rBTHMTW^-'teaaa COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD 'w^v^/v-\J^-'tX'-■c■^>'-^ HX641 37074 RC31 3.C76 C76 Report of Special Co RECAP ^ h REPORT SPECIAL COMMISSION APPOINTED TO INVESTIGATE TUBERCULOSIS REPORT PRESENTED TO THE GENERAL ASSEMBLY OF igog tntifCttpofllmgork COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/reportofspecialcOOconn State of (Tonnecticut PUBLIC DOCUMENT— SPECIAL REPORT OP SPECIAL COMMISSION APPOINTED TO INVESTIGATE TUBERCULOSIS COMMISSION APPOINTED BY THE GENERAL ASSEMBLY OF 1907 H. J. RESOLUTION No. 426 APPROVED JULY 17, 1907 REPORT PRESENTED TO THE GENERAL ASSEMBLY OF iQog HARTFORD Published by the State 1908 Publication Approved by The Board of Control. THE TUTTLE, MOREHOUSE & TAYLOR COMPANY NEW HAVEN INTRODUCTION. The appointment of a commission by the last legislature of the State of Connecticut, for the investigation of tuberculosis in its relation to the welfare of the citizens of the State and to make such suggestions as may seem practicable and suitable for the control of that disease, is a most significant act. It is a recogni- tion of the prevalence and serious import of the disease through- out the State — in every city, town or hamlet — a disease so widely distributed and so destructive to the interests of all who fall under its influence, that no man in the State can truthfully say that it is a matter of no interest to him. It is further a recognition of the all-important truth, that as a result of modern investigation, the control of a disease, once believed to be beyond human relief, has been made possible. The widespread distribution of the disease has placed its control beyond the power of individual effort and imposes the duty upon the State — a duty that, properly performed, must be of the broadest possible economic value to the whole community. The people have a right to demand the assistance of the State in the war against tuberculosis. Every industrious man of ordinary intelligence understands that good health is the most valuable asset he can possess. If it is sacrificed through his own personal shortcomings, he has himself to blame, and he has no claim upon the State beyond what is now given to such unfor- tunates in our institutions for the poor. But when the health of a man is sacrificed, through governmental indifference to proper hygienic precautions — when he is tuberculous, because of being compelled to breathe air that might have been pure if simple rules had been properly enforced — then such a man has a right to look to the State for redress. No one questions his right to look to the State for protection of his property interests — why is this not equally true of his health, which is the basis of material pros- perity in every community? 2 REPORT OF THE COMMISSION In preparing this report, your Commission has endeavored to avoid questions that are still under discussion and to place before the State a simple and practical statement of conditions as they exist, with such recommendations for the control of tuberculosis as may seem to be of value and at the same time within the power of the State to adopt. Investigation into the duty of the State in the effort to control tuberculosis, calls for consideration of the two most important forms of the disease — ^the human and the bovine. It will be shown in this report that there are many points at which the treatment of these two types of tuberculosis is identical. There are other considerations that point to the wisdom of considering them separately. It is highly desirable that the widespread impression that the movement to suppress bovine tuberculosis is solely in the interest of the effort to control human tuberculosis, should be corrected. If this was the truth, surely no higher motive could be conceived of. But the arrest of tuberculosis in the herds of the State has become a matter of extreme importance to the welfare of that industr}^ Until recently there has been so much effort to discredit the transmis- sibility of bovine tuberculosis to the human being, that the owners of cattle have, in the earnestness of the discussion, encouraged themselves in the belief that they were being perse- cuted, that their property rights were being invaded. Your Commission feels that by a separate discussion of the bovine disease, it may be made clear that, independent of all altruistic motives, it is to the interest of every owner of cattle to assist the State in suppressing the disease that is extending alarmingly and is seriously imperiling the dairy interest. FOR THE INVESTIGATION OF TUBERCULOSIS. TUBERCULOSIS IN NEW ENGLAND. It is an interesting question whether tuberculosis was introduced into New England by the white settlers or was already present among the Indians. There are, of course, no official records of the fact, but the historical references to consumption as a disease destructive to the Indians are suggestive. Daniel Gookin, himself one of the earlier settlers of New England, says in his "Historical Collections of the Indians of New England" : "Of this disease of the consumption sundry of those Indian youths died that were bred up to school among the English. The truth is this disease is frequent among the Indians ; and sundry die of it that live not with the English. A hectick fever issuing in a consumption is a common and mortal disease among them." ("Collections of the Massachusetts Historical Society," vol. i, page 173.) This would indicate that the cases referred to were possibly contracted by contact with the whites. On page 140 of the same volume, an Indian authority is given for the following statement: "Before the English came among the Indians, there was two disorders from which they most gen- erally died, viz. : the consumption and the yellow fever." In vol. 7 of the "Massachusetts Historical Collections," Gen- eral Lincoln says, in observations of the Indians of North America : "Their tender lungs are greatly affected by colds which bring on consumptive habits, from which disorder, if my informa- tion is right, a large proportion of them die." Francis, in his life of John Eliot, the Apostle of the Indians, gives as his own opinion : "Consumption seems to have been a common malady among the New England natives." De Forest, on page 20 of his "History of the Indians of Con- necticut," says : "The diseases of the Indians were quinsies, pleu- risies, rheumatisms, quick consumption and such others as would be naturally produced by their exposure and hardships, and by their irregular mode of life." 4 REPORT OF THE COMMISSION In a notable series of papers in the New York Medical Record in August and September, 1892, on "Diseases Among Indians," Dr. A. B. Holder, at one time Agency Physician at the Crow- Reservation in Montana, says : "I do not believe that at any time in their history they (the Indians of North America) have been free from consumption and scrofula. Tuberculosis is coexten- sive with the Indian race. The single tribe that may be said to be free from this disease, I have been unable to find after diligent search. Those who inhabit the torrid swamp of Arizona, and those in the frozen northwest territory of Canada, along the western seaboard and in the Atlantic States, all tribes suffer more or less from consumption and scrofula." Addison, in the Canadian Journal of Medicine and Surgery for May, 1902, tells of finding in an ossuary, near Big Bay Point, in Simcoe County, Ontario, several skeletons of Huron Indians that had suffered from Pott's disease. These skeletons had been under ground for more than two centuries. He concludes that these bones are proof that not only the Indians suffered from tuberculosis before the European invasion, but also that it was a very common disease among them before the white man came. "In Peabody Museum (specimen 17,223), among prehistoric remains, is a part of a vertebral column badly affected with caries- tuberculosis." (Holder.) Certainly no evidence is shown in these quotations that can be accepted as proof that tuberculosis existed among the Indians prior to the advent of the white races, except such as may be inferred from the discovery of skeletons clearly indicating tuber- culosis and possibly of great antiquity. It is a known fact, as shown in the quotation from Dr. Holder's paper, that since white settlement, tuberculosis has been fearfully prevalent among all Indian tribes and has in many instances, practically decimated them. This statement may seem surprising to those who regard the Indian as a child of nature — living the simplest life possible, in pure air and sunshine. The purity and simplicity of Indian habits, however, is somewhat mythical. Their lives were full of hardship and exposure and their camps insanitary in all respects. Their sleeping quarters were close, foul and crowded to excess, and every condition existed favorable to the spread of tubercu- losis. Whatever the conditions prior to white settlement may ^T^^^^T^^nr^T^^"^ FOR THE INVESTIGATION OF TUBERCULOSIS. 5 have been, it is known that the disease was fearfully and increas- ingly prevalent among the early New England communities, and from the settlement of the Colonies up to modern times no disease has been more destructive. Reliable registration of the causes of death is of very recent establishment everywhere. In Connecticut, statistics bearing upon the subject are available for the period from 1849 to the present time. Through the courtesy of Dr. Joseph H. Townsend, Secretary of the State Board of Health, the Commission has received the accompanying table illustrating the tuberculosis death rate and the general mortality since 1849. A careful study of this table discloses many facts of interest. The most striking fact is the marked decrease that is shown in the tuberculosis death rate — somewhat irregular until 1882, but steady and impressive since that year. It was in 1882 that Professor Koch published his dis- covery of the bacillus which is the universally accepted cause of tuberculosis. Prior to that date, the conception of the nature of the disease was unscientific, and whatever may have been done in effort toward social betterment that could have influenced the mortality from tuberculosis to the extent shown in the table was, certainly to a large degree, accidental.' Since 1882, with the knowledge of the cause of tuberculosis based upon unquestioned scientific demonstrations, the movement for the control and ulti- mate eradication of the disease has been steadily growing all over the civilized world. The character of the disease being now under- stood, the effects toward control can be intelligently planned and executed. The impression that tuberculosis is constantly increasing and becoming more destructive is erroneous. The accompanying table shows beyond question the general trend of the disease in Connecticut, and it is a matter of great interest that the records of Maine, New Hampshire, Vermont, Massachusetts, and Rhode Island show a corresponding decrease. All records of mortality are unreliable. The elements of care- lessness, ignorance and willful misrepresentation upon the part of the reporting physicians, cannot be measured or controlled. Unintentional inaccuracy in diagnosis may change the tubercu- losis record very materially, bronchitis, pneumonia, pleurisy, and even typhoid fever being entered as the cause of death, when, in fact, it should have been reported as tuberculosis. These inac- 6 REPORT OF THE COMMISSION curacies, in all records of the character under consideration, are universally recognized as unavoidable. There is, however, no reason to expect more inaccuracy in one state than in another, and the very close correspondence in the records of the New England states speaks for their accuracy. The average tuberculosis death rate for the past five years in Connecticut has been 14.3 per 10,000 population. In the other states mentioned the figures vary from 13.5 to 15.5 per 10,000, a very close correspondence, when due allowance is made for variation in the methods of reporting. Another remarkable fact connected with the Connecticut record is, that it corresponds very closely to the now famous table, pub- lished last winter in Dr. H. Timbrel Bulstrode's English Govern- mental "Report on Sanatoria for Consumptives and certain other aspects of the Tuberculosis Question." In Dr. Bulstrode's table, it is shown that the phthisis death rate for England and Wales fell steadily from 27 per 10,000 living in 185 1 to 12 per 10,000 living in 1904, the decline in Connecticut for the period from 1849 to 1904, as shown in the table, being from 27 to 14. When the tables of mortality from tuberculosis, taken from sources so widely separated, show such a marked decrease, and that, too, to no inconsiderable degree prior to the discovery of the bacillus, the question as to the cause of the decrease is of exceed- ing interest. Your Commission would wish to emphasize the fact that the decrease of the disease in Connecticut within the past fifty years constitutes the most hopeful outlook for the future. It fully justifies the State in every efifort to control tuberculosis, by rectifying all such social abuses as are now known to be most favorable to its continuance. It is further to be understood, that the extremely favorable reports as to the decrease of tuberculosis in our State are not to be taken as evidence of a common experience in all parts of the world. While England shows a decrease of fifty per cent, or more, there is a considerable increase during the same period to the credit of Ireland. In France there is no such encouraging condition as we can claim, and so throughout the world, the decrease is showing an irregularity that is of great interest. The knowledge of the cause of tuberculosis, while it has materially afifected the returns of mortality since 1882, cannot be accepted as the sole cause of the improved conditions in our State. FOR THE INVESTIGATION OF TUBERCULOSIS. 7 The table shows a decHne from 1849 to 1882. The same is true of New England and England and Wales. In Connecticut, then, there has been some influence that has been quietly working toward that most beneficent result — the control of tuberculosis. Where is that influence to be found? In Connecticut, it is unquestionably a result of the movement toward the general improvement in social conditions that has steadily gained a foot- hold, in spite of the opposition of those who were to be most bene- fited. It is well understood that tuberculosis finds its most favorable field among insanitary surroundings. This being admitted, what argument would there be for the State to under- take measures for its eradication if it was increasing. Improved tenements, the regulation of child labor, sanitary science applied to the improvement of cities and towns — imperfectly, to be sure, but far better than in the past — shorter hours of labor in better ventilated shops, the uplifting eft'ect of a higher and broader education, the education of the public into a reasonable attitude to\yard fresh air and sunshine — all of these influences have been gradually developing and becoming the accepted order of life during the last half century. While until very recently efforts toward an improvement in social conditions were inaugurated without thought of tuberculosis, it is interesting to note that there has been a coincident decrease in the mortality from consumption. This helps to establish the claim, that all undesirable social condi- tions are powerful factors in the causation of consumption. It oft'ers encouragement for a broader effort to secure to the public the best possible conditions of living. The State, in all its efforts to secure the improvement of social conditions, is incidentally looking toward the control of tuberculosis. REPORT OF THE COMMISSION TUBERCULOSIS— A CONTAGIOUS DISEASE. The time is certainly at hand for the education of the pubHc everywhere, upon all questions that may lead to a better under- standing as to their individual responsibility in rendering assist- ance in promoting the success of the movement to control tuberculosis. Private organizations and isolated communities that have during the past few years undertaken this work, have felt that the only possibility of success rested upon universal educa- tion of the public as to the danger and its consequences. It has been their effort to publish broadcast, through every possible agency, a statement of the great prevalence of tuberculosis, the ease with which it may be disseminated and the disastrous results that follow in its course. It may possibly seem ungracious to criticise work of this character that has been done and is now being done with the best possible motive. There has been, in some instances, an exaggeration of statement that has been unfortunate in its effect upon those suffering from tuberculosis. It should be under- stood, that the great work in hand contemplates the arrest and the ultimate control of a chronic disease, that does not interfere with the daily habits of life in some instances for months and even years. Care should be exercised not to arouse the public alarm to such an extent as to seriously interfere with the rights of the inno- cent sufferer. The public should be made fully cognizant of all the essential facts to insure rational effort to avoid this disease. It should also be clearly understood, that the unfortunate sufferer is not a leper — not one to be avoided in daily life, if he learns fully his duty to himself and to society and is faithful in its perform- ance. In some instances, this anxiety upon the part of the public has been so acute that serious suffering has ensued. This has in some localities led to a concealment of the disease by patient and physician, a result to be most seriously deplored by all who desire success in the undertaking under discussion. This contagious element in the tuberculosis question has become of the highest importance. The whole question of con- FOR THE INVESTIGATION OF TUBERCULOSIS. 9 tagion — of the method of transmission of any disease from man to man — is most imperfectly understood. Within a very few years, yellow fever was supposed to be air-borne, one of the most highly contagious diseases. Malaria was long supposed to be water-borne and intimately associated with the upturning of the soil. The fact that both of these diseases are now known to be transmitted by inoculation only ; that attendants of yellow fever patients are free from all danger, so long as they are not infected by the mosquito ; that the most pernicious malaria can be avoided by an efficient mosquito bar, in places that were previously almost uninhabitable, must lead anyone studying the contagious element in tuberculosis to hesitate before expressing a positive opinion upon the matter. It can be stated with confidence that tubercu- losis, under proper sanitary precautions, cannot be easily trans- mitted from man to man. If it possesses any contagious quality, it is not in the sense in which that word is commonly used in speaking of scarletina, measles, smallpox and such highly con- tagious diseases. Dr. Hermann Biggs of New York City, a pioneer in all good work for the municipal control of tuberculosis, says : "It seems to me that the difficulties in dealing with the disease have been greatly increased, because of the failure of sani- tary authorities generally to recognize this distinction. Both to the public and to the medical profession the term 'contagious' conveys, a distinct conception of the ready transmissibility of disease from the sick to the well after slight exposure. This is certainly not true of tuberculosis." Since the general public has become aroused as to the importance of intelligent measures to control the spread of tuberculosis, the contagious quality of the disease has been most injudiciously emphasized, and in conse- quence, an increasing fear of the unfortunate sufferers from the disease created. It has been scientifically demonstrated, that under proper con- ditions, attendance and even constant attendance upon tubercu- losis patients is not attended with danger. The sanatoria in all parts of the world report that their attendants of all classes remain free from the disease. If tuberculosis were air-borne and highly contagious to the degree that we suppose the acute con- tagious diseases to be, such a report would be impossible. Dr. Bulstrode, in his report previously quoted, gives many instances in support of the low degree of contagion in tuberculosis and to lO REPORT OF THE COMMISSI© iS^ its innocuousness under proper sanitary regulations. A few quotations will be of interest. "At Falkenstein during- lo years 225 non-tuberculous friends accompanying patients have stayed at the sanatorium — many have stayed for six months and no case of infection has been observed." "At Goebersdorf, where during 40 years 25,000 tuberculous patients have been treated in the sanatoria, pulmonary tuberculosis among the inhabitants in the village — notwithstanding the fact that during the last 30 years the population has nearly doubled — has according to the figures published by Dr. Nahon apparently decreased." This is shown in the accompanying table copied from Dr. Bulstrode. Deaths from Years. Tuberculosis. 1856-1859 7 1866-1869 4 1870-1879 5 1880-1889 5 1890-1897 3 "In the village of Falkenstein before the sanatorium was opened the mortality from tuberculosis was 18.9- 100 deaths, while since the opening — from 1877 to 1894: — it has fallen to 11.9 per cent." As regards our own country, the experience of Dr. E. L. Trudeau, in his world famous sanatorium at Saranac Lake, N. Y., corresponds with the German institution mentioned above. There has not been a case of infection among all the doctors and other attendants who have served the Saranac institution since its opening. It is to be understood that this association, without harm, with the tuberculous, is invariably where the restrictions upon the habits of the patient, now so universally advocated, have been faithfully observed. It is known beyond controversy that tuber- culosis — consumption as it is commonly called — is caused by a specific germ known as the tubercle bacillus. Without the presence of this germ the disease does not exist. The common belief that consumption is usually the result of "a cold," of being overworked, mentally or physically, of being depressed physically because of poverty or prolonged exposure, is not accurate. The germ of the disease is about us everywhere. FOR THE INVESTIGATION OF TUBERCULOSIS. II To those in sound physical condition it is apparently harmless. In those who are ill and below the safe point of resistance, the germ finds a favorable soil and develops. The victim must in some way receive this germ directly or indirectly from an active case. It is a matter of very simple demonstration to prove that through expectoration, through the droplets intimately divided in the breath during coughing, and through other discharges from the body to a less degree, the bacillus is constantly discharged from those suffering from tuberculosis ; and where the simple rules for decency and cleanliness — now so earnestly advocated and pub- lished broadcast in every community — are disregarded, the num- ber of germs daily thrown into the air is innumerable. Once free from their host, the germ soon perishes in pure air and sunlight; but as the air becomes foul and damp and the sunlight is obscured, the life and virulence of the bacillus is prolonged. When the bacillus lodges in dark, ill-ventilated and damp lodgings, it can retain its virulence for an indefinite period. This explains the fact, that while tuberculosis can be found in the homes of the wealthy, living in surroundings that would seem to ensure safety, it is found in increasing frequency as the housing conditions become poorer, until in the crowded tenement it gains a foothold that contaminates the house and renders it unfit for use. Much has been written of late about infected houses. It will be shown that such exist, but space forbids any detailed investigation of this phase of the subject. The two facts that it is most desirable should be clearly estab- lished in the minds of the general public, if a reasonable effort to control tuberculosis is to succeed, are : First, the disease known as tuberculosis, at all times so destructive to human happiness and hfe, is gradually coming under control, as the living conditions of society improve. There is every reason to believe that the day will come, if the measures to destroy the disease are systemati- cally enforced by the State, when tuberculosis will be under control. Second, the sufferers from tuberculosis who are care- ful as to their personal habits and conscientiously observe all the rules for the destruction of the germ as it leaves the body, are not a source of danger to their associates. The effort has been made, in writing of the contagious charac- ter of tuberculosis, to make it clear that the danger of contagion is very slight from association with those suffering from the \ 12 REPORT OF THE COMMISSION disease, when due precautions as to cleanliness are observed and when the patient is in such physical condition as to admit of free social intercourse. When the patient has become so ill as to require personal attendance, it become a very difficult matter to avoid occasional acts of thoughtlessness through which the sputum may be scattered, and at such times the danger of contagion is imminent. When the sufferer is careless, no matter in what stage of the disease he may be, he is a constant and positive source of danger. He is much more dangerous to the community than a patient suffering from an acute contagious disease — a fact that justifies including tuberculosis among contagious diseases. FOR THE INVESTIGATION OF TUBERCULOSIS. 1 3 WHAT IS THE STATE'S DUTY? The efforts that have been made during the past few years to control the acute contagious diseases, have at last met v^ith public approval, and no opposition is felt to reasonable supervision upon the part of the health authorities. Until very recently, the feeling toward the official supervision of tuberculosis has been inclined to be hostile. The character of the disease, its insidious develop- ment, the popular belief that it must necessarily prove fatal, has led to a feeling of scepticism as to the methods proposed for its relief. This scepticism has now very generally yielded to a belief in the possibility of cure, and the day is at hand when all reason- able measures that the State may adopt for the control of tuber- culosis will meet with sympathy. What, then, is the duty of the State? The essentials of success are, first, measures to avert the development of the disease ; and second, the systematic care of all sufferers who may be unable to secure suitable care during their enforced idleness. Measures to control the development of tuberculosis include : 1. Notification and registration of all cases of tuberculosis in every community. 2. Control of indiscriminate expectoration. 3. Rational tenement house legislation, embracing construc- tion and subsequent inspection. 4. Sanitary supervision of all buildings where people are brought into intimate association. 5. Scientific supervision of the dairy and food industries. 6. Intelligent efforts to educate the public as to proper sani- tary precautions. All of these measures are essential to success in securing the control of tuberculosis. It is of interest and importance, in seek- ing state action upon the various measures toward the control of tuberculosis, to emphasize the fact that all other efforts toward the social betterment of the community have a common interest. These various measures, intelligently enforced, would be of the highest possible social and economic value to the whole State. 14 REPORT OF THE COMMISSION THE NOTIFICATION AND REGISTRATION OF TUBERCULOSIS. If a scientific effort is to be made by the State to control the disease in question, it is obvious that no proper estimate of the value of the effort can be secured, unless it is based upon accurate statistical records. No information as to the extent of tubercu- losis can be obtained by any other method than notification, such as is now required in the acute contagious diseases. In attempt- ing to secure an accurate registration of all cases of this disease, no interference with the rights or liberty of the patient is con- templated. Among all those patients who are in position to meet the cost of treatment, the act of registration does not go beyond a confidential record of the case with the proper health officer. A record of those who are unable to meet the cost of treatment is of undoubted value, in bringing to official knowledge the extent and character of relief work that may be required. The opposi- tion to notification of tuberculosis has been very active, wherever it has been attempted, and the most active in the opposition have been the physicians. There seems to be an impression that in some way notification is violation of professional confidence. Certainly a report to the local health officer, accompanied by a statement that the case is under suitable treatment, is not making public the patient's condition. Such an official record is a confi- dential communication and any violation of confidence upon the part of the health officer should be actionable. The cases not requiring official supervision, in the states where notification is enforced, are simply enumerated in the records, showing the prevalence of the disease, and aside from that have no publicity. Notification of the indigent is of the first importance. It is the indigent case that is the most difficult to detect and the most serious as a source of danger to the general public. These cases must be discovered and must be under official supervision, if any good is to be accomplished. No concealment of a tuberculous case that occupies apartments in common with others, is justifi- able, unless there is intelligence to understand the necessity for FOR THE INVESTIGATION OF TUBERCULOSIS. 1 5 precaution and the means and inclination to enforce the same. Among the indigent, it should be left with the health officer to decide as to the trustworthiness of individual cases, when they are reported. In some states there has been an attempt to secure voluntary notification, but the results have been highly unsatisfactory. Even where notification is supposed to be enforced, physicians have been extremely careless in complying with the requirements. Many deaths from tuberculosis are being reported, where no previous report of the case had been received. Notification should be either enforced or not attempted. There is little value in a law that is observed or not, as the individual may prefer. There is no value in inaccurate statistics. The records of the true prevalence of tuberculosis in any state in the Union would be a source of surprise, even to those supposed to be familiar with the situation. The opposition to notification is, to a certain extent, due to a lack of interest in public measures to suppress tubercu- losis, and to an unwillingness to make the slight exertion required for filling and mailing the report. The laws for the control of tuberculosis in Maryland are unusually complete, and it is of interest to note that the notification of cases became much more satisfactory after the establishment of a small registration fee. Such an expenditure upon the part of our own State would yield to the community a high rate of interest, in its influence toward securing an accurate report. If it is understood that the notification of tuberculosis does not place that disease in the same category as the acute contagious diseases ; that the notification is to be treated as a confidential communication and imposes no burdensome obligation upon patients, where the physician certifies that proper precautions are being observed ; when, further, the fact of notification being com- pulsory, relieves the physician from all responsibility in the matter in so far as violation of professional confidence is concerned, the compliance with the law will soon become customary and objec- tion to it will cease. The Maryland plan of making fair payment to the physician for his service, is eminently proper and should be the rule everywhere. In doing his part toward securing reliable records of tuberculosis, the physician is rendering a service of value, for which he should receive compensation. 1 6 REPORT OF THE COMMISSION CONTROL OF EXPECTORATION. It has already been stated that tuberculosis is a disease due to infection, caused by the bacillus that has escaped from someone already suffering with the disease. The chief avenue of escape is of course through the mouth, either in the act of expectoration, or through the minute subdivisions (called droplets) that escape into the air in the act of coughing. Many people in every com- munity have tuberculosis long before they are conscious of the fact; often cases recover without the patient having even sus- pected that he was tuberculous. No man can say that there is no danger in his sputum. That indiscriminate expectoration is the chief source of a disease, so serious in its consequences as to justify large expenditure upon the part of the State to eradicate it, is a fact worthy of thoughtful consideration. Why should men expectorate broadcast over the land, if in so doing they are often casting out the germ that is to bring misery and want, maybe, to many an industrious and worthy neighbor? This is not extravagance : it is simply truth. Why should people spit in an unsuitable place ? Why should they cough directly into the air of any room they may happen to be in? In this whole question of the control of tuberculosis there is much still to be carefully considered. There are many questions justly open to discussion. As to this promiscuous spitting, there is not the faintest shadow of a question — it is indescribably filthy and offen- sive, is dangerous to others, is unnecessary and should be stopped. The efforts made during the past few years to check this unmiti- gated nuisance have been followed by very considerable improve- ment. In most of our cities, the sidewalks are comparatively clean and do not call for that care upon the part of the pedestrian that was formerly required. So much accomplished is a cause for some satisfaction, but the public should understand that offense in this matter does not begin and end on the sidewalk. The greatest source of danger is in the shops, the schools, the churches, in all places where people usually congregate. How FOR THE INVESTIGATION OF TUBERCULOSIS. 1 7 long suffering, to say nothing of the exposure to tuberculosis, are those who are obliged to find their solace in the average smoking car. It is a very simple matter to rectify all this abuse of the public. If certain people must expectorate, suitable receptacles should be provided and they should be properly cleansed. An effort to correct this evil has been made by many of the prominent manufacturers of the State. In some of our shops to-day, instead of walls and floor unspeakably foul, one sees clean surfaces, free from all objectionable matter. That this is a great movement toward the improvement of the health of the employees, is certain. When the movement is universal and especially when the people themselves won't allow promiscuous expectoration, then assuredly one great step forward will have been made, toward the control of tuberculosis. l8 REPORT OF THE COMMISSION THE HOUSING PROBLEM. Early in the development of interest in the question of state control of tuberculosis, systematic investigation of the tenement house conditions in crowded centers of population attracted special attention. Tuberculosis was known to be a disease that was specially frequent and virulent in crowded habitations occupied by the extremely poor and ignorant. The excess of population was not alone responsible for the difficulty. The associated poverty and neglect of sanitary rules of conduct were equally potent factors. The conditions that have been revealed in New York City, Philadelphia, Chicago, and in fact all the great cities of the world, are appalling. Charts of the infected districts in those cities have been published, showing some portions of the poorest quarters so seriously infected as to justify the question whether any of the occupants of such homes escape some degree of infection. In Connecticut we have no great cities. In the neighborhood of the largest cities that we have, within a few minutes' walk of the centers of work, are open fields, ready for occupation and to be purchased at reasonable price. Such being the case and with trolley development rendering even more dis- tant and more healthful localities easily within reach, the develop- ment of the unhygienic tenement is not a necessit}^ and the growth of the nuisance is to be deplored. And yet in most of our cities, with apparently little necessity for overcrowding and unhygienic living, the evil of the tenement house is undoubtedly rapidly increasing. Under present condi- tions, this state of affairs seems to be unavoidable, for two reasons : First, the cheaply built, overcrowded tenement is a profitable investment and the owners of property, who look only for large returns, have a legal right to construct such buildings, if they comply with the building regulations that are specified in the laws for tenement construction. These tenement hou=:e owners form a class in every city that are active in maintaining their right to erect such buildings, and are a political factor that FOR THE INVESTIGATION OF TUBERCULOSIS. 19 cannot be disregarded. Second, most of the people who occupy these tenements are contented with their accommodations and are not in sympathy with the measures that enHghtened members of every community have earnestly advocated on their behalf. The vast immigration to our country, that pours into every city and town annually, thousands of the poorest from the countries of Southern and Southeastern Europe and from the far East, has created a new order of things in our municipal life. These people have left conditions much worse than they find them here. The tenement that to the educated American seems insufferable, is to these immigrants superior to what they have left. They are often densely ignorant and prejudiced against all measures for their relief, regarding with suspicion the efforts of social reformers, whose motives they are incapable of understanding. These immigrants are not only content with the crowded tene- ment, but to a large degree they enjoy the life that brings them into close association with so many of their own class. They will endure privation and impaired health willingly, rather than accept employment iri the open country, where they can receive good wages and clean and. healthful homes. Many of these immigrants are industrious and thrifty, and prefer the cheapest rent pos- sible to enable them to accumulate money. As they become accustomed to the new country and have saved sufficient to admit of living under better conditions, they move into homes of their' own, or into tenements of a better class. The places that they leave vacant are immediately filled by the endless supply that comes from the home country, and their early experiences in America are repeated. The proper regulation of the tenements occupied by this class must ever rest with the local health authori- ties. These tenements are sure to become foci of infection that are a serious menace to the public health, if they are not kept under rigid supervision. This condition of affairs, that seriously complicates all effort toward hygienic living, seems to be destined to continue indefinitely. There is no reason to suppose that the attitude of these foreigners toward sanitary precautions will ever be changed from what it is to-day. The health authorities must ever be on the alert to suppress all vicious practices and thus keep these tenements in a condition as little prejudicial to the public welfare as may be possible. 20 REPORT OF THE COMMISSION The greatest influence that can be brought to bear upon this class of the community is in the education of the children. Every child should be educated in the rules of decent living, and in such rules for the avoidance of practices that lead to sickness as they may be old enough to comprehend. Our public educators have it in their power to do more than any other organization to accustom the children of our cities and towns to an apprecia- tion of the value of fresh air, clean food, decent sanitary pre- cautions. Children can be made to accept all such ideas and to influence their parents in observing them. If tuberculosis is to be controlled, a large part of the influence that is to bring about that beneficent result will come from judicious public school instruction. Another evil is rapidly developing in our cities that calls for special attention. The lodging-house is an institution that seems some degrees lower than the tenement. A house so old that it would better give place to a newer and more suitable structure, is purchased for a very small sum and filled with beds and bunks to its utmost capacity. The occupants have no decent means for personal cleanliness, and it is to be feared that in the majority of cases they are not disturbed by that fact. In such houses the floating and extremely poor congregate. They are the beings most of all likely to be tuberculous, least of all likely to take the slightest precautions, or to receive kindly the suggestions of workers devoted to improving their conditions. To add to the undesir- able characteristics of this lodging-house class, they are a floating population — fifteen cents a night for a bed, no matter where the bed is — in one part of the town one night, in another part the night following. So they roam about and scatter the germs of tuberculosis, with an industry that most of them are not in the habit of displaying in other directions. The occupants of lodg- ing-houses are an indolent, undesirable class, upon the one hand ; or a very poor class, who are soon to occupy better accommoda- tions, as they find work and are enabled to better their condition. That the indolent should be restrained from becoming a serious menace to the public welfare, is right ; it is equally right that careful inspection and regulation of these lodging-houses should render them as little harmful as possible, in the interest of the worthy who are for the time being compelled to occupy them. The profits that come to the owners of low tenements and lodg- \s iN-d-REASL IN POPUSAT/Oy If^ 7i/BE^uioi!S -Death Rcss 24 f- rL< ITCHPIELD fHA^R T F* O Tt D PopvLA.rior/ 324- PX-R- Sq. Mii-X. IndnxASi: in j^puj^rior/ /x lo Yits. , 3Z . Tv3£KCAJtOSlS J^ZATHIZaTI: 16 per IQ.OOOl. ' SZ J R3<^.J IrfCREASn. JN doFOlAT'Off /?,- JOYfiiS'^ T\)3ZRCVLOSI6 SSATtt R.ATE //PS^ /0,00i W I ]V D H A JVI PoPC/ZATlOrf^B FJX. - J'oPt/Z.AT/OAr lZ€ PEJi. Sq fl^CE. /jv-d-JZEASE I/'/ POPUEATION- //^ /O r^t- ^ % 'CLOSES- PEATH PaTB, 36 PER /ooooL/V/NO- PoPUL-ATroU 31-f PER J , . \Ti/&ERCULOSl^ VSATfiJiATE 19 P. ^ V \SE>^ JkO'VLATtON iff \7u£ERCUMOSr3 XlMATff JifiTE I E N ^ FOR THE INVESTIGATION OF TUBERCULOSIS. 2 1 ing-houses are relatively large. In all efforts to secure proper supervision of the business, these owners are found to be financially able to maintain an opposition that is not easily over- come. They have no interest beyond the return that they may get for their investment. It has already been shown, that the unfortunate occupants of their houses are, as a rule, wholly indif- ferent to any measures for their physical betterment. Why then do we not let them alone ? Because it is the State's duty to do the best by every man, even when in his ignorance he scorns the effort, and because, in the foci of infection that are being estab- lished by these undesirable agencies, the well-being of the whole community is being jeopardized. It is within the power of the Commission to publish charts of local conditions in our cities that would fully confirm what has been written upon the subject, but it is deemed wiser to avoid any specific exposure of the evils in question. The facts are known. The health authorities of our cities are fully cognizant of the truth. It is for them to act and for the State to stand back of them and further their efforts. So much has been written of infected districts in our cities, that there seems to be a popular impression that tuberculosis is a city disease. Is this so ? Has the farmer no interest in the question, because of his security from infection? To answer this ques- tion, your Commission has taken measures to investigate tubercu- losis in rural Connecticut, exclusive of the cities. The State of Connecticut has on an average about 200 people to the square mile. New Haven County has 488 to the square mile; Hartford County, 324; Middlesex County, 114; Windham County, 92; Fairfield County, 314; New London County, 126; Litchfield County, 73 ; Tolland County, 58. During the past ten years the population of Connecticut has increased about 20 per cent. The population of New Haven County has increased about 22 per cent. ; Hartford County, 32 per cent.; Fairfield County, 18 per cent.; New London County, 6 per cent. ; Litchfield County, 16 per cent., while the population of Tolland County has decreased 6 per cent. In the statistical year 1905-1906, the death rate from tubercu- losis of all kinds in the different counties was as follows : New Haven, 15 per 10,000; Hartford, 16; Fairfield, 19; New London, 16; Middlesex, 24; Windham, 17; Litchfield, 14; Tolland, 12. REPORT OF THE COMMISSION The death rate in the ten largest cities of the State was as follows : Tuberculosis death City. Population. rate per 10,000. New Haven 121,216 18 per 10,000 Hartford 95,822 16 per 10,000 Bridgeport 84,274 21 per 10,000 Waterbury 61,900 15 per 10,000 New Britain 33,720 15 per 10,000 Meriden 30,658 16 per 10,000 Norwich 25,620 16 per 10,000 Norwalk 21,243 16 per 10,000 Stamford 20,720 16 per 10,000 New London 19,822 16 per 10,000 These figures do not represent an exceptional year. They are approximately representative of the statistics from the different counties for the past ten years as may be seen by consulting the appended tables. COUNTY OF NEW HAVEN.' 1894-1906. Estimated Total Deaths from Deaths from Population. Deaths. Tuberculosis. Phthisis. 1894-95 236,662 4,017 503 429 1895-96 236,662 4,232 491 417 i896-'97 254,605 4.525 470 391 1897-98 , 259,550 4,067 481 404 i898-'99 263,528 4,318 . 515 466 i899-'oo 274,375 4,153 486 437 i900-'oi 269,163 4,773 . 543 484 1901-02 269,163 4,451 498 446 1902-03 281,162 4,371 500 450 1903-04 287,209 4,549 489 417 1904-05 293,200 4,620 510 443 1905-06 299,225 4,848 470 427 No. of deaths No. of deaths No. of deaths to fromT.B. to from Phthisis to 1,000 population. 1,000 population. 1,000 population. 1894-95 16.S+ 2.1+ 1.8+ 1895-96... ■ 17-3+ 2.0+ 1.7+ i89^'97........ 17-7+ 1-8+ 1.5+ 1897-98 15-6+ 1.8+ 1.5+ i898-'99 16.4 — 1-9+ 1-8 — 1899-00 I5-I+ 1-7+ 1-6 — i900-'oi 17-7+ 2.0+ _ 1.8 — 1901-02 16.5 — 1.8+ 1.6+ i902-'03 15.5+ 1.7+ 1.6+ i903-'04 15-8+ 1.7+ 1-4+ 1904-05 157+ 1-7+ 1-5+ 1905-06 14.5+ . I.S+ 1.4+ FOR THE INVESTIGATION OF TUBERCULOSIS. 23 HARTFORD COUNTY. I 894-1 906. Estimated Total Deaths from Deaths from Population. Deaths. Tuberculosis. Phthisis. 1894-95 161,725 2,560 280 250 1895-96 161,725 2,827 303 264 1896-97 172,119 2,987 287 231 1897-98 186,408 2,891 358 309 1898-99 185,858 '2,939 308 27s i899-'oo 189,260 3,217 349 324 i900-'oi 195,415 3.418 339 315 1901-02 195.415 3,082 321 294 1902-03 205,117 2,891 263 242 1903-04 209,683 3,253 316 282 1904-05 214,698 3,367 303 270 1905-06 219,626 3,488 352 300 No. of deaths No. of deaths No. of deaths to from T.B. to from Phthisis to 1,000 population. 1,000 population, 1,000 population. 1894-95 15-8+ 1.7+ 1-5+ 1895-96 17-4+ 1-8+ 1.6+ i8q6-'97 17.3+ 1.6+ 1.3-f i897-'98 15.5+ I -9+ 1-64- i898-'99 15-8+ i.6-f- 1.4+ i899-'oo 16.9+ i.8-f 1.7+ I900-'oi 17-4+ 1-7+ 1.6+ 1901-02 15-2+ i.6-\- 1-54- 1902-03 14-0+ 1-2+ I-I+ i903-'04 15-5+ 1-5+ i-34- 1904-05 15.6+ 1.4+ I.2-f- 1905-06 15.8+ 1.5+ 1.3+ FAIRFIELD COUNTY I 894-1 906. Estimated Total Population. Deaths. 1894-95 166,927 2,817 1895-96 166,927 3,069 i896-'97 172,898 3,063 1897-98 178,074 2,812 i898-'99 179,070 2,807 i899-'oo 182,395 2,892 I900-'oi 184,203 3,220 1901-02 184,203 3,027 1902-03 191,014 3,088 i903-'o4 194,440 3,269 i904-'o5 197.848 3,328 1905-06 201,261 3,453 Deaths from Tuberculosis. Deaths from Phthisis. 335 237 411 291 375 33^ 251 257 341 307 337 299 343 369 322 308 309 330 283 289 341 386 311 336 24 REPORT OF THE COMMISSION No. of deaths to i,ooo population. i894-'95...;.... 16.8+ 1895-96 18.3+ i89^'97 17-7+ 1897-98 15.7+ i898-'99 15.6+ i899-'oo 15.3+ i900-'oi 174+ 1901-02 16.4+ 1902-03 16.1+ 1903-04 16.8 1904-05 16.3+ 1905-06 17- 1+ No. of deaths No. of deaths from T.B. to from Phthisis to 1,000 population. 1,000 population 2.0+ 1.4+ 2.4+ 1-7+ 2.1+ 1.4+ 1.8+ 1.4+ 1.9+ 1-7+ 1.8+ 1.6+ 1.8+ 1.6+ 2.0+ 1-7+ 1.6+ 1.4+ 1-5+ 1.4+ 1-7+ 1-5+ 1-9+ 1.6+ LITCHFIELD COUNTY. 1894-1906. Estimated Population. 1894-95 56,433 1895-96 57,888 i896-'97 59,229 1897-98 60,123 1898-99 62,572 i899-'oo 62,764 i900-'oi 63,672 1901-02 63,672 1902-03 65,696 1903-04 66,712 1904-05 (iTil^T- i90S-'o6 68,735 No. of deaths to 1,000 population. 1894-95 15-9+ i895-'96 16.3+ i896-'97 15.6+ 1897-98 14-7+ i898-'99 13.2+ i899-'oo 14-6+ i90o-'oi 18.2+ 1901-02 15-6+ 1902-03 13.4 1903-04 13.7+ 1904-05 13-8+ 1905-06 15-0+ Total Deaths from Deaths from Deaths. Tuberculosis Phthisis. 899 103 73 944 80 55 928 107 61 888 82 6i 826 95 83 940 108 98 1,163 no 92 997 104 88 884 89 68 914 74 .67 935 102 93 1,035 102 84 No. of death No. of deaths from T.B. to from Phthisis to 1,000 population. i ,000 population 1.8+ 1.2+ 1-3+ •9+ 1.8+ 1.0+ 1-3+ 1.0+ 1-5+ 1.3+ 1-7+ 1-5+ 1-7+ 1.4+ 1.4+ 1.2+ 1-3+ 1.0+ 1.1+ 1.0+ 1-5+ 1-3+ 1.4+ 1.2+ FOR THE INVESTIGATION OF TUBERCULOSIS. 25 MIDDLESEX COUNTY. I 894-1 906. Estimated Population. 1894-95 41,317 1895-96 41,317 i896-'97 44,191 1897-98 44,285 i898-'99 45,125 i899-'oo 44,900 iQCO-'oi 41,760 1901-02 41,760 1902-03 42,203 1903-04 42,426 1904-05 42,653 1905-06 42,867 No. of deaths to 1,000 population. 1894-95 17-7+ 1895-96 17-5+ i896-'97 174+ 1897-98 14-8-1- i898-'99 16.3+ i899-'oo 16.3+ ,i900-'oi 20.1-I- 1901-02 18.0+ 1902-03 i6.8-|- 1903-04 19.4+ 1904-05 18.5+ 1905-06 18.8+ Total Deaths. Deaths from Deaths from Tuberculosis. Phthisis. 733 88 70 72s 112 80 770 89 59 659 58 42 740 82 78 735 71 69 842 76 69 752 90 86 713 82 73 826 83 73 793 84 11 807 104 91 No. of deaths fromT.B. to 1,000 population. No. of deaths from Phthisis to 1,000 population 2.1+ 1.6+ 2.7+ 1-9+ 2.0-f- 1.1+ 1-34- .9+ 1.8+ V 1-7+ 1-5+ 1-5+ 1.8+ 1.6+ 2.1+ 2.0+ 1.9+ 1.7+ 1-9+ 1-7+ 1-9+ 1.8+ 2.4+ 2.1+ NEW LONDON COUNTY. 1894-1906. Estimated Population. 1894-95 79,995 1895-96 79,995 i896-'97 80,903 1897-98 82,156 i898-'99 83,911 i899-'oo 86,951 i900-'oi 82,758 1901-02 82,758 1902-03 83,984 i903-'04 84,593 1904-05 85,211 1905-06 85,894 Total Deaths from Deaths from Deaths. Tuberculosis. Phthisis. 1,415 190 143 1,386 185 149 1,438 188 122 1,372 170 125 1,328 141 120 1,270 125 112 1,587 154 144 1,433 145 126 1,339 144 132 1,492 155 138 1,502 138 119 1,476 140 116 26 REPORT OF THE COMMISSION No. of deaths to i,ooo population. 1894-95 ■•■ 17-6+ i89S-'96 17.3-f i896-'97 17.7+ 1897-98 16.7 — i898-'99 15.7+ i899-'oo 14-6+ I900-'oi 17-9+ 1901-02 17-3+ i902-'o.3 15.9+ i903-'o4 16.4+ 1904-05 17-6+ 1905-06 16.0-)- WINDHAM 1894- Estimated Population. 4-95 43,306 1895-96 46,306 i896-'97 45,690 1897-98 47,536 i898-'99 48,321 i899-'oo 45,448 igoo-'oi 46,861 1901-02 46,861 1902-03 47,192 i903-'04 47,329 1904-05 47,543 1905-06 47,714 No. of deaths to 1,000 population. 1894-95 20.14- 1895-96 19.7+ i896-'97 19-1+ 1897-98 17.3+ i898-'99 16.7+ i899-'oo 17.5+ i90o-'oi 19.8+ 1901-02 15-6+ i902-'03 15.5+ i903-'o4... 157+ 1904-05 16.4+ 1905-06 17.24- No. of deaths from T.B. to 1,000 population . No. of deaths from Phthisis to 1,000 population. 2.34- 1-74- 2.3+ 1.84- 2.34- 1-54- 2.04- 1-54- 1.6+ 1.44- 1.44- 1.24- 1.8+ 17+ 1-7+ 1-54- 1-7+ 1-54- 1.84- 1.6+ 1.64- 1-34- 1.6+ 1-34- COUNTY. Total Deaths from Deaths from Deaths. Tuberculosis. Phthisis. 873 107 79 914 lOI 69 877 96 80 824 97 73 808 94 82 796 87 76 910 108 96 732 75 70 734 72 68 746 85 57 781 78 72 822 83 7A No. of deaths from T.B. to 1,000 population. No. of deaths from Phthisis to 1,000 population. 2.44- 1-54- 2.14- 1.44- 2.1-1- 17+ 2.0-}- 1-54- 1-9+ 1.64- 1.94- 1.64- 2.14- 2.04- 1.6+ 1.44- I-S+ 1.4-1- 1-7+ 1.24- 1.64- 1-5+ 17-h 1-5+ FOR THE INVESTIGATION OF TUBERCULOSIS. 27 TOLLAND COUNTY 1894-1906. Estimated Population. 1894-95 25,892 1895-96 25,892 i896-'97 25,600 1897-98 25,060 i898-'99 24,675 i899-'oo 26,066 i900-'oi 24,523 1901-02 24,523 1902-03 24,417 1903-04 24,356 1904-05 24,303 1905-06 24,248 No. of deatlis to 1,000 population. 1894-95 14-8+ 1895-96 I7-I+ i896-'97 17.4+ 1897-98 i6.o-|- i898-'99 16.3+ 1899-00 14-5+ i900-'oi 18.54- 1901-02 15.1-f- 1902-03 14-9+ 1903-04 17-6+ 1904-05 15-8+ 1905-06 15-2+ Total Deaths fro m Deaths from Death? Tub erculosis. Phthisis. 38s 40 30 449 50 33 447 46 32 402 Z7 35 404 33 27 378 38 36 455 41 40 372 32 27 366 31 28 441 ' 52 31 385 32 27 369 30 25 No. of deaths No. of deaths fromT.B. to from Phthisis to 1,000 population. 1,000 population. ■5+ I.I+ •9+ 1.2+ .8+ 1.2+ .4+ 1-3+ •3+ 1.0+ •4 1-3+ .6+ 1.6+ ■3+ 1.1+ 1.2+ 1.1+ •1+ 1.2+ •3+ 1.1+ .2+ 1.0+ It appears from these tables, that the death rate in our cities has been very nearly the same as that of the whole county. This is not to be taken as any evidence against the excessive develop- ment of tuberculosis in large cities. It is clearly due to the fact that there are no large cities in Connecticut, and that the condi- tions of excessive crowding and poverty do not exist to a great extent in any section of the State. The two cities in the State showing an increase over the county rate are New Haven and Bridgeport, where unsuitable tenement conditions are as likely to be found as anywhere in the State. Of course it can be maintained, in relation to these statistics, that they are not accurate; that many cases of consumption are returned as deaths from bronchitis or pneumonia, or other 28 REPORT OF THE COMMISSION diseases that neither suggest a family taint nor interfere with the full payment of life insurance. But there is no reason to assume that such false returns are more frequent in one county than in another. Early in April, a circular was addressed to a resident physician, the town clerk and the town health officer of each town in the State, in which they were requested, to the best of their ability, to answer the four following questions : 1. Have the cases of consumption occurred frequently in certain houses ? 2. Have these houses harbored cases of consumption only when tenanted by certain families? 3. Have the houses in which cases of consumption occurred been especially damp or dark, or near to unhygienic barns or coops ? 4. Have the cases of consumption been limited to one particu- lar part of the town, or have they occurred in all parts of the, town ? The replies have been surprisingly numerous. We have heard from all but 11 of the 163 towns to which the circular was sent. Most of the men who were courteous enough to answer, were satisfied with saying "Yes" or "No" to the different queries. A few of the town clerks, instead of answering the questions, simply said that there was little of the disease in their towns. As a rule, the most valuable replies were from the physicians, but some of the lay officials showed a remarkably intelligent and sympathetic interest in the investigation. To the first question, "Have the cases of consumption occurred frequently in certain houses?" the great majority of the answers, as will be seen by the table, were in the negative. Yet in the 33 affirmative replies, some interesting facts were developed. Of these, only 16 reported that the houses in which frequent cases of consumption occurred, harbored cases after a first consump- tive family moved out. Only about one-fourth of the reporters say that insanitary environment was usual in the houses in which consumption occurred, and of this one-fourth, a majority lay emphasis on a damp cellar as a common finding in the house of the consumptive. With practical unanimity, the reporters state that the cases of consumption have occurred in all parts of the towns. FOR THE INVESTIGATION OF TUBERCULOSIS. 29 The 260 answers received from the 152 towns may be tabulated as follows : Q. I. Have the cases of consumption occurred frequently in certain houses? A. No, 181 ; Yes, 33 ; No answer, 44. Q. 2. Have these houses harbored cases of consumption only when tenanted by certain families^? A. No, 8; Yes, 16; Doubtful, i. Q. 3. Have the houses in which cases of consumption occurred been especially damp or dark, or near to unhygienic barns or coops ? A. No, 173 ; Yes, 32 ; No answer, 48. Q 4. Have the cases of consumption been limited to one part of the town, or have they occurred in all parts of the town? A. All parts, 202; One particular part, 2; No answer, 51; Two parts, i. The Commission feels that a few of these letters will be of interest. With due appreciation of the courtesy of the writers, it seems best to publish them impersonally. No. I. "To illustrate from my practice, a farmer and wife, apparently healthy, came from with a family of four children, and bought a farm. As children came to adolescence, they died of consumption until all but one were gone, and she has spent years in a sanatorium. They sold the place, but not before they had adopted two children, and moved to another. One of the adopted children is phthisical and father has active focus on lung. No family history. No signs before coming to that house. I can get no history of there having been any in the house, yet where did it come from? They are good, nice, clean, religious people." No. 2 r-eports all the cases occurring in the town since January I, 1904, 43 in number, and concerning them he makes the follow- ing comments : "Nearly all the cases are widely separated from each other, and no two in the same house, except in two instances. I am well acquainted with the location of the houses, and except one on Avenue and one on Street, they are all high and dry." No. 3 says, in answer to question four: "No particular part of town ; though I am of the opinion that the larger number of our cases are in the near vicinity of the Connecticut River." 30 REPORT OF THE COMMISSION No. 4 says : "Cases have not been limited to one particular part of the town. They have been general, and as frequent in the farming sections (if not more) than in the manufacturing sections." No 5. The Commission appreciates highly the response to their questions contained in the following interesting letter: "I am deeply interested in the work of your Commission, and am glad to be of any assistance. I have examined the records of deaths in this town since October, 1896, at which time I assumed the duties of Registrar, and have taken the names of all persons who have died from tuberculosis during the eleven and one-half years which have elapsed since that date. Fourteen deaths have occurred during the period, but I shall exclude one in answering inquiries, because of the fact that in that case the person came into town in the last stages of the disease, living but a few weeks. "I am surprised to find, on looking over this list, that every death occurred within a mile of the Connecticut River, or its tributary, Eight-Mile River. This may be a mere chance, and I had never thought of the disease being at all confined to certain localities, but you will further see that nine, or nearly three- quarters of the deaths, were in one very small corner, as shown by the enclosed map, "In the house marked '4', the first death occurred in June, 1897, the victim being a lady of thirty-six, who had up to a few months before been very strong and healthy. In December, 1892, a brother died, aged twenty-nine, and in May, 1903, another sister was taken, at the age of thirty, after a long illness, which she endeavored to overcome by outdoor life here and in the West. In January, 1906, the father died, at the age of eighty. The house occupied by this family has been the home of their ancestors since before the Revolution, and I am informed that no other cases have ever been known there. Although near the water, the house stands in a sunny, well-drained location. "The house marked '2' is not as well situated, but is near a large marsh and built into a bank on the rear. The first case was that of a girl of sixteen ; the second that of her mother, two years later, the mother having taken all the care of her daughter, and beginning to fail in health soon after her death. With the excep- tion of two, all of the persons dying from tuberculosis since 1896 FOR THE INVESTIGATION OF TUBERCULOSIS. 3 1 have been native Americans, and all but one have lived in this locality most of their lives. "All of the homes are on a par with the average country home, and with two or three exceptions, the locations would appear to be healthful. More than half of the victims were past middle life, and only two were under twenty-five. "In the past, tuberculosis has been by no means confined to one section of the town, and a general examination of the records for fifty years back seems to show that the average death rate from this cause forty to fifty years ago was thirty to fifty per cent, greater than at present. "I hope I have not gone into details too much, but knowing the people of my town and their condition personally, I thought these facts might be of interest. "There have been no deaths in this town from tuberculosis for more than two years, and so far as I know, there are no clearly defined cases here at present." No. 6. Dr. George H. Wright of New Mil ford says, that most of the cases in the neighborhood of New Milford occur among men grinding silica, and he suggests that the State find a way to do away with the dangers of the present methods of grinding, either wet or dry. No. 7 says : "We have in our town two houses, in which the people who have occupied them for the last fifty years have died with tuberculosis. "Taking up the matter of the first house, I would say that the old residents were of New England stock, and with one exception, died with said disease. About fifteen or twenty years ago, a family from Sweden, who were apparently well and strong when they arrived, lost four of the family, who died with the same disease in this house. "The house is free from tenants at the present time ; in fact, has not been occupied for three or four years. The other house, history shows the death of the old New England farmer, his first wife, second wife and himself, who died of consumption. Another family moved in ; the father old New England stock, the mother Irish. They raised seven children, five of whom died with tuberculosis. One daughter, despondent because of her condi- tion of health, and having been told by physicians that she would 3 32 REPORT OF THE COMMISSION die of consumption, drowned herself. The other, a son, was drowned. Then a family from Canada, French people, moved into the house, and the mother has just died with consumption. In fairness to the history, I will say, when the woman came from Canada, the physician told her she had bronchial trouble, but never told her she had tuberculosis. However, after living there a short time, she was taken with the same disease and died. • "Neither of the houses are damp or dark, nor have barns or coops near enough to be unsanitary. The cases of consumption have not been limited to any part of the town, but occasionally in various sections of the town.'' No. 8 says : "In one house built by the father forty years ago, and no other family occupying it, when the youngest of the children was ' about twelve years old, she died with consumption ; in about two years the next oldest died, and in about two years the next died — all girls, and apparently healthy until the first developed the disease. There are two older sisters still living and in fairly good health. The house is in good situation and well cared for. "In house No. 3, built about twenty years ago, there was a case of tuberculosis in the first family residing in it. This family moved away and another family came, and in a few years three of the second family died. When this family moved to another house, another member of the family died in a few months, and then another was taken ill with the disease, but was sent to the Wallingford Home and returned very much improved, and still seems to be improving. This house is on low, wet ground, with damp cellar." No. 9 writes : "I find upon examination of the records of this town, that in the last fifty years, which is as far back as the records are accurate in the matter of deaths, that there were 176 deaths from tuberculosis, an average of about 3^ each year. Dividing this into two periods of 25 years each, it shows that during the first period there were 116 deaths, a little over 4^ per year. In the second period, from 1882 to date, there were 60 deaths, an average of 2^ per year. "Again, taking up the period from 1888 to 1898, 33 deaths, and from 1898 to 1908, 17 deaths, which shows a remarkable decrease. I cannot find any locality where the disease has appeared for any length of time. The cases are scattered over all sections of the FOR THE INVESTIGATION OF TUBERCULOSIS. 33 town, and in the majority of cases, isolated. I find that in some families there have been several deaths in one house, no cases having appeared in that locality or house, either before or after the removal of that family from that particular house or locality." No. ID says concerning that town : "For a manufacturing town, with its mixed population, exceedingly unhygienic tenements, and no general sewer system, we have- very little consumption. Our freedom from it has been ascribed to the fact that so many are employed in the paper mills, which use large quantities of chloride of lime ; also that the chloride not only disinfects those who work in the mills, but tends to disinfect the air. of the town. This would hardly seem to explain the comparative immunity from tuberculosis, for we certainly have enough other infectious and contagious diseases, except typhoid. "In Litchfield County, where I practiced six years, we had a good many cases of consumption, and there were many houses, old, damp and poorly lighted, where several successive families had developed tuberculosis, often two, three and even five mem- bers of the same family dying one after the other. "I cannot say that unhygienic barns or coops were a factor, but dampness, filth, and failure to paint and whitewash, after the house had been infected, were nearly always factors." No. II says, that the cases have occurred 'Tn the valley, and on the mountain top ; in all parts of the town." No. 12 reports: "Many of the houses are very old, many over the century mark, and more from fifty to ninety years of age. In many, no doubt there have been more than one case of tubercu- losis, but I do not recall any marked ones. "Regarding this place, we have had considerable tuberculosis during the thirty-five years of my practice, but I believe not as much as in many towns of like size. It has been amongst all classes, rich and poor, native and foreign born, and I must con- fess, with a good many cases in the same family. "In many years past it is of record that whole families like the Y's, a family of six, and the H's, a family of seven, were taken one by one, until all are gone, or maybe one left to grow old." No. 13 gives the following succinct data: "In one house, same family, six deaths ; one house, same family, four deaths ; three houses, same family, three deaths ; one. family, three deaths in 34 REPORT OF THE COMMISSION two houses ; one family, four deaths in three houses ; nine families, two deaths each in nine houses." He says that 125 cases have been reported since they organized as a town in 1869 — ^44 cases in 16 families, and 81 cases in as many families, scattered. No. 14. The following history is one of unusual interest: "James and Margaret, each now ninety years old, were the parents of seven children, five girls and two boys. The last child died four years ago last fall. All were born and raised on the farm, and all were well developed and well nourished. All but two of them died on the farm. The farmhouse was low-studded, a short roof on one side and a long roof on the other side reaching to the ground. The barn was fifty feet away. In it were usually kept twelve to fifteen cows and horses — no goats or sheep. This barn was unhealthy and located between three swamps, which were an eighth, a tenth and a sixth of a mile distant. Most of the children assisted in the milking of the cows. The milk was used on the place and made into butter and cheese. The girls usually left home when about sixteen years of age, to work in hotels and families as servants, and usually returned home sick, where they lasted from six months to four years." In many of the houses, alluded to in these letters from some of our most beautiful country towns, there may possibly have been nothing to indicate the reason for the persistence of the tubercu- lous infection. In most of them the owners were undoubtedly industrious and worthy people. In practically all of them, it is quite possible that the blinds were tightly closed, the windows always closed, except during house-cleaning, the cellar window- less, or nearly so ; in short, they were all barred against sunlight and fresh air, as has been the almost universal custom in Con- necticut for generations. The sun may fade the carpet, but if it puts healthful color into the cheeks, the exchange is no loss. Upon a farm located in the most healthful part of Connecticut, a family has resided for some years that was of the kind so often described as "consumptive." Four members of the family had died of tuberculosis and two were seriously infected, when one member of the family, in seeking employment, was hired by a sani- tarium for the treatment of tuberculosis. While in service at the sanitarium, the girl learned the value of fresh air and sunlight and returned home to institute reform. The house was completely FOR THE INVESTIGATION OF TUBERCULOSIS. 35 embedded in trees ; the windows were never opened and no attempt had ever been made to disinfect. All was immediately changed ; the trees came down, the fresh air was admitted every- where, paint and work cleaned the place. The two invalids remained at home and began to improve. One is well to-day, the other improving. Not another case has developed in that house. The farm was attractive, the people industrious. The story applies to hundreds of homes in New England to-day. The disease and death are not in such cases to be attributed to a want of cleanliness, but to a lack of understanding as to the vital importance of sunlight and fresh air. From the facts at hand it would appear that Human tuberculosis has occurred in all parts of Connecticut — highland and lov/land and plain, in city or village. There is considerable evidence to show, that in rural Connecti- cut human tuberculosis occurs most frequently in badly drained districts and in houses with damp cellars. The reports received do not support the view, that in rural Con- necticut cases of consumption occur frequently in close proximity to unsanitary barns or coops. While the preponderance of testimony is that in rural Con- necticut only a minority of cases of consumption have been fol- lowed by other cases in the same house, or the same family, the evidence in favor of the hypothesis of "consumption houses" and "consumption families" is often very striking and is deserv- ing of careful consideration. The fact that private houses may become infected with tuber- culosis, as well as the larger tenements, is conceded. Where such residences are occupied by one family, it does not appear that the State has any duty in the matter. With people of even ordinary intelligence, to know the facts should be enough to secure correction of the evil, and the local health officer already possesses the power to disinfect such premises. A physician in attendance upon such a family holds a position of responsibility, and is dere- lict in his duty if he does not recognize the necessity for disinfec- tion and proper living, and make such necessity apparent to his patients. In tenements where several families are under the same roof, it is the duty of the State to see that these families are pro- tected. One careless and indifferent consumptive may imperil the whole tenement, and without the aid of the State the occupants 36 REPORT OF THE COMMISSION of the house have no redress. So long as the laboring people are forced to reside in tenement houses, simply by reason of the lack of more desirable accommodations, it is the duty of the State to protect them against abuses in the construction and main- tenance of the building. So far as the construction of tenement houses is concerned, the law of Connecticut, as it has been in force since June 29, 1905, would seem to be satisfactory and to ensure in all tenements to be erected in the future a sufficient provision of light and air. To secure this result, it is indispensable that the law should be enforced. As to tenements already in existence, the State law has no effect. It controls the construction in the future. It does not affect the old tenement and lodging-houses that have been occupied for many years and are in some instances inconceivably filthy. The control of this evil must reside in the health officer of the community in which it exists. How far the control of the State Board of Health might be substituted, in the matter of tenement inspection, is a question worthy of considera- tion. It is not always easy for a local health officer to combat strong political pressure. It is his duty to do so, of course ; but if the performance of his duty results in the appointment of a substitute more congenial to the tenement owners, then, certainly, no good has been gained. Inspection placed in the hands of an outside inspector, beyond local control, might be more effective. This question is beyond the scope of this report. It is fair to say in addition, that if the public is interested in an effective administration of the local health boards, and is ready to uphold them in their efforts to control these tenement abuses, then they must see to it that the health officers receive a salary to some degree commensurate with their responsibility. Your Commis- sion desires to be on record as advocating state tenement house inspectors, to act in cooperation with the local health authorities and to assume responsibility, if need be, for such action as may be required to protect the public health. FOR THE INVESTIGATION OF TUBERCULOSIS. 37 FACTORY CONDITIONS. It is 'manifestly wrong, that one who is cleanly in person, who takes all possible precautions against infection in the home, should be subjected to possible infection from preventable sources in the place where he or she has to work for a living. It is the duty of the public to see that the conditions in all work- shops are made as safe as is practicable, and that whatever safe- guards may be necessary to that end are provided. What, then, are the sources of danger to be provided against in the workshop? Spitting. This pernicious habit has already been referred to as being especially prolific of harm to the whole community. In workshops and stores it attains its highest efficiency as a destroyer of public health. If persons infected with tuberculosis expec- torate on the floors or walls, the sputum becomes dried and is inhaled by their fellow-workers to their great danger. This is the most easily prevented source of infection, and it should be made a misdemeanor for any person to expectorate upon the floors, walls or stairways of any factory, store, public building or vehicle, and the owners should be required to post the law in conspicuous places. The factory inspector should have the authority to require suitable spittoons, in such numbers and places as may be necessary ; and to require that they be cleaned and disinfected at regular intervals, not less than twice a week, or oftener if neces- sary ; and he should further require that they be kept partly filled with water, or disinfectant. The Massachusetts Commission has recommended that spitting upon the floors or walls of factories be prohibited by law, but their recommendation is not sufficient, as it provides no penalty. At the present time, with very few exceptions, there is practically nothing done in Connecticut to prevent indiscriminate spitting, or to provide spittoons in even the best managed factories. Recently, the subject has been so forcibly brought to the atten- tion of the public, as a measure for the suppression of tuberculosis, 38 REPORT OF THE COMMISSION that a f evvT factories are endeavoring to check the evil. But condi- tions in most factories in this respect are as bad as they can pos- sibly be, all corners and walls being foul with spittle and tobacco juice. The efforts made to educate the public as to this foul and unnecessary habit will in time create a sentiment among the workmen themselves, that will be the most potent influence toward its correction. Until that time arrives, the factory inspector should be endowed with every power requisite to enforce reform. Many manufacturers have expressed to the Commission a desire to be informed as to a simple and practicable method for con- trolling expectoration in the shops. The problem is no mean one — how to cleanse 3,000 cuspidors a day calls for careful con- sideration. The plan adopted by the United States Government Printing Office, which was exhibited at the exhibition in Wash- ington, during the International Congress on Tuberculosis, was so simple and effective that a large part of the pamphlet explaining the work is inserted in this report, with an earnest recommenda- tion that all manufacturers will give the matter due consideration. "In the United States Government Printing Office, approxi- mately 4,800 persons are employed under one roof. A great many there employed have sedentary duties, their work being placed directly in front of them or within a given space. Many use tobacco, which excites salivation and consequent expectora- tion, and as a result of this condition, about 1,400 cuspidors are required for use, and which must be cleaned at the termination of each eight-hour shift. "Some idea of the magnitude of this work may be gained, when one considers that under the old system about 400 barrels of sawdust were used each month, at a cost of $100, to fill spit boxes. The sputum caked and accumulated against the sides of boxes which could not be thus properly cleaned, and as a result they were insanitary and dangerous to health. "Under the present method, now being installed, the cleaner picks up the dirty or used cuspidors, five at one time, in a 'nested' fashion, by a specially designed clutch or device, as shown in exhibit, and with the movement of one arm only. The five vessels, so confined, are then carried to a box truck lined with galvanized iron. After the truck has been filled (they hold 140 cuspidors), in this manner, it is pushed to the freight elevator on FOR THE INVESTIGATION OF TUBERCULOSIS. 39 each of the respective floors, and by this means is taken to the basement, whence the truck is wheeled directly into the sterilizing chamber. "Here the cuspidors are cleaned and sterilized with boiling water and steam, the contents of vessels being carried or flushed directly into the sewer by means of a drainpipe. "After remaining in the racks long enough to dry, where they are placed directly after the steam and water bath, the operator pulls the vessels from the rack and places them back into the truck. As each layer of cuspidors is placed in the truck, about two or three ounces of a disinfecting solution is poured into each. "The solution is used to disinfect the sputum and to destroy or greatly attenuate (weaken) all forms of germ life, including the tubercle bacillus (consumption germ), and the organism causing pneumonia in its various forms, that may be found in the expectorations. The antiseptic remains in the cuspidor until it is washed again. "The solution is composed of bichloride of mercury, citratic acid and a coloring agent, and is odorless. The bichloride of mercury is used for its germicidal and antiseptic properties, tests having shown that the most resistant disease germs die, when brought in contact with this agent, in less than half a minute. The citric acid used retards the coagulation or lumping of albumin in saliva, thus rendering the mercury more potent and penetrating to the mass. The coloring agent (eosin) is used to differentiate the solution from harmless hquids, such as water, only as a matter of precaution. "The operator at no stage of the collection or cleaning pro- cedure touches his hands or person to the dirty vessels, thus avoiding danger of infection to himself and. others. The cus- pidors used in demonstration were especially designed for service in the Government Printing Office, and are made without any sharp angles or overhangs, thus presenting a vessel that is self- draining and permits of very easy cleaning. "Experience has shown that it is almost impossible to have the ordinary stock cuspidors properly cleaned, owing to the sharp undercuts and overhangs and the repugnance of the work in general. The cuspidors now in use are made of hard, tough, vitreous ware, to stand rough usage, and at the same time to withstand the corrosive action of bichloride of mercury, in addi- 40 REPORT OF THE COMMISSION tion to presenting a smooth sanitary surface for cleaning pur- poses. The cost is about thirty-eight cents apiece wholesale. "The chemicals going to make up the solution necessary for an entire year's supply in the Government Printing Office cost about fourteen dollars — five gallons can be made for less than two cents — and may be purchased at any drug store or chemical concern. The labor of one man at two dollars per diem covers the cost of operation for each twenty-four hours, or three eight- hour shifts. "No device or method in connection with this exhibit is patented, and all or any part, if desired, may be freely copied by manufacturers and persons interested in stamping out tuberculosis." Sweeping. The factory inspector should have full power to regulate the method of sweeping in shops and stores. No method should be allowed that results in the raising of clouds of dust that must carry with it and scatter broadcast the material for infection. This regulation is to the owner's interest as well as the employee's. The method of sweeping, whether by damping or by use of some mechanical contrivance for that purpose, should be left to the judgment of the owner. Proper efforts to avoid dust during the process of cleaning the shops are now in force in the best shops in the State. Where attention to the matter is neglected, it should be immediately corrected. Dangerous Occupations. There are certain occupations where tuberculosis is much more common than in others, such as buff- ing, polishing, grinding, working with emery or carborundum in foundries, or in other work on metals where minute particles of metal are taken into the lungs, causing irritation of the passages and creating an inflammatory condition favorable to the lodgment and subsequent development of the germs. Cutlery grinders and stone cutters are particularly prone to contract the disease. All persons working in dusty occupations of any kind are liable to contract tuberculosis. Among the occupations most favorable to the development of the disease may be classed work in rooms where hemp, cotton, woolen or silk is opened, carded, picked or spun, and where dust and fibre are floating in the air ; also in the fur-cutting rooms in hat manufacturies, and in woodworking establishments, such as bobbin shops, where there is much fine sawdust. FOR THE INVESTIGATION OF TUBERCULOSIS. 41 Those occupations are also classed as dangerous where there are irritating fumes of chemicals or metals, such as blast furnaces, nickel and silver plating, japanning, lacquering and hat making, also where persons are subject to extreme heat, such as glass- works, etc., or where the workers sit or stand in cramped positions, as tobacco workers, garment workers, etc. Wet Grinding and Polishing. ^What measures, then, can be taken to make occupations of the above classes less dangerous? It is probable that no step in this direction has been of more value than the substitution of wet for dry grinding in cutlery, the latter, we believe, being nearly eliminated. The same principle could be followed, wherever practicable, in a great variety of cutting and polishing operations in the metal trades, by the use of water or oil, either on the polishing or grinding surface, or in jets of spray which would carry down the dust. Exhmist Fans. Second, the introduction of exhaust fans and dust separators v\^ith hoods over dusty machines, carrying away the dust from the operator, is to be recommended. The same method should be adopted in all places where there are poisonous or irritating fumes. Dressing Rooms. Third, providing washrooms and dressing- rooms, and places to dry the clothing taken off, in such trades as require work in wet clothing, that the workers may not catch cold from going out in wet clothing. Conditions in Connecticut. The state factory inspector reports, that such conditions for the workers in this State are much above the average, and, on the whole, fairly good ; that the laws govern- ing such cases are satisfactory and that the manufacturers show a disposition to do what is right ; and that he is issuing orders as fast as practicable, requiring the introduction of exhaust fans, dust separators, and also washing- and dressing-rooms in foundries. He says that all such orders are complied with in a reason- able time. His report for 1906, the last published, shows forty- five new washrooms, etc., ordered in foundries and other places, and eighteen orders relating to exhaust systems and hoods. Of course, this only represents one 5^ear's work. n those who are deeply interested in measures to ensure safety to those employed in dangerous occupations, will take the trouble to inform themselves by visiting the shops, they will find that in a very large number of cases provision for absolute safety 42 REPORT OF THE COMMISSION has been made. They will further find the safety appliance out of use, because of the singular indifference of the workman to his own safety; or in use, by reason of the careful supervision of the owner. This attitude of the general public, not only in the shops but in all the everyday affairs of life, is the most serious discour- agement the workers for a better social condition have to contend with. To disregard all efforts toward safeguarding the employee because of his indifference, cannot be tolerated. No man in the community belongs to himself. During health he may have the mistaken notion that he does, but if he is injured, he in the vast majority of cases becomes a public charge. Aside from all altru- istic motives, the safety appliances are to the advantage of the community, from an economic point of view, and their use should be required. Full justice is seldom done to manufacturers in such matters. Most men, if shown that any measure will be a decided advantage to their employees in health or safety, will adopt it, even at con- siderable expense to themselves. The average manufacturer thinks more for the health and safety of his employees than the average worker does for himself, and safeguards provided by them are often disregarded or thrust aside by their employees. In the hat industry, the introduction of the kiln system, as well as the substitution of denatured alcohol, has greatly reduced the danger from alcoholic fumes. Formerly the hats were dried on racks, and the men who had to work in these rooms and take out the dry hats were frequently overcome by the fumes. In some instances blindness resulted from this exposure. Now the hats are dried in kilns and the fumes exhausted and the alcohol reclaimed. Owing to the greatly varying circumstances in factories, it is impossible to provide a law, in respect to working conditions, which shall apply to all alike. What would be very good in one place would be very bad in another. The Massachusetts Com- mission has recommended the passage of a law, by which the factory inspector may require any manufacturer to bring the conditions as to dust, ventilation and sanitation in his factory up to the best, where there are similar conditions as to dust, building and employment, allowing an appeal from the decision of the factory inspector. Any such law should be careful to protect the FOR THE INVESTIGATION OF TUBERCULOSIS. 43 manufacturer against improper exactions, particularly in the case of old buildings, but is worthy of consideration. Air Space per Person. Both New York and Massachusetts have laws which require a minimum of two hundred and fifty cubic feet of air space per worker. In New York, four hundred are demanded where there is night work, though this provision is aimed mostly at sweat-shops, of which there are practically none in Connecticut. It is a fact that there is not much overcrowding in our factories, yet some such law might be of value. Ventilation. It is of even more importance that the air in • workrooms should be changed in such manner as to provide pure and uncontaminated air to the workers. The best modern fac- tories are provided with heating apparatus, which supplies an ample amount of fresh air from outside, or through systems which humidify and warm the air at the same time. In the sum- mer there is plenty of ventilation through open windows. Our laws provide for the ventilation of all workrooms, and these laws are, we believe, enforced by our factory inspector. Here again, we do not have to contend with the sweat-shop. But there can be much done to improve conditions. Exhaust fans carry away dust and at the same time provide fine ventilation. The work of our factory inspector in this direction should be cordially supported and its extension helped. Sanitation. The Connecticut law as to sanitation in factories is, in the main, good and sufficient, as regards plumbing, closets and cleaning floors, machinery, etc. The New York law gives the factory inspector authority to order walls and ceilings lime- washed, when the health of persons working may be affected. Connecticut law gives this power in bakeries. It might well be extended to all factories. Bakeries. The Connecticut law in respect to bakeries is excel- lent. No new bakeries are allowed to be built below grade, nor old ones that have been closed to be reopened. Workrooms must be at least eight feet in height, the walls plastered or wainscotted, the ceilings plastered or ceiled with lumber or metal, floors and utensils kept clean and sanitary, the rooms dry and airy. Sleeping places, also all closets, ash pits, etc., must be separate from the workrooms. The inspector might be given the additional author- ity to order medical inspection of all persons employed in bakeries. 44 REPORT OF THE COMMISSION and the same law entire might be extended to cover tobacco factories, confectionery shops, and all factories for the prepara- tion of food, and shops where food products are sold. Laundries. The New York law makes all public laundries factories, and subject to the same inspection and regulation as other factories. It also prohibits such work being done in sleep- ing- or living-rooms, but exempts any female doing custom laundry work at home. Garment Workers. In general, all places where people work in the employ of others should be subject to inspection and regula- tion. It is doubtful how serious the danger may be from clothing that has been made by sufferers from tuberculosis. Doubtless, there is some. The question is far-reaching, and it is doubtful whether anything short of physical examination of all persons employed in making or handling cloth and clothing, and the exclusion of all infected persons from such employment, would much lessen such danger as may exist. This procedure would work very great hardship, and people excluded from their work, by reason of such physical examination, would have to be cared for by the State to an extent hardly to be expected. It would afford no protection against infection from clothing made out- side of the State. We do not think that such a step has been taken anywhere in the world. The New York sweat-shop law is most voluminous and far- reaching in its powers to disinfect, condemn or quarantine goods and garments made in infected or unclean places, and if enforced to the letter would be most drastic; but even this does not con- template anything so severe as excluding from employments, of such a wide range, persons infected with tuberculosis, nor do we believe it to be necessary or advisable. Free Bed Funds. No report on factory conditions in Con- necticut would be complete which did not mention the work of the Workingmen's Free Bed Fund. Started first in Hartford and promoted largely by the indefatigable work of Mr. John Gun- shanan, it has proved to be a work of great value to the working- men of that city. A large amount of money has been raised by subscriptions from the men in the shops, which has been applied to the care of workmen suffering from tuberculosis and to the relief of their families. This plan to secure funds for the care of the tuberculous and for the maintenance of their families dur-. Dealh, TiiU fion ^ n i r y Tuberculosis CHART ^KOWmO- MoRTALir/ FROM AZL FOSAfS OF luSZTi.' pw /o.ooo /mpj Cl/mSIS IN PROXS/A TZR 10.000 of^ fMTOFUIATIOJi- f.om,/87S to /9o3 W7^ 76 11 If, 79 80 8/ ez 83 84 as 8( 81 81 &i 90 s; 52 93 34 95 96 97 9S 39 00 01 02 03 04 OS 06 OJ "SV h?. r "\ 1 ^ im h ,1 Cf ■ 'n. ur- rn( 0, ca mi 11 iiu c P« ra Ltm, SlA \ i A 3/ \l \ ( \ W \ 30 \ Z9- \ 19 \, Zi \ 78 V 'i < hr [z/oJ J. or. r ■ ^j al cL ^Y a, id o, d I3e_ Z/i ^ n. u/ f?A IS? a in e- m U} oi. er \tt OI ?7 , /d-j \ Z(, \ Z5i \ Zf, \^ ?4 \ z4\ \ ZV' s N^ K J uf rn UiT . I lOi en ICf t 25 \ i 1o/ im en cet ^ ??^ y zi \ Zl^ \ Zl 4- 1 "-ac Ye /^ 'tJJlOJV ZO ■ / ^\ o/ '9 £7/- z ?.(k / \ 19- ■ 1 \ S 19 \ ^ ra- ■ y ze 17- n 3UZSTROPFS JXEPORI FOR THE INVESTIGATION OF TUBERCULOSIS. 45 ing the enforced idleness of the invalid, has already been adopted and organized in most of the large cities of the State and is fast developing into a work of magnitude. It has recently been reorganized on a new basis. A number of groups are formed, each one comprising the workers of one factory, or a number of small factories. Each group is to have its own officers and a fund for the benefit of its own members. In some instances, the employer has agreed to contribute a sum equal to the amount contributed by the employees. These funds are devoted to the care of workers, or their families, suffering from tuberculosis. In Germany, the government requires the employer to deduct a certain amount of the wages of the employee, to place with it a like amount, and the fund so created is used for sick benefits and kindred purposes. In some factories in this country, a similar arrangement is in operation, each worker being asked to allow so much to be taken from his wages, the employer adding an equal amount, which forms the basis of a fund to be used for sick benefits. It is possible that some such arrangement might take the place of the subscription paper, as a means of raising money for the Free Bed Funds. This movement to secure an organized effort throughout the State, to establish and maintain a sick relief fund for the care of the tuberculous and their families, is worthy the unusual atten- tion. It goes far, if it can be maintained, toward meeting the serious loss that comes to every man from tuberculosis. It affords him the opportunity for securing proper treatment, and aids immeasurably in that treatment by caring for his family and thus relieving the mental anxiet}^ that is otherwise unavoidable. The German method of sick and invalid insurance has been in operation now since 1884, a-i^d the accompanying chart shows very graphically what has resulted, largely from the influence of that movement. The present compulsory insurances now in force in Germany are 1. Accident Insurance (came into force July 6th, 1884). Provided for by payment from employers only. 2. Sickness Insurance (came into force December i, 1884). Provided for by payment from workmen two- thirds, from employers one-third. 46 REPORT OF THE COMMISSION 3. Invalidity and old age insurance (in force Janu- ary, 1891). Provided for by payment from workmen, emplo3^ers and the state. This sickness insurance subjects to compulsory insurance all worl