July 25, 1901] 



NA TURE 



315 



Often, in such circumstances, the infection is not restricted 

 to a single family, but spreads in densely inhabited tenement- 

 houses to the neighbours, and then, as the admirable investiga- 

 tions 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 favours tuberculosis, but the 

 bad domestic conditions under which the poor everywhere, 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, especially as regards the bed- 

 rooms, are bad, as is the case, for instance, among the inhabit- 

 ants of the North Sea coast. So it is the overcrowded 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, and 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 eftected 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 people about them, to lodge them better ; and this 

 can be done only in suitable hospitals. But the thought of 

 attaining this end by compulsion of any kind is very far from 

 me ; what I want is that the consumptives may be enabled to 

 obtain the nursing they need better than they can obtain it now. 

 At present a consumptive in an advanced stage of the disease 

 is regarded as incurable and as an unsuitable inmate for a 

 hospital. The consequence is that he is reluctantly admitted 

 and dismissed as soon as possible. The patient, too, when the 

 treatment seems to him to produce no improvement, and the 

 expenses, owing to the long duration of his illness, weigh 

 heavily upon him, is himself animated by the wish to leave the 

 hospital soon. That would be altogether altered if we had 

 special hospitals for consumptives, and if the patients were taken 

 care of there for nothing, or at least at a very moderate rate. 

 To such hospitals they would willingly go ; they could be better 

 treated and cared for there than is now the case. I know very 

 well that the execution of the project will have great difticullies 

 to contend with, owing to the considerable outlay it entails. 

 But very much would be gained if, at least in the existing 

 hospitals, which have to admit a great number of consumptives 

 at any rate, special wards were established for them, in which 

 pecuniary facilities would be offered them. If only a consider- 

 al)le fraction of the whole number of consumptives w-ere suitably 

 lodged in this way, a diminution of infection and consequently 

 of the sum total of tuberculosis could not fail to be the result. 

 Permit me to remind you in this connection of what I said about 

 leprosy. In the combating of that disease also great progress 

 has already been made by lodging only a fair number of the 

 patients in hospitals. The only country that possesses a con- 

 siderable number of special hospitals for tubercular patients is 

 England, and there can be no doubt that the diminution of 

 tuberculosis in England, which is much greater than in any 

 other country, is greatly due to this circumstance. I should 

 point to the founding of special hospitals for consumptives and 

 the better utilisation of the already existing hospitals for the 

 lodging of consumptives as the most important measure in the 

 combating of tuberculosis, and its execution opens a w-ide field 

 of activity to the State, to municipalities, and to private benevo- 

 lence. There are many people who possess great wealth, and 

 would willingly give of their superfluity for the benefit of their 

 poor and heavily afflicted fellow-creatures, but do not know how- 

 to do this in a judicious manner. Here is an opportunity for 

 them to render a real and lasting service by founding consump- 

 tion hospitals or purchasing the right to have a certain number 

 of consumptive patients maintained in special wards of other 

 hospitals free of expense. 



As, however, unfortunately, the aid of the State, the muni- 



NO. 1656, VOL. 64] 



cipalities, and rich benefactors will probably not be forthcoming 

 for a long time yet, we must for the present resort to other 

 measures that may pave the way for the main measure just re- 

 ferred to, and serve as a supplement and temporary substitute 

 for it. 



Among such measures I regard obligatory notification as 

 specially valuable. In the combating of all infectious diseases 

 it has proved indispensable as a means of obtaining certain 

 knowledge as to their state, especially their dissemination, their 

 increase and decrease. In the conflict with tuberculosis also 

 we cannot dispense W'ith obligatory notification ; we need it 

 not only in order to inform ourselves as to the dissemination of 

 this disease, but mainly^ in order to learn where help and in- 

 struction can be given, and especially where the disinfection 

 which is so urgently necessary when consumptives die or change 

 their residences has to be effected. Fortunately it is not at all 

 necessary to notify all cases of tuberculosis, nor even all cases 

 of consumption, but only those that, owing to the domestic 

 conditions, are sources of danger to the people about them. 

 Such limited notification has already been introduced in various 

 places, in Norway, for instance, by a special law, in Saxony by 

 a ministerial decree, in New York and in several American 

 towns, which have followed its example. In New York, where 

 notification was optional at first and was afterwards made obli- 

 gatory, it has proved eminently useful. It has thus been proved 

 that the evils which it used to be feared the introduction of 

 notification for tuberculosis would bring about need not occur, 

 and it is devoutly to be wished that the examples I have named 

 may very soon excite emulation everywhere. 



There is another measure, closely connected with notification, 

 viz. disinfection, which, as already mentioned, must be eflected 

 when consumptives die or change their residence, in order that 

 those who next occupy the infected dwelling may be protected 

 against infection, iloreover, not only the dwellings but also the 

 infected beds and clothes of consumptives ought to be disinfected. 

 A further measure, already recognised on all hands as effective, 

 is the instructing of all classes of the people as to the infec- 

 tiousness of tuberculosis, and as to the best way of protecting 

 oneself. The fact that tuberculosis has considerably diminished 

 in almost all civilised states of late is attributalile solely to the 

 circumstance that knowledge of the contagious character of 

 tuberculosis has been more and more widely dissemina.ed, and 

 that caution in intercourse with consumptives has increased more 

 and more in consequence. If better know'edge of the nature of 

 tuberculosis has alone sufficed to prevent a large number of cases, 

 this must serve usas a significant admonition to make the greatest 

 possible use of this means, and to do more and more to bring it 

 about that everybody may know the dangers that threaten him 

 in intercourse with consumptives. It is only to be desi^'ed that 

 the instructions maybe made shorter and more precise than they 

 generally are, and that special emphasis belaid on the avoidance 

 of the worst danger of infection, which is the use of bedrooms 

 and small ill-ventilated workrooms simultaneously with con- 

 sumptives. Of course the instructions must include directions 

 as to what consumptives have to do when they cough and how 

 they are to treat their sputum. 



Another measure, which has come into the foreground ot 

 late, and which at this moment plays to a certain extent a para- 

 mount part in all efforts for the combating of tuberculosis, works 

 in quite another direction. I mean the founding of sanatoria for 

 consumptives. 



That tuberculosis is curable in its early stages must be regarded 

 as an undisputed fact. The idea of curing as many tubercular 

 patients as possible in order to reduce the number of those that 

 reach the infectious stage of consumption, and thus to reduce 

 the number of fresh cases, was therefore a very natural one. 

 The only question is whether the number of persons cured in 

 this way will be great enough to exercise an appreciable influ- 

 ence on the retrogression of tuberculosis. I will try to answer 

 this question in the light of the figures at my disposal. 



According to the business report of the German Central 

 Committee for the Esiablishment of Sanatoria for the Cure of 

 Consumptives, about 5500 beds will be at the disposal of 

 these institutions by the end of 1901, and then, if we assume 

 that the average stay of each patient will be three months, it 

 will be possible to treat at least 20,000 patients every year. 

 From the reports hitherto issued as to the results that have been 

 achieved in the establishments we learn further that about 20 

 per cent, of the patients that have tubercle-bacilli in their 

 sputum lose them by the treatment there. This is the only sure 



