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FiSKE Fund Prize Dissertation. No. XLIV. 
 
 STATE CONTROL OF 
 TUBERCULOSIS. 
 
 CHARLES V. CHAPIN, M. D., 
 
 Superintendent of Health of the Chy of Providence. 
 
 PKOVIDENCE : 
 
 Snow & Farnham, Printers, 
 1900. 
 

 THE Trustees of the Fiske P\incl, at the annual meeting of the Rhode 
 Island Medical Society, held at Providence, Sept. 0, 1900, announced 
 that they had awarded a premium of two hundred dollars to an essay on 
 
 " State Control of Tuberculosis," bearing tlie motto : 
 
 " Festina lente." 
 
 The author was found to be Ciiari.es V. Chapin, M. D., of Provi- 
 dence, R. I. 
 
 GEORGE D. HERSEY, M. D., Providence. 
 GEORGE F. KEENE, M. D., Howard. 
 WILLIAM R. WHITE, M. D., Providence. 
 
 Triditees. 
 HALSEY De wolf, M. D., Providence, 
 
 Secretary of the Trustees. 
 
The State Control of Tuberculosis. 
 
 To successfully control a disease it is necessary to 
 know how it is caused. For a century or more, many 
 acute observers have been convinced of the contagious 
 character of tuberculosis. Experiments were long ago 
 imdertaken to prove its communicability, and some of 
 them, particularly those of Villemin, were successful. 
 The intelligent medical ^vorld was not, therefore, un- 
 prepared for the discoveries of Koch. By him was 
 discovered the essential factor in the causation of the 
 disease. His experiments were a complete demon- 
 stration that the disease we are considering is due to 
 the action upon the tissues of the tubercle bacillus. 
 The bacillus is the cause of the disease. Scores of 
 competent observers at once attempted to prove or 
 disprove Koch's views. This is the proper fate of 
 every important discovery and of every alluring error. 
 Eighteen years have passed, and no person able to 
 judge denies the causative relation of the bacillus to 
 the disease. The definition of the disease is made by 
 the facts. Whatever abnormal condition is produced 
 in the tissues by the bacillus is tuberculosis. 
 
 DISTRIBUTION OF THE DISEASE. 
 
 There are various forms of tubercular disease occur- 
 ring among both men and animals. Of the forms occur- 
 ing in the hmnan species, phthisis is the most common. 
 It is generally said to cause one-seventh of all deaths, 
 but that, at present, is scarcely true, for, owing to the 
 
4 THE statp: control 
 
 diminution wliicli has, of recent year.s, taken place, it 
 does not, luider favorable conditions, cause more than 
 one-ninth or even one-tenth of the deaths. It is diffi- 
 cult to determine just what proportion of tubercular 
 deaths is due to other forms. The recent Royal Com- 
 mission considered that al)out one-quarter of tubercular 
 diseases are not phthisical. In Providence, however, 
 probably not over 15 per cent, are non-phthisical. It 
 is only in infancy that non-phthisical forms are the 
 most prevalent. In Massachusetts, under one year, 
 the non-phthisical are to the phthisical as 116 to 11, 
 and Ijetween the first and fifteenth year, as 61 to 37'. 
 The non-phthisical forms of the disease Ave are consider- 
 ing are retiu^ned, sometimes, as " tuberculosis," some- 
 times as tubercular meningitis, laryngitis, etc. ; again, 
 as hydrocephalous or lu])us. Diseases of the bones and 
 joints and intestinal diseases, especially in young chil- 
 dren, are very commonly due to tubercular infection. 
 In this connection, it must be remembered that the 
 deaths do not by any means represent all the cases. 
 Tuberculosis is not infrequently recovered from, though 
 it leaves its traces in the organism. Marks of tuber- 
 cular infection are frequently found at the autopsy of 
 persons who have died of other affections. Knopf 
 says that traces of tuberculosis are found in 25 per 
 cent, of all such autopsies. In the New York hospitals 
 it runs as high as 30 per cent., and in Vienna, where 
 the disease is particularly prevalent, the marks of 
 tuberculosis are said to l)e found in (S5 per cent, of all 
 autopsies. 
 
 A very large number of species of the lower 
 animals are also suljject to tuberculosis, particularly 
 domestic animals oi" wild animals kept in confinement. 
 
OF TUBERCULOJSIS. 5 
 
 To tiiljerculosis acquired iiatiinilly. the bovine species 
 appears to be more susceptible than are other animals. 
 Next in susceptibility among the domestic animals are 
 swine. Goats and fowls also contract it, and sheep 
 sometimes have it. It is very readilv inoculated into 
 rabbits and guinea pigs. Parrots and canaries have 
 been known to have it, but it is very difficult to pro- 
 duce it in sparrows. The carnivorous animals are very 
 slightly susceptible, though wild animals kept in con- 
 finement, as lions and tigers, occasionally contract it. 
 As a rule mammalia are more susceptible than the 
 other vertebrate classes. Birds come next, and it has 
 only recently been discovered that fishes sometimes 
 have this disease. Even in the Ijovine species, tuber- 
 culosis is not uniiormh^ distributed. The statistics of 
 the Leipsig slaughter-house for 1895 showed that of 
 oxen 28.14 per cent, had tuberculosis ; of heifers, 20.35 
 per cent. ; of cows, 43.51 ; of ])ulls, 23.83, and of calves, 
 0.18. 
 
 It would be of very great interest to know just how ex- 
 tensively tuberculosis prevails among the herds of this 
 and other civilized countries, but we have no accurate 
 statistics, at least, for this country. It is probably 
 much more common in certain parts of Europe than it 
 is in any part of tbe United States. It is said that 27 
 per cent, of all animals slaughtered in Saxony have 
 tuberculosis. No such figures have been obtained in 
 this country, though, in Philadelphia, it is said that a 
 year or two ago 20 per cent, of the slaughtered animals 
 were infected. In the New York slaughter-houses, 7 
 per cent, have been found infected, and, at the 
 Brighton abattoir, 5 per cent, of Eastern cattle. In 
 Massachusetts, wdiere the tuberculin test is required 
 
6 THE STATE CONTHOL 
 
 for all animals imported into the State, it is said that 
 10 per cent, of the animals tested ])rove to he tuher- 
 ciilons. There is ahnost no tnherculosis among the 
 eattle on the ranges in the West, and the most is found 
 among the dairy herds which sn])ply the Eastern cities. 
 Veterinarians seem to he very generally agreed that 
 tuberculosis among cattle has increased considei'ahly 
 during the last few years, at least until steps began 
 to be taken for its eradication. 
 
 It has been suggested that the tuberculosis of man 
 and of the other animals may not be identical. The 
 bacilli which are found in the lesions of the different 
 species are not always exactly the same. There are 
 slight morphological and cultural differences between 
 the bacilli usually found in man and cattle. The 
 bovine bacilli are usually slightly shorter and straighter, 
 and their growth upon artificial media is less luxuriant, 
 and these characters are quite consistent through 
 several generations of artificial cultures. There are 
 some differences, also, in regard to the degree of viru- 
 lence of the different forms. Theobold Smith, who 
 has given special attention to this subject, has rarely 
 found the bovine type in human subjects. He is, 
 however, far from holding that the different types 
 may not pass from one species to another. Recent 
 bacteriological work seems to show that the morpho- 
 logical and physical characters of most species of 
 bacteria can be considerably changed, usually slowly, 
 sometimes raj^idly, by change of environment. Thus, 
 although ordinarily the tubercle bacillus does not grow 
 at a temperature below 98*^ F., it can be made to do 
 so by careful manipulation, hy gradually reducing the 
 temperature for successive generations. The general 
 
OE TUBERCULOSIS. 7 
 
 opinion seems to be that such slightly different forms 
 as the limnan and l)ovine bacillus may readily pass one 
 into the other ; moreover, as will be seen, there is con- 
 siderable evidence to show that the disease is fre- 
 quently transmitted from animals to man and not 
 rarely, vice versa. There are many who go so far as to 
 think the evidence shows that almost all human tul^er- 
 culosis is derived from the lower animals. One argu- 
 ment for this, which has been elaborately presented, is 
 that the prevalence of the disease in the human and 
 bovine species is co-extensive, and that human tuber- 
 culosis is not found where there are no domestic 
 animals affected with this disease. This argument will 
 not, however, bear close investigation, for right in our 
 own section of the country, at Nantucket and on Cape 
 Cod, tuberculosis among cattle is very rare, but is ex- 
 tremely common among human beings. 
 
 While the bacillus is the essential cause of this dis- 
 ease, there are, of course, many other factors in its 
 production. There are, probably, differences of indi- 
 vidual susceptibility to all infectious diseases, and this 
 difference appears to he very marked as regards tuber- 
 culosis. It has long been believed that a poorly 
 nourished body is one of the chief factoi's in the caus- 
 ation of individual cases of the disease. There are 
 certain physical characteristics which are difificult to 
 define, but not so dithcult for the practiced eye of the 
 physician to recognize, which are indicative of a tuber- 
 cular disposition. It is through the inheritance of 
 such characters that heredit}' has its share in the 
 spread of this disease. The disease itself is rarely in- 
 herited, but the susceptibility to it frequently is. It 
 is always difficult to demonstrate the relative import- 
 
THE STATE CONTROL 
 
 aiice of heredity and eiiviroiinient, but ino.st physicians 
 have seen so many cases where tlie influence of 
 heredity appeared to be very great, that most are con- 
 vinced that this is a very important factor. Law re- 
 ports an interesting case where he found eleven cows of 
 a certain herd infected with tuberculosis. These eleven 
 were all of one family, distinct from the rest of the 
 herd. The actual inheritance of tuberculosis does 
 sometimes take place. Calves killed immediately after 
 birth are sometimes found to be tuberculous. In the 
 Munich slaughter-house this is found only once in 
 100,000 cases, and in Lyons the proportion was not 
 much greater. Most European veterinarians consider 
 it a great rarity. It appears to have been seen more 
 often in the United States. The Maine cattle commis- 
 sioners report having met with it in sixty cases. 
 
 What are called unhygienic surroundings, over- 
 crowding, impure air, especially dust-laden air, lack of 
 sunlight, insutficient clothing, and improper food are 
 all good friends of the tubercle bacillus. The State 
 may do much to improve the conditions of life, and, in 
 this way, indirectly control the spread of tubercular 
 disease, but it is not this indirect form of State control 
 which will be considered in this paper. 
 
 METHODS OF EXTENSION. 
 
 That tuberculosis is contagious was incontestably 
 demonstrated by Koch. The difticulty of demonstrat- 
 ing the contagiousness of a disease clinically is very 
 great. For years physicians have felt that such evi- 
 dence was very strong, and, not long since, the com- 
 mittee on collective investigation of the British Medical 
 Association attempted to secure evidence which would 
 
OF TUBERCULOSIS. 9 
 
 satisfuctorih" prove or disprove the point at issue, ))ut, 
 altli(nigh several hundred cases were reported, it was 
 sliown in an ahle pjiper l)y Langstaff that they were 
 not much more numerous than the coincident affection 
 of the two persons could be expected to occur, accord- 
 ing to the law of chance. It has, how^ever, been 
 proved beyond question that among animals the dis- 
 ease ma}^ be and is transmitted from one individual to 
 another. The identity of the lesions in man and 
 animals, and the fact of the universal presence of the 
 bacillus in these lesions renders it certain that tuber- 
 culosis in man also is a contagious disease.- There can 
 be no question that tuberculosis is only caused hy the 
 tubercle bacillus, and that the tubercle bacillus does 
 except under extraordinary conditions, not, grow out- 
 side of the human body. 
 
 In order to grow tlie tubercle bacillus, it is necessary 
 to exercise great care in the preparation of the culture 
 medium. Furthermore, growth will very rarely take 
 place except at the temperature of the body. The 
 conditions are such that it can be said to Ije strictly 
 ])arasitic in its habits of life. If any animal becomes 
 infected, the germs must have been derived mediately 
 or immediately from some other animal. While the 
 bacilli do not grow outside of the l^ody, they may re- 
 main alive for a considerable length of time. They 
 are not, however, so resistant to destructive agencies 
 as are many bacteria. Exposure to sunlight very 
 speedily destroys them, sometimes in a few minutes. 
 Drying, however, does not destroy them. Dried 
 sputum has been shown to retain its virulence for 
 three months, and doubtless, at times, will retain it 
 for a much longer period. The bacillus is readily 
 
10 
 
 THE STATE COXTROL 
 
 killed by beat, exposure to a temperature of 00'^ C. for 
 15 minutes proving fatal. It is, bowever, quite re- 
 sistant to dry beat. It is killed by disinfectants of 
 ordinary strengtb, but tbe action of corrosive sublimate 
 upon sputum requires a strengtb of 1 to 500, as it 
 forms inert compoiuids witb tbe allnmiinous matter of 
 tbe sputum. 
 
 Tbe presence of tbe tubercle bacillus in tbe dust of 
 bospitals, cburcbes, tbeatres, scbools, dwellings, and 
 streets bas been mucb discussed. A considerable 
 number of investigations bave been made to determine 
 its presencein different localities. Some years since, 
 Webb, in Pbiladelpbia, found it in tbe air of places of 
 public assembly. Hance found it in tbe air of Adiron- 
 dack sanatoria, killing 5 out of 25 Guinea pigs wbicli 
 be inoculated. Gardiner did not find it in 8 tests 
 made at a Colorado Springs botel. Tbe most careful 
 and complete experiments were made by Cornet. Tbe 
 following table shows tbe results of bis work : 
 
 Places fko.m w uki 
 
 Sami'les of DrsT 
 
 WEKE Taken. 
 
 In the seven hospitals 
 
 In the three insane asylums.. . . 
 
 In two prisons 
 
 Inhalation experiment room. . . 
 
 Private patients 
 
 Poliklinik, orphan asylum, etc 
 
 Surgical halls 
 
 Streets and hygienic institute. . 
 Streets alone 
 
 Totals : .. 892 59 
 
 
 94 
 33 
 14 
 
 4 
 
 170 
 
 28 
 
 8 
 41 
 
 196 
 
 !£ cS C 
 
 O !3-~ 
 — 0) C 
 
 o ^ S 
 
 •O Si 2 
 oj QJ C 
 
 72 
 
 19 
 
 6 
 
 2 
 
 125 
 
 14 
 1 
 
 16 
 
 255 
 
 76.6 
 67.5 
 42.0 
 50.0 
 73.5 
 50.0 
 12.5 
 39.0 
 55.0 
 
 14 
 
 8 
 
 2 
 
 25 
 
 14 
 
 65.05 137 
 
OF TrBERCULOSIS. 11 
 
 From this table we can make the dediietion that the 
 danger to the inocuLated jinimals of tnbercular infec- 
 tion was in tlie hospitals 47.6 per cent., in the insane 
 asylmns 17.G, and in private dwelling houses of con- 
 sumptive patients 43.6. Cornet's experiments showed 
 that invarial)ly, where the tul)ercle l)acillus was found 
 the patients did not restrict themselves to the use of a 
 spit-cup, but expectorated, also, upon the floor or into 
 a pocket handkerchief. He succeeded only in a single 
 instance in making an animal tul^erculous where the 
 patients had surely restricted themselves to the use of 
 the spit-cup. Twenty-nine of his samples of dust were 
 taken from places not especially frequented l^y tuber- 
 culous persons, such as general hospitals, an orphan 
 asylum, the hygienic museum, public stairways, and, 
 in nine instances, from streets. These samples were 
 inoculated upon 873 animals, not one of which became 
 tuberculous. These experiments tend to make it quite 
 certain that the tubercle l^acillus is not very widely 
 distributed. There is not much chance of meeting 
 with it except in the close neighborhood of a consump- 
 tive or in apartments wdiich have been for some time 
 occupied by a consumptive. Further investigations of 
 the distribution of the tubercle bacillus would be very 
 desirable, but from those already made and from what 
 we know clinically of the spread of this and other com- 
 municable diseases, it is entirely likely that the con- 
 clusions of Cornet would be fully verified. Strauss 
 examined the saliva of a number of persons who had 
 the care of those sick wdth phthisis, and found 
 bacilli present in a few of them. It has been demon- 
 strated by very many observers that the expired breath 
 contains no bacteria of any kind. AVith the conditions 
 
12 THE STATE COXTUOL 
 
 that pre\ail in coughing, sneezing, and sometime.s even 
 in talking, it is otherwise. Under such conditions 
 there appears to be a fine spray thrown out, in the 
 droplets of which bacteria may be found, and tubercle 
 bacilli have thus been shown to be given off from 
 phthisical patients. This spray, however, extends 
 only a few feet from the patient. Experiment, then, 
 seems to shoAv that ordinarily quite close contact is 
 necessary for contagion in this disease. Clinical evi- 
 dence also supports this view. Of course in the 
 majority of cases of marital contagion wdiicli have been 
 recorded, the intimacy was close. Of 213 cases of 
 probable contagion collected by Martin, one-half were 
 marital. Cornet's investigation of the Catholic Nurs- 
 ing Orders in Germany, before precautions were taken 
 to prevent contagion, showed that a very large number 
 succumbed to this disease. Of 2,099 deaths, 1,320 
 were due to tuberculosis, and of course in all these 
 cases there was close contact between the nurse and 
 the patient. 
 
 The evidence, then, seems to be very strong that 
 the tubercle Ijacillus is not widely distributed outside 
 of the body, that it is not found in the air except 
 close to tlie patient, and not then in any quantity if 
 proper precautions are taken. Contagion is found 
 only in the air close to the patient, on the patient 
 himself, and on articles wdiich the patient or his secre- 
 tions have touched. Prol)ably the same conditions 
 are necesary for contagion from animals. 
 
 There are three avenues of infection : , 
 
 First, tkroiKjh the skin. 
 
 There are a number of cases of persons who have 
 been inoculated through the skin. The celebrated 
 
OF TUBERCULOSIS. 13 
 
 Laennec died of pulmonary tiiberculoisis which was 
 thought to be contracted through the accidental inocula- 
 tion of his finger at an autopsy. A more recent case and 
 one concerning which there is little doubt was reported 
 by Pfeiffer, who tells of a veterinarian whose finger 
 was inoculated, whose joints later became involved, and 
 who finally died of the pulmonary form of the disease. 
 Law and Ravenal both report cases of the accidental 
 infection of the hands of veterinarians, and in the case 
 reported by the former, the extension of the disease 
 was only prevented by amputation. Knopf had a 
 similar case in a nurse who l^ecame inflected while 
 dressing a tuberculous wound. Ernst rejDorted a case 
 of infection of the tongue. Heron, in evidence pre- 
 sented to the Connnittee on Collective Investigation, 
 in 1890, reported seventy-three articles dealing with 
 this subject. A considerable number are also reported 
 by Senn in his surgery. Lindeman, Jacobi, and Knopf 
 report a numl^er of cases of infection through the rite 
 of circumcision. There are also on record cases due 
 to the common practice of tattooing. 
 
 In can thus be seen that the danger of infection 
 through the skin is a real one. Nevertheless, the evi- 
 dence shows that the danger is very slight, and may be 
 neglected in any measures undertaken for the state 
 control of the disease. 
 
 Second, throiKjh the respiratory tract. 
 
 It is generally believed that this is by far the most 
 common avenue of infection. This view is based 
 chiefly upon the facts that the pulmonary is the most 
 common form of the disease, and that the lungs are, in 
 such cases, involved to a very much greater degree 
 
14 THE STATE CONTROL 
 
 than are other organs. It is pro])a])le that in the main 
 this reasoning is correct. But it does not necessarily 
 follow that because the lungs are chiefly involved that 
 they were the seat of the primary infection. Wood- 
 head has shown that infection through the intestinal 
 wall may leave very few traces there, the most im- 
 portant lesions being subsequently found elsewhere in 
 distant organs, such as the thoracic glands. 
 
 From the time of Koch, many experiments have 
 been tried to produce pulmonary tuberculosis l)y the 
 inhalation of dust containing the living bacilli. Most 
 of these experiments have been unsuccessful. The 
 attemj)t has also Ijeen made to induce it by the inhala- 
 tion of spray, such as was referred to as given off from 
 consumptive patients during sneezing and coughing. 
 These experiments have been more often successful, 
 but not invariably so. It seems to be quite certain 
 from the experiments of Cornet that have ))een referred 
 to, and from the observations of many careful investi- 
 gators, that pulmonary infection is not readily induced. 
 The breating of a few bacilli by a healthy person is not 
 likely to cause the disease. Chance contact with 
 bacilli in the dust of the street, which has Ijeen much 
 dreaded, probably rarely gives rise to the disease. 
 Most of those who have studied the contagion of this 
 disease clinically, as tlie Committee on Collective In- 
 vestigation, Heron, Martin, Russell, and Cornet, believe 
 that close and prolonged contact is necessary, in most 
 cases, to produce infection. Infection is not carried 
 far by the air. This accords with the known facts in 
 regard to the transmission of other diseases. Scarlet 
 fever and diphtheria do not pass from one tenement 
 to another in the same house unless there is an actual 
 
OF TUBERCULOSIS. 15 
 
 passage of infected persons. The carrying of con- 
 tagion from the sick to the well by a third person is 
 not common. Physicians rarely carry contagions dis- 
 eases. 
 
 It seems most reasonable to jjelieve that the majority 
 of cases of consumption are due to primary infection 
 of the pulmonary tissue, but this is by no means 
 proved. It may be that future investigation may 
 change this view. Even now, there are man}' who 
 hold to the contrary. Knopf believes that fully as 
 many cases of tuberculosis receive their infection 
 through the alimentary canal as through the respira- 
 tory mucous membrane. 
 
 Third, through the a/lnteutari/ tract. 
 
 Medical literature contains the record of many cases 
 of tuberculosis which are presumably due to infection 
 • through the alimentary canal, usually from the in- 
 gestion of milk supposed to be tuberculous. Some- 
 times, however, as in cases reported by Sherman of 
 San Francisco, the infection was caused by kissing or 
 putting infected articles in the mouth. In many of 
 these reported, the evidence of the source of the in- 
 fection was bv no means certain, and in not a few of 
 them, infection through the alimentary canal was a 
 possibility rather than even a probal^ility. Ernst re- 
 ceived 1,013 answers to a circular sent out to physicians 
 and veterinarians, asking for reports of cases of tuber- 
 cular infection through the medium of milk. Although 
 (juite a number of cases were reported, it was not 
 possible in many of them to exclude, with any degree 
 of certainty, other sources of infection. It is thus 
 seen that clinical evidence of infection through the 
 
16 THE STATE CONTROL 
 
 alimentary canal is not very strong. But such a result 
 might well l)e expected. It is ditticult to trace con- 
 tagion in any disease, and particularly so in tubercu- 
 losis, a disease which is slow in developing, and which 
 is extremely common. 
 
 There is certain statistical evidence which indicates 
 that infection frequently takes place through the ali- 
 mentary canal, probably by the ingestion of milk. 
 Tubercular disease of the digestive organs is much 
 more frequent among young children and particularly 
 infants under the age of one year than at any other 
 age. Such children, of course, live largely on a milk 
 diet, and if tuberculosis is transmitted through the 
 medium of milk, we should expect intestinal and 
 similar forms of the disease to be more prevalent at 
 these ages. Again, statistics show that intestinal 
 forms of tuberculosis have not, of late years, diminished 
 nearly as much as has the pulmonary form. The re- 
 port of the Royal Commission states that tuberculosis 
 among children under one year of age has actually 
 increased in England and Wales. In most places, how- 
 ever, cases in infants have diminished somewhat in 
 frequency. It is not, of course, to be assumed that all 
 cases of tuberculosis in young children are due to milk 
 infection. Yet as there is good reason to believe that 
 tuberculosis among dairy animals has of late years in- 
 creased, the fact that tuberculosis retains a stronger 
 hold in infancy than in later life, tends to support tlie 
 view that, in the young, milk infection is no incon- 
 siderable source of the disease. 
 
 The following table illustrating the distribution of 
 the different forms of tuberculosis in Glasgow, also 
 throws some light on this sul)ject : 
 
OF TUBERCULOSIS. 
 1890-5. GLASGOW Death Rates Per 100,000. 
 
 17 
 
 
 tr. 
 
 < 
 
 •2 
 
 Other Tubercular 
 Diseases. 
 
 All Tubercular 
 - Diseases. 
 
 i 
 
 
 CORRECTED FOR AGE 
 DISTRIIU'TION. 
 
 
 City 
 
 Average of three districts 
 with 
 
 (1) Highest death-rate from 
 Phthisis 
 
 (2) Phthisis death rate near- 
 est mean of city 
 
 (3) Lowest Phthisis deatli- 
 rate 
 
 2,336 
 
 3,256 
 2,197 
 1,692 
 
 230 
 
 328 
 213 
 157 
 
 91 
 
 125 
 95 
 67 
 
 321 
 
 454 
 309 
 225 
 
 28.3 
 
 27.5 
 30.9 
 30.2 
 
 
 
 It is seen that all tubercular deaths most prevail 
 where the general death rate is greatest, and there also 
 phthisis is most prevalent, but the other tubercular 
 diseases are relatively less prevalent than in other dis- 
 tricts where there is not only less phthisis, but a much 
 better condition generally, as is indicated by the 
 general death rate. It can scarcely be maintained, 
 therefore, that the other forms of tubercular disease 
 occur as a direct result of the frequency of infection 
 afforded by the prevalence of phthisis. Chalmers who 
 prepared tlie above table states that in the l)etter class 
 districts there is a greater consumption of milk than in 
 the slums, where the other tubercular diseases form a 
 relatively smaller proportion of the tul)erculous death 
 rate. 
 
 Woodhead states that of 127 cases of tuberculosis in 
 children, in which autopsies were made, the mesenteric 
 ulands were involved in 100. He assumes from this 
 
18 THE STATE CONTHOL 
 
 that the source of iiit'eetioii in these 100 cases was, in 
 all probability, through the intestines. In fact, in 
 many cases, he conld trace the infection from the in- 
 testinal wall up through the mesenteric glands to 
 distant organs of the Ijody. Woodhead also believes, 
 from pathological e\idence, that infection not rarely 
 takes place through the tonsils, this often being the 
 soiuTe of the tul)ercTdar infection of the cervical 
 glands. 
 
 A great deal of experimental work has been done 
 upon the jiroduction of tuberculosis hy way of the 
 alimentary canal. A good many examinations have 
 been made to determine the frequency Avith which 
 tubercle bacilli may he expected in the milk supply. 
 There has been much discussion as to the occurrence 
 of the bacilli in the milk of tul)erculous animals. It 
 has been claimed hy some that they will not ])e found 
 in the milk unless the udder is iuAohed ; Init it has 
 been shown that this is not true. Milk is much more 
 likely to Ije tuberculous when the udder is seiiously 
 involved, Init it does occur when no signs of disease 
 can be detected. Ernst examined microscopically the 
 milk of thirty-six animals, which were tuberculous but 
 had sound udders and found bacilli in the milk of 
 twelve. They were found equally in the milk itself 
 and in the cream. In fifty-six samples of milk and 
 thirtv-three sami)les of cream, taken from the general 
 supply of the Cit}' of Boston, no bacilli Mere found on 
 miscroscopical examination. The most certain way of 
 detecting the presence of tubercle bacilli in milk or, in 
 fact, in any material is by inoculating the same into 
 animals. Ernst found in twenty-five inoculation ex- 
 periments performed with milk from the Boston supply, 
 
OF TIBEIICULOSIS. 19 
 
 tliut three gave jKJsitive results. Kaiitliaek, experi- 
 menting in Camljridge, England, found infection in 
 nine out of sixteen dairies supplying that town. The 
 milk, however, was not very thoroughh' impregnated, 
 as only a very few of the animals inoculated succmnljed 
 to the disease. It has been shown experimentally in 
 reii;ard to the tuljercle Ijacillus in milk as, indeed, it 
 has to the cultures of many other bacteria, that the 
 greater the dilution and the smaller the dose, the less 
 the chance of infection. 
 
 Kanthack. as well as p]rnst, has shown that the 
 Ijacilli are found in cream as well as in the whole 
 milk, l)ut when milk is put through a centrifugal 
 machine, the larger ptirt of the bacilli are renio\ed in 
 the sediment. Experiments in Germany have shown 
 that butter may contain tubercle bacilli. 
 
 A number of other experimentors, as well as Ernst, 
 "have found 1)acilli in milk, when the udders were 
 apparently healthy, and. in fact, when tuberculosis 
 could only be detected by the tuljerculin test. It 
 must l)e admitted, then, that we have pretty strong- 
 evidence that if a dairy herd has in it tuberculous 
 animals, the milk fnjm that herd stands a very good 
 chance of being infected. The more disease there is 
 in the herd, and the farther advanced it is, the greater 
 the danger. ~- 
 
 The fact that tul)ercle bacilli are found in milk and 
 may, by injection into the lower animals, cause tuber- 
 culosis, does not prove that milk would cause the disease 
 if taken into the alimentary canal. Of course, many 
 feeding experiments have Ijeen undertaken with milk 
 and other products from tuberculous animals. These 
 have not always been successful. Smith, Law, Nocard, 
 
20 THE S'I'ATE COXTL'OL 
 
 and McFadyeaii coidd not infect rabbits and gninea 
 pigs by feeding tbem witb milk winch was known to be 
 tubercnlons. Pencil, for two months, fed two pigs 
 with milk that, by injection, prodnced tnbercnlosis in 
 rabbits, withont prodncing any effect npon the pigs. 
 Gerlach also was sometimes snccessfnl and sometimes 
 not. On the other hand, many feeding experiments 
 have been snccessfnl. Ernst, nsing milk from tuber- 
 cnlons animals with apparently healthy udders, pro- 
 dnced tu])erculosis in two out of forty-eight calves fed 
 with it. He also infected five out of twelve pigs ; and, 
 in another series of experiments, eight out of tAventy- 
 one calves. Law reports three calves which had milk 
 from sound udders, but became tuberculous. Pearson 
 fed pigs with milk known to be tuberculous, and the 
 animals apparently got fat upon it, Init wdien killed 
 were found to Ije infected. He saj^s instances are not 
 rare in which calves and swine fed with skim milk 
 from a creamery, have developed tul^erculosis on farms 
 that are otherwise free from this disease. 
 
 The evidence, then, seems to ))e that milk of tuber- 
 culous animals is quite likely to be infected, and that if 
 infected it frequently produces tuberculosis in other 
 animals, even of a different species, wliicli partake ui 
 it. If milk can infect human lacings as it does calves 
 and swine, it is certainly dangerous to use in a raw 
 state the milk from tuberculous animals. While we 
 have no incontrovertible evidence that bovine tul)er- 
 culosis is thus transmitted to man, it is extremely 
 probable that it is so. We certainly have very little 
 evidence that it is not, and it would require prett}- 
 strong evidence to show that a disease which can l)e 
 carried over from cows to swine, rabbits, guinea 
 
OF Tl'BEROULO.SIS. 21 
 
 pigs and iiiaiiy other species, cannot he transmitted to 
 Mian. 
 
 There has jjeen a great deal of discussion as to the 
 danger from the nse of meat from tuberculous animals. 
 As the tubercle ))acillus is killed by a moderate deo;ree 
 of moist heat, we can probably safely assume that, in 
 the majority of cases, even if Ijacilli are present in 
 meat, they will be destroyed by cooking. Experi- 
 ments, however, to substantiate this view, are much to 
 ])e desired. In cases where the lungs chiefly are in- 
 volved and the disease has not progressed too far, 
 there is not much likelihood of the muscles being in- 
 fected. In fact, it is very unlikely that the muscular 
 tissue itself will be. infected at all, but when there is 
 a tendency to generalization of the disease, the small 
 glands between the muscles or their fasciculi may be 
 involved. In such cases^ it would be dangerous to eat 
 the meat in a raw state. Feeding experiments have 
 been conducted upon animals with little positive re- 
 sult. Pencil succeeded in infecting two pigs, but only 
 after feeding them for v. long time. Nocard was un- 
 successful, as also were Touissant, Chaveau, Arloing, 
 Martin, and Yallin. 
 
 Perroncito fed eighteen pigs for from three to five 
 months witli condemned tuberculous meat, but none of 
 them were mfected. It would appear that the danger 
 of infection by meat of tul)ercidous animals, at least 
 unless the disease has progressed very far and is much 
 generalized, is not very great. This view is held by 
 many leading veterinarians. It is the practice of many 
 not to condemn the flesh of tuberculous animals wlien 
 the disease is circumscribed. In Saxony, the govern- 
 ment inspectors permit the sale of the larger portion 
 
22 THE .statp: control 
 
 of the llesli of tuhcrculoiis ;iiiiiiials killed at tlie ahat- 
 toirs. This meat, however, is sold on its merits as 
 eoming from tiihereuloiis animals. At the Brighton 
 abattoir, a considerable ])()rtion of the tnberculous 
 ammals their slaughtered are allowed to go upon the 
 market. 
 
 METHODS OF CONTROL ALREADY ADOPTED. 
 
 Notificntion. 
 
 An important step in the control of other infections 
 diseases is the report of cases of the disease to the 
 sanitary authority. This is desired, in order that the 
 cases may be studied and more may l)e leai-ned of the 
 way in which the diseases are spread, and, in order 
 that any necessary methods of restriction may be 
 applied to each individual case. It would appear that 
 notification is as necessary in tuberculosis as in other 
 diseases. In this country, notification has been I'e- 
 quired in a numljer of states and cities. Sometimes it 
 applies to phthisis alone, and sometimes to all tuber- 
 cular diseases. Notification was first required in the 
 City of New^ York, and, at present, is a requirement of 
 the State law in Maine and Michigan, and of the nruni- 
 cipal regulations of Alameda, California ; Buffalo, Cin- 
 cinnati, the City of New York, Salt Lake City, and 
 Yonkers. In these regulations the requirement ap})lies 
 only to i)hthisis. Tuljerculosis is to l)e reported by the 
 State law of Washington and by the regulations of 
 Asbury Park, Minneapolis, San Francisco, and Syracuse. 
 A recent decision of the Supreme Court of Michigan 
 has affirmed the validity of the law in that state. The 
 followinjj: is the rule in the City of New York : 
 
OF TIBERCULO.SIS. Zo 
 
 City of Xew York, Sanitary Code, 1899, Section -ui : 
 
 Section lo^J. That pnhnonary tuberculosis is herein' dechired 
 to 1)6 an infectious and communicable disease, daiijierous to the 
 public health. It shall be the duty of every physician in this city 
 to report to the Sanitary Bureau in writing the name, age, sex, 
 occupation and address of every jierson having such disease who 
 has been attended by or who has come under the observation of 
 such physician for the lirst time, within one week of such time. 
 It shall also I>e the duty of the commissioners or managers, or 
 the jirincipal, superintendent or physician of each and every 
 public or private institution or dispensary in this city to re})ort 
 to the Sanitary Bureau in writing, or to cause such report to l)e 
 made by some })ro}»er and competent ]>erson, the name, age, sex, 
 occupation and last address of every person afflicted with this 
 disease who is in their care or who has come under their obser- 
 vation within one week of such time. It shall be the duty of 
 every jierson sick with this disease and of every person in 
 attendance upon anyone sick with this disease, and of the 
 authorities of public and private institutions or dispensaries, to 
 observe and enforce all the sanitary rules and regulations of the 
 Board of Health for preventing the spread of pulmonary tu])er- 
 culosis. 
 
 These laws and regulations are not Avell enforced. 
 The Secretary of the State Board of Health of Michi- 
 gan informed the writer that probably not one-cjuarter 
 of all the cases appearing in that state are reported, 
 and the board of health of Buffalo report that notice is 
 rarely recei^^ed of a case except when a physician sends 
 in sputinn for examination. In Michigan, whenever a 
 case of consumption is reported from a town, the 
 health officer is required to fill out a Ijlank, stating a 
 large nmnber of facts in regard to the history of the 
 case, possible sources of infection, and methods taken to 
 ]'estrict the disease. On the death of the patient, or re- 
 covery, if recovery takes place, another and final report 
 
24 THE STATE (ONTKOL 
 
 is to be made, giving fucts of inteniiediate history and 
 whether or not disinfection was done. No verv valu- 
 able results have, as yet, been obtained from these 
 investisrations, as onh* a few of the rm-al health officers 
 can be expected to 1)e skilled enough to investigate the 
 cases properly. In New York City, careful record is 
 kept of all cases reported, and, owing to the active 
 interest taken by the health department of that city, 
 more cases are reported there than elsewhere, so that, 
 of late, the number of cases reported has exceeded the 
 number of deaths. A careful record is kept of all cases, 
 and their location is also noted on a map. A study of 
 this map has shown that phthisis prevails to a much 
 greater extent in some districts, and in some houses, 
 than it does in others. 
 
 Notification presupposes correct diagnosis. It is 
 generally admitted that the examination of the sputum 
 for tubercle bacilli is a great aid to diagnosis, though 
 it is to l)e feared that many physicians place too much 
 dependence upon a single negative finding. To assist 
 plivsicians, many states and cities olf'er laboratory 
 facilities for the examination of the sputum. 
 
 Education. 
 
 A great deal has been done, during the past ten 
 years, to educate the public to a knowledge of the 
 contagiousness of tuberculosis. Prol)aldy a large pro- 
 portion of intelligent people now imderstand that 
 tul)erculosis is contagious. A large part of this work 
 of education has been carried on h\ public health 
 officials, particularly those engaged in laboratory 
 work. It is to be feared, however, that some of the 
 teachingr has oone farther than the facts would warrant. 
 
 x^ '^'^" c 
 
OF TI'BERfrLOSIS. ZO 
 
 It is certain that tuberculosis is contagious, but, as we 
 have seen, the exact path of infection is not perfectly 
 known. Nevertheless, dou'inatic statements have been 
 verv common as to the great danger of breathing 
 tuberculous dust, of drinking tuberculous milk, and 
 of eating the iiesh of tul)erculous cattle. It is true, 
 however, that most of the extravagant statements in 
 regard to these matters have not emanated directly 
 from the Ijacteriologists. The pul)lic press, and pseudo- 
 scientists generally, have sometimes misunderstood the 
 meaning of the work of scientific investigators, and 
 have made too much of what are, perhaps, the least 
 important patlis of contagion in this disease. The 
 daily press is of great assistance in sanitary education, 
 but its powers should be called into play with consider- 
 able care. One of the most common and useful means 
 of education in such matters is the distribution of cir- 
 culars of information. Such circulars, explaining the 
 nature and methods of the spread of tuberculosis, have 
 Ijeen issued hy many health officials and l)y the 
 societies for the suppression of tuberculosis. One of 
 the first and best of these circulars was that issued by 
 the Board of Health of New. York City. At present, 
 such circulars are issued by the State Board of Healtli 
 of California, Colorado, Connecticut, Delaware, Indiana, 
 Iowa, Kentiu^ky, Maine, Massachusetts, Michigan, New 
 Hampshire, New Jersey, New Mexico, New York, Ohio, 
 Rhode Island, South Carolina, Tennessee, Texas, \^ir- 
 ginia, AYest Yirginia, and Wisconsin. They are dis- 
 tributed by many local lioards of health in these states 
 m\(\ have been issued by cities outside of the states 
 mentioned, as St. Paul, Minneapohs, Chicago, St. Louis, 
 and Philadelphia. In New York City they are sent to 
 
26 I'lIE STATE CONTROL 
 
 the physicians for (Hstrihiition to their patients, and 
 tliis method is probaljly followed in most cities. In 
 Buffalo tliev are sent to all cases reported, or to tlie 
 friends of tlic patient. In New York City the sunnnei' 
 corps of physicians who visit among the poor, distri- 
 bute some o(),(JO(J annually. In Brookline, Mass., one 
 is sent to every family in the town. In Minnea])olis 
 one form of the circular is printed upon a card which 
 is to be hung in the room occupied by the patient. It 
 must be confessed that many of these circulars are not 
 very ^vell prepared, exaggerate very much some of the 
 means by wliich the disease is spread, pass lightly o^er 
 others, and suggest many unnecessary and impossible 
 things. 
 
 ControJ of expectoyat'ion. 
 
 At one time more importance was attached to the 
 spread of tul)erculosis 1)y the inhalati(ni of the dust of 
 the streets and public places than is at the present 
 time. As a result of the view that tuberculosis is 
 chiefly spread in this way, various ordinances have been 
 adopted to ])revent indiscriminate expectoration. The 
 first rule of this kind was that adopted by the Board of 
 Health of New York City, May 12, 1896. By this rule 
 it was forl)idden to spit upon the floor of the public 
 buildings, of railroad cars and ferry-boats. Rules 
 covering this sujjject have since been adopted l)y a 
 large numl)er of cities and towns and by the State Board 
 of Health of Indiana, but have not yet been incor- 
 porated into statute laws. Many of the rules go much 
 further than that of New York, and forbid spitting in 
 omnibusses, hacks, carriages, vehicles, steam-cars, or 
 any pul)lic conveyance, also in public halls, 'assembly 
 
OF TUBERCULOSIS. li 
 
 rooms, shops, stores, halls, i-ailway stations, churciies, 
 sehoolhouses, and other })Lil)lie places. Some of the 
 rules go further still, and forhid the spitting upon the 
 sidewalk, as in Cincinnati, Cambridge, Colorado 
 Springs, l^rookline. Providence, Springfield, and 
 Rochester. The following is the rule in Cambridge, 
 and perhaps is as explicit as any : 
 
 Cambridoe ; Rules of the Board of Health, April 12, 1S99 : 
 
 The Board of Health hereby adjudoes that spitting upon the 
 floor, platform, or any other part of a public conveyance ; upon 
 the floor, steps, or stairs of any public building, hall, church, rail- 
 way station, or sho]> : upon the sidewalk of any street, court or 
 passageway; or ui)on the patlnvay of any park, square, or com- 
 mon is a nuisance, source of Hlth and cause of sickness, and pro- 
 hibits spitting in any and all such places. 
 
 Many of the rules require tliat copies of the rule 
 shall be conspicuously hung in public conveyances and 
 other public places. Most of the transportation com- 
 panies are very ready to do this, and have welcomed 
 the law, and have tried to enforce it. 
 
 Cases have Ijeen brought for violation of these rules, 
 and it is said that the courts have sustained them. It 
 requires a good deal of effort, however, on the part of 
 the police, to secure any permanency in this reform. 
 It is, perhaps, questionable whether rules of this kind 
 can be enac^ted as necessary for the preservation of 
 ])ublic health, but, fortunately, it is not necessary to 
 prove the exact i-(jle played by promiscuous spitting in 
 the production of tuberculosis to enact such legislation. 
 Promiscuous spitting is a nuisance and may be sup- 
 pressed on that score alone, thus enabling us to try a 
 very practical experiment as to the importance of one 
 alleged means of spreading tuberculosis. 
 
28 THE STATE CONTROL 
 
 The surest way to prevent expectoration in ])laces 
 where it may be dangerous is to keep consumptives 
 out of such phices. It is dou))tless for this reason that 
 Pennsylvania has passed a hiw forbidding tlie employ- 
 ment ])y bakers of persons having consumption, and 
 the sanitary code of Yonkers makes it a misdemeanor 
 for leakers or market-men to pursue their occupation if 
 they have this disease. 
 
 Very little lias Ijeen done Ijy any municipality to 
 control expectoration by regulating the conduct of the 
 individual. In New York City, wdien a case of con- 
 sumption is reported to the board of health, unless the 
 attendant physician recjuests otherwise, an inspector is 
 sent to the home of the patient and gives verljal direc- 
 tions how to dispose of tlie sputum without danger to 
 others. Subsequent visits are made to see that these 
 directions are carried out, and it is claimed that they 
 are in about one-half of the cases. Doubtless, all over 
 the land, educated physicians in private practice and 
 in charge of institutions, have done much to teach 
 patients in regard to this matter, and prol)a])ly have 
 accomplished far more than have the health officials. 
 
 Disinfection. 
 
 Experiments have shown that it is ([uite possible 
 that the apartment occupied by a consumptive patient 
 may become infected with the germs of the disease. 
 Scrapings have Ijeen taken from the Avails and furni- 
 ture of such apartments, and have Ijeen found to 
 contain bacilli. There is not, however, much clinical 
 eA'idence that such apartments may be the cause of 
 spreading the disease. The investigations of Flick, in 
 Philadelphia, and of the board of health in New York 
 
OF TUBERCULOSIS. 29 
 
 City, show that certain houses appear to be the homes 
 of tuberculosis. Certain houses have had cases in 
 them for a long series of years. A minority of the 
 houses furnish a majority of the cases. There are few 
 cases on record, however, where a tubercular family 
 has removed from a house and a non-tubercular family 
 entered it and Jjecome infected. A case of this kind 
 has recently been reported in the Indletin of the Ohio 
 State Board of Health. But such cases are not more 
 numerous than could reasonably he explained as coin- 
 cidences. 
 
 Still, it nnist be admitted that there is some chance 
 of the disease Ijeing spread in this manner, so that it is 
 advisable to disinfect premises that have been occupied 
 by consumptives before they are occupied by others. 
 This is commonly done by municipal boards of health, 
 when requested ))y the family, and such requests are 
 becoming quite common. Doubtless, alsO, many per- 
 sons thoroughly cleanse the premises, practically disin- 
 fecting them, without calling upon the health otiicers. 
 A few cities, notably New York, require the disinfec- 
 tion of such premises ; but the method prescribed is 
 cleansing, rathei- than disinfection. It is required that 
 all walls and woodwork shall be washed with washing 
 soda, one-half pound to a pailful of hot water, and then 
 the room is repapered, whitewashed or kalsomined. 
 Occasionally goods are taken away and steamed. 
 
 HospltaU. 
 
 It is considered that isolation hospitals are a neces- 
 sity for the control of communicable diseases. If they 
 are needed in scarlet fever, diphtheria and small-pox, 
 thev are needed still more in tuberculosis. Jn tuber- 
 
30 THE .STATE CONTROL 
 
 ciilosis, far more than in any otlior disease, does the 
 welfare of the })atient depend npon hospital treatment. 
 By going to a hospital, not only does a patient avoid 
 all danger of giving the disease to others, but he 
 stands a nnich Ijetter chance of getting well. There 
 are not many hospitals for consimiptives in the United 
 States, and some of these are designed more as homes 
 of refuge for the inciu-al)le poor than as true sanatoria. 
 In Germany the use of hospitals for the cure of con- 
 sumptives has been known for a long time. There are 
 many such hospitals, and many patients are cured in 
 them. Knopf says that cures can be obtained in from 
 25 to 50 per cent, of the ca^es. Of 5,032 patients at 
 Goerbersdorf, in Germany, from 1876 to 1886, 11 per 
 cent, were reported as cured, and 15 per cent, as 
 almost cured. Of 1,390 received during the first 
 stage of the disease, 27 per cent, were cured, and 31 
 per cent, almost cured. The other German sanatoria 
 report cures of from 14 to 27 })er cent. Several French 
 sanatoria report cures of from 21 to 50 per cent. The 
 Loomis sanitarium in New York reports 25 per cent, of 
 cures and 50 per cent, of ameliorations. The Saranac 
 sanitarium reports 20 to 25 per cent, of cures. At 
 Chestnut Hill, Philadelphia, where patients in all stages 
 are received, there are 8 per cent, of cures and 11 per 
 cent, of ameliorations. Perhaps the most striking 
 proof of the ^-alue of hospital treatment is shown hy 
 the action of the st?ite-aided insurance companies of 
 Germany. These companies Hnd it for their advan- 
 tage to send their policy holders who become phthisi- 
 cal, to sanatoria, and to pay their board while there. 
 During 1898, Ijetween three and four million marks 
 were expended for that purpose. It has Ijeen shown 
 
OF TrCERCULOSIS. 31 
 
 that it is not necessary to go into deejj forests or high 
 mountain regions to secure a good location for a con- 
 sumptive hospital. Dry and somewhat isolated situa- 
 tions can be found, suital)le for these hospitals, within 
 a few hours' journey of nearly all our cities. Consid- 
 erable difticulty has. at times. l)een found in seeming 
 a site for such hospitals, the people of the locality tear- 
 ing: it mav be the means of introducino- contao-ion. 
 This fear is unfounded. The care which is exercised 
 in hospitals to prevent the spread of contagion is 
 etfectual. It is shown that at Goerbersdorf and Fal- 
 kenstein, the death rate from phthisis has diminished 
 from 18 to 11 per cent, since the sanitoria were estab- 
 lished. 
 
 Hospitals not only help to cure a patient and keep 
 him from infecting others, but they teach him habits 
 of care in regard to the disposal of spntmn, and in 
 •other ways instruct him in the principles of hygiene, 
 so that when he leaves the hospital he is much more 
 likely than liefore to lead a healthful life and to avoid 
 infecting others. 
 
 The cost of treatment in hospitals designed for the 
 care of consumptives is not far from the cost in gen- 
 eral hospitals. The cost in the German hospitals is 6(1 
 to 80 cents per day; the cost in St. Joseph's Hospital, 
 New York Ci^y, is 50 cents ; and of the Chestnut Hill 
 Hospital in Phihxdelphia, 40 cents. These hospitals, 
 however, do not offer the best facilities. The cost at 
 Saranac Lake is from $1 to |1.2o ; at the Loomis San- 
 itarium, $1.43 ; at the Cincinnati Hospital, about 
 .$1.25. The exact figures for the hospital in Massa- 
 chusetts are not given, but are apparently considerably 
 greater. Knopf says it is more economical for the 
 
32 THE STATE CONTROL 
 
 municipality to care for its phthisical poor in special 
 sanitaria than it is in general hospitals. The initial 
 cost may be somewhat greater, but the length of stay 
 is pretty certain to 1)e less, and, in the aggregate, 
 many years of useful life will be preserved to the 
 community. 
 
 Considering tlie advantages wliich are secured hy 
 hospital treatment, it is rather remarkaljle that in this 
 country so little has been done l)y the state to furnish 
 it. The first and only municipal liospital for the care 
 of consumption, with which the writer is ac([uainted, 
 was that at Cincinnati. This is a substantial brick 
 Ijuilding in the suburbs, jjuilt for a, smallpox hospital, 
 but devoted to the care of consumptives since July 8, 
 1897. The hospital and other buildings, exclusive of 
 land, cost about |rSO,000. 
 
 During the first two years that the building was 
 occuj)ied, 330 patients were treated. The visiting 
 physician. Doctor Lyle, reports some cures and many 
 improvements, but he has not been able to follow the 
 cases very carefully after their discharge. This hos- 
 pital, however, is not intended so much as a curatixe 
 institution as an isolation hospital to which patients 
 may go instead of entering the general hospitals of the 
 city. 
 
 Massachusetts has set the example for the establish- 
 ment of State hospitals. The Massachusetts Hospital 
 is at Rutland, in that State, and was opened for the 
 reception of patients on Oct. 1, 1898. It is intended 
 to accommodate 200 patients, and cost over $150,000. 
 It is intended for patients in the early stages of the 
 disease. There is a uniform charge made of 50 cents 
 per day, but poor patients may l)e admitted without 
 
OF TUBERCULOSIS. 33 
 
 charge on application of the poor department of the 
 town to which they belong. Of conrse, this board 
 does not begin to pay the running expenses, and these 
 are met by State appropriation. 
 
 Control of Milk Supply. 
 
 It is, of course, useless to attempt to secure a milk 
 supply which shall be free from tuberculous taint, 
 except by inspection and control of the dairies from 
 which the milk is derived. As yet, not very much 
 has been done along this line, in the United States. 
 In New Jersey and Wisconsin the laws permit of the 
 inspection and licensing of dairies. In Minnesota a 
 somewhat recent law confers upon cities the authority 
 to license milk producers, and inspect and test dairy 
 cows. This law has been tested and its validity 
 upheld by the Supreme Court. Notwithstanding the 
 dearth of specific legislative authority, a considerable 
 number of cities have taken more or less enero-etic 
 
 o 
 
 action, looking to the supervision of the sources of 
 their milk supply. In some, the action taken is 
 merely one of inspection, advice and publicity ; in 
 others, control is exercised over dairies within tlie 
 jurisdiction of the municipality. In others, the at- 
 tempt is made to control all the sources of milk supply 
 of the city.^ 
 
 It is necessary, first, to obtain a knowledge of all 
 the dairy cattle supj^lying the city. To accomplish 
 this, every dealer must be licensed and must keep the 
 authorities informed of the location of every herd 
 from which he obtains milk. This method is followed 
 in New York, Minneapolis, St. Paul, the District of 
 
34 THE STATE CONTROL 
 
 Columbia, St. Louis, Buftalo, Lynn, Nashua, Portland, 
 and other cities. 
 
 The second step is to provide for an inspection of 
 the herds and dairies from which the milk is derived. 
 Sometimes this inspection is confined to the limits of 
 the city, as it is in New York, Baltimore, Cincinnati, 
 and the District of Columbia. Of course, such local 
 inspection cannot accomplish much. Every herd sup- 
 plying the city should ])e controlled. Among cities 
 which have attempted to inspect every herd supplying 
 the city may be mentioned Portland, Lynn, Nashua? 
 Rochester, the District of Columbia, Minneapolis, St. 
 Paul, St. Louis and San Francisco. 
 
 Lastly, it is necessary to test with tuljerculin ever}^ 
 animal from which the municipal supply is derived. 
 By licensing dealers, by registering jDroducers, by in- 
 specting their herds, by testing the cattle witli tuber- 
 culin, and condemning all infected animals, hy tagging 
 the animals so that they may be identified, and by re- 
 inspecting, at intervals, the milk supply may be kept 
 free from tuberculosis. This method has, at present, 
 been successfully adopted only in Portland and Westr 
 brook, Me. ; in Lynn, in Minneapolis, and St. Paul. 
 Such drastic methods are sure to meet with great 
 opposition, and permissive legislation is difficult to 
 obtain. The attempt was made in the District of Col- 
 umbia, and San Francisco, but Avas a failure. In 
 Massachusetts, also, the authority was sought by which 
 local boards of health could, in this manner, control 
 the milk supply, but it was successfully of)posed by 
 the milk dealers and producers. 
 
 The attempt has been made in New Orleans, St. 
 Paul, Indianapolis, and, doubtless, in other cities, to 
 improve the milk sup]3ly by moral agencies. The 
 
OF TUBERCULOSIS. 35 
 
 municipal authorities offered to test tlie dairyman's 
 herd and certify to those which were found healthy. 
 Few, howeyer, took adyantage of the offer, for they 
 did not find that the expense and trouble were com- 
 pensated by increased custom. This method, howeyer, 
 was successful in Indianapolis, where nearly all the 
 dairymen liaye yoluntarily sul)jected their animals to 
 inspection. In 8t. Paul, on the other hand, the city 
 was obliged to resort to compulsory methods. The 
 limited demand for "certified milk" shows that the 
 public is hardly ready to ask for clean milk, or willing 
 to i^ay for it. 
 
 The Eradication of Tuherculosis in Cattle. 
 
 If it is true, as is not improbable and as many would 
 haye us belieye, that a large part, perhaps eyen half, 
 of human tuberculosis is deriyed from cattle, an impor- 
 tant step in controlling the disease in man is to get 
 rid of it in animals. It may. perhaps, be admitted 
 that the eyidence is not strong enough to warrant our 
 taking the radical ste'ps necessary to get rid of tuber- 
 culosis, on account of its danger to human beings. ])ut 
 there are other and ample reasons why the State 
 ^should seek to free its herds from tuberculosis, as it 
 has from pleuro-pneumonia and other infectious dis- 
 eases. In/this work, howeyer, the co-operation of the 
 dairyman and farmer cannot be expected, as it maybe 
 in the acute diseases. Tuberculosis is a chronic aft'ec- 
 tion. The cattle owner can detect it long before 
 death, make use of the milk for a considerable period 
 of time, and finally sell the animal for slaughter, at a 
 small loss, or perhaps no loss at all. The trouble and 
 ■expense incurred in entirely freeing a herd from 
 
36 THE STATE CONTROL 
 
 tuberculosis are considerable, and the average man 
 who hesitates to incur a momentary loss for the sake of 
 future gain, had rather take the chances of losing 
 a little money now and then on a cow, than of going 
 to the trouble of getting rid of the disease altogether. 
 Nevertheless, the aggregate loss from tuberculosis is 
 enormous, and the State would be justified in making 
 large expenditures to exterminate it. 
 
 Various plans have been suggested and tried for 
 getting rid of tuberculosis in cattle. The most radical 
 measures were those adopted in Massachusetts, where 
 the plan was adopted of inspecting every animal in 
 the State, and killing and destroying all which reacted 
 with tulierculiu. Large sums of money were ex- 
 pended, great opposition was aroused, and the plan 
 had to be abandoned. A somewhat similar, but less 
 rigorous method, was adopted in Belgium, in 1896, 
 but it also has been modified. In Baden, herds from 
 which tuberculous cattle are reported by the meat 
 inspectors are examined and measures taken for the 
 suppression of the disease at the expense of the state. 
 In Baden, as in Saxony and other parts of Germany, 
 a part of tuberculous meat is used as food. In France, 
 also, the flesh of tuberculous animals is not always 
 condemned, though animals that are discovered to be 
 tuberculous are always killed. In Denmark, the state 
 offers to test herds for their owners, and tuberculous 
 cattle are killed if the disease is far advanced, and 
 their flesh is then destroyed. In the early stages of 
 the disease the animals may be kept in quarantine, or 
 they may be slaughtered and are largely used for 
 food ; Ijut the milk and cream of quarantined animals 
 cannot be used without pasteurization. A similar 
 plan has been adopted in Norway. 
 
OF TUBEECULOSIS. 37 
 
 It is of specital interest to us to know what is Ijeing 
 done in the United States. 
 
 The importation of tuljerculons cattle into the 
 United States is guarded against by the inspectors of 
 the Bureau of Animal Industry. While this bureau 
 might under the laws attempt to prevent the passage 
 of tuberculosis from one state to another, it has not 
 yet had the means for doing so. This is at. present 
 controlled by the states, and eighteen of them have 
 laws respecting it, among which are Maine, New 
 Hampshire. Vermont, Massachusetts, Rhode Island, 
 New Jersey, Pennsylvania, Iowa, Montana, and Texas. 
 A common form of the law is that requiring that no 
 animal shall l)e imported without a certificate that it 
 has been inspected and tested with negative results. 
 In Texas cattle must not be imported for breeding or 
 dairy purposes, and an exception is made in favor 
 of animals certified to as natives of Colorado or Ne- 
 Ijraska. In New Hampshire animals may be brought 
 in for pasturage only, without the tuberculin test, 
 provided they are sound on physical examination. In 
 Connecticut, when any one imports cattle from an 
 adjoining State he must, within six days, notify the 
 commissioner on domestic animals. 
 
 Very little work has l^een done in eradicating l^ovine 
 tuberculosis Ijy municipal health officers except in 
 connection with the protection of the milk supply. 
 Nearly all the active work, except in a few cities as 
 New York. Minneapolis, St. Paul, Indianapolis, Roch- 
 ester and Lynn, has been done by state boards. Some 
 of this work is done by l^oards of cattle commissioners 
 and some by state boards of health. Much of the 
 following summary is taken from the seventh annual 
 report of the state veterinarian of Maryland. 
 
38 THE STATE CONTROL 
 
 3IassachHsetts. Under Chapter 491, acts of 1894, 
 some 465 inspectors were apjDointed, whose duty it 
 was to inspect cattle and stables, and report the occur- 
 rence of any contagious disease. All cattle visibly 
 affected with tuberculosis were killed and paid for, 
 while many w^ere tested at State exj)ense at a cost of 
 $240,737.84. This does not include the cost of test- 
 ing many more cattle, which was made at the expense 
 of individual owners. 
 
 Condemned cattle were paid for upon written applica- 
 tion for the test to be applied, and upon the provision 
 to thoroughly disinfect their premises, and to introduce 
 none but cattle tested (at owner's expense) in future. 
 This led to an order that cattle to be paid for must be 
 tested Ijy the cattle commissioners or their authorized 
 agent. The large amount of money spent and the 
 numl:>er of animals destroyed caused great opposition 
 and resulted in a change of policy. It is now ref[uired 
 by law that each town and city shall appoint an in- 
 spector who will act in conjunction with the state board. 
 
 This work may be considered under three heads : 
 
 1. The supervision of the traffic in live cattle 
 brought into the State. 
 
 2. A general inspection, the examination of cattle 
 quarantined as diseased by the local inspectors in the 
 various cities and towns, and the payment for those 
 found to be infected with tuberculosis. 
 
 3. Testing entire herds for the purpose of perma- 
 nently eradicating tuberculosis from the premises. 
 
 In 1899, $75,000 was appropriated and only|50,000 
 was to be asked for the next }' ear ; 785 tuberculous 
 animals were killed, for which $17,277.69 was paid ; 
 565 animals were tested for owners who Avere trying 
 to free their herds, and of these 63 were condemned. 
 
OF TUBERCULOSIS. 39 
 
 Maine. Maine was the first of the New England 
 States to adopt the system of placing quarantine on 
 the admission of out-of-state cattle. The law was 
 first enforced in 1802 against Massachusetts, because 
 of the large per cent of Massachusetts cattle that were 
 found diseased. Later it was placed on all out-of-state 
 territory, except on such animals as were provided 
 with certificates of the tuberculin test. The authori- 
 ties in Maine test lierds only on the voluntary applica- 
 tion of the owner. The owner to receive one-half the 
 value, as determined on the basis of health before 
 infection, the limit of compensation being $100 for 
 pedigreed animals and |50 for others. The commis- 
 sion have power to investigate as to the existence of 
 disease and to condemn and destroy such as show 
 physical evidence of disease. During the year 1898, 
 415 head of -cattle were destroyed at an appraisal of 
 $18,122. 
 
 Vermont. Vermont, with its small percentage of 
 diseased animals, has probably been more successful 
 than any other State in its attempts to control tuber- 
 culosis. Since Feb. 1, 1897, 60,000 have been tested, 
 and 2,360 have been found diseased and killed, a 
 percentage of disease of nearly four per cent. In 
 Vermont i^o animals are tested unless the owners 
 allow the entire herd to be tested, and thereafter every 
 animal admitted to the herd must be tested and the 
 stables thoroughly disinfected. The commission test 
 only where application is made by the owner. In 
 their annual report a list of seventy-eight retested 
 herds is given, in which tuberculous animals were 
 found. Twenty-three herds were found free on the 
 second test, and twenty-three had only one case each 
 on the second test. Eight of the remaining herds that 
 
40 THE STATE COXTHOL 
 
 were found diseased on the second test were free on 
 the tliird test. The report states that " the proper dis- 
 infection is a more diffienlt matter tlian is the discovery 
 of the diseased animal."' 
 
 The commissioners have found that cattle Ijuyers 
 from States where no ({narantine was enforced have 
 purchased many suspected animals at a price a little 
 less than would have been paid if not suspected. 
 
 New Hampshire. Diseased animals are reported to 
 the commission through the selectmen, and are released 
 or condemned on physical examination. 
 
 When the owner applies for inspection of his herd, 
 and where there is reason to believe the disease exists, 
 the board may treat the entire herd, the owner receiv- 
 ing half compensation. In 1808,225 herds were tested 
 and 148 animals killed for which $2,894 was paid. 
 
 Hhode Island. Rhode Island has a commissioner in 
 each county, appointed by the l)oard of agriculture, 
 whose duty it is to inquire into the condition of any 
 animal in their county whenever there is any reason to 
 suspect tuberculosis. When any animal is thought to 
 be tuberculous by a commissioner, he shall immediatel}^ 
 quarantine and examine. In 1 898, 49G animals were 
 killed for which $9,014.50 was paid. 
 
 JVeiD Yorli. In New York state, tuberculosis in cat- 
 tle is handled l)y a tuberculosis committee of the state 
 board of health. No appropriation has been made by 
 the legislature for the use of this committee and no 
 cattle have been ordered killed, except where the owners 
 have waived all right to compensation. The commit- 
 tee, however, have received many requests from owners 
 asking to have their herds tested ; and also test the 
 animals belonging to public institutions. 
 
OF TUBERCULOSIS. 41 
 
 JVew Jersey. New Jersey lias a commission of seven 
 members. The commission, on application from the 
 owner, the state board of health or the state dairv com- 
 mission, will make an examinatien of suspected herds, 
 the reacting animals to be condemned and killed. 
 They are appraised at their market value, not exceed- 
 ing forty dollars, the owner receiving compensation at 
 the rate of three-fourths of their valuation. In 1898 
 there were tested 1,438 cows, of which 245 were con- 
 demned. The cost of inspection was $1,179, and the 
 amount paid for the cows was $5,098.20. 
 
 Pennsylvania. It has been the practice in Pennsyl- 
 vania to test herds only on the application of the owner, 
 and then only where the disease was suspected to exist. 
 The application is made on a printed form, and in mak- 
 ing the application the owner promises to observe every 
 direction recommended that tends to the purification 
 of his premises. If he has to tear down half his Ijarn, 
 or cut windows through his stables, or put in new 
 floors, he agrees to do that before the examination is 
 made, and he agrees also to procure his animals for 
 restocking from as healthy a source as possible. It 
 has been impossil)le, however, to comply with all the 
 recjuests sent in, and. as far as possible, the worst herds 
 have been picked out for testing. Reacting animals 
 are all condemned and compensation given the owner. 
 
 At the time of pul^lication of the last annual report 
 the average appraisement for cattle condemned was 
 twenty-four dollars and fifty cents. Since the begin- 
 ning of the last fiscal year the total payments for tuljer- 
 culous cattle to date (January 1, 1898,) amount to 
 $57,191.16 for 2,510 animals, an average of $22.78 
 per head. 
 
42 THE STATE CONTROL 
 
 In Pennsylvania the number of cattle tested up to 
 the 1st of June, 1897, was 0,108 ; the number con- 
 demned as tuberculous was 1,839, a percentage of 20.39. 
 Since the 1st of June, 4,887 cattle have been tested ; 
 of these 671 were found to be tuberculous and were 
 killed ; a percentage of 13.73. All parts of the state 
 are represented among these herds, as only herds sus- 
 pected as diseased are tested. The state officials be- 
 lieve that many of the w^orst herds have been discov- 
 ered, and that the percentage of tuberculosis among 
 cattle at large is being steadily and rapidly re- 
 duced. 
 
 lU'mois. The live stock commission has been con- 
 ducting tests on herds where the OAvners appl}^ for it. 
 All animals are slaughtered w^ithout compensation, the 
 owners having whatever there may be from the sale of 
 the hide and carcass ; where the disease is slight the 
 beef may be sold, if fit, for food. 
 
 During the year 1897, 36 herds were tested, includ- 
 ing 851 animals; of these 77 were found diseased, or 
 about 9 per cent. (This percentage includes a herd of 
 251 that had previously been tested.) Of the 77 dis- 
 eased animals, 41 carcasses were condemned and 36 
 passed as fit for food. 
 
 During the year the board has made tuberculin tests 
 on all dairy herds for which applications w^ere made. 
 There were fewer tests made in 1898 than during the 
 previous year, not because the disease was any less 
 prevalent among the untested herds of the state, but 
 simply because a less number of owners of herds ap- 
 peared to be willing to bear all the loss to be sustained 
 thi'ough the members of their herds that would respond 
 to the test. 
 
OF TUBERCULOSIS. 43 
 
 Mlchifjan. Cattle found to be tuberciiloiis are quar- 
 antined and killed. The laAvdoes not provide compen- 
 sation, however, and, as a result, the commission has 
 met with a good deal of opposition. The commission 
 has followed the plan of inspecting animals brought to 
 their attention as suspicious, and killing such as reacts 
 without compensation. 
 
 During 181J7 and 1808 the commission has applied 
 the tul)erculin test to nearly 1,000 head of cattle, a 
 goodly proportion being milch cows. In fact, a larger 
 number of cattle have been tested for tuberculosis dur- 
 ing the last two years than had previously been tested 
 since the tuljerculin test was adopted by the commis- 
 sion. 
 
 The tuberculin test is apphed only when suspicion is 
 directed toward, or complaint made of, either a single 
 animal or an entire herd. The records of tests made 
 show but a small per cent, of infected animals, and 
 when it is considered that only suspicious herds are 
 tested, it is felt to be a- safe estimate that less than two 
 per cent, of the cattle in Michigan are affected with 
 tuberculosis. 
 
 Minnesota. All cattle which show symptoms of 
 tuberculosis must be quarantined at once and the 
 entire herd tested with tuberculin. When cattle have 
 once reacted the owner has his option of having them 
 killed or continued in quarantine for a j^eriod not to 
 exceed three months, when they are again tested. If 
 they react on the second test, they must be killed within 
 one month. The owner has no compensation for cattle 
 killed, but he is allowed to have them killed under 
 inspection, and, if they pass, he can dispose of the 
 flesh like any other beef. In 1898, 2,975 cows mostly 
 
44 THE STATE CONTROL 
 
 fui'uisliiiig milk to St. Paul were tested and G.37 per 
 cent, were condemned. 
 
 Wiscoitsij/. The state l)oard of health are applying 
 the tubercidin test to infected herds reported, as far as 
 their means Avill allow and condemning the animals 
 that react to the test, the state paying two-thirds of 
 the appraised value. 
 
 It has not seemed necessary in this discussion to con- 
 sider the value of the tuberculin test any more than 
 the causative relation of the tuljercle bacillus to the 
 disease. All competent persons seem agreed that in 
 tuberculin we have the Ijest means possijjle for making 
 a diagnosis of this disease. It is not infallible, hut per- 
 mits a very much surer diagnosis than can be obtained 
 by any other means. Without it, the eradication of 
 tuberculosis would be much more difficult and expen- 
 sive than with it. 
 
 With tuberculin the recognition of the disease is the 
 most certain part of the work. Perhaps the most diffi- 
 cult part is the disinfection of infected premises. The 
 following directions which the Massachusetts Board of 
 Cattle Commissioners insist on being carried out on all 
 premises that they attempt to free from the disease are 
 perhaps as good as any : 
 
 REGULATIONS OF MASSACHUSETTS liOARD OF CATTLE 
 COMMISSIONERS FOR CLEANSING AND DISINFECTING 
 BARNS. 
 
 lliese Must he (.'oiiqilied With by Ov:ners of Cattle, U'/ilrh the State 
 
 Payn For. 
 
 In attempting to get rid of tuberculosis in a herd of cattle, it 
 should be remembered that not oul}" is it necessary that all the 
 diseased animals be picked out and either isolated or destroyed- 
 
OF TUBERCULOSIS. 45 
 
 but that no new animals should be introduced unless they have 
 been tested and are known to be free from disease. 
 
 The barns should also imdergo a thorough renovation and be 
 properly cleansed and disinfected before they are again occupied. 
 
 In renovating or remodelling barns the great imjiortance of 
 sunlight, thorough ventilation and good drainage should always 
 be borne in mind. 
 
 Disinfection of the barns is always necessary to destroy any 
 infectious material that may have been left after the removal of 
 diseased cattle. The best disinfectant we know is sunlight. 
 Germs of disease will live but a short time when exposed to the 
 direct rays of the sun, and for this reason, if for no other, a 
 southerly exposure and plenty of windows in the barn are to be 
 desired. 
 
 In proceeding to disinfect a barn the first, and perhaps the 
 most important step to be taken is to collect all rubbish, have the 
 walls, ceilings and floors thoroughly swept and cleansed of all 
 litter, dust, cobwebs, and the like. The floors, mangers, feeding- 
 troughs and stanchions should be carefully scraped and cleaned, 
 special care being taken with the corners, and all of the rubbish 
 xjollected and burnsd. 
 
 All odds and ends of boards and old and broken mangers and 
 partitions should also be removed and burned, and when occa- 
 sion requires it, new plank floors should be laid in place of old 
 ones. 
 
 After cleaning thoroughlj^ with hoe and broom, and hose if 
 running Avater is convenient, and if the barn contains a boiler Avith 
 scalding water, or live steam, applied with a hose, or failing that, 
 with boiling water and soft soap or Avashing soda. A solution of 
 bichloride of mercury (corrosive sublimate), 1 to 1,000 parts of 
 Avater, should be applied Avith a AvhiteAvash brush and poured over 
 the floors. (CorrosiA-e sublimate should be used in Avooden ves- 
 sels, as it corrodes metal ones.) 
 
 After applying the corrosive sublimate, the ceilings, Avails, par- 
 titions, mangers, etc., should again be washed and gone over Avith 
 warm freshly made white Avash ; a half pound of chloride of lime 
 to the gallon of AvhiteAvash is an addition that may make it more 
 effective. Fumigating with sulphur or chlorine gas is not of any 
 great value in ordinary stables. 
 
46 THE STATE CONTROL 
 
 In using corrosive sublimate it must he borne in mind that it 
 is a dangerous poison, and mangers and partitions should be care- 
 fully Avashed after applj'ing this mixture, and then again scalded 
 or whitewashed. 
 
 If at a season of the year when the animals can be turned out, 
 the stables should l)e left vacant for some time with doors and 
 windows open. 
 
 Six months after the first test the herd should again be tested 
 and undergo a careful physical examination, so as to be certain 
 that no diseased animals have been overlooked, and the barns 
 should again be thoroughly disinfected. 
 
 Great care also should be taken that all animals have been 
 tested before their introduction to the herd. 
 
 THE DECREASE OF TUBERCULOSIS. 
 
 Over most parts of Western Europe, Great Britain 
 and the United States, there has, for half a centiuy, 
 been a marked decrease in the number of deaths due 
 to tubercuhxr diseases, and particuhxrly in deaths from 
 consumption. The figures, of coin^se, vary somewhat 
 in different localities, but the fact of marked decline is 
 illustrated by almost all registration rejDorts which 
 cover a considerable number of years. It seems liardlj^ 
 necessary to present a mass of statistics to demonstrate 
 this, but it may not be uninteresting to examine the 
 data from local sources which are herewith presented. 
 The followino; table is from the advance sheets of the 
 report on births, marriages and deaths in Providence, 
 for 1899. The main fact of the decline is shown 
 graphically in the succeeding diagram : 
 
OF TUBERCULOSIS. 47 
 
 Decedents from Phthisis, Forty-four Years, 1856-1899. 
 
 
 Parentage. 
 
 Sex. 
 
 1 
 
 S 
 
 
 American. 
 
 Foreign. 
 
 Males. 
 
 Females. 
 
 ft 
 
 YEARS. 
 
 to 
 
 5 
 
 OS 
 
 c 
 
 
 ai 
 
 5| 1 
 
 IS 
 
 
 . 
 
 ftp 
 
 1 = 
 
 1 
 
 ftp 
 
 1° 
 
 O 
 § 
 
 a 
 o 
 
 1 
 
 1856-60 
 
 1861-65 
 
 1866-70 
 
 1871-75 
 
 1876-80 
 
 1881-85 
 
 1886-90 
 
 1891-95 
 
 1896 
 
 1897 
 
 1898 
 
 1899 
 
 525 
 
 495 
 
 532 
 
 553 
 
 570 
 
 573 
 
 '62^ 
 
 486 
 
 91 
 
 92 
 
 87 
 
 99 
 
 364 
 329 
 306 
 252 
 
 235 
 227 
 204 
 
 no 
 
 153 
 151 
 135 
 149 
 
 236 
 
 405 
 
 480 
 
 520 
 
 682 
 
 928 
 
 1,177 
 
 1,206 
 
 1,202 
 
 259 
 
 229 
 
 238 
 
 268 
 
 391 
 
 i 
 420 
 
 384 
 
 332 
 
 322 
 
 371 
 
 329 
 
 286 
 
 285 
 
 246 
 
 243 
 
 264 
 
 326 
 
 379 
 477 
 490 
 668 
 676 
 824 
 863 
 846 
 180 
 178 
 178 
 177 
 
 324 
 387 
 339 
 279 
 267 
 304 
 288 
 253 
 249 
 233 
 228 
 219 
 
 551 
 498 
 562 
 667 
 822 
 926 
 872 
 842 
 170 
 148 
 147 
 190 
 
 421 
 352 
 342 
 301 
 301 
 310 
 266 
 233 
 218 
 185 
 174 
 218 
 
 285 
 
 930 
 
 975 
 
 1,052 
 
 1,235 
 
 1,498 
 
 1,750 
 
 1,735 
 
 1,688 
 
 350 
 
 321 
 
 325 
 
 367 
 
 1 
 
 375 
 368 
 340 
 290 
 285 
 307 
 277 
 243 
 233 
 ; 208 
 
 ; 200 
 
 218 
 
 44 years 
 
 4,632 
 
 1 / 
 
 7,594 
 
 5,831 
 
 285 
 
 6,395 
 
 1 
 12, 226 j 285 
 
48 
 
 THE STATE CONTEOL 
 
 Pkovidknce, R. I. 
 PHTHISIS. 
 
 Deaths pkh 100,000 Living. 
 
 18.55-1804 
 380 
 
 180.5-1874 
 317 
 
 187.5-1884 
 298 
 
 188.5-1894 
 259 
 
 1895-1897 
 212 
 
 It lias been claimed by many that this diminution in 
 the death rate of phthisis is, to a large extent, due to 
 the application of the knowledge recently acquired. 
 
 The writer, however, does not believe that this is 
 the case. Certainly, in most places, as has been shown, 
 very little has as yet been accomplished in regard to 
 the purification of milk supplies or the eradication of 
 bovine disease. Expectoration laws are not enforced, 
 and no more consumptives are cared for in hospitals 
 than formerly. It is true that some few cases do, 
 
OF TUBERCHTLOSIS. 49 
 
 undouhtedly, take rational measures to prevent infect- 
 ing- others. Physicians have been a)jle to teach a 
 minority of their patients to do this. It can scarcely 
 be believed that such very little progress has produced 
 such marked results. The decrease in consumption in 
 the United States has not jjeen due to state control, for 
 the excellent reason that the state, as yet, has not Ijeen 
 able to excercise any efficient control. The only city 
 where anything of consequence has been done to check 
 the spread of tuberculosis from man to man is New 
 York. An inspection of the death rate from phthisis 
 in that city does not show that it has decreased any 
 more rapidly since 1895 than it did before. 
 
 It is not necessary in this paper to attempt to explain 
 why consumption of late years has diminished to a cer- 
 tain extent, but it is generally believed to be due to 
 improved living on the part of our people. Better 
 food, better clothing, better shelter and better care of 
 the sick have done much to improve the general health. 
 Shorter hours for work and more time spent in the 
 open air, especially by women, are supposed to be ele- 
 ments in causing the decrease. 
 
 METHODS OF CONTROL PROPOSED. 
 
 Notification. 
 
 The writer believes that one of the most important 
 things to be done to control tuberculosis is to study still 
 further the manner in which the disease is caused. 
 Experimental evidence is desired on many points, as 
 has been referred to in the preceding pages. Clinical 
 evidence is still more to be desired, and this can be best 
 obtained by government investigation. It is neces- 
 sary to study a very large number of cases etiologically. 
 
 4 
 
50 'rilK STATE CONTKOl^ 
 
 If for no other purpose than to give an ()])portnnity for 
 such Htudy, the wtate should recpiire the report of all 
 cases of tuhercnlosis. It is just as important to study 
 other varieties of tuberculosis as it is to study ])hthisis. 
 They should all he reported as is recjuired in a number 
 of existing regulations. There has been considerable 
 opposition to the notification of this disease, but it is 
 believed that this has been due largely to a fear that 
 the health officer would interfere with the family phy- 
 sician by the advice which he miglit give to the patient. 
 If the health officer does not so interfere, but merely 
 co-operates with the physician, it is believed that it 
 will not l)e any more difficult to secure reports of tuber- 
 culosis than it is of scarlet fever. It should be the 
 duty of the health officer to study with the help of the 
 attending physician the causation of every case re- 
 ported. Notification presupposes correct diagnosis, 
 and therefore every state and city should certainly 
 offer facilities for tlie examination of suspected 
 sputum. 
 
 Education. 
 
 Every sanitary official should do all that he can in 
 every way to spread abroad a correct knowledge of the 
 causation of this as of all other communicaljle diseases. 
 The daily press usually affords valuable assistance in 
 this. Another and most useful means of educating 
 people is by means of circulars. Every local health 
 officer shoidd provide himself with a circular explaining 
 the means by which tuberculosis is spread, and describ- 
 ing what precautions should be taken to prevent its 
 spread from one person to another. Such a circular 
 should be prepared with very great care. It should be 
 
OF TIBEIICULOSIS. 51 
 
 expressed in language wliicli can be readily under- 
 stood, and it is very important that it should contain 
 no statements which cannot be fully substantiated. 
 Impossible things should not be required. It is advis- 
 able to send such a circular to every family in the 
 community, stating upon it that this is done. By 
 so doing, no one can be offended. It is, of course, very 
 desirable that it should be made certain that the family 
 of every consumptive should receive a copy, and where 
 there is a physician in attendance, the circulars may 
 well be presented by him. The following is offered as 
 a form of circular for general distribution : 
 
 Consumption, or tuberculosis of the lungs, is caused by the 
 bacillus of tuberculosis, a kind of germ or microbe. This germ 
 also sometimes causes consumption of the bowels especially in 
 children, and sometimes it causes disease of the bones or of other 
 parts of the body. All these different kinds of tuberculosis are 
 caused by the germs getting into the body in one way or another. 
 
 Persons who have consumption usually have a cough, and the 
 matter that they cough up contains great numbers of the tiny 
 germs which cause the disease. If the sputum or matter coughed 
 up gets on the carpet, floor, furniture or clothing, it may become 
 dry and powdered, and float about in the air. It may then be 
 breathed in by another person and thus start another case of the 
 disease. 
 
 In cases of consumption the face and hands are likely to become 
 soiled with this sputum, and cups, spoons, forks, pencils, handker- 
 chiefs and othfer things are likely to be infected in the same way.' 
 If other persons use these things before they are thoroughly 
 washed they are likely to catch the disease. 
 
 In cases of consumption germs are not given off by ordinary 
 breathing, though in coughing or sneezing they may be. But 
 there is probably not much danger from this except to a person 
 who remains much in close contact with the patient. A person 
 who has consumption should always sleep alone. 
 
 Cows have tuberculosis as frequently as human beings do. 
 When they have it the milk is likely to contain the germs of the 
 
52 'I'lIK STATE (CONTROL 
 
 disease, and ])ers()iis wlio drink tlie milk are likely to have tuber- 
 culosis. No milkman ought to keep a tuberculous cow in his 
 herd. He ought to have his cows examined every year and kill 
 all that are sick. It is a good }>lan for all persons to iiKjuire of 
 their milkmen as to whether their cows have been tested for tuber- 
 culosis. 
 
 It is the duty of every ]»erson who has consumption to take 
 the greatest care of his sputum, for it is this that is particularly 
 dangerous to others. AVhen at home he should always spit in a 
 cup which should contain water, so that the matter may not dry. 
 This cup should be emptied into the water closet at least twice 
 each day and be thoroughly washed in boiling water. Paper 
 spit cups may l)e used which can l»e burned. These are furnished 
 by the health department to those unable to pay for them. When 
 away from home a person who has this disease should sjiit into a 
 pocket flask which should be emptied into the water closet and 
 scalded on returning home. These flasks are furnished by the 
 health dei)artment. A person with consumption should never 
 spit anywhere except into a spit cup or flask. He should take 
 great pains not to get sputum on his hands or clothes. Hand- 
 kerchiefs used to wipe the lips and nose may be carried in a rub- 
 ber-lined pocket so arranged that the lining can be removed and 
 washed. Handkerchiefs should be washed frequently. 
 
 As the face and hands of the patient are certain to be more or 
 less infected they should be frequently washed in hot water and 
 soap. It is best for a mail with consumption not to wear either 
 mustache or beard. All dishes used by a consumptive should be 
 thoroughly scalded before they are used by another. The bed 
 clothes and night clothes of a person with consumption should be 
 changed often. 
 
 AVhile consumption is contagious the contagion is almost 
 entirely in the sputum, and if this is taken care of there is prob- 
 ably not much danger in living or woi-king with a consumptive. 
 
 Consumption is not always a fatal disease. A great many per- 
 sons who have the disease recover from it. A large proportion 
 of cases get well if they take proper care of themselves. 
 
 When a person with consumption has been sick a long time in 
 one room, even if great care has been taken, the woodwork and 
 
OF TUBEKCT'LOSItS, 00 
 
 furniture are liable to be infected and should be tborougbly 
 washed. It is a good jilan to use Avashing soda for this. The 
 walls should be repapered, the old paper being taken off. Car- 
 pets and rugs should be disinfected with steam. 
 
 Conti'ol of Ex2)ectoration. 
 
 As has been said, indiscriminate spitting is a nuis- 
 ance and should Ije stopped. Spitting in pul)Uc places 
 should, bj statute law, Ije made an offence. In place 
 of statute law, if such cannot be obtained, every muni- 
 cipality should have a regulation of this kind and 
 enforce it. It is not at all improbable that such en- 
 forcement mig-ht have considerable influence in check- 
 ing the spread of consumption. 
 
 It is perhaps possible for the health officer to do 
 much in the way of helping the individual to care for 
 his expectoration. The plan followed in New York 
 city of visiting the patient, unless the attending physi- 
 cian requests otherwise, appears to be a good one ; 
 and, in that city, has been productive of good results. 
 Subsequent visits shauld, however, be made, and if the 
 inspector has tact and gains the confidence of the 
 patient, much may be accomplished. When in the 
 house, it is probable that the best thing for a patient 
 to do is to use a spit-cup. These are made in various 
 forms and one made by Seabury & Johnson, which has a 
 paper lining which can be removed, and, with its con- 
 tents, burned, is a very good one. If a person is able 
 to be about, and, particularly if he is alile to work, he 
 must be j)rovided with a pocket flask and perhaps, 
 also, with some sputum receptacle at his place of busi- 
 ness. A pocket flask made of aluminum in two pieces, 
 so that it can be readily taken apart and cleaned, has 
 been devised by Knopf and is probably the best that 
 
54 THE STATE CONTliOE 
 
 can be obtained. If snch a flask is not employed, 
 handkerchiefs may be used, Ijut, if tliey are, the pocket 
 which hohls them shonhl have a rubber lining kept in 
 place by clamps. Cups, flasks and rubber lining should 
 all be frequently washed and scalded, and disinfected if 
 feasible. If the consimiptive can l)e induced to thus 
 take care of his expectoration, the danger of his trans- 
 mitting the disease to others will be reduced to a min- 
 inuuii. The health inspector, either by himself or with 
 the assistance of the attending physician, can doubtless 
 do very much to bring about this desired end, but it is 
 not, by any means, recommended that any compulsion 
 should be employed. It might he advisable for the 
 municipality to furnish the spit cups and flasks to those 
 who cannot afford them. 
 
 Dismfection. 
 
 Every municipality shoidd be ready to show how 
 apartments can be disinfected after cases of consump- 
 tion have been removed from them, and should stand 
 ready to disinfect if it is probable that it will not other- 
 wise be properly done. It might, perhaps, be advisable 
 to require Ijy ordinance that all premises occupied by 
 consumptives should Ije disinfected before they are 
 occupied ]jy others. There seems to be little doubt 
 that cleansing, as practiced l)y the board of health in 
 New York, is as good as disinfection. Disinfection, if 
 practiced, should always be hy washing, and steaming, 
 if necessary ; gaseous disinfection should not be relied 
 upon. 
 
 Hosjntals. 
 
 There is no question in the mind of the writer that 
 hospitals furnish the Ijest means availaljle for the state 
 
OF TUBERCULOSIS. 55 
 
 control of tuberculosis. The majority of consum})tive 
 patients are among the poor or people in very moderate 
 circumstances. It is extremely difficult for such to 
 take the precautions necessary to prevent the spread of 
 the disease ; therefore the danger is greatest from this 
 class of persons. Unless something is done to help 
 them, they are almost certain to die. If they can be 
 cared for in suitable sanatoria, a large proportion will 
 recover, provided they, are taken in hand early enough 
 in the disease. Furthermore, during the whole time 
 of their treatment, there will be no danger of their 
 infecting others. The state should provide hospitals 
 for the curative treatment of consumption in its early 
 stages. The consumptive poor who are suffering from 
 the last stages of the disease should also be cared for 
 by the state. Although the danger to be apprehended 
 from this class is not great, because they do not move 
 about so freely, and although the chance of cure is slight, 
 humanity demands that they should receive the best of 
 care. General hospitals very properly do not like to 
 receive them, but they are frequently obliged to, to the 
 danger of other patients. The state should also receive 
 them, as well as incipient cases, in its hospitals set apart 
 for this disease. If the state or the municipality can 
 only do one thing to control tuberculosis, it sliould 
 establish hospitals for consumptives. 
 
 Control of the Milk Supply. 
 
 As has been shown, the evidence is pretty strong 
 that a consideralde amount of tuberculosis in human 
 beings is caused by the ingestion of infected milk. 
 This seems to be sufficiently certain to warrant the 
 making of a very strong effort to prevent the sale of 
 
56 THE STATK OONTitOL 
 
 inilk tVom tuberculous jinimals. This action is tlic 
 more warranted, because it will ultimately l)e to the 
 great advantage of the dairymen, though at first it 
 may cause tliem some trouble and expense. The only 
 certain way to accomplish the desired result is to license 
 all dealers, register all cows, test them with tuberculin, 
 and slaughter all that are infected. Such drastic 
 measures will rarely meet with popular support, l)ut 
 must l)e carried out by numicipalities tliat really desire 
 to protect their milk supply, provided they can secure 
 the necessary legislative authority. If this is impos- 
 sible, as it frequently is, it is w^ortli while to try the 
 Indianapolis })lan and endeavor to encourage dairymen 
 to voluntarily eradicate tuberculosis, in order that they 
 may secure from the city a certificate that this has 
 been done. 
 
 The Eradication of Ttfherciilosi.s in Cattle. 
 
 From a review of what has been done and attemj)ted 
 in this line in the United States, it is quite evident that 
 it is impossible to successfully carry out any A^ery dras- 
 tic measures. Little can be done without the co-opera- 
 tion of the cattle owner. The plan which seems to be 
 most successful is for the state to offer its assistance in 
 freeing herds from tuberculosis. If the owner will 
 agree to the application of the tuberculin test, and will 
 agree to improve and disinfect his stables, as required, 
 and thereafter to purchase none Ijut tested animals, the 
 state should test his herd, slaughter and pay for all 
 infected, and assist in disinfection, and, subsequently, 
 ins|)ect from time to time to see that the health of the 
 herd is maintained. It is believed that by thus grad- 
 ually securing healthy herds in different parts of the 
 
OF 'iri'.KifcrLosis. 57 
 
 state, enough friends will finally be seciu'ed for the 
 carrying out of more radical measures and the compul- 
 sorv cleansing of those herds whose owners still per- 
 sist in maintaining them as foci of the disease. The 
 eradication of tuberculosis in animals, except as it is 
 incidentally involved in the protection of municipal 
 milk siip])lies, had best be attempted by state rather 
 than munici])al aiithoi'ities. 
 
 To sunnnarize what seems to be feasible for the state 
 at present to attempt in the way of control of tubercu- 
 losis, it may be said : 
 
 First. Every state or city should require the noti- 
 fication of the disease, and offer assistance in diag:nosis. 
 
 Second. State and municipal health authorities 
 should do everything possible to educate the people by 
 publications and by verbal instructions, in all cases co- 
 operating with and never superceding the attending 
 physician. 
 
 Thii'd. The spitting habit should l)e controlled as 
 much as possible, and effort made to instruct and help 
 the consumptive to care for his sputmn. 
 
 Fourth. Municipalities should assist in cleansing 
 premises occupied b\' consumptives. 
 
 Fifth. Tlie state or the municipality, or both, should 
 offer hospital facilities for the care of this disease. 
 
 Sixth. If , j)ublic opinion will warrant, no milk 
 should be sold except from cows tested with tuberculin. 
 If this canncjt l)e done, effort should l)e made to induce 
 dairymen to apply this test. Such work must, at 
 present, be chiefly done by municipalities. 
 
 Seventh. The state, by means of state officials, 
 slioidd strive to secure the co-operation of cattle owners 
 in the eradication of tuberculosis from their herds, and 
 should test and pay for slaughtered animals. 
 
DUE DATE 
 
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