462 ANNUAL REPORT OF THE Off. Doc. 



work. How can the uecessary cleanliness be secured under such 

 circumstances? How is such a helpless patient to remove his 

 spulum, so that it may do no harm? But let us go a step further 

 and picture the condition of a poor consumptive patient's dwelling 

 at night. The whole family sleep crowded together in one small 

 loom. However cautious he may be, the sufferer scatters the morbid 

 matter secreted by his diseased lungs every time he coughs, aod his 

 relatives close beside him must inhale this poison. Thus whole 

 families are infected. They die out, and awaken in the minds of 

 those who do not know the infectiousness of tuberculosis the opin- 

 ion that it is hereditary, whereas its transmission in the cases in 

 question was due solely to the simplest processes of infection, which 

 do not strike people so much, because the consequences do not ap- 

 pear at once, but generally only after the lapse of years. 



Often, under such circumstances, the infection is not restricted 

 to a single familj-, but spreads in densely inhabited tenement-houses 

 to the neighbours, and then, as the admirable investigation?? of Biggs 

 have shown in the case of the densely peopled parts of New York, 

 regular nests or foci of disease are formed. But, if one investigates 

 these matters more thoroughly, one finds that it is not poverty per se 

 that favors tuberculosis, but the bad domestic conditions under 

 which the poor everyw^here, but especially in great cities, have 

 to live. For, as the German statistics show, tuberculosis is 

 less frequent, even among the poor, when the population is not 

 densely packed together, and may attain very great dimensions 

 among a well-to-do population when the domestic conditions, es- 

 pecially as regards the bedrooms, are bad, as is the case, for instance, 

 among the inhabitants of the North Sea coast. So it is the over- 

 crowded dwellings of the poor that we have to regard as the real 

 breeding-places of tuberculosis; it is out of them that the disease 

 always crops up anew, and it is to the abolition of these conditions 

 that we must first and foremost direct our attention if we wish to 

 attack the evil at its root, a«d to wage war against it with effective 

 weapons. 



This being so, it is very gratifying to see how efforts are being 

 made in almost all countries to improve the domestic conditions of 

 the poor. I am also convinced that these efforts, which must be 

 promoted in every way, will lead to a considerable diminution of 

 tuberculosis. But a long time must elapse ere essential changes 

 can be effected in this direction, and much may be done meanwhile 

 in order to reach the goal much more rapidly. 



If we are not able at present to get rid of the danger which small 

 and overcrowded dwellings involve, all we can do is to remove the 

 patients from them, and, in their own interests and that of the peo- 



