixn. Recently, while visiting a tuberculosis camp for
children that closely touched a summer fresh-air camp whose occupants were
forbidden to cross the boundary, I came upon some boys stoning the happy
(unhappy) tuberculous children. Here lies a danger that, in warning
against the infectious hacilhis, the warning he interpretetl against the victim.
Great care should be taken lest the more facile imagination of the simple be
turned to an instrument of torture, instead of to one of healing.
Uncle Kcmus says, "Chirn you mus' learn to don^t." While listening
to the previous papers read at this Congress on the eonsumptive^ the bacillus,
and the disease, I am more and more impressed with the danger of creating
such fear of tuberculosis that it will become an obseasion that will mean
ostracism and persecution of the victim instead of the disease, so that you
may have to organize a *' Society for the Suppression of Phthiaiophobia.'^
Language crytitallizes and preserves our fears. Leper has come to mean
what the leper never deserved. The word has been taken over from the
physical to the moral, and moral leper is the last term of condemnation.
Let us be warned by this esperienue, so that the word " oonsimiptive *' may
not have such a history.
Let us not lay stress among the common people upon the bacillus. The
infinitely small and the infinitely great are beyond our finite understanding,
and the mystery of it is more likely to create abject fear than any other
feeling. Let us^ therefore, emphasize health, especially with children^
emphasize the positive aide — ^liealth and again health. Consciously fighting
for the permanent good, they will unconsciously become powerful in re-
Eostance against evil.
736
srJCTH INTERNATIONAL CONGRESS ON TCBH:RCUtX>SIS.
In cure oa well as in prevention the imaglimtion has its uses, the less needed
airice the sick man will obey to save himself, while he who i^ well thinks him-
self the one immune. In the prescription of food there should be taken into
accouat what is palatable according to the patient's custom of eating; in
the preacription of exercise or occupation, ordinary avocation, habits, and
aocial customs, Instances couJd be multiplied of caaes such as those in A
tuberculosis camp for children of which the head physician told me, where
patients had constantly lost weight and appetite because food, thou^
varied, was too fiat and tasteless to their palates accustomed to highly
seasoned food — patients who gained as soon as this was changed.
If, then, we would cany the war into the enemy's country with any
hope of success, imagination must help us enter into the thoughts and feelings
and customs of those whom we would protect, that we may be able to rouse
their imagination, so that^ through it, they shall learn to protect themselves.
It must rouse us to the pitch to which we would be roused if we sow a child
staggering uphill under a burden l>elon^ng to a man walking leisurely by
Ms side. There are few who would not despise and condemn the man;
there are many who would hasten to help the child until the man himself
would be shamed into carrying the weight, scarcely a burden to him. Im-
agination must rouse us to recognize exploitation less flagrantly before us,
be it in poor pay, long hours, strain, or unsanitaiy conditions of manufacture
or living, until it ehafl bring upon those responsible for such social crimes
misprision in the smaller social sense, and penalty in the larger social sense,
through protective laws so difhcult of passage aD(i inforcement now, and
which, after all, can have real force and power only when they rest on a
profound social conviction.
Imagination having realized a healthy, happy, strong, and powerful
people, we must work, consciously and conscientiously, toward this endj
through custom and law, losing our selfish motives, finding our sacred
sanction in that liigher patriotism that expresses itself not in the power to
kill, and in worship as hero of the victor, standing with bloody sword over
a grave, but in the power to guard and give a life true liberty and happiness —
not merely the right to its pursiiit — to the meanest among us, and such
health and strength as shall call no longer for a propaganda of prevention,
and for no uses of the imagination other than those that shall develop further
this higher patriotism of health and peace for humanity.
1
I
I
I
La Imaginaci^n en la PreveDci6n de la Tuberculosis* — (American.)
Pocas cosa se han llevado d cabo sin el ejercicio de la ima^naci6D
Btructiva. Asi es como la causa de la tuberculosis ha venido a ser coa-
BOME USES OF THE IMAGINATIOV-^AMERtCAN.
737
Ik
ocida, de las mlsmas fuentes tambie la propaganda de la prevencion ha
aacjdo.
La abuadancia, y aim desperdido, i un lado de la escala goclal, hace
dificil comprender laa necesidades del otro extremo; la demasiada abuo-
dancia de alimentaci^n hace cast incomprensihle la existencia de la ea caaa
alinientaci6n, Nosotroa debemos depender de la imaginaci6n para poder
ver laa condicionea del vicio y sus causas, a fin de despertar eatre nosotrofl
el eentimiento irresistible de luchar por el procuramiento de tin salario
indispensable para ta vida, la dlgminucidn de las boras de trabajo, la pro
tcGci6n contra el humo que cauteriza loa pulmones y todas las condicionea
insalubres de laa factorial.
En la cura, aid como en la prevencidn, la ima^uacidn tiene &us ixsos:
en la prescripcidn de alimentoa que sean apropiados segun la costumbre del
pacientep en la prescripci6n de ejercicios u ocupauones de acuerdo con otras
oostumbres sociales.
Entonces nosotros podriamoa Uevar la guerra al terreno del enemigo
eegiiTos del exito> la imaginaci6n debe servirnoa de ayuda ya sea en los
pensamientos 6 en el sentiniiento de aquellos a quienes deaeamoa ayudar^ a
fin de quej por medio de la imaginaci6n, eetos puedan aprender a protejeae.
Eato debe despertar en nosotros el mismo sentiiidento que se apodera de
nuestro ser al ver a un niCo vacilar en una pendiente bajo el peso de una
cargo que pertenece i un hombre que camina indiferente al lado de 6L
La iniaginaci6n debe ser fomentada en nosotros al panto de reconocer
la explotaci6n menos escandalosa ante el pUblico^ sea con relaci6n & los
salaries pequefios que ee le pagan al obrero, largas horas de tmbajo, con-
dicionea insalubres en las factorias 6 en los modoa de vida, hasta que ^lla
produscia en aquellos que permiten tales condicionas, lo mismo que en los
culpables, una prisi6n limitada en el sentido social, y la penalidad, en un
sentido mas amplio de los leyea protectoras, las leyea y costumbrea que,
despues de todo, pueden tener una fuerza y un poder real cuando ta imagin-
aeidn llegue d constituir un pueblo sano, feliz y poderoao, nosotros traba-
jamos consiante y conciensudamente hacia tal fin, menospreciando el
egoismo, y buacando solament* la sanci6n del alto patiotismo que se expresa,
en el poder de guardar y dar vida, libertad y felicidad al mas pequeno entre
Qosotroa.
L'imagination dans la prevention de la ttibefculose. — (Auericak.)
H s^est accompli peu de choses dans le progrds humain sans rexerciae
de rimagijiation constructive: Ainsi a-t-on connu les causes de la tubei^
culose et commence la propagande de la prevention.
VOL. HI.— 24
738
SIXTH INTERNATIONAL CONGRESS OK TUBERCVU)61B.
L'abondance de biens et de nouniture dana les hautes ctaaaee de la
BOci6t6 rend presque impossible rintelligence de riusuffisance contmuell«
de biens et de nourriture dans les classes inf^rieures. Nous devons done
compter sur rimfi^nation pour nous i^v^ler les mauv^ses conditions et
leurs causes afin de nous forcer k une ciimpagne efficace pour de meilleurs
gages^ dea heures plus courtes, la protection contre les vapcura qui briileat
les poumons et toutes les conditions matsaines des fabriques ou de la maison.
Dans les cures^ comme dans la prevention, Timagination a son utiliti:
dans les ordonnances pour une nourriture qui sera bonne en compar^Bon
de la nourriture uauelle du matadej dans rindication des exercises pbydques
ou de I'occupation k choisir.
fei nous voulons que cette batailJe soit une victoire, il faut que Timai^na-
tion nous aide k comprendra les pens^es et les aantiments de oeux que nous
voulona prot^ger, afin qu'ils se prot^nt eux-m^ines par leur imagination.
II faut que nous 8oyon& agit^a au point oh nous le serions, si nous voyicnt
un enfant monter une colline en cbancelant sous un f ardeau qtu appartiendmt
k un bomme marchant tranquiliement k c6t^ de lui.
II faut que Fima^nation nous excite k reconnaStre I'exploitation qui
est devant nous d^une mani^re moins flagrante, soit dans la pauvret^ des
salairea et les heures longues et forcdes, soit dan^ les conditions nialsainfe
de la manufacture ou de la vie; j'usqu^ k ce que noua attirions, sur ceux
qui lea permettent comme Bur ceux qtii en aont coupables, le m^pris du
monde, au sons le plus bas, et le cMtiment, au sens social plus ^lev^, des
ois pratectricea: lois et coutumes qui ne peuvent avoir une vraie force et
un vrai |>ouvoir que quand Timagination aura vu un peuple sain, heureux,
fort et puissant, et que nous aurons travaill4 sciemment et consciencieusemejit
pour ce but, trouvant notre r^comj>ense dans se patriotisrae plus ^lev4 qui
s'exprime par la puissance de prot^ger et de donner ta vie, la liberty et le
bonheur aux plus pauvres d^entre nous.
Einbildungskraft bei der Verhiltuag der Tuberkulose.^(AMEHiCAN.)
Wenige Fortschritte ini Menschengeschlechte aind ohne die Ausi'ibung
eincr aufbauenden Einbildung gemacht worden. So aind die Ursachen
der Tuberkuloae bekannt geworden, so ist die Propaganda der Verhutung
geboren worden,
Genug, ja Itberflusa an dem einen Ende der sozialen Leiter macht
es schwierig, den Mangel an dem anderen Ende aich zu verwirklichen;
immerwdhrendes Schwelgen macht den Gedanken von immerw§hrendem
Hungem l>einahe unbegreiflich. Wir milssen von der Einbildung abliangen,
urn una acblimme Zustande mit ihren Ursachen darzustellen, so dass ein
^
I
I
.^3^:.
SOME USES OF THE IMAGINATION. — ^AMBBICAN. 739
aufgestacheltes Gefiihl uns zu einem widerstandslosen Kampfe fur einen
lebensf&higen Lohn, fur kurzere Arfoeitszeit, fur Schutz gegen Dunste,
die unsere Lungen sch&digen, und fur alle gesundheitschadlichen Zust&nde
der Werkstatte und des Heimes zwingen wird.
In der Heilung und Verhiitung hat die Einbildung ihre Gebrauchs-
anwendungen: in dem Veischreiben von Nahrung, die gem&ss der Lebens-
weise des Kranken schmackhaft sein soil, in dem Verschieiben von Bewegung
Oder Beschaftigung gem^iss anderen sozialen Gebr&uchen.
Wenn wir also den Krieg in das Fdmdesland mit irgend einer Hoffnung
von Erfolg tragen wollen, muss die Einbildung uns helfen dnzutreten in die
Gedanken imd Gefiihle derjenigen, die wir beschiitzen wollen, damit durch
ihre B^bildung sie lemen sollen &dch selbst zu beschutzen.
Einbildung muss uns anregen, weniger fiische Ausbeutung vor unseren
Augen zu erkennen, einerlei ob dieselbe aus schlecht^ Bezahlung, langen
Stunden und itberanstrengung, gesundheitswidrigen Zustanden in der
Werkstatte oder in der Lebensweise besteht, bis sie uns zu denen bringt,
die es erlauben, als auch zu denen, die dessen schuldig sind — Missetat in
dem kleineren sozialen Sinne und Strafe in dem grOsseren sozialen Sinne der
Schutzgesetze: Gesetze und Gebrauche, die alles in allem wirkliche Kraft
und Macht haben kdnnen nur wenn die Einbildung ein gesundes, gluckliches,
starkes und machtvolles Volk verwirklicht hat, und wenn i/nr, bewusst und
gewissenhaft fiir jenes Ziel arbeiten, und unsere selbstsiichtigen Motive
verlieren und unsere geheiligte Sanktioa in jenem h6heren Fatriotismus
finden, der Ausdruck findet in der Macht, Leben, Frdheit imd Gluck auch
dem niedrigsten imter una zu geben und sie su beschutzen.
DIET AS AN ELEMENT IN INCREASING RESISTANCE,
WITH SPECIAL REFERENCE TO THE
PROTEIN RATION.
Bv J. H. Kellogg, M.D»,
Battle Creek. Midueio.
Chronic tubercular infection has long ceased to be regarded as a local
disorder. The studies of Cbamn, Roger, and numerous others, and espe-
cially the ingenious and illuminating researches of Wright, have shown that
the essential factor in tubercular infection is the weakening of the defeosea
of the body, the breakdo\yn of the vital resistance in such a way as to permit
the development within the body of the particular parasitic organism char-
acteristic of this disease*
The enormous advance which has been made within recent years in the
therapeutic conquest of tuberoulofiis is based entirely upon the recc^nitioo
of this fact. As long as research was confined to the quest for drugs or phys-
ical agents capable of destroying the tubercle bacillus, no progress was made.
The patient who is subject to tubercular infection is ill, not because he has
happened to come in contact with tubercle bacilli, but because his body
has lost the power to prevent invasion of the tis&ues and the development
therein of the tubercle bacillus and its toxic products. It was the recog-
nition of this fact that led Detweiler to exclaim, in speaking of remedieSp
"My kitchen is my pharmacy." The success of the open-air method, the
cold-air method, the dietetic method, or what may be termed in general the
hygienic method of treating tuberculosis, depends alone upon the im-
provenieat of the patient's vital condition, of his tissue reastance*
The value of the outdoor life as a means of increasing vita! resistance is
now fully appreciated, and the methods of utilizing this curative measure
are fairly well developed and fixed; but there remain many questions re-
lating to the dietetic management of the tuberculous patient which will
require considerable study and discussion before they are entirely and finally
settled. There is, moreover, such & wide diversity in the dietetic manage-
ment of this class of cases by different physicians and in different Institutioiis,
as has been pointed out in the able and timely paper of Professor In'ing
Fisher, that it seems evident that some of the more important of these
740
4
DIET AS AN ELEMENT IN INCREASING HESI8TANGE, — KELLOGO.
741
unsettled questians should remve early conaideraiioa, especiaUy as the
problem of nutrition ia admittedly a fundamental one^ and a factor which
must exercise a controUicig lufiueace in the battle of the tuberculous patient
against his malady.
Twenty years ago it was impossible to compile data bearing on this
question having sufficient scientific value to command consideration; but the
more exact studies of nutrition wliich have been conducted in recent years
have developed a great number of imjiortmit and cogent facts which when
brought together seem to justify important and clearly defined conclu-
fdons.
Prof. Fisher's tables show so great a divei^ence in the ration employed
by different authorities tliat it cannot be a matter of indifference to the
patient wMch ration is selected for liim. For example, between the ration
employed by Werner at the Rotcn-Krcua Sanatorium (5500 calorics), and
that of the Brompton Hospital, East Kensington, London (2400 calories),
there is a difference of 3100 calories. Thus a patient on tlie Werner ration
would be required to eat more than double the food consumed by a patient
on the Brompton ration. It cannot be that both these patients have an
equally good chance for recovery. Either one is partially starved, or the
other is enormously overfed.
In the instance cited above, the difference in the protein ration is still
greater than that of the total ration, being 410 calories at Brompton, and
1200, or practically three times as much, at the lloten-Kreua Sanatorium.
If the Brorapton patient receives as much protein as he is able to appropriate,
certainly Werner's patients must be compelled to do an enormous amount
of urmecessar}' renal work in the elimination of surplus nitrogenous wastes,
to say Qotliing of other unnecessary burdens borne by vital organs whose
perfect functioning is essential to vigorous hfe and high resistauce*
Without professing to have wholly solved the problems under considera-
tion, the purpose of this paper is to bring together a few facts which must
have a direct bearing on the subject. The time allotted for this paper will
not permit of a complete survey of the question of diet in tuberculosis,
hence I shall restrict myself to facts and considerations relating especially
to the protein ration in this disease.
In the stuiiy of diet with reference to the dietetic management of pul-
monary tuberculosis, or in relation to any equally grave disease^ considera-
tion must be given first to the effects of the particular diet suggested upon
general nutrition; andj second, to any special relation which may exist
between the diet suggested and the characteristic pathological conditions
or tendencies of the disease.
742
SIXTH INTEENATIONAl* CONOEBSS OI* TUBEBClTbOSia.
I, The ReIjAtion of tiie Protein Ration to General Nutbition asd
Vital Kesietance.
Within the last ten years there hug been a manifest trend of opinion
among physiologists toward the recogmtion of a lower Btandard for the
protein ration In ortUnary conditions of health. The observations of Chit-
tenden, Mendel, Folin, Gautier, Hirschfeldj Idemperer, Bordet, Lapicque
and numerous others have shown conclusively that the nitrogen balance
may be maintained under ordinary conditious of life, and even that nn
actual gain in strength and physical vigor may take place, under a ration
furnishing aot more than one-half or even one-third of the amount of protean
required by the older standards. For example, Chittenden, in an experiment
upon tweuty-six men — sixteen soldierSj six athletes, and four colle^ pro-
fessors— extending over a period of nine months^ was able to show a distinct
gain in health, strength, and general vigor on a dietary wluch fumiabed
.625 gram, or 2.56 calories of protein, per kilogram of body-weight. In this
experiment he was himself one of the subjects, and reduced hia protein to
about 31 grams, and has since continued the same ration for several yearSj
with evident advantage.
Hirachfeld, who weighed 73 kilograms, 16 kilograms more than Chitten-
den, maintained himself in nitrogenous equilibrium with 43,3 grams of
albumin per dienij .00 gram, or 2.46 calories per kilogram of body-weights—
even less than the Chitt<?nden standard
Klemperer reduced the nitrogen intake to ,47 gram of albumin (1.00
calory) per kilogram of body-weight,
Bourdet maintained that .75 gram of albumin (3.07 calories) per kilc^ram
of body-weight is quite sufficient,
Folin maintained body-weight and muscular strength for ten days on
a diet in which the nitrogen was reduced to one gram per diem.
The writer is able to add from his own observations and exi>erience a
number of facts which he has thought it worth while to place on record.
Early in life circumstances led me to adopt a low-protein dietary^ wtuch
has now been closely followed for more than forty-two years. During this
period flesh meats have been excluded from my dietary, and for about half
of the time e^s and milk have also been excluded almost entirely, so that my
dietary has practically consisted of such quantities of protein as are naturally
found in bread, fruits, potatoes, and oth^ y^etablea, with the occasional
use of nuts.
I have enjoyed some special advantages for the study of dietetacs through
the fiict that for thirty-two years I have had charge of a medical instituttoii
in which a low-protein diet^uy is made an essential part of the r^ime for
both patients aiut employees. In this institution tliere are employetl 30
physiciansj over 250 nurs^ and medical students, and between 500 and 600
I
«
DIET AS AN KLEICENT IN INCREASINO RESlEtTANCE. — KBLLOGQ. 743
other persons. During the thirty-two years the number of different persons
employed has been between 10,000 and 12,000.
Some ten years ago (1898) a dietary study was made for the purpose of
detennining the proportions of protein, fats, and carbohydrates consumed
daily by our workers. The experiment included some 265 persons— 125
men and 140 women.
TABLE I.
Showdtg thb Results or a Dietary Stitdt of 126 Mxn Ain> 140 Woioen Durino
FouBTEBN Days.
Men. WofeCKH.
Gal-
Qkaus. Calories. ORAin. oriss.
Protein 84.82 348 76.54 314
FaU 36.78 360 30 05 279
Carbohydrates 453.49 1859 447.44 1834
Total 576.09 2567 654.03 2427
Kilos. Kmum.
Average weight at b^inning 61.2 64.1
Average weight at end 61.5 64.1
Average gain 0.3 0.0
Average gain in strength of ten selected persons 225 68.6
The figures obtained for protein were considerably below many of the
old standards, though above the standard recently established by Chittenden
and others. More recently the amount of protein consumed has been con-
siderably reduced. This has been the result of the study of Chittenden's
work and the introduction of a larger amount of fat into the dietary, which
was evidently needed.
The work required of physicians and nurses in the institution is very
exacting. The hours are long and the work itself is hard. The demands
made upon physicians and nurses, especially during the summer months,
are unusually severe. Notwithstanding, cases are very exceptional in which
physicians and nurses do not improve in health after becoming connected
with the institution, and there is a noticeable exemption from such common
maladies as appendicitis and other intestinal disorders, skin diseases, pneu-
monia, and infectious disorders. Twenty years age cases of tuberculosis
occasionally developed among the employees, but since the introduction
of a lai^er proportion of fat into the dietary, this tendency has disappeared*
There is generally a noticeable improvement in the appearance of persons
who make a change to a low-protein dietary on becoming connected wth
the institution. The skin becomes clearer, acne, when present, disappears,
and there is usually a gain in flesh and in endurance.
A Low-protein Diet does not Deteriorate the Blood. — A study of the blood and
blood-pressure in 100 of our nurses and assistants, made by Dr. J. T. Case,
gave the following average results:
744
SIXTH INTERNATIONAL CONGRESS ON TUBERCtTU>S19,
TABLE II.
40
Hemoglobin (Dare) W£f%
Red corpUBCles per cu. mm 4^790,000
White TOrpusplea* per cu. nun 7,353
C-olor-indei 101
Blood-pressure (narrow armlet) 132J
Puke (i^tatidiog) , 76
The above figures certainly show no tendency of a low-protein ration to
deteriorate the blood* imd entirely agree with the ohservatioas on endurance
made by Prof. Irving Fisher, of Yale University, the results of which wiH
be given later in thia paper.
The Uniie in Low-protein Subjects, — Within a year & careful study has
been made of the urine in 46 subject-s, — 24 men and 22 women^ — ^for the
purpose of determining normal standards for persons living upon a low*
protein ration. The subjects employed in this study were placed upon &
ration which furnished *80 gram of protein, 1.10 grams of fat, and 4JiO
grams of carbohytlrates for each kilogram of body*weight. Flesh foods of
all sorts were excluded. The quantities obtained by Folin with an ordicuur
mixed or high-protein diet are given in the table for the purpose of compari-
son. It should be stated that both the men and the women were healthy
persons between the ages of twenty and tliirty years, all enga|;ed in active
auties as nurses and office or laboratory assistants. The table gives the
average of all the subject6.
TABLE IIL*
OBZtlh'ART DR BlGS 1>9W PfeOTEXV
(Folin). Meat.
Quantity c.o- 1430 1 000
Specific gravity.*... ., . 1.015
Fraesiing-point LIS
Urinary depuration . . , 4,287
Acidity ii] Ivrnis of HgPO^ gtti. 2.01 0.940
Totftl nitrogen gra. 16.00 6.-ii0
Urea gm. 29.80 11.650
Uric bcid gm, 0.370 0.323
Ammonia in terms of NH| ...... -gm. 0.850 0.247
Crpatinin gm. 1.550 0,815
Chbrida gm. 10.050 0.455
Pbcwphates. temis of PjO*. ... gnu 3 .870 1 A35
Total stilphatcfi. terms of SO, gm. 3.140 1.071
Ethereal sulphates, in terms of SO, gm. 0.22Q 0. 1 10
Total sulphur, in t^rms of SO, , gm. 3.310 1.399
Neutral sulphur, in terms of SO, gm. 0.170 0.192
luJIran (FctLtiog's solutioa 100) 77 00 5.60
*The l(¥lmtcal chemical and other detailed work involved in the prepanttion of
this tnbie vras cbirflv done at the aiithor'js request, and under his ^iiperviaionp by Dn,
E. H Ui^lpy Paid L^oth, and Jean W, Mor^. The author also takes pleasure m ac-
knowledsing bis, indcbtcdtiesa for many oourte^ics extended by Profeseon L. B. Mendd,
M. H. Cnittfndpn. 0)to Kolin, and C. A. Hortefi in admitting hw assiatanU to their
labomtoricfl for special innitruption and the verifii^ation of technical mpthods; aitd to
Pmfessorfi Francis G. Denedict, N. Zunta^ and Irw'ing Fisher for valuable suggMtioitft
Bud ioformatiuQ.
DIET AS AN ELEMENT IN INCREASING RESISTANCE. — KELLOQQ. 745
The figures ^ven in the above table afford the most indubitable evidence
of the diminished work required of the liver and kidneys in dealing mth
waste and toxic products under a low-protein dietary. Such an advantage
ought to become apparent, especially in tests of endurance. Prof. Irving
Fisher, of Yale, was quick to recognize this fact when he first visited Battle
Creek about four years ago, and he some time later devised and applied a
series of tests for the purpose of determining the effect of high- and low-
protein dietaries upon muscular endurance. In this experiment a number
of our young men who had been for months or years accustomed to a low-pro-
tein dietary were submitted to a series of severe tests, which were afterward
applied to a considerable number of Yale University athletes who were
accustomed to the ordinary high-protein dietary. The results of this
endurance test were published by Prof. Fisher in the " Yale Medical Journal"
of March, 1907, from which we make the following brief extracts summing
up the results:
" In the absence of any exact mechanical method of measuring endurance,
three simple endurance tests were employed: first, holding the arms hori-
zontally as long as possible; second, deep knee bending; third, leg raising
with the subject lying on the back. All of these tests were made before
witnesses.
"The first comparison (for arm holding) shows a great superiority on
the side of the fiesh-abst^uners. Even the maximum record of the flesh-
eaters was barely more than half the average of the flesh-abstainers. Only 2
of the 15 flesh-eaters succeeded in holding their arms out over a quarter
of an hour; whereas 22 of the 32 abstainers surpassed that limit. None
of the flesh-eaters reached half an hour, but 15 of the 32 abstainers exceeded
that limit. Of these 9 exceeded two hours, and 1 exceeded three hours.
" In respect to deep knee bending, if we take the number 325 for reference,
we find that, of the 9 flesh-eaters only 3 surpassed this figure, while of the
21 abstainers, 17 surpa^ed it. Only 1 of the 9 flesh-eaters reached 1000,
as against 6 of the 21 abstxdners. None of the former surpassed 2000 as
against 2 of the latter.
" In respect to leg-raising, the records show little difference.
"The results indicate that the users of low-protein and the non-flesh
dietaries have far greater endurance than those who are accustomed to the
ordinary American diet."
The figures given in the tabulated results of Prof. Fisher's tests (Table
IV) and the analysis of the results by Prof. Fisher, above quoted, demonstrate
that persons subsisting upon a low-protein dietary are in no degree inferior
in endurance to those subsisting upon a mixed or high protein dietaiy, but
are much superior.
SIXTH INTERNATTONAI* CONGRESS ON TUBEECULOSIS.
TABI^ IV.
SHOwma R18ULTB OF Tbbts Conducted by Prof. Irving Fishhii to Dvncfunxx th»
IN/LUXNCK of BlOH-PROTElN AND LuW^FROTElN DlKTAa[£A V^OH £j>(l}UtULNCC.
Arm-holding Test.
Lowprotdji Bubie<9t4, 32; bl^-protun lubJAcU, 15.
Low-protein 8ubJ^t«j average minutes , . . 49
High-protein subjeote, average minutes lO
Low-protein subjects, mfLximum minut® . , , . , , . . . . 200
High-protein subject*, maximum minutes , , . 22
Numticr of low-protein subjects who exceeded 15 minutes 22
Number of higb-protein mibjecta who exceeded 15 [Qinutfls . , 2
Number of Iow-prot-(>iii subjc-cta who exceeded 30 minutes .,.,... 15
Number of high-protein eunjectfl who exceeded 30 minutes . 0
Number of low-protein subjoc** who exceedetl 60 mmutefl *.,,,.. 9
Nimiber of low-prof-oin aubjecta who eit^eded ISO minutca ............ 1
Total mitiutes' work done hy IJi low-protcin subjects . , 1,336
Total minutes' work done by 15 hlgh-prvUin athletes « 150
•JO
ii
60
u
47
0
28
IIJ
Deep Knee-bending Tat.
Low-^protdD flubjcteta. 21i hi^-pratain vabJHU, 9.
Low-protein subjects, average number times , 833
High-prot*in sithjectfl, average number times 3S3
Low-prolein aubjecta who aiLrpaseed 325 .. ..».». ^ ,.,...,. 17
High-protein subjects who surpassed 325 3
Low-protein subjeets who reaclied 1000 6
High-protein subjects who reached 1000, .,*,,.....,...<,.,..*.....- 1
Low-protein aubjecte who reached 2000 2
High'protein fiubjects who reached 2000. ,,..,..,... ,.....,..,. 0
Low-pttjtein best subjeetfl (fl) number times ]2».'}35
High-protein athlut{» (^) number time^ , . r r 3,447
Fa
46
81
33-3
28.6
It
9.5
0
28
This fact was made still clearer by the performance at a later period of
one of our nurseH^ who made the deep-knee l>eiid 5002 timet?, or 3773 times
more than the best performance of the high-protein athletes. This subject
waB a young man of twenty-two years who had lived upon a low-protein
and flesbless dietary for about two years. Experiments in the French army
clearly demonstrate, according to Major P. Joly, that the reduction of the
protein ration to the extent of 120 grams, substituting therefore 120 grams
of carbohydrates (cane-sugar), resulted in a marked improvement in the
health of the men who were subjected to severe muscular exerfioiL The
effect of this lowering of the protein ration was to decrease the number of
heart^beats and respiratory movements, a marked increase in endurance, and
a decrease of the sick-rate. Men were foimd to be able to endure the heat
and fatigue of marching and maneuvers much better on the low-protein
ration than on the higher ration.
The average number of our guests during the last thirty-two years has
been between 3000 and 4000 yearly, making about 100,000 persons in &1J
who have been subjected to a low-protein dietary. The present number h
DIET AS AN ELEMENT IN INCBEASINa RESISTANCE. — KELLOGG- 747
about 7000 annually. For the last three years, the Chittenden standard of
•80 gram of protein per kilogram of body-w^ght has been very closely
followed. No injurious results have been observed, but instead a veiy
decided improvement in the proportion of recoveries and in the rate of
improvement.
The cooking and serving of foods and the bills of fare are so arranged
that the number of calories of protein, fats, and carbohydrates taken at
each meal and for the day may be easily determined, and the advantages
of a low-protein dietary is so manifest that both physicians and patients
readily adopt and adhere to the new standard. The following results have
been particularly noticeable:
1. Clearing of the skin; the disappearance of skin eruptions, sallowness,
etc., and rapid improvement in color and texture of the skin.
2. Improvement in the blood-count and in hemoglobin as shown in
Table V.
TABLE V.
SHOwmo THE Effects or a Low-protein Dietary upon the Blood in Chronic
Invalids.
GAUr
Pn
Bkfobb. Aitsm. CSNT.
Average blood-count in 1000 consecutive cases 3,885,200 4,359,340 12.2
Hemoglobin 73.3% 88.4% 15.1
Blood-count in 30 cases of anemia 1,989,600 3,140,000 58.2
Hemoglobin in 30 cases of anemia 47% 67% 20.0
Numerous observations made by us in the last twenty years have shown
the correctness of the practice recently inaugurated by Prof. Krauss, of
Berlin, who recommends a low-protein dietary in pernicious anemia, sup-
pressing entirely the use of flesh meats in cases of pernicious anemia.
3. Lowering of blood-pressure when abnormally high. Another im-
portant effect observed has been a noticeable fall in blood-pressure in cases
in which it was, on arrival, much above normal. This has been noted
particularly in the first two or three weeks after arrival. While a low-
protan ration has been found quite sufficient to mainttun the blood-pressure
at the normal standard, it has shown itself to be a most efficient agent in lower-
ing the blood-pressure when abnormally high. In over 33,000 blood-pressure
determinations carefully made, it has been almost uniformly observed that
a decided fall in blood-pressure occurs within a few weeks after the adoption
of the low-protein dietary in cases in which the blood-pressure is at the be-
diming abnormally lugh. The instrument used in taking the blood-pressure
is the Stanton modification of the Riva Rocci apparatus. The observations
were all made between 12.00 u. and 1.00 p. m.
The average pressure in 138 cases in which the blood-pressure was above
normal was 181 ; later, or at the time of discharge, the average pressure was
748
SnCTH INTERNATIONAL CONGRESS ON TUBEBCUZjOSIS.
158, a fall of 23 millimeters of mercmy, which I believe may be justly at-
tributed, in chief part, at least, to the low-protein dietar>% through suppres-
ffion of pressure-raising toxins produced in the alimentary canal, and
the better elimination of tissue wastes. No pr^sure-lowering drugs wete
adnuDistered.
The facts above stated would certainly seem to indicate that a low-
protein dietary exercises a decided influence in iraproving general bodily
conditions. The improvement in the conditions of the blood and the
blood-vessels, in the appearance of the skin, in muscular and nervous en-
durance, in greatly lessened development of toxins in the body, as shown by
the urine, are facts which all point toward a decided improvement in vital
resistance.
Numerous other facts well known to physiologists show the advantage
of a low-protein dietary as regards endurance and vital resistance. For
example, East India surgeons have frequently remarked the extraordinary
ability of the rice-eating natives of East India to endure ver>^ severe surgical
procedures, recovering under conditions which would almost csertainly
prove fatal to a European accustomed to a high-protein dietary. Captain
Sanderson, the famous elephant hunter of India, in his charming volume*
''Fouilecn Years in the Jungle/' makes the observation that antelope were
often encountered carr}^ing about great festering sores, the results of terrible
wounds inflicted by lions and tigers, yet apparently in excellent condition;
while a email bullet wound in a leg was almost certain, sooner or later, to
prove fatal to a tiger or Hon through blood-poisoning.
The hunters of the Roclcy Mountains and of the Scottish Highlands feed
their dogs upon a very low-protein diet, Wien asked by the writer what
he gave hia dogs to eatj a Scotch hunter remarked, ** The same as I eat nay-
self, Sir, — brose, bannocks and potatoes,"
Paget (" Lessons on Clinical Surgery ") believed that the higher death-rate
from surgical operations in cities as compared with rural disitricts was due to
the high-protein dietary of the urban population. Lauder-Brunton attrib-
uted the greater frequency of death from chloroform aneslhesia in England
as compared with India to the high-protein dietar>' of the English people.
The nimiers of East India, the miners of Mexico, the swift-footed Tara^
humaris of the Sierra Madre Mountains, who sometimes run 175 miles Ln
twenty-four iiours over steep mountain paths, also subsist upon a very
low-protein diet, and accompDsh feats of endurance which have never been
equaled by ^K^rsons subsisting on a high-protein dietary.
Modern researches confirm the conception of Liebig that protein Is
essentially a ti^ue-building substance, and not primarily intended for body
fuel. A dog fed upon lean meat free from fat requires a ration having a
much higher caloric value than when fed upon a diet consbting largely of
I
I
I
DIET A8 AN BLEUKINT IK tNCRHAaiKQ RESISTANCE.— KELLOOG.
49
fats and carbohydrates^ thus showing that as a source of energy, protein b
much mierior to fats aod carbohydrates. The relation o^ the two classes of
food principles appears to be essentially the same as that of metal repairs
and coal to the locomotive. The value of protein other thao as a source of
material for the repair of living tissue seems to be rather incidental, and
greatly inferior to that of carbohydrates and fat.
Professor N. Zuntz, of Berlin, recently informed the writer that experi-
ments made by himself and his associate have shown that pi-otein requires
a much greater expenditure of energy in its digestion and utilization than
does any other food principle. For example, the energy required for the
digestion of fats is only 2i per cent, of the t-otal energy represented In
the case of starch the energy expended in digestion is 10 per cent, of the
total; while protein requires an expenditure of 16 per cent, of the energy
represented. That is, protein requires an expenditure of 1.6 times as ranch
energy in its utilization as docs starch, and 6.4 times as much as does fat
in proportion to the amount of energy supplied.
It cannot be doubted, of course, that reduction of the protein below the
actual needs of the body causes a depreciation of vital resistance, through
disturbance of the nutritive balance. The same is true with reference to
any other food principle; but the question under discussion is not the effect
of an actual deficiency of protein, but the effect of an excess*
There are still other facts bearing upon the question which the writer
believes to be of even greater importance. Vital resistance depends more
directly upon the blood than upon any other factor concerned in the body
defense. That wisest of lawgivers and most sagacious of sanitarians,
Moses, declared, '^The life is in the blood," and John Hunter's experi-
ments showetl the scientific accuracy of the ancient Hebrew's dictum.
Roger, Charrin, Bouchard, Schiff, Cohnheim, Minkowski, Roux, Nocard^
Fraenkel, Helraann, and others, have shown us how immediately and posi-
tively vital resistance fluctuates with changing conditions of the vital fluid.
Says Charrin, "The alkalinity of the body-fluids is synonymous vnth. or-
ganic protection/'
The blood of an animal subjected to a bigh-prot^in dietary is over^
chai^d with protein wastes because of the excess of protein ingested. The
result is deficient oxidation of protein wastes, and a marked diminution in
the alkalinity of the blood. With this dimioished alkalinity is associated,
OS a necessary consequence, diminished vital resistance. Thi3 condition of
the blood is indicatetl by an excesaive quantity of urea and uric acid and a
high degree of acidity of the urine. In a healthy man upon whom I experi-
mented some years ago^ the urea and acidity were quadrupled within a week
on a heavy meat diet. The burden thrown upon the liver and kidneys by
this excess of protein must liave been increased in the same proportion.
750
SIXTH INTERNATIONAL COXGBESS ON TaBEBCUlX>SI8.
The dlfTerence in the chcbracter of the products of protein metabolism
and those of the metabolisra of fats and carbohydratos ia a matter that
seems worthy of consideration. The CO^ resulting from the combustion of
fats and carbohydrates is quickly eliminated through the lungs. On the
other hand^ the products of protein metabolism, nitrogen and nitrogen com-
pounds highly toxic in character, require for their elaboration and elimina-
tion a very considerable amount of work, in which not only the liver and
kidneys are concernetl, but the adrenals, thyroids, and various other or^SJa^
The elimination of CO, through the lungs and skia apparently has no
injurious effect upon these organs] whereas the circulation through the
liver and kidneys of an excess of t!ie poisons which find their exit through
the urine, and wliich are prepared for elimination by the liver, unquestion-
ably gives rise to irritation which sooner or later results in grave disease;.
A Low-proiHn Dietary does not Lower the Tuhercxdo-Opsonic Index, —
Sir Michael Foster's observation that the tuljerculo-opsonic index was
reduced under a very low-protein dietary proves nothing in favor of an
excessively high-protein ration. At my request, our bacteriologist, Dr.
A. W- Nelson, has determined the opsonic index in twenty-alx of our nurses
and others connetrted ^ixh the institution who have for some years (two
years to forty-two years) lived upon a low-protein dietary^ having eaten
no flesh food during that time. The tuberculo-opsonic index was found to
range from ,87 to L95, Only three out of the twenty-six persons tested
were found with an index below normal These were ,87, .92 and .98 le*
spectively. The average was 1,26.
In a case of phthisis pulmonalis now under observation, the opsonic
index rose on a low-protein dietary (Chittenden standard) from ,47 to L47
in four weeks.
These figures certfiinly do not indicate any depreciation of resistance to
tubercular infection as the result of a low-protein dietary.
Rdation of InteMinal Autointoxication to Tuber(yulosis,^-Another question
which it seems pertinent to raise is whether too exclusive attention has not
been given in the study of the protein ration to tissue metabolism. The
careful taludy of the bacterial flora of the intestine which has been made
within recent years by Eserichj Tiasier, MetchnikofF, Herter, Levin, Roger,
AdamI, Cohendy, Gilbertj Dominici, Strasabei^er and others has shownn the
immense influence exerted upon the functions and tissues of the bod)' by
bacterial toxins formed within the alimentary canaL Ab8orl>ed into the
portal blood, these poisons are circulated through the liver, where they are
in part oxidised and rendered innocuous, and find their way out throu^
the lungs, skin, and especially the kidneys. Th^e investigators and others
have shown that there is a close relation between the protein ration and
intestinal putrefactions.
4
niBT Aa AH EtEBIBWT IN IKCREA8OT0 RESISTANCl!.— KELLOGG, 751
Pasteur imagined that bactena were a necessary aid to intestinal diges-
tion^ and essential to both animal and plant life* His pupil, Roux, showed
that beans will grow in a sterile soil. Nuttall and Thierfelder kept guinea-
pigs alive in a sterile medium. Levin examined 480 animals at Spitsbergen,
— beariii, seals, reindeer and other animals, — 53 species, and established the
Ifact that in the Arctic region tlie intestines of mammals are usually stcnie*
It seems to be fiimlly settled that bacteria are not necessary for the nmin-
tenance of animal life, and certainly that putrefactive bacteria are not only
unnecessary, hut harmful. Nevertheless, these bacteria are present in the
intestine in enormous quantities. Gilbert calculates the number of bacteria
daily discharged from the body at 12 trillions. Strassbcrger makes the
number 120 trillions. Roger enumerates 240 species of i>acteria wliich
have been foun<l in the human intestine. Many of these produce substances
which are in the highest degree toxic. On a high-protein diet, the poison-
forming bacteria rapidly increase, ^ving rise to int^tinal autointoxication.
German medical authorities have been rather slow to recognize this condition,
but Senator, Backman, Mester, Brieger^ Hoppe-Seyler, Krauss, Ewald,
Jaf!C% Albu, Hirschler, Munck, Rovighj, Gravits, and others of equal note
have recognized the validity of the teacliing of Bouchard, and have in recent
years expressed therapeutic views in harmony therewith.
The writer has for some years pursued studies in relation to this question^
and recently by the aid of the improved methods of Hertor, Folin, and other
recent investigators, has made several observations which seem to have a
practical bearing. Five healthy young men were fed upon various diets as
intlicated in the tables presented herewith, and a careful study was made of
the stools and the urine. In making these studies the stools were studied
both chemically and bacteriologically. By plate cultures and gram st^ining^
the number of aerol^es and anaerobes per gram of dried feces was determined,
and by means of the useful method of Rettger the same determination was
made respecting the number of putrefactive organisms. By distillation of
a portion of the feces and testing by Herter's method, the amount of indol
produced was determined in each specimen. This determination was made
quantitatively by means of a colorimetric scale carefully worked out by
my colleague, Dr. Risley, The urine was examined, and a careful deter-
mination of the amount of indican present was made by Folin's method.
The amount of the daily ration was 1800 calories to 2400 calories. The
principal carbohydrates were bread and potatoes. Fat in proportion of about
30 per cent, of the total ration was taken in the form of butter. The protein
ration was varied from 125 calories to 450 calories- The amount of protein
per kilogram of body-weight was varied from ,50 gram to I. SO grams. The
lower quantity was in connection with a fruit and cereal diet. Each special
dietary was closely followed for five to eight days, and was employed with
752
BiXra IWTEEINATIOKAJ. CONORBBS ON TDBERCtTLOeiB.
two or more persons, and in ^veral instances repeated a number of timea
The figures ^ven in the accompanying table are the avemges obtained from
all the observationa made^ the number of which is indicated in each caae.
TABLE VI.
Showing the Amoixnt of Intebtinal Putrefaction as Indicated by the Amouxt
OP Ini>ol Found in the Feces axi> or Indican in thb Urine with
THE Seveoaij Dtcra Indicated.
n
n
Group I. Moderat«^ly high pro-
tein dJet. 1.00 ^rams
or more per kib. of
body -weight
Group II. Low-protein diet (veg-
etable) . ^^ .**...*** *
Group in. Low-protein diet be-
low Chittenden stan-
dard (vegetable) . . . ►
Group IV. Fruit and cereal diet ., .
Group V. High - protein diet —
meat and vegetablea .
Dailt
RjLTIOlf
IN
CALOftliB.
2187
2064
2040
2075
2200
Ckamb Or
Pkoteih Pbh
Kilo op fioDt-
Wkigbt*
1.00-L80
0.49^.96
0.49-^.SO
0.4^-0,70
1.57-1.80
OF Ob-
HERVA-
TWSB.
.51
38
10
Amocnt
No, Mouft,
1.2270
0,3^11
0,1227
0.0567
1.3508
AvamAdB
Imdican
iir Vtaxn
SCXLM\
6.00
0.00
0.00
OJOO
9^
It is most clearly shown by the above tables, ^ving the results of 212
observations, that the amount of intestinal putrefaction ia directly propor-
tional to the amount of protein ia the dietary. With a moderately high-
protein ration of 1,06 to LSO grama per kilo of body-weight, the indol of
the feces was ten times as much as on a low-protein diet (Chittentlen stand-
ard). On a meat and vegetable diet afTording 1.57 to 1.80 grams of prot^m
per kilo of body-weight, the indol was iacreased elevenfold. The amount
of indican found in the urine with the high-protein dietariea bears further
witness to the increase in putrefaction with increase of proteia in the food*
With a fruit and cereal diet the indol was reduced to 3.7 per cent. — \em
than one-twenty-fifth of the amount found with a mixed high-protein dieU
The results expressed in the table are much more strongly shown tn
the protocols. For example, while taking a high-protein meat ration, the
subjects of experiment not only showed an increase of indol to ten or even
twenty timea the amount previously present when on a low-protein diet|
and a corresponding quantity of indican in the urine, but they experienced
very decidetl discomforts and inconveniences arising from the increaaed
toxicity of the intestinal contents. The usual symptama were headache,
drowsiness^ loss of appetite, loss of energj% and general malai.se. In every
case the subjects of these experiments were verj' glad to return to their
accustomed low-protein dietary.
I
DIET AS AN ELEMENT IN INCREASING RESISTANCE. — KELLOGG. 753
Results identical with the above have been obtained by others who have
studied this question, among whom should be especially mentioned Combe,
Mester, Backmann, Salkowski, and Ja£f^.
Salkowski and Jafif^ have shown that the intestinal putrefactions in-
crease in proportion to the amount of albumin ingested.
Miiller and Ortweiler showed that on a meat diet products of bacterial
putrefaction in the intestine increase, and that aromatic substances, espe-
cially indol and phenol, appear in considerable quantities in the urine.
Backmann showed the same to be true of white of egg, but much less
so than with meat, as indicated by the following table:
CONJOOATB
BULPHATBS.
1. Ordinary diet 0.167 gram
2. Ordinary diet plus 200 grams of eggs 0.184 "
3. Ordinary diet plus 120 grams of meat 0.234 "
Mester compared fresh meats and "prime" meat with the following
result:
conjdoatb
Sulphates.
1. Ordinary food 0.058 gram.
2 Ordinary diet plus meat 0.113 "
3. Ordinary diet plus prime meat 0.328 "
4. Ordinary diet plus meat in advanced stages of decay 0.694 "
A second series of observations was carried on collaterally with the above.
To various mixtures of foods of equal weight (25 grams) was added a definite
quantity (10 grams) of feces which had been previously examined for indol
and bacteria. The whole was then placed in an incubator at body-tempera-
ture for three days. The quantity of indol produced was determined by dis-
tillation and testing by Herter's method.
TABLE VII.
Sbowino the Amount of Indol Produced in Equal QuANrrms of Various Food-
stuffs (25 Grams) Mixed with 10 Grams of Human Feces and
Incubated for Three Days.
Indol,
MxATS. Indol, Mom. Milk Pboddcts. Mom.
Driedbeef 2.Vl UnboUed milk 626
Smoked herring 4,30 Boiled milk 520
Dried codfish 4.90 Yogurt cheese 126
Salmon 5.91 Cheeee 2.910
Sardines 7.35 Average 1.045
Beef (fresh) 12.42
Poric (freeh) 1372 Vki«abl. Food..
Mutton (lean) 17.02 Cereals (av. of 20) .065
Average 8.54 Raw vegetables 147
Ckx>ked vegetablee .078
Cooked fraito 222
Bananas .404
Avemge 181
754 snCTH [NmRNATTONAL COKGRE58 ON TOBEXtCtn^SIS.
The table shows that the vegetable foods on an average produced only
about 2 per cent, as much indol as the average produced by flesh foodsi
whUe the best vegetable foods, the cereals, produced only 0.3 per cent m
much indnl as the most toxic Besb. food — mutton. MLlk products, including
ordinar}' cheeae^a very questionable food — produced 12 per ireak w
much indol as average meat^; but without ordinaiy cheese produoeil cfclj
7 per cent.
These results are entirely in harmony with the results obtained in the
feeding experiraenta, and^ taken with them, show very clearly that food-
stuffs which undergo putrefaction outside the body when brought in contart
with colon bacteria, produce when ingested a very marked increase of the
intestinal putrefactions.
The above facts seem to furnish abundant reason for holding that a
high-protein diet tends very decidedly to weaken general vital r^stance
through the enormous extra burdens which it Imposes upon the liver and
other poison-destroying glands, and upon the kidneys, the most important
of poison-excreting glands. May we not, then^ justly nuse the question
whether in the high-prote'm feeding of patients suffering from pulmonary
tuberculosis, conaderable risk may not he nm of doing the patient harm by
letisening his ability to resist the further encroachments of hi^ malady or
to repair the damages already done?
n. Special Pathological Consitions Present in Phthisis Pulmonalxs
WHICH CONTHAINDICATE A HiGB-PROTEIN DlETARY.
The marked tendency of the tuberculous patient to loss of flesh and to
the development of anemia has naturally directed special attentioD to tbe
importance of encouraging the fat^building and blood-making prooQflseft of
the body. But there are other indications which are equally deserving of
attention, and which should be permitted to influence the dietetic manage-
ment of these cases. The materials ingest^ must be metabolized and elimi-
nated as well as digested and absorbed. Incidentally, while undergoing
digestion, they may also undej^ fermentations and putrefactions which
may bo change their nature as to render them not only useless as nutrients,
but toxic and in the highest degree damaging. Hence the welfare of the
liver and other toxin-destroying glands and of the kidneys, poison-eliminat-
ing glands^ must be considered as well as the need of the organism far lu
increase of adipose tissue. A simple increase in the thickness of the pan-
niculus adiposus cannot be of any very great advantage to a man whose
botly has been invaded by a vast army of tubercle bacilli. Before the
infection took place there had been a depreciation in vital resistance, a
deterioration of tissue and function which made the invasion possible, and
with each advance of the disease this weakening of the ability of the oI^
I
DIET AS AK ELGUE^rr IN tPfCKeAStXG RESISTANCE. — KELLOOC.
755
gaoism to battle against its foes is lessened. Recovery can only be secured
by improving the integrity of tissue and function to such & degree that the
ability of the organism to combat its assailants will be raisetl higher than
before the invasion occurred.
The average subject of tubercular infection presents a number of patho-
logical conditions which must be considered in preparing & therapeutic
reigimen. Among these may he especially enumerated the following:
1, Diminii^ed Alkalinity of the Blood, — This signifies diminished vital
redstance^ diminished efficiency of the blood as a germicide^ diminished power
to develop immunityj diminished power to repair damaged tissues, diminished
power to oxidise wastes. Anything which tends still further to diminish the
alkalinity of the bloorl must be to that degn^ a hindrance, rather than a help,
in the battle of the organism against the tubercle bacillus. One of the notable
and constant effects of a high-protein dietary is to diminish the alkahnity of
the bloocL
2. Diminish^ Hepatic Effid^ficy. — In tuberculosis the liver is nearly
always seriously crippled, Ullom* declares that passive congestion of the
liver is found in nearly every case of pulmonaiy tut>erculosis. This is the
natural result of diminished respiratory activity, since the circulation of the
hver is chiefly maintained by the movement of the cheat in respiration. To
the evidences of chronic passive congestion of the liver are added, according
to Ullom, many other evidences of a lowered vitiU state in this organ^ among
which are amyloid and fatty degeneration, tul^ercular infection, and fibrosis
or cirrhosis. Ullom expresses the opinion that fibrosis of the liver is not due
to tlie tubercle bacillus, but to '* other etiological factors," Boix and
others have shown what these factors may be. According to Boix^ the toxins
formed as a result of putrefactive processes in the intestine are the chief
cause of hepatic fibrosis. He was able to produce cirrhoaif* of the liver in
rabbits by mixing with their food cultures of colon bacilli and also by feeding
extracts of feces.
That a high-protein ration — that is, a dietary consisting largely of flesh
foods — favors hepatic congestion, is a fact long known to physicians. A diet
which encourages intestinal putrefaction and an abundant anaerobic flora
in tlic intestine must in the lughest degree encourage hepatic congestion and
various functional and organic changes in the liver, and thereby break down
this important defensive barrier and prepare the way for its invadon by the
tubercle bacilli. It need not, then, be a matter of surprise that Ullom found
in 37 autop^es on cases of pulmonary tuberculosis a tul>erculous condition
of the liver in 81 per cent, of the cases. Fatty degeneration of the liver waa
found in 24 per cent, of the cas^^ and in only two cases (5,4 per cent.) wu
the liver found approximately normal.
* Henry Phlppa Indtilutc, Second Annual Report.
756
SIXTH INTEBKATIOXAL CONGBESS OK TDBEBC0lOai8.
Arnold reported tub^ruiasis of the liver as an almost constant finding in
pulmonary tuberculous. Simmondff reported tuberculosia of the b'ver in
78 per cent. The pasave congestion of the liver which iiaturaUy results from
the overwork of the right heart and the dimimsbed mobility of the cheat,
together with the speoal eipoeure of the liver to infection through the portal
drctilation and the extra w<H'k required of it in metabolizing the excessive
nitrogenized waste which accompanies the febrile stage of pulmonary tuber-
cdooU, certainly suggest the importance of guarding the integrity of thk
vitally important organ in every poesible way, and contraindicate a high-
protein dietary, which imposes exaggerated and unnecessarj' hepatic worL
3. Degeneration of the Thyroid Glaml. — Entirely in harmony with the
considerations pr^ented above is the interesting fact to which Roger, Gamier,
De Quervain, Sarbuch, and others have recently called attention, viz., the
occurrence of general aclerofflsof theth\Toid gland without tubercular leatMB
of the gland itself in cases of tuberculosis affecting other parts of the body.
In a case of tuberculoma of the lungs by Camot and Delion, death occurred
from tetany, and post-mortem examination showed caseous degeneration of
the parathyroids.
This condition of the thyroid and pamthyroids is attributed to "the
effect of the action of the diffusible toxins produced by the tubercle bacilli."
it 13 well known that other toxins, especially those produced by putrefactiTO
changes in the intestine, are capable of producing diseased conditions of the
thyroid, the natural r^ailt of the overwork of the glands resulting from ex-
cessive saturation of the blood with thede toxic substances.
The enormous burden added to the labor of the defensive organs of the
body by a high-protein diet, and the great injun' which must result when these
organs are weakened, is illustrated by what happens ^-hen certmn toxin-
destroying glands are removed from the body or rendered functionally in-
active. It is well known, for example, that the removal of the thjToid gland
(Breisacher, 1890) of a dog is quickly followed by the death of the animal
if it is fed upon a meat diet, while life is prolonged indefinitely and the animal
enjoys good health when fed upon a diet of bread and milk. When such a
dog 18 fed upon meat which hits been well boiled, it suffers leas and lives much
longer than when fed upon raw meat.
Blum holds that the function of the thyroid gland is to neutralize poisons
derived from the putrefaction of albumin in the intestine. KLiihi holds that
the thyroid destroys a poisonous substance, a nucleoprotein which is formed
in the intestine after the ingestion of meat.
These facta are alone sufficient to condemn a high-protein flesh diet in »
disease in which the thyroid gland is already overworked, and in which it
35 likely to be seriously crippled. Is it not po^ble, indeed, that the effect
MET AS AN ELEMENT IN INCREASrNG RESISTANCE. — KELLOGG,
757
of such a diet in a case of pulmonary tuberculosis with degenerated thyroids
may be almost as deadly as in dogs deprived of their thyroids?
In the ingenious Eck fistula experimeataja anastomosis is made between
the portal vein and the vena cava, a ligature being applied to the portal vein
close to the liver^ thus cutting out the liver from the portal circuit, A dog
thus prepared and fed upon meat dies in three days; when fed upon a diet of
bread and milk^ the animal lives in excellent health for an indefinite length
of time. The urotoxic coefficient of such a dog was found to be increased to
nearly three times the normal after the tying of the portal vein, from which
the conclusion may be drawn that with a high-protein meat diet the poison-
destroying work of the liver and of the body is three times as great as on a
low-protein or non- flesh dietary. (Urotoxic coefficient before ligature
<344 ; after ligature, .902 — Pawlow.)
4, Disease oj the Adrenals. — Authoritiea agree in regard to the great
frequency vrith which the adrenals are involved in connection with tubercular
afifection of the lungs. The relation of these glands to oxidation, to general
vital resistance, and to the toxin-destroying functions of the body, gives
great significance to this fact. Behring showed that blood-serum (sheep's)
possessed aterHizing properties far superior to those even of the stronger
solulions of carbolic acid and corrosive sublimate, which was formerly era-
ployed in surgical operations. This property of the blood beings very
probably, largely due to the adrenals, m well as the ability of the blood and
tissues to oxidize or destroy toxins, it needs no argument to indicate the
importance of promoting intestinal asepsis in all possible ways in pulmonary
tuberculosis, and especially by avoiding a dietary which must flood the
blood and the tissues with waste and toxic products to a most extraordinary
degree.
5, Ctmcurrcnt Disease oflhc Kidneys. — Drs. Flick and Walsh,* in a paper,
state that ''nepliritia occurs very frequently in tuberculosis." Among the
causes they mention the effect of *'the toxin excreted through the kidneys
from lesions elsewhere."
Graucher and Martin produced nephritis in dogs by attempts to establish
immunity mth increasing dosesof tubercle bacilli, "The longer the animal
lived and the liigher the resistance it attained, the greater were the chances
of nephritis."
Drs. Flick and Wabh regard nephritis as "one of the complications in
tuberculosis moat to be dreaded"; and especially "because it is a com-
plication which comes through the very process which leads to recovery,
namely, immunization/' These eminent observers assert that "many
patients ^ith tuberculosis die by way of nephritis as the real cause of death/'
and indicate aa the symptoms pointing toward nephritisi "a pasty skin,
* American Medicine, July 22, 1905.
758
SIXTH IKTERNATIONAt CONGRESS OS TCTBERCUl/lSIS.
unusual fati^e upon dight exBrtion, shortness of breath, high specific gr:ixity
of urine, hyaline and granular casts, albumin, etc."
The Third Annual Report of the Phipps Instituiej 1905, contains an ei-
ceedingly interesting report by Joseph Walsh of the autopsy fiadings^ from
which it apixiars that 84 per csnt. of the cases showed chronic changes in the
kidneys. Tuberculosis of the kidneys was obsen^ed in 58 per cent*, or about
two-thirds of the cases in which the kidneys were aftccted. In the other
one-third the cases were due excluavely to the excessive amount of toadia
which the kidnej's were compelled to eUniinate* The fact that the majority
of patients in whom diseases of the kidneys occur are not subjects of tul>er-
culosis afifords sufficient evidence that other toxins besides those produced
by the tubercle bacillus may be important factors in the production of thia
condition. That renal disease^ both acute and chronic, may result from the
absorption of toxins orij^nating from putrefaction in the alimentary canal
Is no longer doubted. The renal ledons present in various intestio^ inleo-
tians are sufficient evidence of this.
In the face of such facts it would seem to be quite unnecessary to urge t^
necessity of exercising every possible care to avoid excea^vely taxing the
kidneys, not only by suppressing irritating condiments, the need of which ia
recognized, but by avoiding any unnecessary increase of nitrogenised wastes^
of which the kidney is the chief outlet.
A ration furnishing 410 calories, or 100 grama, of protein will demand of
the kidneys less than one-third as much work as a dietary supplying 1200
calories, or 300 grams, of protein.
In the face of these facts it seems proper to raise the question whether
the feeding of largo quantities of protein in tuberculosis may not a^ravate
one of the most grave and incurable of the lesions incident fo this malady.
Indeedj it is even proper to inquire whether a high-protein dietary may not
be very largely responsil^le for the great number of cases of renal disease ob-
served as a complication of pulmonary tuberculosis. Certainly it cannot be
denied^ in the face of such evidence as this, that the kidneys must be consid-
ered when arranging the bill of fare of the patient suffering from phthi^s
pulmonalis.
Every modem author on the dietetic treatment of renal disease insists
that the amount of work required of the kidneys must be diniinished as much
as passible, and that hence the proportion of protein should be retluced,
and the extractive matters of meats should be especially avoided, and even
that the amount of sodium chlorid should be reduced to the minimum*
Hutchison urges that flesh foods should be allowed only in very small quan-
tity in renal disease, and advises that the proteins should be "derived laT;ge]y
from vegetalile sources." Friedenwakl and Rahrah entirely prohibit strong
meat broths and beef-teas^ and redu ce the protein to 30 or 40 grams. T hey also
4
4
I
DIET AB AN ELEMENT IN INCKEA5IN0 RESISTANCE.— KELLOGG.
759
limit the chlorid of sodium^ and state that "meat should be used cautiously."
In chronic intcrstitiii! nephritis they advise that the protein ration should be
reduced as low i\& 60 gratii^.
Hirachfeld emphasised the inability of the diseased kidney to eliminate
nitrogen. The tliseaisetl kidney is like an obstructed filter, With a diet of
70 gn'^vms of albumin m healthy kidney eliminates 10,1 grams of mtrogeUf the
diseased kidney 9.3 grams. When the albumin ration is increased to 130
grams, the healthy kidney eliminated 14.5 grams, and the diseased kidney
only 11.7 grams. When the ration of 130 grams is continued for a few days,
the disproportion increases, the diseased kidney eliminating only 12.7 grama,
while the healthy kidney eliminates 18.6 grams. Thus the diseased kidney,
under a ration funuHiiLug 5S3 calories of protein, — considerably losa than
the amount often given consumptives, — is able to eliminate only two-thirda
of the nitrogen intake.
It is evident, then, that the consumptive patient who is fed on a high-
protein diet is thereby not only rendered more liable to fatal hepatic and
renal complications^ but, through the accumulation of the retained products
of pixjlein metabolism^ all lus functions are liiuderedj and oil bis tissues are
exposed to a damaging influence.
Gautier emphasizes the necessity of reducing, in renal disease, "the
toxins and other offeiLsive products to the minimum by diminit^hing the
consumption of the food piinciplo from which they originate (protein)."
He permitg meat in small quantities, 20 grams of protein, and recommends
especially bread and cereals, cereal soups, purees of vegetablcSj potatoes,
rice, and all fruits, giving as the reason that *' these foods do not produce,
or only in very small quantity, urinary toxins*"
W* Gilnian Thompson says: " Whatever views may be entertsuned in
tegard to the causation of albuminuria, it is agreed by all that cooked meata,
eggs, and highly seasoned foods in general are injurious in all cases,"
Senator, of Berlin, in cases of serious renal disease, prefers to prescribe
only vegetables, salads, fruits, or an exclusive milk diet of two liters per diem.
It seems a just conclusion from the facts presented in this paper that the
recommendations made in relation to diet in renal disease are ef|ually appli-
cable to the average cases of pulmonary tuberculosb-
If a high-protein ration in general is open to suspicion in tuberculosiSj
a flesh diet is particularly questionable for several reasons:
1, Flesh foods more readily undergo putrefactive decom|X>sition than
do vegetable proteins,
2. Flesh foods as eaten always contain, ready formed, a considerable
amount of toxins which have resulted from putiefactive processes which
take place in the flesh after killing, while being ripened in pteparation for
the market.
DIET AS AN ELEMENT IN INCREASING RESISTANCE.— BCELLOOG,
^61
stated that a very considerable number of patients have been seen to make
good recoveries from well pronounced tubercular disease of tho lunp on a
dietary which furnished not more than 300 calories of protein in the form of
eggs, milk, and vegetable protein, and often less. On the other hand, there
has frequently been a rise of temperature and an aggravation of other
symptoms when a digression was made to a diet of flesh foods, such as beef-
steak, etc. Several times patients have come under our care who had
been subjected to forced feeding with disastrouH results* The enthusiastic
advocacy of forced feeding by D<^bove, Broca, and Dujardin-Be-auraetz, and
the slavish way in which for a time the example of these cUnicians was fol-
lowed, has led in not a few instances to most disastrous results* The chief
evils of these large dietaries doubtless result from the excess of protein and
fats. The coccess of protein encourages intestinal decomposition, as do also
the fats, while fats inhibit the gastric secretion of hydrochloric acid, and
thus interfere with both the digestion and the disinfection of the excess of
proteins, and so still further promote intestinal autointoxication. Lawrasoa
Brown, in Osier's "Modem Medicine/' especially warns against an excess of
proteins.
Bardawell and Chapman found that "patients make much less satis-
factory progre^ on the very lai'ge diets than on diets of considerably smaller
nutritive value.** The same Lnvestigatora obiserved that "any' considerable
uicrease in the protein in the diet produced a disproportionate excretion of
nitrogen, an increase in the amount of imperfectly oxidizeti proieins in the
urine, a decrease in the percentage of nitrogen absorbed, and an increase
in the amount of aromatic sulphates excreted^ indicating increased intestinal
putrefaction/* These authors conclude that the most satisfactory diet
for the consumptive *'i3 one which represents only a moderate increase of
a diet suitable for him in ordinary health," They recommend a diet con-
sisting of ** 120 grama of protein, ISO gnims of fat, /JOO grams of carbohy-
drates." A smaller amount of protein will still further dimini.sh the intes-
tinal putrefactions^ and the writer believes will secure even better results.
Advantage will be found in employing vegetable proteins instead of animal
proteins, because of their more ready digestibility when presented in the
proper form, their absolute freedom from bacteria^ and the less readineaa
with which they undergo putrefaction. WheSrt glutens and the vegetable
proteins of peas, beans, lentils, and nuts, are readily available, and when
properly served are easily digested and readily absorbed.
Dr. Lawrason Brown notes in his admirable article on the treatment of
tuberculosis in Osier's "Modem Medicine" that the method of forced alimen-
tation rarely jnelds permanent success, and also warns against the use of
foods which are likely " to give rise to toxic action of the liver and kidneys."
If meats are not to be included in the clasi of fooc^ which ** encourage to^c
762
BOCTB IKTEENATIONAL CONGRESS ON TUBERCtTLOSlS.
effects upon the liver and kidneys/' and hence must be avoided, tmusud
care must be taken in their preparation. The meat should be cooked ss
quickiy as possible after the aninial is killed, and should be eaten within »
day or two unless kept at freezing temperature. In no other way can th*
putrefactive processes which begin almost immediately after death be
prevented. The ordinary cooking temperature does not destroy the spo»-
bearing bacteria. The temperature of the interior of a portion of meat
seldom reaches the boiling-point during cooking*
As regards plant proteins and flesh proteins, my observation has been
that consumptives, when taking a non-flesh dietary, frequently experience
an elevation of temperature and an aggravation of symptoms on changing
to a mixed diet.
At the time of this writing the writer has under his care a patient who
was recently discharged from an excellent sanatorium wliere he was appar^
ently cured of pulmonary tuljerculosia, but is suffering very seriously from
intestinal autointoxication as the result of a high-protein flesh diet- He
is rapidly improving under a low-protein dietaiy.
Mr. Horace Fletcher and others have shown the essential importance of
thorough maaticationj not only as a means of securing good digestion and
assimilation of food, but as a means of regulating the proportion of food
principles. The effect of thorough chewing or Fletcherixing of the food i%
in general, to reduce the amount of protein ingeste<l. This seems to be the
natural result of giving the gustatory nerves a chance to act in conjunction
with the psychic centers which are associated with the digestive process^
The nerves of taste seem to be an admirably accurate regulator of nutrition
in health, and not infrequently in diseased conditions the suggeijtions of
this ever alert monitor cannot be with safety altogether ignored. If the
appetite craves protein, then protein is doubtless needed to satisfy the body
needs.
The main facts presented in this paper may be briefly summarized as
follows ;
1. A low protein dietary, .80 to LOO gram of albumin per kilogram of
body-weight per diem, is entirely conastent with health, vigor^ and a high
degree of efficiency and endurimce, in health.
2» While a patient suffering from pulmonary tuberculosis doubtless
requires a small increase in the intake of nitrogen, an excessive increase
involves grave dangers to the patient, both (a) by decrea^ng his genexil
vital resistance, and (5) by imposing unnecessarj'^ and dangerous burdens
upon the liver, kidneys, thyroid, and other organs which are already over-
burdened and ofteti seriously crippled in this disease.
3. There is no e\idence that a larger proportion of consumptives recover
under a high-protein diet than under a protein ration sufficiently above tte
1
DlCr AS AN ELEMENT IN INCREASINO RR8I8TANCB. — SBLUXKl. 763
Chittenden standard to replace the nitrogen loss due to febrile conditions
in cert£un states of the disease.
4. The majority of consumptives die from disease of the liver and kidneys.
The toxins peciiliar to this malady, and the process of immunization ag^nst
tubercular disease, while tending to cure the latter, tend at the same time
to produce disease of the kidneys, and to such a degree that patients not
infrequently die of renal disease after having apparently recovered from
tubercular disease.
5. In consumption the organism is required to deal with various highly
virulent poisons which overstimulate and ultimately cripple or destroy the
thyroid, adrenals, liver, and other antitoxic organs. A high-protein diet
produces similar effects in healthy animals and persons, and destroys life
in animals whose poison-destroying functions are seriously impaired.
6. A high-protein diet is recognized as an important factor in the causa-
tion of renal disease, and is universally condenmed in grave affections of
the Uver and kidneys. Vegetable proteins are much less objectionable than
flesh proteins, for the reason that they are entirely free from toxins and very
much less readily undergo putrefactive changes in the intestine.
It readily appears to the writer that the logical and inevitable conclusion
from these facts is that a high-protein dietary is not only unnecessary but
injurious, and even dangerous, in the treatment of phthisis pulmonalis, and
that vegetable proteins may be with advantage largely substituted for flesh
proteins in the dietetic management of thb malady.
REFERENCES.
Araold: Virchow's Archiv., voL 82, 1880.
Backmaon: Zeit. f. klin. Med., voL 44, p. 409.
Bardswell and Chapman: "Dieta in tuberculosiB."
Blum: NeuroL Centralbl, voL 21, p. 605.
Bordet, G.: Bull, thdrapeutique, Dec. 10, 1000.
Broca and Wims: Bull, de th^rap., 1883, p. 289.
Cbarrin: "Le8 Defenses Naturelles de TOrnuiisme," Paris, 1898.
Chittenden, Ruseel H.: "The Nutrition of Man."
Combe, A.: "L' Auto-Intoxication Intestinale," 1907.
Debove: "Sur le traitement de la phUmie pulmonaire par I'alimeniation forc^,"
Bull, de th^rap., Nov. 30, 1881.
Duiardin-Beaumets: Bull, de tberap., Ju^ 15, 1881.
Fiflher, Professor Irving: "Statistics of Diet in Sanatoria for ConsumptiveB," American
Journal of the Medical Sciences, October, 1906. "The InjQuence of Flesh-
Eating on Endurance," Yale Medical Journal, Blarch, 1907.
FUck: L. F., and Walsh, J.: American Medicine, July 22, 1905.
Folin, Otto: American Journal of PhyBiology, vol. 13, Nos. 1 and 2.
Gautier, Armand: *'Diet and Dietetics."
Hirschfeld, Felix: " Untersuchungen Qber den Eiweissbedarf des Menschen," PflOger's
Archiv. f. d. gesammte Physiologie, vol. 41, p. 533.
JafF6: Virch. Archiv., vol. 70, p. 370.
Joly, Major P.: Arch, de M4d. et de phannacie militaires, April, 1907.
Klemperer: " Untersuchungen ilber Stoffwechsel und Ern&hrung in Krankhciten/'
Zeit. f. kUn. Med., vol 16, p. 650.
Kraufis: Zeit. f. phys. Cfaem.; vol. 18, p. 173
764
BIXTH INTEKNATIONAI. CONGRESS ON TUBEECUTjOSIS*
Lcwin: Hofmetfiter'e Bcitroge, I.
Mester: Zeit. f. klin. Med., vol. 24, p, 453.
NuttalJ and Thierfelder: Zeit. f. phys. Chem., vol. 22» p. 71.
OrtwcUcr: Dist^rtatioD, Koempbei^.
Paget: '* Lessons on Clirtif^ Surgery."
Roger, G. H.: "Infe^-tioiiB Di»eases." Also ** Alimentation et Digestion.''
Salkowski: Deuta. Geaell., 1876, p. 138.
SimmondK; Dcut. Airhiv. f. kDn. Med-^ 1888.
Tbompeon, W. Gilman; "Prjictiml Dietetics,"
Tissier: Ann. Inst. Paat^rur^ 1902, p. 12,
UUom; ll^nry Pbipps XnEtiiute, Second Annual Report.
La Dieta Como un Factor en el Aumeato de la Reslstencia.— (Kellogq.)
En defensa de la disannucidn en la cantidad de laa sustancia^ mtro-
geaadaa en la cUetA el articulo da los hechoa siguentes:
1, La poca cautidad de austancias nitrogenadas aumeuta el ■vigor, La
resiatencia vital^ mental^ nerviosa y muscular.es capaz de inatitenerelestado
normal de la sangre y al mismo tiempo disminuye conciderablemente d
trabajo de! higado, los riaones y de otrofl organos destinados a la eliminad6n
o deatrucc6in de los venenos en el organismo.
2. El valor dc la dlsminucion de las sustancias nitrogenadas en Ia dieta,
Be demueatra en el hecho de que esto estimula la nutrici6n general y a}-uda
en el recuperamiento de mas de cien mil personas afpctadas de enfermedadea
cr6mcas, Lncluyendo entre ^llas peraonas afectadas de la tuberculons
pulmonar.
;i El examen de los cadaveros demu^tra que B0% de las personaa que
BUcumben de la tuberculosis pulmonar presentaii lesiones graves de los
rii^oTies, 95% presentan enfermedades del higado ye en muchoe casoa t&mbien
ae observa una degeiieraci6n de las glaudulas tiroideas. Estos hechtis
demuestran la tendencia esi3ecial de la afecei6n de los 6rganos destinadus
a la eliniinacion o destruccJ6n de los venenos en el organis en esta enfennedad,
E^tos hechos tHnibi^n Bon sufieientes para condenar la dieta rica en aus-
tancias nitrogeQadaa. Tal dleta necesariamente aumenta el trabajo requcr-
ido del higado, de los riiiones, lo mi&tno que de las glandulaa tiroidea y otraa
glandulaa itnti-tdxicas. La dleta de carne es especialment'e contramdicadf^
debido a la gran uantidad de extractos t^xicos y niicrobios que son
troducidos con dicha dieta,
4. La raci6n de sustaneiaa nitrogenadas de Chittenden es de 0.8 gramoa
per cada kilogratno de peso de lu personaj suplenientada por una cantidad
Buficiente para reponer las p^rdldaa extras ocacionadas por las cx>ndic]ones
de La fiebre.
DISCUSSION.
Dr. C. Demaoni M. Augustin Rey, Mr* Benjamin C* Marsh, and Dr.
■ods Hutchinson participated in the discussion.
noaV
lad 1
i
786 SIXTH INTEHNATIONAL CONGRESS ON TUBEBCULOSIS.
The part which mastication plays is more than that of griading the food inw
particlea fine enough to be swallowed. It performs a number of importiuil
offices in the work of digestion. The first of these ia to accelerate the Sow of
saliva and stimulate its digestive power by increasing the alkatizuty.
This is of the higher importance to the digestion of the whole great class
of foodHtufTs known as carbohydrates. The saliva 19 capable of practically
completing the digestion of the starches and sugars — ^if they are retained ia
the Qiouth long enough and subjected to sufficient mastication — ^before ihey
are swallowed into the stomach. Starch-contaimng foods conatitute a
relatively large bulk of the nutriment consumed daily. A habit of thorough
mastication proniotea digestion at the very gateway of the alimentary tract
It is a habit which should be encouraged, but encouragement avails nothing
when there are no teeth with which to chew.
In the small intestine there comes later another opportunity for the di-
gestion of starch, but for a number of reasons it is undesirable not to tiike
full advantage of the first opportunity nature offers for the prcpamtion of
this im])ortant foodstuff for future use. Besides, thorough and dehbente
mastication, through a fine comminution of the food particleSi is a cotudder*
able aid to the digestive processes which take place in the stomach and in-
testine. It is the only phase in the digestive process over which the individual
has control. When sufficiently mixed with saliva, there are few starchy
foods which are indigestible.
The thought, taste, and smell of tempting food stimulate salivary flow.
When food is bolted half-chewed— and this not infrequently happens from
neglected and painful oral and dental conditions— the ta^te is swallowed with
it, the palate is only moderately stimulatedj only little appetite juice is
produced, and the first step in digestion fails. An unclean mouth and
decaying and painful teeth cannot pave the way for any pleasurable anti-
cipation or for easy and thorough digestion.
Mastication increases the amount of alkaline saliva pasdng into the
stomach, and this prolongs the period of starch digestion in the stomach,
and by its influence upon the gastric contents it aids in the work of digestion.
It assists the gastric and intestinal juices to carry on the digestion of the fata
and proteids. The secretion of the gastric juice is started by impulses which
originate in the mouth; the mere chewing of food is sufficient to cause a
liberal secretion of ttus digestive fluid. Dental cripples cannot get the full
nutritive value of their food.
Neglected teeth lead to their own destruction. Tooth-rot spreads.
Every cavity in a tooth is a focus of infection. And y^t dental caries or
tooth-rot is ignored and complacently allowed to go on even to 'suppuration —
a condition which in any other organ of the body would cause grave anxiety.
Decaying teeth not only destroy themselves, but they work harm in other
U.
Fig. H. — Tli*> ]i(tii'-yi^Lir-(*ltl iKiy frtun whrmi llie>ie pufri«l reerh were reiunvinl Imii within
tliree year* severe atiaokh «f iliplKhorift ntul hCftrlei fever.
!■
^^^^H0^ .. v'tBm^^^I
*^^^ ^^H
^1
^^^^^^^^^^^^^^^_^^^^£jflH
^^^H
Fig. 4.-
Miemseopiral view of rieeompof-mg (oo<1 and tooth siilwlanee laken fmrii a
deeavH toolh — taken from v In fi*;, H.
THB IllPOBTANCE OF OBAL AND DENTAL CONDITIONS. — ^WOODBUBT. 767
and Femote parts of the body. They become human culture-tubes with
ideal culture-medituns. They are wide-open and imguarded storehouses of
infection which are a constant menace to health. The mouth cavity offers
generous room for receiving and harboring the germs of disease. The
teeth alone present twenty-five square inches of surface, and when they are
mere hollow shells filled with decaying tooth-substance and decomposing food,
they invite the germs of disease and provide them with favorable conditions
for their growth and spread Tubercle bacilli need but little encoiu'agement;
they survive conditions which would kill most organisms.
Diseased teeth keep the mouth foul and inflamed; they interfere seriously
with digestion; they lower the vitality; they aggravate a bad condition of
the tonsils and throat; they cause infiammation and infection of the glands
of the neck; and they infect the food which finds its way to the small intestine,
where digestion is completed and absorption of the digested food material
is begun.
The importance of the alimentary canal as a portal of infection in tuber-
culosis is bdng confirmed by scientific research. There is a growing con-
viction that tubercle bacilli pass through the intestinal wall. Thb belief is
supported by a large number of investigators. Granting that there is a possi-
bility of tuberculous infection through the digestive tract, there is every
reason why the condition of the mouth and teeth should be given the closest
attention; they should be kept in the best condition possible. They are not
receiving proper consideration; they never have received it. Evidence of
their neglect is in the fact that 96 per cent, of school children have decayed
teeth. One-fifth of the entire population are in the way of becoming easier
victims of tuberculosis. They are forming wrong life habits of eating, habits
which interfere seriously with their nutrition and which lower their resistance
to disease. Many of the parents of these children have as little appreciation
of the importance of proper care of the mouth and teeth as do the children
themselves. Even well-informed medical men ignore the necessity of a
dean mouth and well-cared-for teeth. The natural teeth should be saved,
and at any cost. Diseased teeth should be closely watched and treated.
A deep-laid habit of keeping the mouth and teeth clean prevents decay
and disease. Instruction in oral and dental hygiene to school children is
the primer of the teaching of the control and prevention of tuberculosis. In
early childhood this habit should be formed. The child should be
taught and encouraged to keep the mouth as clean as the face, and the
habit should become as nearly as possible an instinct. In the home
the foundation of the habit should be laid. And parents should have a deep
enough groundwork of knowledge concerning the teeth to give the child a
motive, to give him a satisfactory reason, why he should spend five minutes
every day in the care of his mouth and teeth. In the schools, public and
768 8TXTH INTERN ATI ON AI« CONOHESS ON TUBERCUUO&iB.
private, is tbe opportunity to emphasize the full meaning of unclean mouj
and neglected teeth. Every child should be taught that a dean mouth and
weU-cared*for teeth help prevent tuberculosis.
Hygiene now hohls the place of honor in modem medicine. At the present
time the interest in medical art is mainly centered in the prevention of disease*
The New Hygiene seeks out and deals with first causes — the sources of diaaaae.
Its goal is to promote successful living by helping man harmonize himself
with Ilia necessary conditions, natural and unnatural. A part of this New ^J
Hygiene is a popular movement for better care of the mouth and teeth, fl
much-neglected organs of nutrition* Helping the prevention of tubenni- ~
losis is but one factor of this newly organized crusade* It deals first hand
with all the infectious diseases, and in school hygiene It is a feature of first-
rate importance. ^^^H
Significant Facts Concerning the Physical Welfare of Schooi^^^|
Children. ^^^^
If New York school children are typical of school children in the United
States, there must be in the schools of this country 12,000^000 children hav- ^M
ing physical defects more or less serious that should receive attention from ^i
parents and family physicians. Of the school children in New York city
and in the United States, there must be handicapped by:
Malinitrition 41,600 in New Yoi-k Cily; 1,248,000 iti United StAies
Enlarged glands 182,000 " " " 6,460.000 •'
Bacltecth 299.600 *' *' '* 8,9S§,000 " «
Bb^ teeth only 83,200 '' " " 2,496,000 " «
Defective breathing ,... 230,400 '* '* " 7,092,000" "
La Bouche et les Dents dans la Tuberculoses — (Woodbtjrt.)
Les denta biea soign^s et la boiiche propre aident 5. ^viter la tuberculose.
Une bouche pleine de chicots carife ne peut pas bien fonctionner. EUe ne
pent pas compl^tement mdcherlanourrituredontlecorpsabeaoin pourpouvcar
combattre les maladies. La mastication est la clef qui fait ressortir Is
nourriture cachfe dans lea aliments. Quand on m&che conipl^temont et
avis^ment, les aliments sont bien m<^lang^3 avec la salive, ^l^inent d'inipor-
tance supreme dans la digestion. La salive est le premier dea fluides digestifs
que reneontrent Jes aliments. La l>onne nourriture, en quantity bien suffi-
aante^esttapremi^re n^cessit^ pour soigner la tuberculose: c'est un esaentiel
pourgu^rir cette maladie;c'eat auasl un pr^ventif fort important.
Lea denta cari^es n'amnent pag seulement leurs propres pertes, mai9
foumissent aussi un terrain de culture id6al ; elles constituent les verres da
culture humains pournounir et r^pandre I'mfection; ellea sont les magasins
d'infection, pleines ouvert.es et sans veilleurs, qm menaeent continuollo-
ment leurs propri6taireg auasi bien qu'autrui.
I
I
THE IMPORTANCE OP ORAL AND DENTAL CONDITIONS. — WOODBURY. 769
Les dents malades gravement entravent la digestion, rabaissent la vitality
et amSnent le gonflement et I'lnfection des ganglions du cou. Les autres
organes peuvent subir I'lnfection par les aliments lnfect6s qu'on avale.
Les estropi^ quant k leurs dents peuvent facilement devenir les victimes
de la tuberculose; ils invitent cette maladie, qui, une fois acquise, ne donne
pas chez euz grand €spoir de gu^rison. II faut ainsi surveiller et soi^er
m^ticuleusement les dents quand elles sont malades.
On doit enraciner T habitude de tenir propre la boucheet les dents pour
emp^cher la carie et les pertes qu'elle entratne.
Quatre-vingts-seize pour cent des ^coliers ont des dents cari^es. Pour
enseigner la prevention de la tuberculose il faut pr^alablement instruire les
^coliers dans Thygi^ne dentale.
Mtmd- und ZahnzustHnde bei Tuberkulose. — (Woodbury.)
Wohlgepflegte Zahne und ein reingehaltener Mund sind Hilfsfaktoren
2ur Vermeidung der Tuberkulose. Mn Mund mit caridsen Z&hnen kann sei-
ner Aufgabe nicht gut nachkommen. Er ist unf&hig, die Nahrung grundlich
zu verarbeiten, die doch den Kdrper bef&higen soil, Krankheiten bek&mpfen
zu kdnnen. Mastikation ist der Prozess, der aus den Essmitteln den
Nahrstoff ausscheidet. Vollkommenes, zielbewusstes Kauen durehmischt
die Nahrung mit dem Speichel^^in wichtiger Faktor in der Verdauung.
Der Speichel ist der erste Verdauungssaft, auf den die Nahrung stfisst. Gute
imd nahrhafte Kost in ausgiebiger Menge ist einer der Hauptfaktoren in der
Behandlung der Tuberkulose ; sie ist unerlasslich zur Heilung und von hoher
Bedeutung zur Verhiitung des Leidens.
Cariose Zahne fiihren nicht nur zurSelb8tvemicht\mg, sondembildenauch
ideale Kulturmedia; sie sind als menschliche Kulturtuben zur Fdrderung
und Verbreitung der Infektion zu betrachten ; sie gelten als weit offen stehende,
unbewachte Infektions-Speicher, gefahrdrohend fiir den Eigenthiimer sowohl
als fiir andere.
Schlechte Zahne stehen der Verdauung hinderlich im Wege ; sie setzen die
Widerstandsfahigkeit des Organismus herab; ja ae fuhren zu Schwellung
und Infektion der Halsdrusen ; die infizirte Nahrung wieder, die geschluckt
wird, mag ihrerseits andere Organe des Korpers contaminiren.
Zahnkriippel fallen leicht der Tuberkulose zumOpfer. Sie setzen sichdirekt
dem Leiden aus; und wenn einmal contaminirt, haben sie geringere Aussicht
auf Genesung. Cariose Zahne sollten genau iiberwacht und behandelt werden.
Gewohnheit vom Kindesalter an, Mund und Z&hne rein zu halten, ver-
hiitet Caries und Verfall. 96 Prozent der Schulkinder haben caridee Z&hne.
Unterricht der Schulkinder in Zahnhygiene ist das erste Kapitel der Lehre
iiber die Verhiitung der Tuberkulose.
voc. m, — 25
THE PROMOTION OF IMMUNITY THROUGH PHYSI-
CAL EDUCATION.
Bt Dr. Thomas A. Storey,
AMooate ProfcMor and Dinetor of Phyakal lattraetio^ GoBe«B of ttw Oty <tf N«v Tovfc.
The production of active immunity is a function of some of the fixed and
circulating cells of the body. When pathogenic organisms within certain
limits of virulence gain access to the tissues, they are destroyed or rendoed
innocuous by one or more of several processes. They may be devoured by
phagocytes; they may be killed and dissolved by agents in solutkm in the
tissue- juices; they may be imprisoned and walled off locally from the rest of
the tissues; and their toxic products may be neutralized or destroyed by
soluble antibodies in the tissue-fiuids. These several defenave activities
are carried on directly by the tissue ceUs or indirectly by the products of the
vital activities of those cells. On the cells of the body depends the exhibitioo
of the phenomena of immunity.
The degree of immunity produced is related directly to the beahh
of the cell. An impoverished, poorly nourished, unhealthy cell will pot
react to the same extent and with the same success as will the normal
healthy, well nourished cell.
The health, and therefore the inununity-produdng pow^, of the odl
depends upon its nourishment, including food, water, and oxygen; upon its
relief from the influence of its own waste products; upon its exercise; upon
its opportunities for rest and repair; and upon a reasonable freedom £rom the
direct and in<Mrect influences of pathogenic organisms. These facts have
everywhere been forced upon the attenticm of men who are experimenting
with the immunity reactions of the blood. They find healthy blood is neces-
sary for good reactions. Bactericidal phenomena, phagocytosis, bacteriolysis
agglutination, the productions of antitoxins, and the other phenomena of
immunity are all more marked in blood taken from healthy animals. It
has been found in laboratories everywhere that a reduction in mortality and
a more successful experimentation with the vital phenomena of cellular
structures in experimental animals accompanies the provision of good and
sufficient food, exercise, and careful sanitation.
We have so far been dealing with the cells of the body. We may now
proceed to the statement that the health, and therefore the immunity^ of the
770
iBonmnT through physical education. — storet. 771
whole body depends upon the health of all its constituent parts — on the
health of its oelb. If the cells are all well nourished, active, and protected
from extremes of pathogenic influences, their summated health will be the
health of the individual whose body they in combination make. That such a
healthy individual is possessed of a certain degree of immunity has been
proved empirically and experimentally, and it is equally well established that
the possession and conservation of the healthy body depend upon the observ-
ance of several simple hy^enic procedures. These hygienic procedures are
the same as those which I have already stated were essential to the body-
cells. Furthermore, these procediues must be the fundamental procedures
in any wise and well ordered policy of personal health control.
Physical education is concerned primarily with human health. It em-
ploys the same hygienic procedures for its piuposes that are essential for the
development of health and consequent immunity-producing powers in the
cells of the body. Its principles are based upon the fundamental facts of
hygiene. It employs reco^ized hygienic precepts in the procedures which it
lays down for health. The well planned scheme of ph3rsical education of to-
day teaches men to eat properly, to drink properly, to breathe properly, to take
proper care of the excretions and wastes, to exercise wisely, to rest wisely,
and to keep reasonably clean with reference to disease-breeding organisms.
Such governing principles lead to and conserve human health. Failure to
respect any one of these principles will jeopardize the success of the others.
No rational scheme of phyracal education nowadays relies upon exercise
alone for health nor upon any other one procedure or habit. One must observe
all of these several requisites in order to work under a wise policy of physical
education — of personal health control. The man who regulates his habits of
eating and takes no exercise cannot expect health. The man who exercises
properly and eats wisely will fail to secure health if his habits of sleep are bad.
On the other hand, a reasonable observance of these several simple hygienic
laws on which physical education is based cannot fail to secure and conserve
health for the average individual.
Such an individual will be possessed of millions of active, healthy cellular
structures working for his protection, constructing for him a defensive
armamentarium, and ready on demand to respond with supreme reaction
against invasion of disease.
La Promoci6n de la Immunidad per Medio de la Educadon Ffsica. —
(Storey,)
La producci6n de la inmimidad activa, es una funci6n de las ovinias fljas
y en circulaci6n del cuerpo. La acd6n funcional de la c^lula esti en relad6n
durecta con la salud de la c^lula. La salud dela o^ula y por k) taato la
772
BIXTH INTERNATIONAL CONGBEBa ON TUBERCtTLOSIS,
producdda de inmnidad de la c6lula, depende su tmtnd6n, mcluyendo d
alimeDtOr agua y oxigeno* lo mismo que I& de eliminacioa de Iob productos
excreroenticios y de la secreci^n por medio del ejercicio, de las oportunidades
para el descaoso y si reciiperaci6Q y una razoDable imunldad contra las
microbioa patog^cce* La salud y, eD conaecuencia, la inmunidad del iadi*
viduo es el conjunto de ta salud de las celulas que forman el organlsmo.
Se ha probado, por medios empErioos y por experimentos, que la salud
individual posee un cierto grade de inmubdad. Es un hecho establecido que
la salud y la inmunidad dependen de ciertoa principios liigii^mcos- La edu-
cacion fkica ^a conciderada ccmo la base de la salud del hombre; haciaeste
fin la educacion ffsica haee uso de los mlaoioa princlpios higienicos qxie son
tiecesarioa para el desarrollo de la salud y la inmunidad de laa c^ulas del
cuerpo. Un plan bien organlzado sobre la educaciun fkica, par lo tanto^
debe promover la inmunidad.
La Promotion de I'lmmunit^ an moyen de PEducation physique. —
(Storey.)
La production de I'Lmmumt^ active est ime fonction de quelquea-unes
des cellules fixes et cLrculantes du corps. L'activitd fonctioiineUe d'une
cellule est li^ directement h la sant^ de la cellule. La sant^ de la cellule et
par suite la production de rimmunit^ par la cellule depend de la nutrition de
cette cellule, qui comprend la nourriturefreau et I'oxyg≠ elle depend ausa
de ce qu'elle se d^barasse des influences provenant de sespropresexcr^tions;
de son exercice; des occasions qu'elle a de se reposer et de se refaire, et enEn
de ce qu'elle est k Tabri des influences directes et indirectes des organismes
pathogi^niiques. La sant^ et par consequent Timmunit^ de rindividu est
la somme totale de !a sant^ de ses tissues cetlulatres.
On a prouv^ empiriquement et exp6rimentalement que l*individu sain
poss^^'de un certain degr6 d*immunit4, C'eat un fait bien dtabli que certains
proc§d6a hygii^niques produisent la santS et par consequent rimmunit^
L'^ucation physique s'occupe tout d'abord de lasatit^ humaine; elleemploie,
pour atteindre son but, lea memes pi"oc^d6s hygi^niques qui sont n^ccssalres
pour le dC'veloppement de la sant£ et la production du pouvoir d'immuBitS
dans les cellules du corps qui en est la cons^uenee, Un plan d*^vjtyition
physique intelligent et bien organisd doit par cons^uent produire rimmunitd-
4
4
Die Haters tUtzuBg der ImmumtJit durch kSiperliche Erziehung. —
(Storbt.)
Die Hcrvorrufung der aktiven Immunitat iat eine Funktion einiger der
fcsten und cirkulierenden Zellen des Korpera. Die funktionelle Aktivitat
der Zelle ist in direktem Zusammenhange mit der Gesundheit derselben.
IMMUNITY THKOUGH PHTSICAL EDUCATION. — 8TOBET. 773
Die Gesundheit der Zelle und daher die Produktion der Immunit&t durcb
die Zelle hangt von ihrer £m&hrung, einschiiesslich Futter, Wasser und
SauerstofiF ab; von ihrer Befreiung vom Einfluss auf ihre eigenen Zerstorung?-
prodxikte; von ihrer Bewegungsf&higkeit; von ihren Md^ichkeiten fiir Rube
und Ersatz und von einem erw£lgenswerten Freisein des direkten und in-
direkten Einfiusses patbogener Organismen.
Die Gesundheit und dadurch die Immunitat des Individuums ist eine
Sumtnierung der Gesundheit seiner Bewegungszellen. Es ist empirisch und
experimentell bewiesen worden, dass das gesunde Individuum einen bestimm-
ten Grad von Immunitat besitzt. Es ist eine fest dastehende Tatsache,
dass gewisse hygjenische Massnahmen Gesundheit und daher Immunitfit
bervorrufen. Die korperliche Erziehung strebt vor Allem die mensch-
liche Gesundheit an; sie verlangt dieselben hygienischen Massnahmen fur
ihre Zwecke, die fiir die Entwickelung der Gesundheit notwendig sind und die
daraus erfolgende Moglicbkeit der Immunitilt in den Korperzellen. Ein
weise und gut organisierter Plan koiperlicher Erziehung muss daher die
Immunitat erbdhen.
THE RELATION OF INfMIGRATION TO THE PROB-
LEM OF SECURING SOCIAL CONDITIONS
FAVORABLE TO GENERAL IMMUNITY.
Bt Robert Watchobn,
of Imauamlkm alt Ik Pbrt d New Tarfc.
Whether immigration conduces to the qnread of tuberculosis or tends to
nefnire c^^nrlitions favorable to its suppression b a question about which
differences of opinion exist that are quite as acute as the difiTerences of
opinion in regard to the admisraon of aliens to these shores. No matter how
diligently the question may be investigated at a port of entry, it scarcely
HCMsniH [Xjflsible that any such inquiry can develop facts bearing on it likely
mJequately to illuminate it. The answer must rather be sought in the oom-
rimnitieH where aliens are wont to settle. But a multiplicity of inquiries or
investigations made even there, under varying auspices, is likely to add to
the (!onfuHion rather than to dispel the doubt and uncert^ty as to the effect
irninigruntH have as a whole on the health conditions of the country. It is,
tlujroforo, to \)0 hoped that satisfactory auspices may be foimd imder whicha
iH)niprohonMivo, intelligent, and scientific inquiry may be made, and resultant
irrefutable data furnished.
With such data as are at my command I do not hedtate to express the
opinion that such on inquiry will undoubtedly demonstrate that the stream
of immigration pouring into this country, subject as all aliens are to the dose
scrutiny of the Public Health and Marine Hospital Service, is so nearly
nlwolutoly untainted by this dread disease as to render it a mighty important
factor in Hocuring "social conditions favorable to general immunity."
Whatever tendency there has been to a development of tuberculosis
among aliens in America has almost invariably been found in places where
aliens citlonizo, and the remedy for its suppression, under these circum-
Htmuxv), nuiy Iw regarded as devolving upon municipal rather than upon the
Federal Ciovornmcnt. Those municipalities that have, by laws and ordi-
niuut^, mmio lui effort to correct the evils growing out of overcrowding
have taken the initiative toward curtailing the disease in one important
partiriiliu*, anil deserve great credit for the taking of this beneficent step.
Hut when it is rt^olised that malnutrition posably contributes as largely to
tho dovolopinont tuul spread of tuberculosis as unsanitary conditions do, it
will l>o obe*er\-cd that no matter how thoroughly sanitary the dwellings of
774
RELATIOM OP IMMIGRATION TO OKNXRAI* IMMUNITY. — WATCHOBN, 775
the poor may be made, there will stiJl remain a very importaat factor to be
dealt with.
It has been aaserted that 25 per cent, of the aliens amving on these shores
for the first time are ''birds of passage," which may he interpreted to mean
aliens whose object in coming here is to earn as much and to spend as little as
possible in order that they may accumulate a few hundred dollars in the
shortest possible time, with a view to returning to their native land. During
their temporary sojourn a very strenuous effort is made by them to acquire
the objective amount of money, and to that end every privation that the hu*
man system can endure is self-imposed. Malnutrition reaches its high-water
mark among this element, and whatever latent disease there may be in any
of them is, as it were, given incubator-like facility for development.
Among this class of aliens a camp^gn of education mil )>e required in
order still further to increase the tendency to immunity that the presence
of aliens tends to assure us, A campaign of education along these lines will
not be an insuperable difficulty, l>ecause there is ample proof that these
''birds of passage/- on their first return voyage^ do not find in their native
land that permanent abode to which they had cast such fond and hopeful
retrospective glances. Indeed, very few of them who are healthy enough
to make a second voyage to America fail to do so, and on their second or
third visit to this country they live under much more improved conditions
than when they first arrived- Permanent homes are divested of most of
the deplorable fe^itures that characterize the dwellings of "birds of passage/'
in that they conform more nearly to the American standard of liWng.
Eminent medical men have written very lucidly on this subject, and no
matter what differences of opinion doctors may hold, they are almost a
unit in declaring malnutrition to be one of the prime causes of the develop-
ment and spread of this dread disease* It is, therefore, devoutly to be
wished that, whatever steps may be taken with a view to its suppreedon^
this very important factor will be given due attention.
Climatic conditions probably exert a great influence in respect to tuber-
culosis on aliensj and certainly urban life in America appears to produce ill
effects on European ruralists. Having been inured to open-air life, the
changed conditions under which they live in this western climate, plus the
malnutrition previously referred to, in no small measure account, not only
for the death-rate among alien children, but for the development of tuber-
culosis in alien adults.
The medical inspection all aliens must undergo on arrival at the port of
New York is comparatively severe. Notwithstanding this, during the 6scal
year ended June 30, 1907, out of a total of 1,004,756 alien arrivals, only 410
cases of tuberculosis were discovered, and of these only 40 were of the
pulmonary type. For the fiscal year ended June 80^ 1008, out of a total
of 5S5,970, only 590 cases of tuberculosis were discovered, and of these only
776
8IXTH DrrEBNAflONAt COKO&ESS OW TTTBERCDXOera.
37 were of tbe pulmonary type. No doubt, aome casea, betng in ft state cf
undiflcoverable indpiency, passed undetected, bui for all practical pajpoaoi
these figures may be iaksi to repres^ii the staodard of bealth of the voliiise
of immigration arriving at the pc»t of New York.
The two races that furnished the bulk of the cases of detected tubefctt-
loBJs during the fiscal year ended June 30, 1907, were HJebrews and Italians^
the former furnishing S and the latter 11. It is also inter^ting to know that
by occupations 1 1 of them weie farm laborers and S ordioary labofeiB. Of
the arrivals afflicted with tuberculosis for the Oscal year ended June 30^
1908, 7 were German, 4 Hebrews, 7 Italiai^, 4 ScandinaviaDS, 2 Hnlaiidefa,
and 5 British. The majority, as in 1907| woe clasafied as (ami laborers
and ordinary laborers.
It camiot be doubted that, in point of freedom from tuberculosis, arriTing
aliens take high rank, but, as previously stated^ the real test as to the pbjrsicil
condition of aliens should be made subsequent to their laadiiig^ and while
they are undergoing the process of acclimatization.
The data at my command relating to those who become disabled and
dependent by reason of being aflfUcted with tuberculosis I submit in the form
of tables — A and B showing the numbers thus afflicted, natlonalityp sex,
and length of time in the United States by months; and C showing the place
of origin, distinguishing between urban and suburban life.
For the infonnation of those unacquainted with the method of remoTinf
dependent aliens from the United States, it must be stated that the OovcnH
ment has authority to remove any alien who, within three years of his arrival,
has become a public charge from causes existing prior to landing. The cases
indicated in the aforementioned charts were removed under said statutor>'
authority. It has been claimed that others, finding themselves afflicted
with tuberculods, have voluntarily returned to their homes, so tbat the
charts may not adequately represent the number who thus became aflKcted;
but they may^ for all practical purposes, be taken as fairiy indicative of tht
numbers who thus became dependent. One of the most noteworthy features
of this showing is that^ although the majority of them resided in such cities
as New York, Boston, Philadelphia, and Chicago, nearly 90 per cent, of
the 112 maleSi and every one of the 17 females, hailed from rural EuropeftB
abodes, which may possibly indicate that those inured to rural life in Rurope
are not specially adapted for urban life In America.
These figures have been compiled from official records, and may
regarded as fully authentic. They are offered in the hope that they may
throw some helpful light on a subject than which no more vital one may
engage the attention of thoughtful and skilful men, for if this dreaded and
devastating disease be not successfully combated, it will continue to destroy,
and the sad and melancholy havoc it has already wrought will be disti«a»-
ingly augmented.
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780
SIXTH IKTERNATIOMAIt CONQRKBS OS T17BSECmX»t9.
Ia Rdjtd6n de U Inmlgrmci^n con el problema de la General Inmtnndai
— (Watchors.)
En ^ afio que tenoino el 30 de Jumo de 1907, con su total de 1 ,004,71
Qtttndaa, s61o 410 caaos de tuberculosia fueroa descubiertos y detenidos,
da «it08 86lo 40 eran puIcDonaresi. En el lUtimo ano, de un total de 5S5/i7
Mo 900 caaos de iubereukeia ae descubrieroa, y de elloa a61o 37 ex&n pu
inoDaitB,
S la iubeiTukiaB prevaleoe entre la poblacidn extranjera, sus cflOd
deben buacvrae m la eondidooea en que elJos vivea. En otnis paUbn
las aiitoffidados ooostitutdas de la municipaiidad y del pats son eD gran par
raBpoambles del ma! riesultada Editidos sanitarios con su£ciente luj y ain
eon pun y abundaute provisida de agua, pueden ser procurados pot leyi
eficientes y enfonades. Hasta la mala nutnd6n puede ser favorableioenl
modificftda a» instnicttdn higi^oica Itbre 6 insistencia sobre los requisit
de afiooentOB puroe. La uiseacia de tal extricta supenngilancla pijblicii I
aumenia coo «l hecho de que una considerable proporci6n de nualn
inniigrant<?s traen el intento de la mfis grande ganancta en el m^
tiempo, i^LTw poder pronto regresar A su pals natal. Esto hace que
tariamente descuide toda comodidad no eaencial y se disponga ^ soportl
toda privacidn personal posible.
Del cuadro que acompatia 4 este escrito se desprende que las condlcioiif
de acUmataci6a, y eepectalmente las condiciones de la vida de ciudad con
parada con la del campOi est&n ea estrecha relaci6n con la presencia de
tuberculosis entre extr&njerog residentes* Aparece alU que en los aSos
1907 y 1908^ de 129 extranjeroa tuberculosos, 112 varones y 17 hembra^
deportados subsecueatemente ^ su admijEddn — tal deportaci6n e^t^ autori^ad
par uu Uempo de tres aikWt probatorio — 20 varones, uing:una hembn
viuierou de palses eitranjeros, mientras que 92 varones y 17 hembras viniera
del pals. AI contr&rio, en otro cuadro acompanada, se veiA que de estc
129 deportadoe subsecuentemente i 3U admkidn, 117 se encontraban
nuestras ciudades y sdo 12 en el campo. Usando la frase de Carlyle^ est
significa mucbo.
Uimmigradon el les conditions sociales favorables i rimmiinit^ g^n^rale
— (Watchobn.)
En Tami^ fimasant le 30 juin, 1907, avec son total de 1,004,756 d'arri\
Beulement 410 cas de tuberculose furent d^couverts et exclus, et de oeux-^
ci seulement 37 ^taient des cas pulmonaires.
Si la tuberculose existeparmi nos habitants Strangers, il faut encherch
1^ sources dans lea conditions sous lesquelles ils vivent, Autrement dit
lee autorit^ des munlcipaUt^s et des viUes sont en g^n^ral respotisablQ
BELATION OF HOaGBATION TO GENERAL lUUUNITT. — ^WATCHORN. 781
pour le mauvtus r^sultat. Des habitations sanit^res, asaez de lumidre et
d'air, une abondance d'eau pure, tout cela peut 6tre assur6 par Tapplication
efficace de la loi. On peut m^me modifier favorablement le manque de
nouriiture par Tinstruction hy^^nique gratuite, en insistent sur le besoin
de la nouniture pure.
La necessity d'une telle survdllance publique est augment6e par le fait
qu'une proportion considerable de nos immigrants s'achame k gagner le
plus possible dans la plus courte dur^ de temps, afin qu'ils puissent retoumer
k leur propre pays le plus t6t pos^ble. Pour cela ils se d^privent de tout
confort non-essentiel et supportent volontiers toute privation personnelle.
En consultant la table qui accompagne ce m^moire, on verra que lea
conditions d'acclimatation, et surtout les conditions de la vie urbcune com-
part k la vie campagnarde, sont ^troitement lito k la prince de la tuber-
culose parmi les residents ^trangeis. II parait done que dans les ann^
1907 et 1908, de 129 strangers tuberculeux, 112 miles et 17 femelles, renvoy^s
apr^ leur admisdon — tel renvoi k n'importe quel moment pendant une
p^riode probatoire de trois ans 6tant autoris^ par la loi — 20 m&les, aucune
femelle, vinrent de villes ^trang^res; tandis que 92 miles et 17 femelles
vinrent de la campagne. De I'autie c6t6, on verra dans une autre table
ci-jointe que de ces mdmes 129 renvoyds apr^ admission, 117 furent trouv^s
dans nos villes et seulement 12 k la campagne. Four employer le mot de
Carlyle, c6\k signifie beaucoup!
Beziehung der Einwandenmg zu dam socialen Problem der allgemeintn
Immunitftt gttnstige Verhilltnisse herzuschafFen. — (Watchorn.)
Im Jahre, welches am 30. Juni 1907 endete, wo 1,004,756 Einwanderer
angekommen sdnd, wurden nur 410 an Tuberkulose Leidende entdeckt und
ausgeschlossen, und unter diesen waren nur 40 lungenkrank. Dieses Jahr,
aus einem Totalbetrag von 585,970, wurden nur 590 Tuberkuldse entdeckt
und ausgeschlossen, and unter (tiesen waren nur 37 lungenkrank.
Wenn die Tuberkulose unter unseren fremden Einwohnem herrscht,
miissen wir den Ursprung davon unter den Zust&nden, worin sie wohnen,
suchen. Die Behorden der Gemeindebezbken und St&dte sind grdsstenteils
fiir das schlechte Hesultat verantwortlich. Nur durch streng ausgefiihrte
Gesetze sind sanit&re Wohnungen, geniigendes Licht und frische Luft mit
dner FiUle von reinem Wasser zu erzielen. Sogar schlechte Nahrung kann
man durch unentgeltliche Gesundheitslehre und dadurch, dass man auf die
Notwendigkeit guter Nahrung Gewicht legt, giinstig modLfizieren.
Die Notwendigkeit solcher strengen, dffentlichen Aufsicht wird dadurch
vergrdssert, dass ein ziemlich grosser Anteil unserer Einwanderer so viel
Geld als mdgiich in der kurzesten Zeit verdienen woUen, um mOglichst bald
782
BDCra INTVBNATfONAL OONORBBS ON TDBEBCUIiOeiS.
in ihr Vftteriukd surucksolodirai. Sie entbehien geme aUe unnofij
Beltt^idikeit«n und ertnsen fekht alle mogiicben, personlichen E
Durch ci&e (fiese Schiift begltttaMle Tabelle siefat num, dass die Ac
noaliaeniiigssust&nde, und besooden die Zust&nde des Stadtlebens i
dem bnHHrhen Lriien ver^iclieiiy mit dem Vortiandensein der Tuber
lose unto- fremden Einwohnem eog verfounden sind. Da erscheint
daas in den Jahren 1907 und 1906, unter 129 tuberkuldsen Fiemden, :
m&nnlich und 17 weiUicli, nach ihrer Zulassung deportiert — denn soli
Deportation lu iigend eino- Zeit wfthrend einer Prufungsperiode von c
Jahren wird gesetitich erlaubt — 2D M&nner, keine Weiber, von fieoK
Stidten gekonunen sind; dagegen 92 M&nner und 17 Weiber vom Lan
Andererseits ist es an dner anderen be^eitenden Tabelle ersichtlicb, daas >
<fiesen 129, die nach Zulassung deportieri wurden, 117 in unseren Stad
and nur 12 auf dun Lande gefunden wuidai. Um Cariyle su citiren: I
bedeutet viell
DEUX ASPECTS NfeGLIGES DE LA LUTTE CONTRE
LA TUBERCULOSE: LES TUBERCULEUX PSEUDO-
BIEN PORTANTS; LES BACILLIF£RES
CACHECTIQUES ET MISE^RIEUX.
Par Dr. H^sicourt,
Paris.
n est admis aujotird'hui que la lutte contre la tuberculose doit se faire
& Taide d'un armament vari£, qui comprend:
1. L'6ducation du public, relativement au danger de la contagion (publi-
cationSf conferences).
2. La suppression des poussi^res dans les rues et les ^tablissements
publics.
3. L'usage du crachoir de poche par les malades.
4. La d^nfection du linge des malades.
5. L'assainissement progressif et syst^matique des habitations insa-
lubres (casiers sanitaires des maisons, etc.).
6. L'envoi 4 la campagne les enfants issus de tuberculeux, mais non encore
atteints par la contagion (oeuvre de preservation de Tenfance).
7. Le s^jour dans des sanatoriums de plaine, de montagne ou marina,
des malades curables (par la cure d'a^ration, d'alimentation et de repos).
8. Le d^pistage, le traitement et r^ducation des tuberctdeux par les
dispensaires urbains.
9. La surveillance hygi^nique de viandes de boucherie et du lait.
10. Les campagnes anti-alcooliques.
IL L'attenuation de la mis^ par les oeuvres chaiitables (v^tements,
aliments, etc.).
Get armament, on le voit, est tr^ complexe, et riche en moyens puissants
et en bonnes intentions. Nous ne voulons pas ici faire la critique de oes
moyens, et mesurer leur valeur. Nous estimons que tous peuvent 6tre
eflicaces, et doivent Stre oonaervis. Mais nous pensons ausai qu'ils doivent
6tre r^duits k I'impuissance, pour oette raison qu'ils ne sont pas completes par
deux actions antituberculeuses primordiales, sans lesquelles la lutte contre
la tuberculose restera toujours une agitation vaine.
Nous voulons parler de la protection (a) centre les tuberculeux bien por-
783
7W
filXTH tNTSaKATIONAL COKCIRESS ON TUBERCULOeiS.
tantA (aous nous expliquerona sur oette expression) ; (b) cx)ntre Ics ta
phtiaques, cacbectiques et incurabloa.
Om tuberculeux constituent lea deux expressions oppos^es, aiitith^t)qu4|
du trnJ Imcillaire, 11a sont 6galement rcdoutal^les au point de vue de
cootaipon; et, pour des motifs que nous aUons d^nancer, on Jes loisse r^pandn
oette contagion Imminent et librement.
Lea tuberculeux Men portauts, ce sont ces sujets alteinta de foi
ohroiuqii69 tic la tuberculose, de l^ons scUreuses des pouiuotid, de pr^tea
dues lironchiies chroniques avec ou sana emphys^me, qui laiasent, avi
Taptitude au travel, TappateQce ext^rieure de la sant^. En effet, c
pseudo-l>ien-lx)rtants passeat dans la vie, et font face ^ se-s exigences,
peu pres corarae des individus normaux- Us travaillent. gagnent de Tai^gea
se marient, oat des enfaaU, et pamennent souvent h une bonne vieiUi
tie s'eiant d'ailleurs que trte rarement, siuon jamais arret^is pour cauoe i
maladie. Leur aspect ext^rieur est d'ailleurs tout^^-fait favorable. 1
ont l>oiine mine, et sont d'un embonpoint normal, parfoia meme inferieur
la nioyeune, Seulement^ ib toiissent et cracheat, peu T^t^, beaucoup rtiive*
lis sont plus ou moina es9oufB6&, et avouent un peu d'asthme. Au total
sedi^clarent bion portants, et pr^tendent m&me h. la vigueur; se vantant parfea
de n'l^tre jamais malades. Or, oe Bont des tuberculeux, et des tuberculeu]
k expectoration bacillairej de fagon permanente ou intermitt^nte.
Aussi le danger de cette forme de tuberculose n*est pas individuel,
est familial et social*
Familial; cea tuberculeux pseudo-bien*port^nt« peuvent parvenir
la vieillesse; mais dansle oours de leur existence ils tuent tous ceux qui lei
approchent intimement. Success! vement, leurs enfants meurent de broncho-
pneumonie ou de m^^ningite; oeux qui survivent seront phtisiques di& Tado-
lescence. Leurs femmes finissent par ^tre contamin^ k leur tour, et bien
Bouvent ces broncbitiques cbroniquea sont remari^ lis multjplient leurs
-victimes, et leur survivent, toujours avec un aspect florissant, et ^atisfaits
de leur sant^. Cette histoire du man bien portant, quoique tousseur et
cracheur, qui travaille et refuse de recevoir des conseils m^dicaux^ qui d^truit
sa famille, et tr6ne sur les ruines de son foyer, est d^plorablement banale.
Dans la clientele des dispensaires on le rencontre au moins une foia sur deux.
La tuberculose torpide, attenu^, acl^reuse, cbronique — comme on voudra
Tappeler m^dicalementr— mais qui, socialemeot, est la tuberculose "ma^u^/*
e«st done la grande pourvoyeuse de la contagion, A maintes reprises,
depuis plus de vingt ans, j'ai d^nonc^ le danger extreme, h oe point de vue de
la contagion^ des formes attenu^ des maladies,*
Ici, ce danger eat tel qu'on pourrait, sans exagdration, lui attribuer le
plus grand nombrc des victimesdu mal bacillaire. Car son actioa n^fastef
* Les frontiers de la makdie, Flammanon, PanB.
ASPECTS N^UQAb DE LA LUTTB CONTRE LA TaBERCULOSI8.-H6BICOURT. 786
le tuberculeux masqu^ ne Texerce pas aeulement dans son foyer: il Texerce
encore dans Tatelier, dans la rue, oil personne ne se gare de son voisinage ei
de ses excretions, et oil son activity, semblable ^ oelle d'lin individu bien
portant, multiplie les chances de contamination. Elle est done bien sociale, la
gravity extreme de cette forme de tuberculose.
Contre ce danger redoutable que faire? Inaccessible aux conseils de
rhygi^niste et du m6decin, le tuberculeux bien portant est de ceux qui r^f usent
obstin^ment Tusage du crachoir de poche. Bien souvent c'est un fumeur,
qui multiplie au contraire sea expectorations; c'est lui qu'on voit aprfes le
travail, aupr^ de la chemin^e — qui peut Stre en mdme temps la cuisine
du manage — ^r^pandre ses crachats autour du foyer.
Je n'ai pas de rem^e ^ proposer k ce mal; nuus je demande qu'on en
cherche; car tant qu'il n'aura pas ^t^ reduit k Timpuissance, la lutte contre la
tuberculose ne sera qu'un vain mot.*
Les tuberculeux cachectiques et miserables constituent une autre reserve
bacillaire et une source de contagion non moins redoutable. Bien entendu,
nous entendons ici parler des nus^reux, de cette clientele des hdpitaux, que
les hdpitaux rejettent apr^ les avoir abrit^ quelques jours ou quelques se-
maines; et qui, sans ressources, incapable de travailler, errent par les rues, de
dispensairesen dispensaires, vivant de vague charity, et mourant des quelques
fimes que les Bureaux de bienfaisance leur allouent chaque mois. Personne
ne veut de ces malheureux; ils n'ont plus de foyer; si les hdpitaux les expulsent
les sanatoriums leurs ferment leurs portes; les dispensaires, avec quelques
bonnes paroles, leur distribuent une apparance de m^cament; ils mendient
leur pain, se reposent dans des asiles de nuit, ou dans des chambres d'hotel
innommables, attendant une fin qui tarde k venir; mais, en i'attendant,
ils sement largement, dans tous les lieux publics, dans la rue, surtout, cette
graine contagieuse que demain, les passants, quelle que soit leur condition,
absorberont sans s'en douter. C'est le juste prix de ce crime contre la
solidarity sociale.f
Car cet abandon cynique du phtisique miserable est bien la plus grande
honte de notre civilisation. II est r^voltant de voir le luxe et Tabondance
s'afficher k c6t6 de telles plaies. Mais les liens qui unissent les hommes sont
des liens d'airain, et par une fatality inexorable, les riches et les bien portants
paient leur indifference et leur inconscience; et c'est dans leurs rangs que
*J'entreTois bien un remade possible: c'est le crachoir individuel, obtigatoire
pour tous les bronchitiquee et catarrneux, avec defense de cracher dans les rues et lieuz
publics.
t Les incurables dont il s'agit constituent la plus dangereuse r^rve du contago
tuberculeux, parce que; (a) ilsexpectorenttrdeabondamment; (&)il8 sont vagabonds et
multiplient aussi leurs lieux de s^jour: (c) ils sont in^uquables, se sentant perdua
(pas ae crachoirs de poche possible, etc.); C'est parmi oes malades aigris et r^voltin^a.
qu'on rencontre se vantant de semer le contagion, et y travaillant d^ib^r^ment. A
eux seuls, ces maiades sont plus dangereux que tous lee autres tuberculeux ensemble.
SIXTH an^otiOKmAL conoxwrn on ursBacoiiOBiB.
voDi tomber les Tictimes de l& eantagiim i^tMndoe par le pbtisique qu'ils oirt
buaa^ mourij &ur U Toie publique* Qoaad «ette le^cxi de Goiidant^ sen44)
done comprise? Ce acaiMfalp est d'atituit pitas gratid, qu*il tie serait pastil
difficile d'y mettre un terme.
S&DS doute, I*bo6pita]isation des tuberculeux dans dee ^lablisseniento
spikiaux a dt4 d§}^ enviaagfe; mais en France au moins, rien n'a ^t£ fait dans
cette vole, parce qu'on a reculd devaat les fTma d^une telle instituticuL. Chei
nous, en efifet, on ne oomprend les bdpitaux que comioe des vasies ^tablisse-
menta en pierre de taille^ avec un peTsonnel nombreiix, dee pares tout
autour, etc. A ce compte, on eut bientct fait de trouver quIJ faiKtrait^
pour hospitaliser tous les tuberculeux, un certain oombre de miJliards,
et la question, bien entendue, en est rest^ Ik
Or, en coostruiBant autour de chaque ville, de simple ^baraquementa poor
cinquante ou cent malades, en nombre proportioanet k celui des phUaquoe
k recueillir, la question serait solutionn^, dans des conditions surpFenaists
d'^conoDiie, Toute meubl^, Miiiee sur un terrain donn^ par tes munid-
palit£s, avec un petit jardin, une baraque comme oelle qui doit scrvir d'bopital
temporsdre, c'est k dire, abaolument confortable au point de vue du cbaufTagei
de Ta^ration et de I'^clairage, ne devrait pas coiiter pour cent malades, plus
de quarante mille francs,* Le co^t de la nourriture de ces cent maladee,
par an, k 500 francs I 'un, ressortirait ^ cinquante mille francs. Si vous suppo-
eez une a^immistm-tion redulte k son minimum: une dame ^conome etcomp-
table^ une cuLsini^re, deux iniimiit^res et un hoinme de peine, solt une somme
de cinq mille franca pour traitement de ce personnel, vous arrives au total
tr6s largement pr6vu de sobtante mille francs pour hopital de cent lits,
Notez que ces cent lite recevraient peut^tre detix ou trob cent maiades
par an; car il est bien entendu quits seraient surtout destines au pbtisiques
avanc^s et misdrables, dont la survie n*est gdnSmlement pas longue; mais
au surphi.s, on auralt certainement la surprise d'en gu^rir im certain nombre»
contre tout Gf^poir; et lee bienfaits de telles institutioos auratent ainsi une
double caractdre, Prenons une grando ville comme Piiris, Coinbien faud-
rait^il de ces baraques hdpitauxpourpurger ses faubourgs, ses voics pubUquea
de phtisiques mia^reux qui y circulent, et pour all^ger scs hfipitaux des in-
curables qui lesencombrent, au grand ddtriment des autres nwdades?
D'aprfes Texp^^rience que nous avons tirde de notre direction d^un dispen-
Baire-eanatoriuni foncUonnatit dans la r^gjon de Paris la plus contarain^ par
la tul>crculose| la construction imm^Jiate de dix de ces KApitaux-baraqucs
capahica de reccvoir deux k troia mille phtisiques mis^rables, rfeoudrait la
question en cequ'ellc a de plus urgent, k savoir la cessation du scaodale que
nous avona d6noncde* Et la premiere ann^, construction comprise, la
I
I
*Au moiiu dann rindusfrio prirde, ear bl I'^tat bc mdbitde cette constmctioa, eUe
lul revicoflruit facUcmofit au double ou tn^toe au tHpJe.
ASPECTS NiGUG^S DE LA LtTTTE CONTRE LA TUBERCULOSIS.-H^COURT. 787
grande ville pourrait s'en tirer pour la modeste somme d'un million t Nous
sommes loin, on le voit, des milliards pr^vus.*
Toutes les villes devraient 6tre tenues d'h^bei^r ainsi leure phtiaques
mis^reux, n'ayant ni famille, ni foyer ou lis puissent se soigner, se reposer,
et mourir en pdx. Sans doute une telle mesure ne tarderait pas k se traduire
par la diminution du nombre des phtisiques; et alors, au fur et k mesure, que
les baraques deviendraient inutiles, on les d6truindt. Mais sans mdme
escompter un tel avenir, par une telle mesure, on aurait mis fin & un scandale
de l^se-humanit^ qui est en m^me temps un gros danger social, et qui sterilise
aussi une partie des efforts d^ploy^s actueiiement dans la lutte contre la
tuberculose. Bien entendu, le principe des baraquements en question
sendt violemment combattu par les municipality et les particuliers. Ne
savons-nous pas que se sont les gens bien portants qui protestent contre
rusagedescrachoirs de poche pour les malades? Mais il yaunut 1^ une belle
occaaon de lutter contre Tinconscience et Tignorance des foules.
Puis on objectera contre Torganisation de ces refuges de tuberculeux
incurables que ces baraques, od Ton entrera que pour y mourir, auraient
bient6t ime telle renomm^, que nul malade ne voudrait en franchir la porte.
C'est 14 une grosse erreur, provenant de Tignoranoe de la situation des malades
auxquels ces refuges sentient destines. £t vraiment pense-t-on que des mal-
heureux, se trainant k peine, mouiant de falm autant que de maladie, sans
famille, sans abri, errant de porte en porte, k la poursuite d'une charity qui
se d^robe, pense-t-on que les malheureux refuseraient le lit, la table qu'on
leur offrirait dans les conditions confortables et de bonne apparence que
nous venons de dire. II faut, pour soutenir oe paradoxe, n'avoir pas entendu
les imprecations de ces pauvres gens contre la soci^t^ qui les laisse mourir
dans la rue; il faut aussi avoir oubli6 que le tuberculeux cachectique est tou-
jours d'une mentality optimiste, et qu'il ne s'assimile jam^s aux moribonds
qui I'entourent.
II faut bien cependant admettre que les individusqui vousd^clarentfroide-
ment qu'ib n'ont plus qu'4 se jeter k I'eau, — et nombre d'entre eux le font
comme Us le disent, — accepteront avec empressement ime situation qui
actueiiement, leur apparalt comme un r^ve irr^alisable.
Quoiqullensoitdes r^medes que nous proposons contre les deux dangers
que nous venons de signaler, il 6tait, pensons nous, indispensable de les sou-
ligner au milieu de tons ceux qui r^ultent de la libre circulation de malades
emincemment contagieux; car il est urgent de faire quelque chose. Si du
moyen-age, on s'^tait arr^t^ aux considerations qui, aujourd'hui paraly^ent
toute la defense contre la tuberculose, il est vnusemblable que nos societ^s
seraient des societ^s de l^preux; et nous sommes vr^ment en voie de d6-
vouer des societes de tuberculeux.
* Hettons, si Ton veut deux millions, et ne diacutons pas.
788
StXTR INTERNATIONAL C0N0RZS8 ON TUBEBCOIXkBia.
Mfus est-ce hien dans le pays oil dea municipaJitds ont eu le bon
le courage d'Micter rinterdictiou de cracher daiia les rues, qu'il faut
pour pronver que souvent lea meaunes en apparence le plus impratic
sont dependant d'une application extr^mement facile*
Eti tout, ii suffit de vouloin
Th« Well-appearuig Tuberctilous, and the Incurable Cacliectic
sumpti ves,— H ^Ri court.
The armament againat tuberculosis is very complex:^ and very ri
good intentions. Two esseatials are, however, misaing from the 8c
defences against the well-appearing (pseudo-hien-portant) tuI:>ercaIo
against the cachectic incurable consumptives. The former cUas
up of *' chronic broachitics," who have indolent discharging tu
their lungSr but remain apparently well. They are active and suci
buMnesSf they marry, have children, and often outlive wife and chil
They expectomte tubercle bacilli, continuously or intermittently, but i
seem never t^j be sick* This " masked tuberculoaia" is gravely dangerou
family life and aocia! life. The only defense against these bacillifera appi
to be a regulation, requiring all persoas, having bronchitis or cjitarrh,
carry sputum requisites. The author does not recommend this defi
but insists that some defense must be provided. The antitheaia of the
appearing tuberculous is the cachectic incurable consumptive^ dependea
charity, though not admitted to any hospital or other refuge; unable to
roaming the streets, and often dying " in the open.'* These consumpt
are desperatCj cynical, unteachable; sometimes malevolent, and they
aeminate their surroundings most lavishly.
The only way to deal with this danger is to build hospitals enough to
commodate 2000 or 30O0 of these people. Paris, the author thinks, co
well afford to spend 2,000,000 francs to provide insolation hospltala for
cachectic incurable consumptives.
SECTION V.
Hygienic, Social, Industrial, and Economic Aspects
of Tuberculosis (Continued).
EIGHTH SESSION.
Friday afternoon, October 2, 1908.
THE RESPONSIBILITY OF SOCIETY FOR TUBERCULOSIS.
The eighth session of Section V waa called to order by the President, Mr.
Edward T. Devine, on Friday afternoon, at half past two o'clock.
ADDRESS
Bt Mr. Jacob A. Rns,
New York.
When Dr. Flick in 1890 demonstrated that certain houses became in-
fected with tuberculosis, I had been for years attached to the Board of Health
as a newspaper man. I knew Dr. Herman Biggs* had watched his work,
and I imderstood. Up till that time I had been imable (with a growing family
and only my reporter's pay to provide for it) to obtcun any insurance on my
life, because each time I tried I was obliged to own that I was the last of
twelve brothers. All the rest who grew into young manhood — some did
not grow up — had filled consumptives' graves. There was no special taint
in the family to account for it, but there was the old house we lived in; the
feather-beds we slept in — very old they were, for they cost much money;
there were the clothes that descended from one son to another, for, with so large
a family to support on a teacher's small pay, nothing must be wasted. There
was no effective sanitation, no disinfection. The disease was a mysterious
visitation of God, to be submissively borne. I alone, of the twelve, had gone
abroad and stayed away, and I alone survived. One elder brother had spent
789
790 nXTB HfTEBlf ATIOWAL COMOUBM CH
thrne yeani abroad, and returned as strong ai
gravi! wan made Ijeaide those of the oiheiB.
Ho I unrJervftood, and I went back to mj Daniwh home as xna as I eosid,
and \wAuit] the ground over, I talked with the old famSj doeior^ «k> ksd
live^l t^; wjc a new daybreak, and I kK>ked at the old bovae. It was sifl
thfire, but after my family had moved away from its tragar ■wwiiiiiwi it
ha#] Ijeen entirely overhauled, refitted, and painted, and from then md
turn there has tieen no case of tuberculosis in it. What I amm and leanvd
I put Utfore the life inmiranoe company, and I have hmd. no troofafe matt,
T\viiy n\m 1eamc<], and knew.
An a refforter, I ha^l read Dr. Flick's story of how, in Italy, m. hmicM
yeant U^fore Dr. Koch proved it b Germany (1782-1882), they Ind jamped
U> the conclumon that consumption was infectious, and had enacted lawi
whif;fi mwle an end of it. Thc^ applied the despotic power of the State—
they Imrried tlifHxKlding and the buildingB, and banished whoever woold not
fall in with their scheme. N24>le8, wluch on account of its MST»«t»» ||^ bog
the nifuge of consumptives from all over Europe, — exactly as Colorado and
New Mexico are with us t<Mlay, — until the proverb grew i^, "See Nspks
and die," a proverb which we have since perverted to mean somethmg quite
difTfjrerit, Naples at last, so utterly has the old disgrace been wiped out,
ImcarrM! wluflcw^me. Its death-rate from consumption is now much kywer
than that of New Vf>rk dty.
TluiHC tliingM I roa<l, and I have implied them since to other things than
my owncfwe. Can wo not do, under our democratic form of government, with
all tlu) now knowledge, all our public intelligence upon which we profeas to
build, what tliey did in the old ignorant days under a despotic govemmoit
that nia<ln no pretence of "fxsing of or for the people"? If we cannot, then
as a i>(H>plo wo are directly responsible. We have made ourselves re^xmaibfe
bofons tlu) world . Our democracy will have failed then. It is a fair test.
Can w« bfittle successfully with the destroyer when it is shown, as it has
Ixien, that it is simply a question of understanding pl^ rules of healthand
conduct, and of being willing to act them out rather than throw the respon-
sibility and the bill on the government? We took the government from a
ruling doHH to nm it ourselves. If we cannot run it successfully in a matter
whicli Ko nearly touclics the life of our people, then we are not fit. I think
wo can. Wo may not bo able to bum or banish, — I sometimes wish we coiild;
it would onormouHly Rimplify some things, especially, to banish somebody
now mid then, -yet Dr. Koch has told us that we in New York do some things
bfittor than even in Germany, with all the care they take there that people
shall nut go wrong. You have heard from Dr. Biggs how we have reduced
the mortality from this cause in the metropolb since 1866, when we first
began to take real notice.
ADDRESS. — CROTHERS. 701
Consider the distance covered, and what common sense has already come
Into it all. I remember the old respirator that was the first equipment of
a consumptive. As soon as the character of his ailment was discovered,
they clapped a patch of black silk over his mouth, so that by no chance a
vagrant breath of fresh air should enter, and I have no doubt there were fam-
ilies of consumptives in which that instrument of sure death was handed down
from invalid to invalid with its accimiulated load of contagion. All the way
from that have we come to the day that recognizes in God's pure air that is
free to all, — or, if not yet free to all, is being made free as rapidly as we can
wrest the greedy hands of the slum landlords in our cities from the throats
of their victims, — the sovereign cure for his curse.
What remains is merely a question of understanding. In ten years we
should, with our machinery of to-day, be able to wipe out consumption as
completely as smallpox has been wiped out. It is a question every man can
decide for himself to-day, whether he will have smallpox or not.
It is a question of imderstanding. Therefore we hiul everjrthing that
makes the story plain. It is for that reason I am glad the Red Cross Society
has taken up the Danish Christmas stamp. The point about that is not that
it brings in so much money for the fight, not that it builds sanatoiiums for ack
children, but that it tells the story abroad. Wherever a letter goes with
that stamp, it sets people to thinking and talking, and when once questions are
asked, you have tuberculosis on the run.
We, as a people, have made ourselves sponsors for common sense in a
oonunon people's government. We should be able to deal successfully with
this plague, and we are justly held responsible before the world of public
opinion, in the light of what we now know.
ADDRESS
Bt Rev. Sauuel McX^hord Crothers,
Ounbridce, Man.
Among the different profesdons represented in this Congress, the min-
istry has place, for it should be remembered that it was an English non-
conformist minister, Joseph Priestly, who discovered oxygen. This was
greatly to his credit, for it is an element which is not always easily discover-
able in a meeting-house.
The main lines of strategy in the campaign agzdnst tuberculosis are plain.
The chief interest in the Congress centers upon the frontal attack upon the
center of the enemy's position. Eminent experts have been engaged in
7fl2 SIXTH INTERN ATIONAI. CONORES6 ON TUBERCntX>ftIB.
that work. Their endeavor is to conquer the disease when it has developed
They are seeking in every way known to science to discover a cure.
But there b another work which is recogtii^ as of great importanoa
It is of the nature of a flank movement rather than of a direct attack. The
endeavor is to strike at the lines of comniunication and the base of supplier
A wide enveloping movement is planned, vnth social forces conver;^ng upon
the position of the foe*
Here we may learn a lesson from military experience. It is a maxim d
sound strategy that an enveloping movement can be successful only when
it ia attempted with an adequate force. A small army cannot effectimJly
surround an army larger than itself. In extending its lines to inclose U»
great a space, they become weak and are easily broken through.
The same principle holds true in all social effort. In extending the scaope
of our effort, we must increase our forces and mtist make sure that they are
at every point made available. If this is not done, the result is vaguenes
and ineffectiveness,
It is proverbial that what ie "everybody's business" is poorly done.
It must be so until everybody is actually set to work. If I have correctly
followed the proceedings of this Congress, it has been shown that the preven-
tion of tuberculosis is everybody's business. To stamp out the plague ia
poaaible if everybody's attention can be attracted to a few ample facts,
and everybody's conscience be quickened. The eminent experts and the
members of the medical fraternity cannot do the work alone. Dedd^
specialized knowledge, there must be a broad stategmanlike power at work.
All social forces must be mobilised and brought to bear on one point.
It was a saying of Edmund Burke that " a crude umelated truth is in
the world of practice what a falsehood b in theory."
That is to aay, the speciallaed truth must be related to the whole body
of human experience before it does the beneficent work of truth. In these
conferences the effort has been to relate scientific truth to the needs of
humanity. The various agencies of civilization are enlisted in one corn-
prehensive plan. We have considered the work that can be done by the
schools, by the press, by the law, in the attack on this great evU.
May I say a word for the work which may be done by one of the eldest
and most fully organized of these institutions for social betterment — the
Church. The Church is fitted by its veiy constitution to do one thing {or
this cause, namely, to preach it.
It was an old discovery of the Hebrew prophets that if we are to change
the opinions or practice of men, we must do a great deal of preaching. It
is not enough to give a warning once. There must be "line upon Une,
precept upon precept, here a little, there a little."
The pulpit is not ashamed of this ceaseless rdteration of truths that
ADDRESS. — CROTHERS, 793
need to be repeated because they are so often forgotten. Now, we must
have the doctrines of this Congress preached "in season and out of season."
And we need not only the method of preaching, but we must enlist the
agencies of preaching for this cause.
We must ask the Church to conader whether it is not necessary for it
to revise its list of sins in the light of modem science.
The old stoics^divided all evils into two classes: those that are avoidable
and those that are unavoidable. Those that are avoidable, they said, are
within the range of moral action or judgment. We are to be blamed if
we bring upon ourselves or others an evil. But there are other evils which
we cannot escape. They are simply the work of cosmic law. These are
to be accepted with resignation. They belong to " things indifferent."
Christian ethics made the same distinctions. There are some evils which are
sins because they come by our own act. There are others which are to be
received as a part of the tragic mystery of existence.
This distinction is clear enough, but with growing knowledge many
things wluch once were misfortunes come under the category of sins. In
the infancy of medical knowledge all disease belonged to the realm of mystery.
It was a trial which came men knew not how. The " pestilence that walketh
in darkness" was an "act of God," like the lightning stroke or the earth-
quake. We all must feel the tragedy of it, but we could do nothing to
avoid it.
But the time comes when the disease is traced to a specific germ. The
life-history of that germ is made clear, and the conditions under which it
multiplies. When that knowledge comes, we enter upon a new phase of
effort.
"The pestilence walks in darkness," men used to say, "and we can do
nothing," " Yes," says the modem spirit, " it walks in darkness, its breed-
ing-places are the dark, unventilated rooms in which we have allowed
helpless people to live. Who is responsible for that darkness which means
untimely death? " It is our bumness to see that that darkness no longer
exists.
The new knowledge brings with it new responsibility. It gives new
definitions to the ancient conceptions of sin and righteousness.
Long ago men would say that any one who deliberately and wilfully
poisoned a well, or who, knowing that well was poisoned, allowed another,
without warning, to drink of it, was virtually a murderer: he was guilty
— he was not unfortunate; it was a crime — an absolute sin, and they held
him responsible for it. And why? Solely because experience had demon-
strated that any one drinking thereof died. Wherein is the difference
between a poisoned well and a poisoned air-shaft? Suppose, deliberately
and knowingly, we allow our fellow-men to inhabit rooms, to live under
794
SIXTH INTERNATIONAL CONGRESB ON TUBEHCUIjOSrS*
oonditiond, which mean a lingering death. The thing has to be prove
us l>eyond question; then the moment that it has been proved bej
question it l>ocomes nnt simply a scientific question^ it beeomed a quo
of nionilSf a question, ultimately, of roltgioa.
I like that phraae in the Old Testament where, speaking of those
violate certain fundamental principlea of health and well-beings the t
ment was made that aueh a man was "an abomination unto the La
Now, we want that tauj^ht to the landlonJ as well as to the tenant,
there are some things which are abominations unto the Lord, and them
persona who are abominations unto the Lord.
The moment we begin to work for the alwUtion of the contiitions ^
cause tul»ertviloHfl, that moment we get beyond the individual work
the vastly dilhfult public social work, and we cannot avoid it.
As we go through these rooms we see many devk^es by which individ
may escape contamination. These devices are like the safety-lamp wii
the miner carries in a mine filled with inflammable gas, Tliis is good,
perfect safety demands something more than a Bafety-lamp. Them
need of a comprehensive system of ventilation.
It hfts been shown in these meetings that the precautionary measures
beyond the scope of merely individual effort. Society must use all
power to protect itself from a social menace.
And just here comes the great difficulty. These meastires for the pub
safety are coatlyj and they often come in conflict with private greed. Thfl
sands of precious lives can be saved —but not without some efTort, Are
willing to give the effort? Mere pity will not avaiL
It is as if we were standing on the shore and saw a vessel drifting up«
the rocks. We sec the danger, but we can do nothing but pity thera. B|
suppose at that juncture, as we watch them with tender resignation, son
one cries: "Here is a lifeboat, and you may save every one alive if ^tJ
venture out." And what if we should say: "We prefer to pray for ih
people rather than to risk anything to aave them." T\m would not I
Christian piety, it would he sheer cowardice.
It is in that situation that we stand. Throughout the world millions ai
thff^stened with death by a preventable disease. Is the humanity of tl
<«vihscd world strong enough to take the necessary measures for preventioi
-gffgmce t«'ls ^^^ w^^*' *'^*^ measures are; the institutions for moral and reli]
i(ii}ci ruHofC must be enlisted in the work of carrying them out, Al>ove
MMt ^le H*ve men and women with civic courage who will not be deteira
«y^ J^ aOMlUon of sel^h interests.
m^ ll|r. Great-heart Avas conducting his company of pilgrims on thei
^«niy was stopped by Giant Grim and his lions. It was a situi
U where weaker spirits say: "It is evident that wb
ADDRESS. — STAFFORD. 705
is excellent is not practicable." Mr. Great-heart draws his sword and says
to the giant: "These women and children are going on a pilgrimage, and
this is the way they are to go, and go it they shall, in spite of you and your
Hons/!
In every community we must have some Mr. Great-heart with his defiance
of the lions in the way, and with his inastence that ''go it they shall."
ADDRESS
By Dr. T. J. Stafford,
Dublin , Iraland.
We have in Ireland one of the highest death-rates from consumption.
I should hke to mention one rather peculiar fact with regard to that high
death-rate in Ireland. Since 1871 the death-rate of Great Britain, the death-
rate of England and Scotland, has steadily gone down; since 1871 the death-
rate in Ireland has gone up.
We have for many years attributed this very largely to social conditions,
but it is a peculiar fact that, notwithstanding the great improvements which
have been made in the social conditions of our people, our death-rate has
not been favorably affected. Our housing, previous to 1851, and our food,
previous to the great famine of 1847, was extremely bad; but in recent years
we have spent an enormous amount of money in improving the housing of
our people. The Government advanced large sums of money; the local
authorities have contributed largely also to improve the housing, not only
in the towns, but particularly in the rural districts. But as I stud before,
with this enormous improvement in the condition of the housing of the
people, tuberculosis has gone up. Similarly, the feeding of our people has
improved. Since the famine days of '47, when so many people had to leave
our country, the feeding of the people has improved beyond all recognition.
They live better; their wages are better, they are better housed, better fed,
they have better wages, and notwithstanding that we have made no senable
reduction in the death-rate, but it has actually gone up.
Now, under these melancholy conditions, a great lady two years ago came
to our land — ^the wife of the Viceroy of Ireland, Her Excellency the Countess
of Aberdeen. She was enormously impressed by the conditions, and she
started an endeavor to improve them as far as possible; and I should like,
as I see a great number of ladies present, just to mention what her methods
are. Lady Aberdeen commenced, first of all, by going to the medical pro-
fession, the men who she thought could best advise her, and upon their
796
BrXTH t>rrERNATIONAL CONORBSd ON TTTBEBCUtOSlS.
advice proceedeti to take ccrtmu action. The actioo she took was to fo
wonieira national assodatioru She saiil,— and very properly,— ^'Tli
very largely women's work, " She formed a central association, whic^
called the National Asaodation of Women, and then she formed bi
asdonatiorm, in every i-own, in every village and hamlet in Ir^
8he thi>n, from her wntrai committee, sent out to all tliese branches lite
which waa suitable for them to distribute; she got her central conunitti
educate the Becretaries and the active meml>ers of these various a^ssoria:
throughout the whole country, and when this literature had been distribi
among them, sFie sot them to work in their variotis distjicts to educiiting
people. These variouB associations got hold — as ladies will do — ^r^ cic
clergy; then they got hold of the school-teachers and of the legal meai,
in this way they distributed their propaganda of teaching. Nov, i
these associntions were formed, she started a tuberculosis exhibiuoa.
first went through the south of Ireland; then through the northern part;
interested many people, and had distributed a good many documents
would interest the people. The exhibition remained in a to\*Ti from
davH to perhaps a week, and during the time that it was in the town the iM
committees saw that it was fully advertised; they saw that the people
and that the right i>eopIe came; they saw that the working clasecs
and the working clashes came in their thousands; in the six months in veh
the cxiiibitiun vfn& working nearly eight hundred thousand people viated
Of thf«e people, the very great majority were perhaps of the working cl
Ijidy AlionU^^n herself went around to the big towns, and she opened
ex lubi lions in many of the large towns and cities, and through the whole ti
kept fully in touch with all they were doings and all the instructions gi\'en
givf^n under the ad\nce of her central committee. At these exhibitions tltf
were lectures. Medical men lectured in the afternoon and evening, and in
dition to that she had a special corps of trained women, who lectured to t
people as they came in to the exhibition and brought them around the ex
hition and pointed out to them the various things of interest, and tb
educated an enormous number of people.
A respected physician from America, about a week before I left Dubli
mid to me; "I arrived this. morning by the early boat, at six o'clock in
morning, and I drove through your city, and I have never seen in any ci
t^VMAJ open windows. '' Had the respected physician come twelve mom
M6, t think he would have said he had never seen so many closed windoi
^MVtlyii^*^ that 03 an iUustration showing the work which has been do
M||)|tJlMA t>y the women in Ireland. 1 believe that work nil] bear fru
^/l^i^lll^^ \htA n*ork done by these women will bo a great means of edueatij
i%e «vo«d what^ after all, is a preventable disease.
ADDRESS. — PANNwrrz. 797
ADDRESS
By Dr. Gotthold Pannwitz.
Berlin. Qemuuiy.
There is a very close relation between the red cross and the antituber-
culosb double red cross.
The last International Conference at Vienna accepted the proposal that
the double red cross should cooperate with the red cross, and last year, at the
International (Conference of the Red Cross Society in London, they accepted
the same proposition. Therefore we must consider how to bring into the
greatest development this wonderful idea.
In 1864 a great convention was held, in order that intelligent and patri-
otic men and women might help to care for the ill and wounded in time of
war. By and by the question was asked whether intelligent people, instead
of being active in this line only during times of war, should not help in
the daily social war in the street and in the families of poor people.
When in the nineteenth year of the last century the general cam-
paign against tuberculosis b^an, the Red Cross Society in Germany
and in Russia took up this matter, for times of peace. I had the honor
to make the report as German delegate to the Sixth International Red
Cross Conference, and Dr. von Martin, who made, with your President,
the proposal for bids in the Russo-Japanese war, accepted the proposal
that the Red Cross Society must have an activity in times of peace, and
be prepared for the time of war, and especially the women's Societies
of the Red Cross. Since this time they have taken a great part in the cam-
paign against tuberculosis. In Prussia there are 1500 women's societies;
they have them in nearly every town. They are now the center of the anti-
tuberculosis campaign. We have dispensaries for the poor people. They
care for the poor consumptive people in sanatoriimis; and they take care
of the families while the father or mother is a patient in the sanatorium,
and so on.
In the last year, especially, the children's sanatorium department has
done a great deal in the antituberculosis campaign.
You cannot think what enormous factors in the social work these are,
especially the women's associations. I shall make an appeal especially to
you ladies of this section, that it would be of great importance to the future
development of the antituberculods campaign in connection with the Red
Cross, if you would try to combine in the same way these two great humani-
tarian and patriotic ideas.
798
BDCTB INTEIU«ATtONAL CONOIUBBS ON TUBEIUTDLOSIS.
ADDRESS
By Mma Helen Todd.
The Bubjprt. for to-day ia aur^ly an ideal one with which to clnm
congress as this, the whole nf the iire<*iluig sesidons having led in an
anij luteal manner to this di^uussion on the responsibility of the eiti
n Tnrnilier of society, for the prcvfilence of tuberculous ilisQnse, No
nowadays with the elightest pretent^e to education can be ignorant of
fact thjit tul>ercuIou3 diaeaae is preventable^ and that ita cx>nUnuance
disgrace to civiliaod humanity in this twentieth eentury.
Perhaps one of the chief values of sufh an assembly of experts as
lies in the fact that the deliberations, being held more or leas in public
reported in the general press^ are brought forcibly upon the notice of
man in the street, who can^ thereforOp no longer plead ignorance ai
reason for disregarding or evading hia responsibilities in this parti
matter.
No prophet is necessary to teach in wtiat this reeponsibility con
but, alas! those of us who have worked among consumptives, whet
rich or poor, in their own homes or in eanatoriunis, can testify in no iimt^rt
manner as to the grave lack of recognition of p(?raonaI responsihilit}' for
causation of tuberculosis, not only on the part of patients themselves, iM
relations and friends, but also of those more in<lirettly conceme*l, such'
the landlords of stum property and unsanitary tenements, and the purveyi
of a tainted meat and milk; supply.
Legislation on this, or, indeed, on any other subject, will be of no avi
even though i^erfect, theoretically, If it be nmuh above the general level
the habits, education, and morals of the average man; and hyg^eoic lai
however enlightened, will be utterly unable to pruduw the desired e£l
unless the ordinaiy citizen can first be prepared by being taught the
tude of hia responsibility toward the community at large.
In order to realize how enormously important is tliis question of
nition of responsibility, it is net^esaary fij'st to remember that no child
bom into the world a victim of tuberculosis; if it contracts the disea
some one is guilty of evading a responsibility; it may be the mother, wht
ignorant^, poverty, or careleasnesa prevents her from providing pto|
nourisliment for the child, or who ^mply neglects to see it supplieil
air of Bulficient purity, and generally 'M:»rought up" on hygienic lines, B|
even if the mother's intentionb are good, her efforts may be frustrated
f^
ADDRESS. — TODD. 799
the dairy farmer, who, for purposes of g£un, supplies her with infected milk;
or even by some fond relative, who, while suffering from phthisis, fondles
and kisses the poor infant.
If all these perib are escaped, fresh dangers are encountered, as youth
and manhood succeed each other, in the shape of foul and unventilated
workshops, offices, and factories; in disguised tuberculous meat, and in the
infectious dust so frequently foimd in public houses, railway carriages,
chapeb, and churches.
Other dangers there are which will readily occur to you, and which are
too numerous to mention, but which chiefly arise from a want of the sense
of responsibility in three great classes: (a) Those concerned in the produc-
tion and dissemination of meat and milk; (6) those who suffer from tuber-
culous disease; (c) their attendants or those living with them. Let these
three classes once realize their responsibilities toward their fellow-citizens,
and a great step will have been made toward stamping out the disease.
In England, at all events, one of the most hopeful signs of the times lies
in the "pure milk" a^tation in London, and in the steps certsun municipali-
ties are taking to obtain control over the sale of milk and meat.
The responmbility of the patient toward his fellows is almost too obvious
to mention. One has seen, not once, but repeatedly, whole families struck
down by the disease, the one plainly infecting another. This class is, how-
ever, gradually becoming aware of its responsibility, by means of leaflets
and other such educational agencies as sanatoriums, the out-patient depart-
ment of chest hospitals, and local sanitary authorities, but their friends
and relatives have much to learn; the giving away of infected clothing
is still a common practice, and this especially after the death of some
wealthy consumptive, whose furs may prove a veritable death-trap to the
unfortimate recipient. Lod^ng-house keepers, as a class, are sadly averse
to the dlMnfection of their rooms and bedding after the tenancy of a tuber-
culous patient, and, indeed, it is to be greatly feared that such a precaution
will remain, to a large extent, a counsel of perfection until the notification
of tuberculous disease in all its forms is made compulsory.
Public and circulating libraries, at all events, in England, and especially
in English health-resorts, are not an immixed blessing, and those respon-
sible for their management have not, as yet, grasped the elementary fact
that books read and handled promiscuously may be a very real source of
danger as carriers of infection.
Books are notoriously difficult to diranfect without damage, but, in
spite of this well-known fact, it is by no means uncommon to see a phthisical
person reading a work of some value without taking any precaution against
contaminating the volume with the spray caused by coughing. (The same
remarks hold good of the fancy work, knitting, etc., done by consumptive
vntmxMTKmjkL
OSr TtTBBXCUUOSB*
flftd whieh wiH not Kand tbe action of cfiainferlantSr
It k ^«y jiiiBlr. tfcea, the duty d ewrj mpomibfe cHiwo
ovBMnity to arqont l«ii«elf foDy with sucrfa (ietailB ftfl
,<»^hcyAi,iBgDiiiyiwlMH awMMBT OQ the pabBc htalth;
to thm wpaad off iafacCioaB cfinHB be can no loiter ^._.
B7 bvotber't kerper?'* and we may anrely flam up the whole sii
«ane «nch flBafteneHt aa tfais: finmpirtn neogydtaoo and dt»
the part of the cMiaan of faia ifUpcawflaitiBa reg^nfing the ovigtn
of taafaemikKii liaeaae «tQ nfiee, m a very short period of time, to
hatatal
ADDRESS
Ht Mjss K£T% Bahxasd,
the davn of csviintioD every ag? has had its pn3bletn8 of
anddinaae:, sod the gnai qoestion of chrifisatiofi xa how to
these pioihwi- In the jean that aie gone, other geneistioEis have
v^ tfaeb best iieV eflott m a Tarn caideam to rescue m*»fc<»rf
daadottDg and d^M&g tnfioeQeefl ifhich icault from these triple
the human nee, and n to-day are aasembled for the poipoee of eoncenti
the worid's thooght in a naited effort to ehmmateooe of the greatest
niraes — that of dasnem. How shall ve stamp out tohcrcakMidi, that
flBfluy of OMuafcind?
I have feed that over a BBilfiaa people vill this year aiinender their
irictiins of tubemdoas; that oi>e hundted and fifty thooaaiMi of these
die in the Uoited States, and fifteen thoosand b New York city
E\«ry day yields its three thousand, each minute two lives aa n
this plague.
At the root of every disease fies a (suae^ and since tidxRtdoflts ta a
dtaeaae^ the questioa arises: Are there well-defined active eatnea at^
in the United States winch pfodaoe^ or tend to produce.
Having had aome anall ezpetieiue as facton' inspeetor, charity
and investigator in the shims, tenonenta, and worlohops. 1 b&ve
the toQchiakxi that there are proiiDunoed eocial and tfidodtriAl causes
sre every day swelling the ranks of eoDsumptives in the United
One Dccds only to read the "Stop Shutting" signs ia our botefe,
and stfeet-carsy and to know that nearly every city of our land has
ADDRESS. — BARNARD. 801
an ominous ordinance providing a penalty for those who expectorate in
the streets, to realize that lung diseases are to-day making inroads in America;
and where eighty million people are threatened with one general complaint
there must be a well-defined^ common cause. Let us see if we can find this
in the condition of the industries of our country.
Disease-Producinq Industries.
First among these are the dust-producing trades, which cause various
throat and lung diseases. In the cement factories, whose one business it
is to produce dust, the workers are surrounded and work in an atmosphere
made foggy with small particles of quicklime, which makes up the major
part of the commercial product called cement. Add to this the fact that
part of the workers, in order to adjust the machinery, must pass constantly
up and down between immense rolling cylinders heated red-hot by long
sheets of flame, and you have a faint idea of a cement-worker's life.
In Missouri I learned that before the factory inspector was appointed
in that State thirty men had fallen dead from overheating, as they kept
up their ten hours' constant pace through this heated atmosphere and dust.
The factory inspector ordered the men worked in two-hour shifts, thus
enabling each worker to reduce his temperature and fill his lungs with
whatever fresh air was available before returning to his death-dealing work.
When I approached this cement factory in company with the Missouri State
Factory Inspector, we could mark the building half a mile away by the
clouds of dust that arose around it, almost obscuring the building from
sight. I think the cement factories of America might well be called '' homes
for tuberculosis."
In the fertilizing plants the terrible, sickening, thick dust which the
laborer must breathe all day is equally bad. I have never forgotten my
experience in one of these mills. I am told that lye factories are even worse
than this.
In the glass factories children work in the same intense heat as their
fathers do in the cement works, but with this difference: that while the
father is breathing quick-lime dust, his child is breathing pulverized glass;
the one eats out the tissues of the lungs, and the other irritates them until
both are in a receptive condition for any germ disease. In both instances the
intense heat enervates the man, reduces his vitality, and weakens the fine
lung tissues, thus helping the destruction which would otherwise come from
the breathing of cement and glass dust.
In the mines, while the fathers are being crushed, crippled, and killed,
the children are working in the coal-breakers above. There is hardly an
emplo3nnent more demoraUzing or physically injurious than the work in
the breakers. For ten or eleven hours a day these children of ten and
VOL. in — 29
802
SIXTH INTERNAnONAIi CONGRESS OK TUBERCULOfild.
eleven years of age etoop over the chute and pick out the s!ate and
impuritiea from the coal as it moves pajst them. The air is so black
coal dust that they wear lamps on their caps at noon-day in order to
the coal which is moving under their foct. The roar of the crushers
screens and of the rushing mill-race of coal is deafening. Many cont
minar's asthma and consumption- Breatliing continually day after
the clouds of coal dust, their lungs become black and choked with i
particlea of anthracite. There are about forty-two thousand children
employed in mines and quarries, thus contributing a con^itant active (
for the production of tuberculosis. I have read somewhere that a pei
having consumption can expectorate in a day seven billions of gennaj
tuberculosis bacilli; that the sputum from the diseased lungs dries in
pulverised dust which is blown through the streets, tenements, facto:
etc. If tills be tniej what lurlong death lies in the wake of the street-swofl
and the charwoman I In (act, what danger there must be for all of us
must breathe the common atmosphere which these diseaaed lungs brea'
Thiiik of the consumptive bakers who ai-e to-^lay baldng your bread,
the tailors and dre^ssmakers who are breathing their tainted breiith upon
fabrics which you are to wear. The disease is being spread even by
child workers who spin, weave, and help to dye the cloth- In the rol
milisj around the glass furnaces, the heat is so intense it bums out the
tissues of the lungs. I had to sign my own death warrant before I
permitted to enter one of these places* Think of the bone dust the 1
button polishers must breathe I
Then there are the diseases which result from handling and oorain^
contact with poisonous materials used in the chemical industries — poiso:
from lead, acids, and gases. Lead poisoning among printers and pain
is a common thing. Each linotype worker sits by a pot of molten me
composed of tm, lead, and antimony. A gas-burner under this pot combi
Tvith the metal in sending off poisonous fumes ami gases which the opei
must constantly inhale. Thus it is that the Typographical Union of Ami
finds it necessary to maintain a giant hospital for tuberculosis patient)
the ozone air of Colorado.
Fathers and children in the industries here dcsciibed have no altema
but to work, or starve and die. Your tUscoveries are of no value to tl
until they have shorter hours, better pay^ and more sanitary conditu
They cannot avail themselves of your splendid prescriptions or yo
advice.
In compapy with a factory inspector I vim tod a feather-renov
establishment one hot August day^ and saw a score of young girls worl
in the most stifling heat. Here old feathers are renovated. The
putrid with decaying animal matter from the feather ends, yet all the
ADDRESS. — BARNARD. 803
dows must be closed lest a current of six smother the workers in heaps of
feathery down. The same afternoon I visited a drug company, and found
the floor-walker pacing up and down gazing impertinently into the faces of
the girl workers. I indignantly inquired why. He answered, "These girls
are bottling arsenic. When their lips turn white, I take them out for air."
Thus are young American girls being slowly martyred for the demands of
trade. In a bagging factory in the same city I saw about two hundred girls
sewing bags on electric machines. The burlap material is made of coarse,
heavy jute. As the girls were doing piece-work, they worked like mad to
make a living wage. One could hardly hear for the din the machines were
making. Experts can make something like a sack a minute. As the
material passes under the machine, a coarse, stringy, hairy lint arises. The
sax was hot and stifling and so laden with lint as to appear like a fog. When-
ever a girl's foot touched on the electric pedal, the machine reached out
like a Uve thing to catch and gnaw her Angers. There is great stress and
hurry in this kind of work, which exhausts the vitality of the worker no
less than the wiry, stringy, lint irritates the lung tissues. It is another
"home of tuberculosis."
America can never maintain strong robust womanhood in places like
this. Factory life may spell race degeneracy.
I have seen children in the cotton mills, silenced by the deafening roar
of the machinery and stifled by the hot steam and Unt-laden air — ^long rows
of little, old, thin-chested, stoop-shouldered, sallow-cheeked, Icadened-eyed,
pipe-stem flgures, hurrying back and forth before the flying shuttles, tying
threads — tying, tying threads, — ^and the broken threads are t3rpical of the
broken life of the baby whose fingers tie them, and of the destroyed and
calloused conscience of the nation which will thus exterminate its kind.
A nation which destroys its young has turned its face to the oblivion which
it richly deserves, and the " white plague " is not too great a curse for those
who would coin wealth out of the life of a little child.
How THE Disease Spreads.
1. Among the Workers, — One day I visited a sweat-shop'on Biddle Street
in St. Louis. A hollow-cheeked, sallow-faced, stoop-shouldered, consump-
tive mother was making overalls for thirty cents a dozen! While she toiled
nervously and desperately, her two wee children played midst the garbage
cans and dirty water in the filthy gutter of a street on which faced her
barren shack called "home." The furniture consisted of a battered stove,
a few tin dishes, pine boxes for table and furniture, a rickety sewing-machine,
and an old bed covered with tattered, soiled bedding, stacks of overalls —
and a consumptive baby. It was crying and feverish, and the mother
groaned a pitiful dirge to the accompaniment of her ^yiag fingers. These
804
SIXTH INTERNATIONAL COKGBES9 ON TUBERCTJXOSIS.
overalls were Ehipped (^ various poLnts in the Umted States and sold lo
American laborers* The laborer carries Ma bargain home and shakes out
the consumptive germs to inoculate his family.
2, The Disease Reaches the Rich. — ^Thia laborer is a baker* He works
long hours imloors, which reduces his vitality. His wage is small, cooad-
quently he eats inferior food and lives in a badly drained part of the dty,
The dread plague attacks him, but poverty compels him to continue at work,
80 he coughs and spits over the bread he makes. A rich man buys the bread
and the disease spreads. So it is with the cigar-maker; he buys his overalb;
gets the disease and continues to roll your cigars. Your cook or your nurse
may bring the germs from the consumptive husband at home.
Death in the Bargain Counter.
The bargain counter is the curse of the present civilization. Upon its
surface lies the beautiful, flimsy^ lacy bargain. Behind it lies the sweats
shop and the disease germ. The American Federation of Labor has a label
which manufacturers who are "fair" may use. If the goods you buy
carry tliis label, it shows that long hours and unsanitary conditions did not
prevail where this garment was made. There should be an international
label and an International Industrial Honor Club, or something of that
kind, which would foster a broader conception of the public good. Id a
complicutetl ctvilization like tliis of to-day, the good of one is the good of
all, and each must work for the general good or all must perish*
A rich woman advertised for a wel^uurse. A robust young woman
answered the call and was employed. Later the child developed tubercu-
losis. Investigation proved that the disease emanated from the nurse's
family, although she herself appeared free from it. .Ajnong the workers
in a packing town, where the work is dirty and confining, where hours are
long and wages poor, food insufficient and homes unsanitary, you would
be astonisheil to see liow many of the men who put up your meats are infected
with tubercular disease. Go down to the hovels and tenements and see for
yourself.
A Living Wage.
John Mitchell says that anytliing under six hundred dollars a year wiD
not permit a laboring man to maintain himself and family in physical
efficiency with the present high price of food, rents, etc. Because a large
percentage of the workers do not receive a li\'ing wage, or are unemployed
for part of the year, there are estimated to be at least ten millioa persons
in the United States who are underfed, underclothed, and badly housed.
I wish the memlx^rs of this convention would take the trouble to look up
the national statistics and find just how many workers are receiving less
*
ADDRESS. — BARNARD. 805
than six dollars per week. This is not sufficient to maintain a family,
consequently the women and the children must neglect the home to earn
the mill pittance. Is it any wonder when these workers return to their
filthy tenements or disease-infected hovel homes that their tired lungs
easily take on the diseased condition found therein? Three hundred and
sixty thousand dark rooms in Greater New York alone! Poor, tired mor-
tals, deprived of light and air, of quiet and rest, and everything else that
life finds dearl It would be well for this country to know to what extent
overcrowding and badly ventilated rooms are responsible for broken vitality,
debility, and exhaustion; what amount of work is lost, and what amount
of poverty is responsible for the spread of tuberculosis.
Unrestricted International Competition.
The conditions of industry which I have descriljed above are unsound
and abnormal. The first great cause, in my opinion, is unrestricted inter-
national competitioR. By this I mean that desperate struggle between
nations to control the markets of the world — a struggle which has caused
unscrupulous manufacturers of the different nations to reduce wages below
the bread-line, thus reducing workers to the very verge of pauperism,
starvation, and physical decay. At present the manufacturer who works
his men for the longest hours and the least pay undersells his competitor,
and thus controls the market. And manufacturers all over the world have
been persistently lowering wages or lengthening hours in order to gain ad-
vantage over competitors. In their extremity they have employed women
as being cheaper than men, and now many of them have resorted to the last
bitter extreme of employing the children at ten and fourteen cents per day
— sweating out their very life's blood for this pittance in order that they
may still be " king of the market and ruler of the financial world." Franklin
H. Wentworth says of Fall River, Mass.: "Stricken Fall River cannot
compete with the child labor of the south without using skilled operatives
and grinding their lives out." It may be inhuman, unchristian, and anti-
social to starve men and sweat them, and exhaust the vitality of childhood;
but it is the law of trade, and the law of trade in the twentieth century is
the law of tooth and nail. The fact that governments have adopted no
minimum wage scale and no maximum hours enables this inhuman com-
petition to go on, getting worse and worse year by year, but absolutely
unrestricted. If a man is starving, there is no law in the land to prevent
an employer from working him for ten cents per day.
Parasite Industries.
As a result of unrestricted competition certain industries have become
social parasites, and Uve and thrive on the very life-blood, and at the peril
806
SIXTH INTERN ATIONAI^ CQN0R1:BB ON TITBERCULOSI8.
of the health of their workmea, pajHng a wage so small that the worke
lire unable to m.aintuin their physical efficiency — a wage that \\tI1 notaffa
them plain food, piain dotliing^ and sanitary homes. ThuB large maaa
of workers are compelled to live in miserable, dilapidated hoxises, where t
water-supply is impure, where there is an utter lack of enforcement
health laws concerning the disjx^sal of refuse and decaying matter. 1\m
are compelled to cat unwholesome and insufficient food, thua bringing aboi
physical degeneracy and race decay. These parasite uidustries are livii
on the vitala of the laboring pet^pie, undermining the health of the con
munity, and are unworthy to exist in a civilized world. Any industa
wlu'ch pays a wiige so low aa to impair the physical eflS^cienoy of the worki
creates a pt>verty problem for the community to solve. If a man mui
work in order to live, he must have euffieient foodj clothing, and shelter, di
it will impair his ability to work. Any industry which pays a wage lei
than will provide these things is a social parasite, and should be dealt wil
as such, Thase industries which employ little children just long enou|
t^ sweat out their vituHty for a few cen<fl a day^ leaving them diminutii
little wrecks to drift aimlessly and listlessly thi'ough a long, de|^nden
pauper life, should also be classed as social parasites. Who can teU ho
niuch of the tuberculoais scourge is due to the working of children, and tl
lack of proper nourishment and proper sanitary environment which
low wage compels?
iwy
International Inddsthial Commission.
As these matters are national, or rather international, in scope, nothli
win affect them but widespread industrial and social legislation. I ahou
like to ace an international commission appointed for the adjusting
hours and wages between nations, with a view to securing phyacal efficiem
for the workers — =a commission which would force u]X)n the governmen
of their various countries a recognition of the neces^ty of an intemationj
agreement for a minimum wiige scale, maximum hours for work, and
minimum standard of sanitation and housing conditions. This commissio
should adopt an international label, which would be granted for use to su
factories only as produced their goods and wares under these prescriba
conditions. The press, society, and the business world should then taba
and boycott socially and financially all those traitors to human good wh
refused to hve up to these ideas, \yithout an international agreeme:
of this kind, those manufacturers who are humane in their dealings Vfi
emploj^ees thereby produce their goods at a greater cost than their unworth
competitors, and are handicapped because of the very humane prineipl
which should recommend them to all buyers. They are forced to a
their warea^ made under fair wage, fair hours, and s^anitary conditional i
ADDRESS. — BARNARD. 807
competition with the sweat-shop products of the world. Thus does civil-
ization, intentionally or otherwise, favor the parasite industry. I should
like to see an American wage commission, which would not be influenced
by money nor intimidated by wealth, make a thorough and impartial
inspection of the industries of our country, with a view of ascertaining the
true conditions under which the great masses of our laborers are obtaining,
not a livelihood, but a mere existence, to-day. If they find men working
in steel mills and foundries, in charcoal, coke and lime biuners, and in other
industries under such intense heat that bread-winners are falling at the
rate of thousands a year, creating a terrible mortality and swelling the
poverty problem for the United States; if they find that breathing this
intense heat breaks down the tissues of the lungs and produces an irritation
which, fostered by the dust-laden atmosphere, causes tuberculosis and phys-
ical decay, let them declare four or six hours to be the legal work-day under
such conditions, instead of eight, ten, and often twelve. If they And the
dust of the coal-breakers, the lint of the cotton mill, the pulverized glass
and the heat of the glass factories, ruining the lung tissues of the workers,
let them liberate the two million children who are wage-slaves in our coun-
try to-day, and secure a decent wage and work-day for the father, so that
the child may quit the factory and yet have bread. Eighty-two thousand
children are breathing the Unt of cotton mills as I speak. Eight hundred
and three are working with acids and breathing the fumes of the bleachery
and dye-works. Five thousand three hundred and sixty-five are breathing
pulverized glass. Eleven thousand four hundred and sixty-two are steep-
ing their systems in the nicotin of tobacco factories, and forty-two thousand
are breathing the dry dust of the coal-breakers. In the laundries little
^Is are standing all day sorting filthy linen or feeding flat pieces into a
hot mangle where the heat is so intense that they must work almost without
clothes. Many times these children are worked far into the night, and must
return to their homes through the dark and deserted streets of the cities,
uncared for and improtected. I knew one little girl who was discharged
because she would not work after twelve o'clock at night on Satxurday night,
although she had begun work at 7 a. m. that day. The air is filled with
steam, and the girls going home in the wintry night get rheumatism and
pneumonia from the dampness of their clothes. Let this commission adopt
an international label, furnished by the Governments of the world, to those
manufacturers only who maintain sanitary conditions, decent hours, and
a living wage — all goods without this label to be boycotted by the enlight-
ened patriotic citizens of the world. The white plague is only one symptom
of the national troubles which are being brought about by those industries
which are to-day violating all the fundamental principles of human rights.
The effort of this convention should, in my opinion, be directed toward
808
SIXTH mTERNATIONAL CONGRESS ON TXJBERCUtOStS.
such legislation as will remove the soci^ and industrial conditions whicl
Act OS a cause for tuberculosis, instead of treating isolated cases of the dis-
ease, which 18 plainly the effect,
OldahomEL has set you the pace in this by passing at its first l^^aturfi
thirteen labor laws calculated to better wage and sanit-ary conditions and
compel such hours of work that all may be assured sufficient time to sleep
and rest. Some of these laws have been t^rnied drastic by the friends of
great corporations and the parasite industries; but manifestly it will appeali
to the fairness of the world that a man should not be compelled to enter
the tire-tkox of an engine wMle it is under a steam pressure of more than
eighty-five pounds. It will shock no one but a friend of the "interests"
that a bill has been passed preventing a train-crew from being ordered
on duty after a long run until the men have been allowed eight hours to
rest and sleep. Ml of these labor bills are calculated to protect the health
and life and the earning jK>wer of employees, and we hope in this way to
build stronger and more robust constitutions, thus malriTig our work^s
leea receptive to the ravages of the tuberculosis scourge*
I have said very little of slums and tenements because I realize that if
the working-man's wages are right and employment regular, he will no
more choose a slum or tenement for a home than you or L He Lives there
Itecause lus earnings will not pernut him to live elsewhere, Wheo the for-
eigners who are present return home, they should discourage immigratioa
lu this country until the United States takes such action as will insure
workers sanitary homes. I should like to see every industry eliminated
fironi within the borders of the United States which sweats mea's vi
out and reduces them to physical degeneracy by long hours and so I
\\7ige that the workers cannot secure sufficient food to sustain physical
efficiency or enable them to rent sanitary homes. I should like to see every
man tried for treason who would coin money out of the life of a little child.
I should like to see society quarantine itself against the man who owns
double-deck tenement or parasite industry, just as it quarantines
against the terrible white plague wbuch these pest-houses produce,
was made for men — the world was made for men, first — for industry
ward.
ADDRESS
Bv De* Egbert Koch,
Beriiu«
U is now twenty-five years since the discovery of the bacillus of ti
oulo^ and the consequent proof that tuberculosb is a contagious
ADDRESS. — KOCH. 809
It took many years to enforce this belief in the specific bacillus of tubercu-
losis upon the scientific world. But persistent work forced the acceptance
of this bacillus as the cause of tuberculosis. Many more years have been
necessary to establish this with the general public. It is now universally
admitted that tuberculosis is infectious.
The discovery of the bacillusi however, was only an initial step of a
..^usade ag£unst tuberculosis. It has been followed by many years of
scientific investigation in all the subjects closely connected with tubercu-
losis and the secondary subjects of investigation resulting from this line of
scientific work : for instance, the great problem of animal tuberculosis.
The announced and demonstrated statistics of mortality at this Congress
show striking variations. It is seen that the mortality from tuberculosis
in England is slowly diminishing; the same b true for Scotland, but in Ire-
land it is slowly increasing. Not only is this variation manifest in different
coimtries, but even in different cities of the same country. It is seen that
in Boston the mortality is diminishing, while in Minnesota an assembled
general mortality of the cities shows persistence at the same level. Why
such difference of mortality exists in different localities b a question which
it is very important to determine. Many ^milar problems require thorough
and exhaustive investigation. With time and effort, all of the factors
which influence the communicability and progress of tuberculosis are to
be fixed, and then united world action must be taken that shall be effective
in blotting out this plague.
Such investigations are enormously expensive. They are too costly
for the laboratories of universities, health departments, or Government
institutions. The German government has, during recent years, contrib-
uted annual sums for accomplbhing such work in laboratories in Germany,
but these sums may be exhausted and may cease at any time.
I wish to devote myself for some years to come to further inves-
tigations of these problems of tuberculo^. Thb year the activity
of the Preddent of the International Antitubcrculosb Alliance has en-
listed the cooperation of all grades of society in Berlin, and has created a
foundation in commemoration of the twenty-fifth anniversary of the dis-
covery of the tubercle bacillus, and thb foundation has been named the
Koch-Stiftung. The fundamental rules and purposes of thb institution
have been publbhed and a copy of them b deposited with your Pre^dent
to be publbhed in your Proceedings. For the work of thb institute not
alone b the assistance of all Germany invited, but that of all countries of
Europe and America, and all such aid will be most cordially accepted.
An American citizen, Mr. Carnegie, contributed a sum of about two hundred
and fifty thousand dollars, the income of which will help such investigations
very greatly. But such sums would permit thb institute a merely passive
810 SIXTH INTERNATIONAL CONGRESS ON TUBERCUIiOSXS.
rdle. The institute should have an active r61e, and really influence the
antituberculosis crusade.
At least two million dollars are requisite for the institute to properly
undertake its great work and worthily carry out the wide range of investi-
gation that these numerous problems in tuberculosis so imperatively demand.
Such an institution should also be a central depository and clearing house
of all the scientific work of the world in this subject of tuberculosis.
SATZUNG DER ROBERT KOCH-STIFTUNG ZUR BEKAMPFUNG
DER TUBERKULOSE.
I.
Am 24. Marz 1907 waren 25 Jahre verflossen, seitdem Robert Koch die
Entdeckung des Tuberkelbazillus bekannt gegeben hat. Der Gedenktag
dieser fur die Erforschung der Infektionskrankheiten, insbesondere aber
fiir das Verstiindnis und die Bekampfung der Tuberkulose iiberaus bedeut-
ungsvollen Veroffentlichimg bietet dem Unterzeichneten den willkommenen
Anlass zur Errichtung einer Stiftung, welche den Namen "Robert Kocb-
Stiftung zur Bekampfung der Tuberkulose " fiihren soil.
§2.
Zweck der Stiftung ist, wissenschaftliche Forschungen zur Bekampfung
der Tuberkulose zu unterstutzen.
§3.
Die Stiftung hat ihren Sitz in Berlin. Das Geschaftsjahr lauft vom
1. April bis 31. Marz.
§4.
Der Vorstand der Stiftung besteht aus 11 Mitgliedera:
1. dem Wirklichen Geheimen Rat Professor Dr. Robert Koch;
dieser hat das Recht, sich einen Nachfolger zu bestellen, den Nach-
folgcrn steht die gleiche Befugnis zu;
2. cinem Mitgliede, welches Seine MajestSt der Kaiser und Konig
emennt;
3. dem Prasidenten des Kaiserlichen Gesundheitsamts;
f 4. dem Direktor des Instituts fiir Infektionskrankheiten;
i 5. einem Vertrcter des Deutschen Zentralkomitees zur Bekfimpfung
i der Tuberkulose;
] 6. einem Vertretcr des Reichsausschusses fiir das &rztliche Fort-
bildungswesen ;
7. einem Vertrcter des Deutschen Arzte-Vereinsbundes;
8.-11. aus vier vom Vorstande gewahlten Mitgliedem.
Wenn eine der unter 1-7 bezeichneten Stellen nicht besetzt wird, so
erfolgt die Erganzung im Wege der Zuwahl.
§ 5.
Zu Ehrenmitgliedem kdnnen durch einstimmigen Beschluss des Vor-
ADDRESS. — KOCH. 81 1
standee solche Persdnlichkeiten emannt werden, welche sich um die Zwecke
der Stiftung besonders verdient gemacht haben.
Die Ehrenmitglieder sind berechtigt, an den Sitzungen des Vorstandes
mit vollem Stinunrecbt teilzunehmen.
§ 6.
Der Vorsdtzende, der Schriftfiihrer und der Schatzmeister, sowie deren
Stellvertreter werden vom Vorstande aus seinen Mitgliedem gewahlt. Der
Vorstand ist beschluasfahig, wenn mindestena 5 der unter § 4 Ziffer 1-11
bezeichneten Mitglieder anwesend sind. Er entscheidet mit einfacher
Stimmeomebrheit. Bei Stimmengleicbbeit ^bt der Vorsitzende den Aus-
scblag. XJber jede Sitzung wird ein Protokoll aufgenommen. Dieses wird
vom Yoratzenden imd dem Scbriftfiibrer imterzeichmet.
§ 7.
Der Vorstand wird j&brlicb mindestens einmal von dem Vorsitzenden
unter scbriftlicber Mitteilung der Tagesordnung zusammenberufen. Ihm
liegt insbesondere die Beschlussfassung ilber die zu bewilligenden Unter-
stiitzungen ob. Hierbei ^d Robert Koch alljahrlich vorweg diejenigen
Mittel zur Verfugung zu stellen, welche nach seinem freien Ermessen fiir
die von ihm angeregten oder geleiteten Arbeiten in Anspruch genommen
werden soUen.
§8.
Das Grundvermdgen der Stiftung besteht:
1. aus dem Stiftungskapital von M 211,000;
2. aus Zuwendungen, welche der Stiftung gemacht werden, sofem
nicht dabei eine andere Verwendung bestimmt ist;
3. aus 10% der jahrlich aufkommenden Zinsen, welche solange zum
Kapital geschlagen werden, bis dieses die Summe von 2 Millionen
Mark erreicht. Dem Vorstand steht es frei, auch iiber den Betrag
von 10% hinaus Zinsen, die nicht zur Verwendung gelangt sind,
dem Kapital zuzuschlagen.
§ 9.
Das Grundvermdgen ist miindelsicher anzulegen.
§ 10.
Zur Verwendung fur die Zwecke der Stiftung sind bestimmt:
1. Die Zinsen des Stiftungsvermogens, soweit sie nicht nach § 8 dem
Kapital zuwachsen;
2. Zuwendungen, welche mit dieser Bestimmung der Stiftung ge-
macht werden.
Der Vorstand ist befugt, sobald das Grundvermogen der Stiftung die
Summe von 1 Million Mark iibersteigt, aus besonders gewichtigen Griinden
durch einstimmigen Beschluss innerhalb des iiber diese Summe hinaus-
gehenden Betrages fiir die Zwecke der Stiftung auch das Kapital anaugreifen.
§ 11.
Der Vorsitzende ist verpflichtet, eine Sitzung des Vorstandes anzu-
beraumen, sofem der Antrag hierzu von drei Mitgliedem unter Angabe des
Gegenstandes der Verhandlung schriftlich gestellt wird.
812
SIXTH INTERNATIONAL CONGEESft ON
I 12.
Die Fubrung der laufendcn Geschifte liegt deni
§ 13.
Die Priifung dcr Jahresrechnung hat durch zm
die vom ^^orstande bestcllt werden.
§ 14,
Wer der Stiftung eine Zuwendung voa mind
hatf wird ah Donator ini Goldeneu Buch dauemd
solrhe Zuweniliing iinter dem Namen dea Spend©
in dera Atat der Stiftung gekeonzeichnet,
5 15.
Antrdge auf AndoTung der Sntzungcn miissen
vor der Sitzung den Mitgliederu des Vorstandes
Besehlussfaasung ist t^iiie Mehrheit Vi>n j der air
glieder (5 4 und 5) orforderlich; aussenlein beilarf eg
es sich uin den Zvveuk der Stiftung oder ihro Auf
nehmigung Seiner Majestat dea Kidaers und Kon
Aufaichtsbehorde.
Berlin, den 3. April 1908.
Althoffj Wirklicher Gehelmer Rat M. Meyer, Rfl
L. Berl, Baakier Dr. Nietiier,
Dr. Brieger^ Professor, Geh. Med.-Rat tar dea Dei
Brugger, Geh. Reg.-Rat zur Bekam
Dr. Biimra, President dea Kaiser- Dr. PfuhJ, i
lichen Gesundheitsamtes arzt
Dr. Forster, Miniaterialdirektor Herzog von I
Dr, B. Frankel, Profeasori Geh. Med .- Dr. Schjemfi
Rat stabsarzt c
Dr. Freund^ Vorsitzender der Landes- Sanitatskoj
versieherungsanstalt Berlin Dr. Schmidt
Dr. Gaffky, Professor, Geh. Ober- Marine
Med .-Rat Dr. K Schrai
Graf von Hntten-Ezapski Reg-Rat
Dr. Kirchner, Professor, Geh. Ober- Dr. J< Schwal!
Med. -Rat Fretherr von S
Dr, KrauB, Professor, Geh. Med .-Rat Tilmamij Geh
IL
Auf den Bericht vom 16. Mai d. Js, will Ich
'* Robert Koch-Stiftung zur Bekampfung der T
begriindeten Stiftung auf Gnind der anliegendeQ
1908 hierdurch Meine landesherrliche Genehmigung
Prokelwitz, den 23. Mai 1908.
(gez.) Wilhehn R.
(gges.) Beseler. v. Moltke.
An den Justizminister, den Minister des Innen
geistlichen pp. Angelegenheiten.
ADDRESS. — BROWN. 813
ADDRESS
Bt Mr. Eluer E. Brown,
ConuniaaioDer of Education. Wasbingtocu
This is just at the close of a veiy entertaining session, and I shall not
defer that close; for niany of us have engagements that are calling us away,
and I shall not take more than three or four minutes of your time at the most.
Just now, in the Bureau of Education, we are facing the problem of tuber-
culoms, practically as a problem of the saving of the race of natives in Alaska.
The reports that have this year come in to us show that from 5 to 10 per cent,
of the natives in some of the villages are affected with pulmonary tubercu-
losis, and many others are affected by tuberculosis in other forms. We are
accordingly undertaking to recast our educational work, in the belief that the
important demand of education is so to educate those people as to save their
very lives; to have sanitary inspectors at work teaching them how to keep
their little huts clean, and how to protect themselves against disease, and then
to teach the people themselves how to cooperate with these sanitary inspec-
tors. That, in a word, is the program; but as we have studied this problem,
it has occurred to us that the lesson we are learning is not solely for the
savage races, but might be applied to other parts of the world. It has often
happened in the history of the world that we have learned from the defective
or the diseased, or that the backward have helped to teach those who are
normally constituted, and I think we are little by little learning this lesson;
that some sort of a recasting of the ordinary education of ordinary people is
necessary to the saving of human lives, and that change, that modification
of our educational plans, seems to amount in general terms to this. This
cooperation means cooperation between health authorities, who are intelligent,
and the masses of the people, who do not know these things. We know how
to work with the health authorities.
I leave this right here. This is the problem as it is shaping itself up,
and I believe it is a good suggestion for the whole range of our educational
work.
814
ADDREBB. — DETIWE.
CLOSING REMARKS OF THE PRESIDENT,
By Mfi, Edward T, Devik£.
It is now time for me to biing the deliberations of this Section to a c
and I do so with more regret than 1 ever have thought possible. The
atldress has been ma<ie; the last appeal has been made to the understand
the sympathies^ and the imagination of those attending. The matter is
in your Imnds.
1 cannot help reechoing at the close of this meeting the inquiry w
one of the speakers made in a paper he presented to you, asking you to i
this away with you, as the burden of the Congre^ss on your hearts and mi]
The inquiry made by Dr. Pryor, as to whether the poor consumptive ii
receive any benefit from our discussions here^ is what 1 am referring
Tliat is the question which has come to ua. Are the poor, are those wha
not have control of the means of cure entirely at their disposal, are the |
consumptives to get any benefit from our deUijerations? I believe
they are,
I feel under very great obligation to those who have done the wo
preparing the papers; to those who have come in from the other sectJi
technical sections, where they are perhaps more directly interested,
tins Section to discuas with us these problems.
I appreciate the great honor which fell to me in arranging the prog
of this section. I appreciate the forbearance with which si^eakers have
mitteJ themselves to be calle<l to order, and their apparent lack of
nient, though I have known sometimes that it must have been ^onietl
of a tiial to them. 1 have been as lenient as has been possible. I thank
I hope that you will continue your interest in this subject, and that i^
of the coramunitiea represented in this Congress, whether in Americt
other aationSj the poor consumptive will be benefited by our deliberatj
Index to Volume III.
Addams, Miss Jane, and Hamilton, Dr.
A.— The "Piece-Work" System as
a Factor in the Tuberculosis of
Wage-Workere 139
Address. — Miss Kate Barnard 800
Address. — Mr. Elmer E. Brown 813
Address. — Rev. Samuel McChord
Crothere 791
Address. — Dr. Robert Koch 808
Address. — Dr. Gotthold Pannwitz. . 797
Address. — Mr. Jacob A. Riis 789
Address.— Dr. T. J. Stafford 795
Address.— Miss Helen Todd 798
Advanced and Incurable Cases of
Consumption, The Hospital Care
of the.— Miss S. H. Cabaniss, 543
*Akademischen Schulen der Vereinig-
ten Staaten und der Feldzug gegen
die Tuberkulose, Die.— Prof. W.
H. Norton 613
American, Miss Sadie — Some Uses of
the Imagination in the Prevention
of Tuberculosis 731
Anders, Dr. H. S.— The Body or the
Bacillus — which shall be empha-
sized in the Hygienic Education of
the Public? 614
♦Angieterre et Gallee — Notes sur la
mortality de la phtisie tuberculeuse;
— sur la perte de vie resultant de
cette maladle dans les differentes
occupations. — Dr. J. Tatham . .218, 221
Anvers — La Lutte Antituberculeuse
sur un nouveau plan — par I'ceuvre
des dispensaires antituberculeux
anversois.—Dr. L, V. Bogaert 291
Arloing, Prof. S., and Courmont, J. —
Le Dispensaire Antituberculeux de
Lyon 300; 307, 309
Associations de la propri^t^ batie en
France — Note sur le r6le des — au
sujet de la tuberculose, et particu-
lidrement de la Chambre Syndicale
de Paris.— M. A. Marc 713
Attitude of the Modem District Nurse
toward Tuberculosis, The. — Miss
F. R. Smithwick 670
Awakening of a State: an educational
campaign against tuberculosis;
The. — Mr. John A. Kingsbury 93
♦Azul; La Estrella. — Dyar, Miss Clara
E 680
Bacillifftres-pseudo — bien portants;
cachectiques et mis^rieux; Deux
aspects n^ig6s de la lutte contre
la tuberculose. — Dr. Hericourt .... 783
Barnard, Miss Kate. — Address 800
Barr, Dr. M. W.— The Relation be-
tween Tuberculosis and Mental
Defect 88, 91, 92
* Behandlung der pr^tuberkulosen
Falle durdi besonclcre Institution-
sen, Die.— Dr. A. J. Richer 723
Bequest for the benefit of Consump-
tives; The best use of a large. —
Mr. Wm. F. Slocum 341
Berger, Mme. B6rot. — Preservation
antituberculeuse chez les jeunes
fillcs dans les centres manufac-
turiers *. 253, 255
BisseU, Miss E. P 133
Bloede, Mr. Victor G. — Comprehen-
sive Plan for the Treatment of the
Tuberculosis Problem 398, 405, 406
Blue Star: a simple and practical way
to interest people in tuberculosis
and to raise funds to combat
the disease, The. — ^Miss C. E.
Dyar 676, 680, 681
Body or the Bacillus: which shall be
emphasized in the hygienic educa-
tion of the public, Tne. — Dr. H.
S. Anders 618
Bogaert, Dr. L. V. — La Lutte anti-
tuberculeuse sur un nouveau plan
k Anvers par ToeuvTe des dispen-
saires antituberculeux anversois . . . 291
Bonney, Dr. S. G.— The Relative
Value of Climate in the Campaign
against Tuberculosis 296
Boyd, Miss L. C, and Fewsmith, Miss
S. — The Nurse and the Tlibercu-
lous Patient 520
♦ Abstract.
815
IS1>ZX. ^H
^^^^^^^^^^^^^K^^U
fAoa
1
^^^^^^^^^^H^^l Brewer, Hon. David J.— The Legjti-
Courmont, uJ
^^^^^^^^^^^^^^^^^H mMe Exercise of the Power
g. Le didfl
^^^^^^^^^^^^^^^^^H the Prolection
23&
dt hyQal3
^^^^^^^^^^^^^^^^^^^^^^H Brown, Mr. Elmer E. — Aildrosg
813
ConrrooiM^H
treliU^^I
217
*Co&t« ^^H
^^^^^^^^^^^■^^H *Bilrdeii der Tuberkulose. Die Indi-
Urns, ^^^1
^^^^^^^^^^^^^^^^^H uml Families Suferiegten. —
Crafer, i^^H
^^^^^^^^^^^^^^^^^H Kingjsl^y.
M
peeCad^^l
^^^^^^^^^^^^^^^^^^^H Burdens entailed by Tuberculo&ui on
Cnme *^^^|
^^^^^^^^^^^^^^^^^^^H IcidividualB aod FiunilieSr Th^.^
Helati^^^H
^^^^^^^^^^^^^^^^^H Mr. S. Kinney
47
B. ItK^|H
^^^^^^^^^^^^^^^^^^^H Burg«i8. Mrs. R. — Saoatqrimn
•Criniinel iW
^^^^^^^^^^^^^^^^^H Atmofipherc
^^^^^^^^^^^^^^^^^H Butler, Misa
518
Tuberculoa
5^
aom
Crothere, Rev,
^^^^^^^^^^^^^^^^^1 Cnhanias. Kiss S. H. The Hoepitftl
•Cturndft con
^^^^^^^^^^^^^^^^^^^H Oflkie of Ad\niicctl and Incurable
Confercncia
^^^^^^^^^^^^^^^^^^HH CtoCB of Coti!«umptmn.
^^^^^^^^^^^^^K^U Cannon, Mis» Ida M.~The Tubcrculo-
543
S. A. Knop
•Cuerpo 6 el
^^^^^^^^^^^■■B OB Work the Social Service Dc-
DeberiS Coi
^^^^^^^^^^^^^^^^I^H patnneat the HasBacbu£ctt3
^^^^^^^^^^^^^^■■B Central Hospital at Boston
fasis en la ]
531
Pueblo?—!]
^^^^^^^^^^^^^^^^P^|H Care of Patients after Diseham from
^^^^^^^^^^^^^^■Hl SanatoHunist, The, — Farm Colonies
^^^^^^^^^^^^^■|HI and Industrial Settlements, The
Day Camp, T%
^^^^^^^^^^^^■■1 QuQirtlons of.— Mr^. E. W. Newcomb 3ST
Dental Condi!
^^^^^^^^^^^^^^^^I^U * Cargas que Jmpono la Tuberculosis
The import
^^^^^^^^^^^^^^^^■^^1 aobre Individuofl y Familiaa.^ — Mr.
W. R. jH^I
^^^^^^^^^^^^■^n Kingaley.
52
*Dentjs S|
^^^^^^^^^^^^^^■^■I Carter, Mih^ Luey N. — Tuberculofiia
Bnticfae 9rl
^^^^^^^^^^^^^■I^IH among; the Indiana. , . .
574
bury .J
^^^^^^^^^^^^^^^^H^HI Chapial. ^Ilte. L. — Histoire d'un Did-
Dcvine^Mr.^
^^^^^^^^^^^^^^^^^^H^^H pen^aire Fauborg
^^^^^^^^^^^^^^^^■^Bl * Charges Impo6^es par la Tuberculoso
2S4
dresB of tbel
Cloidn^^n
^^^^^^^^^^^^^^^^|^H| aux aux Faimllcs,
♦ T>ingwi^^^^B
^^^^^^^^^^^^^^M^^M L^.^Mr. S. C. Kingsley
53
diateZ^^^
^^^^^^^^^^■I^B Chaw, Dr. H. L
552
vue ^conoffl
^^^^^^^^^^^^^HIHH Oiniate the Campaign tucatixst
Diet as an Ek
Tbbertrulosi.^, The Relative Value
aUtaace: n
of.— Dr. S. G. Bonnty
•OolegioB de los Estados Unidoe y \a.
29G
to the Ptot
Kellogg....
*DietaCSmot
Campana contra la Tuberculosis*
Lofl.— Prof. W. H. Norton
612
de la Redil
Colleges of the United Slates and the
lo^c
H
Campai^in a^ain^t Tuberculosis,
*DilScult&«
^1
The— Prof. ^V. H . Norton , . .
002
naiMttnoe j
loee; et a
^M
♦Cflionias Rurales de Tuberculoeoa.—
^M
Mrs. E, W, Newcomb
389
pouryreml
E. 0. Otis. ,
^1
Commons, Prof. J. R.^^tandardiBa-
^M
lion of Investi eat ions 120, 130, 131 I
Difficulties (P
H
Comprehensive Plan for the Treat-
of the Earlt
^1
ment of the Tubcrculoais Problem,
H
A.— Mr. V. G. Bloede
308
tbeRemedj
0. OtiB.....
^1
•Corps Hucnainou du BaoiUe — Lequel
—Doit fl\*oir la Pr^ponderanoe
H
* Dificiiltadea
ales) en el I
H
dans Pd'ducation Hygi^niauo du
PubHcT— Dr. H. S. Andcre
^1
619
turo de la Ty
^^^^^B ^^^^^^^^^^1
H
Con^in, Dr. R. W
347
Sugestionea C
^1
Cost of Tiibeixulosis in the United
gunas de \aa^
H
States and its Reduction,^ — Prof.
Discharged ^ad
^^^H^^^^^l
Irving Fisher
5
4
—Mlf^lLM
INDEX*
817
PAGB
Disinfection in Tenement Houses in
New York City.— Miss E. T. Patter-
son 600
Disinfection of Houses, The (What
is not Done).— Miss Marie T.Phelan £02
Dispensaire antituberculeux de Lyon.
— M. S. Arloing et J. Courmont 300
Dispensaire de Fauborg, Histoire
' d'un.— Mile. Chaptal 284
Dispensarios Antitut>erculo608 en
Lyon, Los. — M. S. Arioing y J.
Courmont 308
^Dispensaryin Lyon, The Antituber-
culous. — M. S. Arloing and J. Cour-
mont 309
District Nurse in Providence, R. I.,
in the Cam^gn against Tubercu- .
losis, The.— Dr. J. Perkins 610
Dock, Dr. George. — The Influence of
Overwork and Nervous Strain in
Tuberculosis 135
Duffy, Mr. Frank.— Tuberculosis 191
Pyar, Miss Clara E.— The Blue Star.
A Simple and Practical Way to
Interest People in Tuberculosis and
to Raise Funds to combat the Dis-
676
*£cole6 Publiques, La Tuberculoee et
lee.— Dr.L.H.Gulick 690
Economic Aspects of Tuberculosis in
Milwaukee.— Mr. T.W.B.Crafer.. 196
Economic Loss to New York State
from Tuberculosis in 1907; Some
Considerations Regarding the. —
Prof.W.P WiUcox 37
*Economico de la Tuberculosis, As-
jpecto,— Mr. T. W. B. Crafer 206
*£conomique de laTubercubse; As-
pect.—Mr. T. W. B. Crafer 207
*E!ducacidn de Enfermeras Profesion-
ales en las Institucionee para Pa-
cientes Tuberculosos, La. — Dr. G.
J.Hatfield 411
*Educacion Fisica, La Promocl6n de
la Immunidad por Medio de la. —
Dr. T. A. Storey 771
^Education Physique, La Promotion
de I'Immunite au moyendel'. — Dr.
T. A. Storey 772
Educational Propaganda throua^ Lo-
cal Xjay Agencies: Especially in
Schools, Settlements, and Charity
Organisations. — Prof. Henry B.
Ward 606
Educational Value and Social Sig-
nificance of the Nurse in Tubercu-
losis Work.- Miss L. D. Wald 032
*EinbildungBkraft bei der VerfaOtunjS
der Tub^kuloee. — ^Miss S. Ameri-
can 738
PAOB
*Einwanderung zu dem Socialen Pro-
blem der Aiigemeinen Immunit&t
GOnstige Verh<nisse Herzu-
schaffen, Beziebung der. — Mr. R.
Watchom 781
Elementary Instruction as to Tuber-
culosis.—Mr. A. E. Winship 686
*Encarcdadoe, Relacidn de la Tuber-
culosis con los. — Dr. J. B. Ransom. 329
*Enfermera en el Trajode la Tubercu-
losis; La Signification Sociale y el
Valor Educativo de la. — Miss L. D.
Wald 638
England and Wales, Notes on Mor-
tality from Tuberculous Phthisis
in, and on Loss of Life by this Dis-
ease in the Various Occupations. —
Dr. J. Tatham 218
*Enseignement de THygidne iltoien-
taire dans lea Colleges et Ecolea
^^mentaires de Grande Bretame
et d'Irlande; Rapport sur l'.— Dr.
G. A. Heron 710
*Erziehung von Profeesionellen Kran-
kenfiegerinnen in AnstaltenfOrdie
Pfic«e von tuberkulOsen Patienten.
Bencht Qber die Ausbildungsschu-
len des Henry Phipps Institute
und des White Haven Sanatoriums.
—Dr. C. J. Hatfield 413
*ErziefaungBpropa^anda durch Lokale
Laien-Or^inisationen, besonders in
Schulen, Fortbildun^chulen und
Wohltfttifl^ts - Anstalten. — Piof .
H.B. Ward 600
♦Etoile Bleue, L'.— Miss C. E. Dyar . . 681
Experiences of a Sanitary Inj^)ector
with Tuberculosis. — Miss J. von
Wagner 406
*Fabrikventilation, Cber den Baar-
wertheiner.— Prof. C. E. A. Winslow 189
Factory Legislation and Tuberculo-
sis.— Mr. John Martin 179
Factoiy Ventilation, The Cash Value
of.— Prof. C. E. A. Winstow 184
Farm Colony Experiment, A. — Dr. H.
B. Jacobs 392
*Farm-KoIonie, Ein Experiment einer.
—Dr. H. B. Jacobs 395
Farrand, Dr. L. — ^A Comprehensive
Program for the Prevention of Tu-
berculosis 236
Favill, Dr. H. B. — Legitimate Exer-
cise of Police Power for the Pro-
tection of Health 222
*Fenune dans la Prevention de Ut Tu-
berculoee, La.— Mrs. Isabel H. Robb 730
*Fermidre, Essai d'un Colonie. — Dr.
H.B. Jacobs 396
Fewsmith, Miss S.— ^The Nurse and
the Tuberculous Patient 620
SIB
IKDEX.
rxaE
Fiflhberg, Dr. M, — Tuberculosis
ariLou^ tba Jews 415, 420, 427
FiBber, Prof. Irving. — Tlie Cost of
Tiit>orcult>8ia iu the United Slatoa
mitl iu Kixluction . , 5
Flick, Dr. L. F. — lYiberculoaia iu the
Irish Race 473
Foley, Miea Edna L, — Hgnie Teach-
ing in TubcrntWiij Caac8. ,.,...... 539
Folks, Mr. Homer.— A BXute Aroused.
IvfTc'cthe Control of Tubcrculowia
in Small Cities nnd Rural Conkmuni-
ties 110
♦Ffttu in iler Verhtltun^derTuberku-
loftc, Die Vemntworllichkcit der, —
Mrs. I. H. Itobb 730
Fulmcr, Mis3 Hoirbt. — The Impor-
tance of Nursing anil Supervmotk
of Atlvanced Caffcs of Tuberculosis . 546
Fulton, Dr. J. S 5S0
l<\iQCtJoDs of the Tuborculosia Nurse,
The True.— Miaa M. E. Lent 570
•FUrRoreeMtelle in I-yon, Die Antitu*
b«fkuTo£C,^M. H. Artolng UDd J.
Gourmont. 307
Gallflgfaer. Miss M. Alice.^Tbe Dis-
chargetl Sanatorium PntiEnt - 556
♦GastoB dela Tub<jrculi>eis en los Ea-
tadoe Unidos^ Los. — Prof, I- Fisher. 35
♦Geifitigen Defccten; Ober die Bezie-
hung der Tuberkulose xxi. — Dr M.
W. Barr 92
Glover, Prof, James W. — ^The Mone-
tary I.rfj6S m the United States due
to Tuberculoflia, based on the Ke^
turofl of the Twelfth Ccnaua of the
Unitad 8tat«s 55
Gulifk, Dr. L. H.— Tuberculosis and
the Public Schoola Q&2
Hamilton, Dr, Alice,— The "Piece-
Work" System ns a Factor to the
Tuberculosis of Wage-Workera 1 39
Harrington, Dr. T. F - 5Si
Hatfidd, Dr. C J.— Tratning for I'ro-
feaaional Nursiag in Institutioos
for Tuberculous Patients. A R^
B»rt of the Traming Schoots at th^
eiiry Phtppf^ Institute, and tho
White Haven Sanatorium. . ^ ..... . 407
Head, Dr. G. D. — l*uliiionaty Tuber-
oulosb aiuong the Seandinaviana. . 403
Henderson, Prof. C* R, — Indutitrial
Insurance in Relation to the Con-
flict with Tiibemilasis 263. 2S1, 282
Henry Phipus loatitute Training
School for NursM, The.— Miss. A.
K. Sultoii 560
H^Hcourt. Dr. — Deux aspects n^
gligfis ae la lutte contre la tubei^
culo«er lea tubcrculeux poeudo
bien portantfl^ les bacillif^res ca.-
chectiqueset mis^rieux. ....,,..,..
Heroti, br. G. A. — Report on the
Teaching of Elementaiy Hy^ene
in the Colleges and Elementary
SdiooLA of L^land and Great Brit-
ain 693,
Hcssler. Dr. R
^Higienica en loa Eacuelas, 1a In-
Btnjccion. — Dr. H, B, Jacobs. ......
Hoffman, Mr, F. L. — Tuberculosis aa
an industrial Diseasi^.
*Uogar de loa Tisicos en el Oc^le de
liondros, Condtcionas del, — Dr> E.
B. Hulberl and Dr. J. E. Squire
Holraan, Mtsa Lydia. — Tuberculosis
in Rural North CaroUna. ...,.,,...
Home Conditiotis, How to Deal with
the Danger of a Return to Unfavor-
able.— Mr. W. E. Kruesi.
Home Condi tioa^ of Poor Consump-
tives iQ the West of London, A
Five Vear»' Inquiry into the. — Dr.
E. B. Hulbert and Dr. J. E. Squire .
Home Occuijatioas in Famslios of Con-
sumptives and Possible Dangpra to
the Public »^MiaB H&bd Jaoquee .
Home Teaching in Tuberculosis CafiCs.
— Misa Edna L. Foley.
Hofltctter, Miss Frances. — Report of
the Nuraes^ Work in the Tubercu-
lotiU Class of the Presbyterian Hos-
pital, Phila-.Pa.
Hnllicka, Dr. Alea. — Contribution to
the Study of Tuberculosis id the
Indian - -
Hulbert, Dr. E. B.— Five Yeara* In-
quiry into the Home CoDditiooa of
Poor Con^mptives in the West of
London ,,.,....,,....
♦Holfeleiatungan tuberculoaeKranfce,
Ein Flan fiir.— Dr. L. R. Williams .
Hutchinson, Dr. W,— The Relation
between Income and Tuberculosis. .
Hy gi enic I natruction in Bchobk.— ^
Dr, H, B, Jacobs. . ,
*Hygi^nique dans lea €coles^ In-
etructions, — Dr, H. B. Jacobs .....
♦Hygenischer Unterricht in Schul^i.
—Dr. H. B. Jacobs
+Imaginac)6Q en la Prcvencion de la
Tuberculosis, La. — Mias Sculie
Arnenean
*Iniagt nation Jan^ le pn^ventton de la,
Tuberculose, L/ — MJsa B»die Amer-
ican
INDEX.
819
PAOB
Imagination in the Prevention of Tu-
berculosis, Some uses of the. — Miss
Sadie American 731
^Immigration et les conditions sociales
favorables & I'immunit^ g^n^rale,
L'.— Mr. R.Watchom 780
Immigration, The Relation of, to
the Problem of Securing Social
CJonditions Favorable to General
Immunity. — Mr. R. Watchom 774
Importance of Early Recognition,
Prompt Relief and Prevention from
an Economic Standpoint. — Dr. J.
H. Pryor 349
*Impre8ores, Tuberculosis Pulmonar
entre los.— Dr. J. A. Miller 216
♦Imprimeurs, — La Tuberculose Pul-
monaire chez les. — Dr. J. A. Miller . 216
Income and Tuberculosis, The Rela-
tion between. — Dr. Woods ^.utch-
inson 717
Indian, Contribution to the Studv
of Tuberculosis in the. — Dr. A.
Hrdlicka 480
Indians, Tuberculosis among the. —
Miss Lucy M. Carter 574
♦Indios, Tuberculosis entre loe. — Dr.
A.HrdUcka 493
Industrial Disease, Tuberculosis as an.
—Mr, F, L. Hoffman 141
Industrial Insurance in Relation to
the Conflict with Tuberculosis. —
Mr. C. R. Henderson 263
*Indu8triale8 (Aseguros) en Relaci6n
con la Lucba contra la Tubercu-
losis.— Mr. C. R. Henderson 281
*Industrie-Krankheit, Tuberkuloseals
eine,— Mr. F. L. Hoffman 177
*Industrielle (Assurance) dans son
rapport avec la lutte contre la tu-
berculose.— Mr. C. R. Henderson 282
*Industrielle, Tuberculosis commeune
Maladie.— Mr. F. L. Hoffman 176
*Infirmier dans le travail contre la
tuberculose; La signification so-
ciale et I'importance, _pour I'edu-
cation, de 1' . —Miss L. D. Wald .... 639
*Infirmidres dans les Institutions pour
le soin des tuberculeux, Forma-
tion d'.— Dr. C. J. Hatfield .... 412
*Inmigraci6n con el problema de la
General Immunidaa, La Relaci6n
dela.— Mr. R. Watchom 780
^Institution des Phtisiqnes Pr^coces
ou Avanc^, lequel est le plus im-
portant des deux. Le Soin dans
une.— Mr. J. H. Schiff 366
Institution "Halsan" (Health) and
its Work, The.— Dr. C. Neander ... 310
Institutional Care for the Early or for
Advanced Consumptives. — Mr. J.
H.Schifl 361
TAOm
*Instrucci6n Elementaria acerca de la
Tuberculosi^— Mr.A.E.Winship.. 687
*In8truction El^mentaire en oe qui
conceme la Tuberculose. — Mr. A.
E. Winship 688
*Instruire, Le Tuberculeux quePonne
saurait. — Miss La Motte 261
Irish Race, Tuberculosis in the. — Dr.
L. F. Flick 473
*IrlandaiBe, La Tuberculose dans le
Race.— Dr. L. F. Flick 477
*Irlandesa, La Tuberculosis en la Rasa.
-Dr. L. F. Flick 476
^IrlAndischen Rasse, Tuberkulose bei
der.— Dr. L. F. Flick 478
Irwin, Dr. J. W.— Study of the Relar
tion of Prostitution to Tuberculo-
sis 332,338
Italians in the United States, The Pre-
valence of Tuberculosis among the
the.— Dr. A. Stella 429
*Italienem in den Vereinigten
Staaten, Verhatung der Tuberku-
lose unter den. — Dr. A. Stella 461
Jacobs, Dr. Henry B. — A Farm
Colony Experiment 392, 395, 396
Hygienic Instruction in Schools
621,625,626,627
Jacques, Miss Mabel. — Home Occu-
pations in Families of Consump-
tives and Possible Dangers to the
Public 664
Jews, Tuberculosis among the. — Dr.
M. Fishberg 416
♦ Juden, Tuberculose unter den, — Dr.
M. Fishberg 427
* Juifs, La Tuberculose parmi les. — Dr.
M. Fishberg 426
*Kampfe gegen die Tuberkulose;
Die Bedeutung all^mein verst&nd-
licher Vortrdge im. — Dr. 8. A.
Knopf 675
Kellogg, Dr. J. H. — Diet as an ele-
ment in Increasing Resistance, with
Special Reference to the Protein i
Ration 740, 764 '
Kingsbury, Mr. J. A. — The Awaken-
ing of a State: An Educational
Campaign for the Prevention of
Tuberculosis 93
Kingdey, Mr. S. C— The Burdens
Entaued by Tuberculosis on Indi-
viduals and Families 47, 52, 63, 54 .
Knopf, Dr. S. A.— The Popular Lec-
ture in the Crusade against Tuber-
culosis 663, 673, 674, 676
Koch-Stiftung zur Bekfimpfung der
Tuberkulose, Satzung der Robert . . 810
Koch, Dr. Robert 712,808
820
INDEX.
FAOll
*K5rper ocicr tier Bacillus, Der.
Welches soil bei der hygieni*icbeji
Krziehutigdcfl Publikums mit Nach-
druck bctoat werdeQ? — Dr, H, 3.
Anders . . 620
*Kt>rperlichc Erjsiehung, Die Unter-
sttiUung der Imojmiirfit durcb. —
Dr. T, A, Storey. ......... 772
* korperlichcr unci geifftiger Uberan-
streti^ng auf die Tuberkulo^,
EinflusJi von.— Dr. G, Dork 138
* Kost^Q der Tuberkulose in den Ver-
einigtea Staatea, Die. — Prof, Irving
FiMher....... 36
* KrankeawOrtcrianeD be! der Be-
BcbiiftigLLng mit Tiiberkuloae; Die
Soziaki Erscheinung und der cr-
BJeheriflche Wert der. — MiBa L. D.
Wald 639
Krueaij Mr. Walter E. — DUcussion. . . 133
How to deal with the Danger to
PatienU of Return to Unfavor-
able ConditfonB 381
LaMotte, Miss E. N.— The Un-
teachable Consumptive. , , , 250
* Land-Koloniea.— Mrs. E. W. New-
comb 390
Lee, Dr. Benjamin, — The Value of a
Nurae ia the Tubercuiosia Dis-
pensary .,..,...,,,......,, 55i
Lent, Mifa Ma.ry E.^Thc Tme Fune-
tiona of the luberculodis Nut^e 576
Lou In the United States due (o Tu-
berauloflia: Based on the Retuma
of the Twelfth Cenaua of the
United States, The Monetary.—
Prof. J. W. Glover 55
* Lutte contre la Taberculosej LaCon-
f6rcnce Populaire dans la. — Dr. S,
A. Knopf. 674
* Lyon, Der Kampf Regen die Tuber-
kulose in. — Dr. P. Courtnont ...... 653
* Lyon, La Lucha contra la Tubercu-
losis en. — Dr, P. Courmont ^55
Lyon, La Luttc ixintro la Tuberculose
i.— Dr. P. Courmont 641
*Lyon, The Fight against Tuberculo-
sis in.— Dr, P. Courmont 654
McLean, Mr. F. H.—The Function of
Itclirf Agencies and Ita Viiriationg
in the Campaign for Social Coatrol . 245
llfMfthon. Prof. James. — Method of
VVtimafing the PrcReot Value of the
K*< Prospective Earnings^ Lost by
I^^iUm (rom Tuberculosis in New
V«fe8t«t«mCtaeYear. 42
1^^ IIml a. — ^Nole eax le rCJe des
MgBUlljUtoM do ^ propria ti^ batic
^ V%MMI^ M iujet de la fubercu-
Martin, Mr
tion and T^
Mental Defea
Tubcrculoa
* Mentality, E
cuiodeet Iq
BazT. ,. .
Method of
Value of th
ingB lost b;
losia in N.
Prof. J. Mii
Miller, Df. J,
culoi^is am<
* Mujer en la
culosis, La*'
Neandcr, Dr.
"Ualfian"
*Negre3( La
^t-ello due
—Dr. R. Wl
Negroes, la
culosis am
Tendeocyf'
* NegroB, Tube
bida a una T
Dr, R. Wi
Newcomb
Patients afi
atonums: T
Colonies ac
ments
•Norma
Prof,
* Normaleinhej
fraclmngen, j
Commons..]
Norton, ProfJ
of the Unitj
paign again
Nut% and th
Tlie.— Misa
L. C. Boyd,
Nurse as a Sck
culosis — MJd
Nursea' Worl
Class of th4
Phila., Pa.,
F, Hostette
Nursing and £
Caaea of *
portance of.'
NunsLng [n In
of Tubercu'S
for Profesaio
Training Sch
Iii^titut^
torium.—
* Okonomiac)
Tuberki
its.... ,^
nade id
F. J. rTC
INDEX.
821
Otis, Dr. E. O.— The Early Recogni-
tion of TubercutofiiB. Some of tlie
Difficulties, Professional and Social,
and some Suggestions as to the
Remedy 353,368,359
Overwork and Nervous Strain in Tu-
berculosis, The Influence of. — Dr.
G.Dock 135
Pannwits, Dr. OotthoM. — Address. . . 797
Patients Exposed to Tuberculosis and
Patients Suspected of Having Tu-
berculosis, Examinations of. — Dr.
L. R. Williams 367
Patterson, Miss E. T. — Disinfection
in Tenement Houses — 600
* Pcrdidas Economicas del Estado de
New York a Consecuencia de la
Tuberculosis, Las.— Dr. W. F.
WiUcox 46
Perkins, Dr. J. — The District Nurse
in Providence, R. I., in the Cam-
paign against Tuberculosis 610
Phelan, Miss M. T.— The Disinfection
ol Houses. What is not Done 502
Physical Education, The Promotion
of Immunity through. — Dr. T. A.
Storey 770
"Piece-work" System as a Factor
in the Tuberculosis of Wage-
Workers. — Miss J. Addams A Dr.
A. Hamilton 139
* Poder de Polfcia para la Protecci6n
de la Salud, Eiercicio Legitimo del.
—Dr. H. B. FaviU 227
Police Power for the Protection of
Health, Legitimate Exercise of. —
Dr.H.B.FaviU 222
Police Power in Protecting the Life
and Health of Employee, The Le-
f'timate Exercise of. — Hon. D. J.
rewer 230
* Polieeigwalt fQr den Schutz der Ge-
sundheit, Die gesetzmfissige Austi-
bung der.— Dr. H. B. FaviU 228
Populflj- Lecture in the Crusade
against Tuberculosis, The. — Dr. S.
A. Knopf 663
Preservation antituberculeuse chez lee
jeunes filles dans les centres manu-
tacturies. — Mme. B6rot-Berger. . . . 253
President's Address.— Mr. E. T. De-
vine 1
President's Closing Remarks. — Mr. E.
T. Devine 814
* Prevention of Tuberculosis in Young
Women Wage-Earners. — Mme. B6-
rot-Berger 255
Printers, PulmonaiT Tuberculosis
among.— E>r. J. A. Miller 209
PAOB
Program for the Prevention of Tuber-
ciuosis, A Comprehensive. — Dr. L.
Farrand 236
Proposition to Introduce a Public
Health Week into the Public
Schools, A.~Dr. C. W. Stiles 628
Prostitution to Tuberculosis, Study
of the Relation of.— Dr. J. W.
Irwin 332
* Prostitution zur Tuberkulose, Das
Verh<nias der.- Dr. J. W. Irwin . . 338
Piyor, Dr. J. H. — The Importance of
Early Recognition, Prompt Relief,
and Prevention from an Economic
Standpoint. 349,351, 362
PubUc Schools. Antituberculosis
Work in Pittsbutgh.- Miss B. L.
Stark 506
Public Schools, Tuberculosis and the.
-Dr. L. H. Gulick 682
Putnam, Dr. H. C. — Discussion 234
Tuberculosis and Two Thousand
Dollars a Year 666, 66 1 , 662
Ransom, Dr. J. B.— Relation of Tu-
berculosis to Crime and the In-
carcerated Criminal 320
Ransom of a Great City, The.— Mr. T.
Williams 132
Relief Agencies^ Hie Function of,
and its variations in the Campaign
for Social Control.— Mr. H. F.
McLean 245
* Renuente a la Instruccion, El Tu-
berculoso. — Miss La Motte 261
Richer Dr. A. J. — Le Traitement
des Etats Pr^Tuberculeux dans
les Institutions Sp^iales (Preven-
toriums) 722
Riis. Mr. Jacob A. — ^Address 789
Robb, Mrs. Isabel H.— Woman's Re-
sponsibility in the Prevention of
Tuberculosis 725, 729, 730
Robbins, Miss Susan F. — The Day
Camp 649
San, Miss lyo Araki — Tuberculosis
in Tokyo and Vicinity 673
Sanatorium Atmosphere. — Mrs. F. R.
Burgess 618
Sanatorium for Tuberculosis in Italy,
The First Open-Air. — Miss Amy
Turton 525
Scandinavians, Pulmonary Tubercu-
losis among the. — Dr. G. D. Head . . 463
Schiff, Mr. J. H. — Institutional Care
for Early or Advanced Consump-
tives 361
* Secourir les Malades Tuberculeux,
Un Plan pour.— Dr. L.R. Williams. 373
^^^^V 822 INDEX. ^^^^^^^^^^^^^H
^^^^^^^H PAQK
^
^^^^^H * Semana do Salud Pubtica CQ loa Ea-
Todd , Miss Helen— Addren 1
^^^H ruo)n:i Publicfu,— Dr. C. W. Stiles . . G30
Tokyo and Vicinity, TubercuIo^U iiu
^^^^^H *Skaiidinavicni, i«ungentul>crkulwe
— Miaa L A. San
^^^^^H Mtiterdeu— Ur. G. D, Hoad ,. 471
* Trabaj6 Exesivo y Fatiga Nervioe*
^^^H Blocum, Mr. W. K^Bcfit Use of a
sobre la Tubemiloeis, Influencia
^^^^^^H Lat^ tk^quc^t iu the l^rcction of a.
del.— Dr. G. Dppk
^^^^^ft 8armtoriuni for the Benefit of Con-
Traitement des Etats Pr^-Tubercu*
^^^^^1 eiiitiptives , ,,.,. 341
leuz don.^ lea Inatitutions Bp^iales
^^^^H Hmithwlck, Miss F. R.— Tho Attitude
(Prcventoriuma), Le.^Dr. A. J.
^^^^^H of Ihs MofJcrn District Nurse
Richer
^^^^^H townr<t Tubereiitosb ...,,,.. ^ ,.. . 570
♦ Traitement ^t^ndu et suti^^ant dtt
^^^^^H SncfldeD, Mr. David S. — Trainiog
Problfime de la Tuberculosa, Ce
^^^^^H Teachers lot Education ug^oet
qu'il faut pour le.— Mr. V. G,
Bloede..
^^^^■1 TubcrculoK]^. , ....,,.,... £S9
^^^^^fl * Socorro, L& Functii5n de las
• Treatment of Pretuberculous Coiid>^
^^^^H A^ndfts.— Mr. F. U. McLean 2^1
tions in Special Institutions. — Dr«.
^^^^^H * Suutagcmcnt dea Ptuivrea, Fooction
^^^^^H doe AaaoriatioDs pour la. — Mr. F.
A. J. Richer. ,
* Tuberculoee, La.— Mr. Frank Duffy.
^^^H H. McLean..... 252
* Tub©pculoee et 12,000 par an. La.—
^^^^^M BqtJtre, Dr. J. E.— Five Years* [nquiry
^^^^^H into the Home CondUion.? of Poor
Dr. H. C. Putnam . . ............
Tuberculflsie.- Mr. Frank DuiTy
^^^^^^1 Consumptiveii in the West of
Tuberculosis and Two Thousand DoJ-
^^^^^Hl London. ... . . . . .,...,. ^ , 374
lara a Year. — Dr. H. C. Putnam. . . .
^^^M BtaiTord , Dr. T. J .—Address 795
Tuberculosis in Rural North Carolma.
^^^^^Hl BtcLndardizaliona of Inve&tigationa. —
—Mias L. Holman ,..,,,,,,,,
^^^^n Frof.J.R. Commona 120
* TuberculofiOfl, Vt\ Plan para Admin-
^^^^■1 Stark, Misa D. L.— AnMtubcrcuIosia
istrar Socorro d los. — Dr. L, R,
^^^^■1 Work iti the Pittsburgh Public
Wilhams
^^^Hl Schoob 505
♦ Tuberkulose, Die.— Mr. Frank Duffy
^^^^■1 StaU Amused: Effective Control in
Tuberkuloao und $2,000 jahrUcb,
^^^^^^Hl Small Towns and Rural Communis
Die.— Dr. H. C. Putnam
^^^^H tics.A— Mr. Homer Folkfi .... 110
Turton. Misa Amy— The First Open-
Air Sanatorium for Tuberculomas in
^^^Hl gtetla, Dr. A.— The Prevalence of Ta-
^^^^^Hl bemilosis among It&lionjj in the
^^^Hl United States. 420, 451
Italy. -
****./ , .,....,.,,, + .-.•.#,.,
^^^^B BViha, Dr. C. W.— A Proposition to
♦ Umfasaende und Hinlansliche Be-
^^^^H Introduce a Public Ilcahh Week
handiting dea Tuberkulofie-Pno-
^^^^n into the Public «Scbootii 62«, 630
blcmg. Das Notwendiga filr sine. —
Mr. V. a Bloede
^^^^H Storey. Dr, Thotii£u« A.— The Promo-
^^^^^^H Uon of Immunity through Phy.f-
*UngclebrigESchTvindsQehtige,l>er. —
^^^^H icol Education 770, 77L, 772
Uiea U Motto
^^^^^^B * Surmenn^^e et de la FMiguc nerveuse
*Unit^ pour ha EnquCtes, Etablisse-
^^^^■B suT k TiiberculoBe, LTnfluenoe
ment d'un Sysl^me d'.— Prof. J.
^^^■n du.— Dr. G. Dock 138
R. Cotntnona
Sutton, Mias A, K.— Tho Henry
Un teachable Consumptives, The. —
Phinps Institute Training School
for Nurbca 560
MisB E. K. La Motte
* Unterstfllzungavereiuo^ Funktioa
der.— Mr- F. H. Mclean.
Upjohn, Miss Elizabeth P.— The Tu-
bcrculrtHin Nurse a^ a Social Worker
Tatham. Dr. J.— Notes on Mortality
from TubcrcidoUfl Fhthtaia in Eng-
land and Wales, and on the Loss of
Value of a Nurse in a TubercuIoeU
Life by this Disease in the Variovia
Diapeusaty, Tlie.— Dr, Benjamin
Opcupationa ,,,._.. .218,221
Lee ^
Teacliers, Training, for Education
UKuinst TulierculDaia.— Mr. D. S.
* Verbrechen, Bexiehung der Tuber-
culose £11. — Dr. J. B. Ransom. .....;
^^^H|l| Sneddcn ..... 589
* Volks-schulen, Tuberk\ilofie und die.
^^^^^Hp Teaching of Elementary Hygiene In
— Dr.L. H.Gulick
the Training Colleges and Elemen-
tary Schoola of Great Britain and
Ireland, Report on the. — Dr. G. A.
Wagner, Mias J. von— Experiments
ofa Sanitary Inspector with TUber-
Heron. 693
culoaifl ...,............»,.,>.....
J
INDEX.
P&OB
Waid, Miss L. D.— Educational Value
and Social Significance of the
Trained Nurse in the Tuberculosis
Campaign 632, 638, 639
Ward, Prof. Henry B.— Educational
Propaganda through Local Lay
Agencies 696, 600
Watchom, Mr. Robert — ^The Relation
of Immigration to the Problem of
Securing Social Conditions Favor-
able to General Immunity . 774, 780, 781
* Well-appearing Tuberculous, and
the Incurable Cachectic Consump-
tives, The,— Dr. Hericourt 788
White, Dr. W. C 683
* Wichtigkeit der frOhen Erkennung,
schnellen Erieichterung und Ver-
hinderung, von einem Okono-
mischen Standpunkte aus, Die. —
Dr. J. H. Piyor 353
Willcox, Prof. W. F.— The Economic
Ijoss to New York State from Tu-
berculosis in 1907 37, 46
WiUiams, Dr. L. R.— The Examina-
tion of Patients exposed to Tuber-
culosis and Patients Suspected of
having Tuberculosis 367, 373
PAOB
WilliamB, Mr. T.— The Ransom of a
GreatCity 132
Wilson, Dr. Robert, Jr.^Is the
Prevalence of Tuberculosis among
the Negroes due to Race Tendency?
464,462
Winship, Mr. A. E. — Elementary In-
struction as to Tuberculosis
685, 587, 588
Winslow, Mr. C. E. A.— The Cash
Value of Factory Ventilation , . . 184, 189
Woman's Responsibility for the Pre-
vention of Tuberculosis. — Mrs. I.
H. Robb 725
Woodbury, Dr. Wm. R.— The Im-
portance of Oral and Dental Con-
ditions in Tuberculosis 765, 768, 769
Work of the Social Service Depart-
ment at the Massachusetts General
Hospital of Boston, Tuberculosis. —
Miss Ida M. Camion 531
* Zahnxust&nde bei Tuberkulose,
Mundund.— Dr. W. R. Woodbuiy. 769
!l
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