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sale or donation of objects which have been in use by consumptives unless they have been thoroughly disinfected.
"7. Compulsory disinfection of hotel rooms, sleeping car berths and steamer cabins which have been occupied by consumptives, before other persons are allowed to occupy them."
The City of London Hospital for Diseases of the Chest, the North London Hospital for Consumption, the Royal National Hospital for Consumption, the National Sanitarium, the Manchester Hospital for Consumption and the Victoria Dispensary for Consumption issue instructions to be observed by their patients to prevent spreading the disease. These all comprise the use of spit cups, disinfected cuspidors, the prohibition of expectorating on the floor indoors, or on the ground out of doors, and the avoidance of swallowing the sputa to prevent re-infection.
- In the various sanatoria for tuberculosis in Germany and in many in this country similar instructions are issued. Some progressive private practitioners in this country have had cards printed containing concise instructions for the disinfection of sputa, and other measures to prevent the further spread of the disease.
The various practicable measures for the restriction of tuberculosis may be summed up as follows:
I. Notification to the health anthorities of all cases of tuberculosis, more especially of tuberculosis of the lungs. This report should be made by the physician who becomes cognizant of the case in the line of his professional duty, and by the householder himself. In order to reach all cases, such notification should be compulsory. While it is probable that some cases would escape report through the negligence or wilful disregard of the medical attendant, these would be few and would diminish as soon as the benefits accruing from attention to this regulation became apparent.
All public institutions, as hospitals, prisons, schools, asylums, etc., should be required to promptly report through their managers or executive officials, under penalty, all cases of tuberculosis occurring in such institutions.
3. Upon the recovery, death, or removal of a consumptive from one house or apartment to another, notice should be given by the patient or his guardian, the householder or the physician to the health authorities in order that appropriate measures of disinfection of the vacated premises may be taken.
4. Concise instructions for the guidance of patients with pulmonary consumption, or persons coming into frequent contact with them should be furnished, free of charge by the health authorities, upon notification of a case, or at the request of any person interested. These instructions should cover especially the means for destroying or rendering innocuous the sputa. The isolation of patients is not necessary. When the material containing the tubercle bacilli,—in these cases the sputa-is destroyed, the consumptive is no longer dangerous to his most intimate associates.
5. The health authorities should be empowered to employ special inspectors to visit all cases of consumption reported, instruct the patients themselves and the family, or those brought closely and constantly in contact with them in the best means of avoiding self-infection and the communication of the disease to others, and to disinfect the apartments occupied by the consumptive if found necessary. It may be objected that this will interfere too much with the rights and privileges of the attending physician, but the latter would doubtless often be willing to be relieved of the tedious details necessary. There could, of course, be no objection to the attending physician performing these duties himself, provided they were thoroughly done.
Neither the inspector nor any other officer of the health department should be allowed to comment on the physician's treatment or to offer any suggestions in this particular. I
believe it will be generally conceded that sanitary officials conduct themselves with tact and discretion in their relations with physicians.
6. Municipalities should be urged to establish special hospitals for the treatment of indigent consumptives. General hospitals should provide special wards for patients with this disease, and enforce in them the proper measures for the limitation of infection.
7. Railway and steamship companies should be required to change and disinfect all bed-linen and other materials liable to infection from consumptive travelers.* Dr. Albert L. Gihon in an address before the Pan-American Medical Congress has graphically referred to the danger in steamship travel with consumptives, and Dr. J. T. Whittaker has pointed out the many sources of possible infection in the Pullman
Such are, in outline, some facts and suggestions that I have thought not inappropriate to present to you on this occasion. The facts are vouched for by leading investigators, physicians and sanitarians. The suggestions are legitimate deductions from the facts recorded. No one who studies the question without prejudice can resist the conviction that tuberculosis, "the great white plague" is a preventable disease; that by concerted action on the part of physicians, sanitary authorities and the public it can be stamped out among all civilized peoples; that, like leprosy and the black death, it should be of interest in the future merely to the historian of human progress.
*It is reported that on one of the Hungarian railway lines, special railway cars will be furnished for consumptives. These will be renovated and disinfected after each trip.
PREDISPOSITION TO PHTHISIS.
BY JAMES T. WHITTAKER, M. D.
Professor of the Theory and Practice of Medicine and of Clinical Medicine, Medical College of Ohio, Cincinnati.
Turn where we may in the practice of medicine, we have to face tuberculosis. Laennec declared in his day that more than one-third of the patients in the hospitals of Paris were affected with phthisis. That was seventy-five years agoSix years ago Cornet extended the number with the declaration that at least one-third of all mankind are, or have been, affected with tuberculosis. Cornet did not include in this statement bone and joint diseases, skin and gland affections, and the various hidden depots of the disease. Though they underestimated its frequency, the old masters did not err when they spoke of tuberculosis as the scourge of the human race, and we may hear the appeal of the later authorities all the way down from Louis, who wanted the various governments of Europe to unite in a crusade against it, to Koch, who, at the International Congress at Berlin, invites the nations of the earth to vie with each other in the study for means of relief.
To be more exact: In 4250 successive autopsies made in Breslau last year, gross macroscopic lesions of tuberculosis were found in 1393, that is, in one-third of all the cases on the post-mortem table. Schlenker (1894) made thorough inspection of one hundred bodies, finding lesions of tuberculosis in sixty-six. Of these cases it was the cause of death in 53 per cent., was of great importance in 6 per cent., and was quiescent in 41 per cent. Boltz, of Kiel, found 424 cases in 2576 autopsies. Biggs found characteristic lesions in the
lungs alone in 60 per cent. of his autopsies, Brouardel in 75 per cent. of his cases at the Paris morgue, and as many cases show only fine lesions and others recover without lesion, it is evident that it is scarcely possible to overestimate either the frequency of the disease or the variety of its manifestations.
Tuberculosis, as we know, may attack any body and any organ of the body in any or every grade of mildness and malignity.
Why does tuberculosis kill one man, spare another, and run a benign course in a third?
Because, we say, one man is more predisposed than another to suffer attack.
Is it real, this predisposition, or is it a paraphrase; is it a fact or a word?
What is meant by it?
Not climate, or altitude, or dryness, or soil, or environment; not difference in the cause in quantity or character. The term is elastic, but it is never extended to include anything more than intrinsic cause.
Disposition is defined as a defect in the constitution of an individual which lessens his resistance, and thus makes him more liable to invasion of the disease.
It is understood at the start that it is not a question of liability or immunity of different animals to the same disease. Different animals differ so much that we are warned against any interchange of blood in the operation of transfusion. It is a question of the same animal, and with us here, of man. Moreover, predisposition here does not mean increased liability to any disease, but to one particular disease, to wit: to phthisis.
Pfeiffer makes the position plain by an example from ophthalmology. It has long been known that eye-strain produces myopia. The condition is seen to increase with increasing study, or strain, and is aggravated by bad light,