ON THE 
Prevention of Tuberculosis. 
by 
JAS. B. RUSSELL, B.A., M.D., LL.D., 
Senior Medical Officer of Health, Glasgow. 
Republished, by permission, by the State Board of Ilealth of Massachusetts. 
BOSTON: 
WRIGHT & POTTER PRINTING CO., STATE PRINTERS, 
18 Post Office Square. 
1896. ON THE 
Prevention of Tuberculosis. 
BY 
JAS. B. RUSSELL, B.A., M.D., LL.D., 
Senior Medical Officer of Health, Glasgow. 
Republished, by permission, by the State Board of Health of Massachusetts. 
BOSTON: 
WRIGHT & POTTER PRINTING CO., STATE PRINTERS, 
18 Post Office Square. 
1896. PREFACE. 
The following paper upon the “ Prevention of Tuberculosis ” was ptrl>* 
lished in Glasgow during the earlier part of the present year. The sub- 
ject is so clearly expressed and so admirably treated that the State Board 
of Health, with the consent of the author, has decided to reprint the prin- 
cipal portion of the pamphlet for popular distribution, with the hope 
that the information therein imparted may aid still further in diminish- 
ing the destructiveness of consumption in Massachusetts. The omitted 
portions are mainly the appendices containing local matter, and the 
recently issued circulars of different municipal authorities. 
The diagram on page 35 has been remodelled so as to include the 
statistics for consumption in Massachusetts. A table is added giving 
the figures of Massachusetts together with those of Glasgow. The cir- 
cular of the Board on the same subject is also appended. 
It is hoped that this paper will tend to quiet unnecessary alarm 
in relation to the real dangers from the infectious nature of consump- 
tion, since, while it shows very conclusively that the disease is infectious, 
it also shows that, with proper precaution, there is practically no danger 
from association, even quite intimately, with consumptives. CONTENTS. 
Page 
Introductory, 7 
Tuberculosis in General, 9 
What is Tuberculosis ? 9 
The Biology of the Bacillus, 10 
Tuberculosis in Man, 13 
Infection by Sputum and other Discharges, .... 14 
Infection by Milk and Flesh, 16 
The Conditions which control Infection, 17 
Wiiat ought the Local Authority to do? . . . . 20 
Is Tuberculosis an “ Infectious Disease ” ? . . . 20 
Compulsory Notification ?. . . . . . . 23 
Isolation? 24 
Disinfection ? 25 
Popular Instruction ? 23 
Cornet’s Leaflet — “ Protection from Consumption,” . 27 
Berlin Leaflet — “Measures against the Spread of Con- 
sumption,” 28- 
Tuberculous Milk, 32 
General Hygiene in the Prevention of Tuberculosis, . 34 
Statistics, 34 
The Dwelling and Consumption, 37 
Summary of Suggestions, 39 
Appendix, 44 
Tables of Death-rates from Phthisis and other Tuberculous 
Diseases, 44 
Circular of State Boai’d of Health, 45 ON THE 
PRETENTION OF TUBERCULOSIS. 
Introductory. 
In December, 1891, the Medico-Chirurgical Society of Glasgow, 
after a discussion, came to the following resolution: — “That 
a Memorial be presented to the Town Council of Glasgow call- 
ing their attention to the fact that tuberculosis is now fully 
recognized as an infectious disease, and asking them to take the 
matter into their serious consideration, with a view to the pro- 
tection of the community from the infection.” A Memorial was 
accordingly drawn up and submitted to the Committee on Health 
in January, 1892. It was remitted to me for consideration and 
report. 
The signatures appended to this Memorial are sufficient to 
secure for it respectful consideration. They guarantee that 
whatever it contains of positive statement as to the nature of 
tuberculosis is accurate, and that whatever of suggestion it makes 
as to practical measures is judicious. Still, the attitude of the 
administrative mind towards the contributions of science to the 
stock of knowledge and towards their executive application and 
effect is different. We receive implicitly and with gratitude 
the results of the laboratory and the study; we apply our own 
judgment to executive proposals. We are bound to consider 
their bearing on general policy, and to determine their expedi- 
ency from a forecast of the advantages and disadvantages likely 
to follow their adoption. This distinction was clearly pi-esent 
to the minds of the Memorialists. No representation relative to 8 
the duties of the Local Authority could have been made with 
greater tact and discretion. It is a distinction which is very well 
illustrated in the history of the subject of the Memorial. Koch’s 
paper on “ The Etiology of Tuberculosis,” published in 1884, 
contains practically all the scientific facts necessary for the 
guidance of preventive administration. No essential statement 
made by Koch has been impugned, and nothing of importance 
has been added.* It is otherwise with the detailed application 
of his facts. This has been gradually developed by remarkable 
investigations specially directed to that end ; by the discussions 
of such bodies as the Congress on Tuberculosis, held in Paris 
in 1888, 1891, and 1893, the French Academy of Medicine in 
1889-90 ; by successive International Hygienic and Medical Con- 
gresses, etc. ; by specialists engaged in administration, such as 
the German Public Health Association in 1889, and the Incor- 
porated Society of Medical Officers of Health of England in 
1893; by reports on special references made by these bodies 
to experts; and by numerous State and Municipal Authorities 
in various parts of the world, who have from time to time actu- 
ally taken administrative action. There has, therefore, been an 
obvious advantage in delay. In the enthusiasm naturally inspired 
by a new discovery, there is always an element of danger. 
When the issues concern interference with human conduct, and 
involve the personal liberty of a considerable section of the 
community, even on the plea of the safety of the remainder, 
we are bound to ask if the game is worth the candle. The 
first disciples of a new doctrine must be enthusiasts. The regi- 
men dictated from the laboratory is gradually moderated by the 
expediency of the administrative bureau. The practical methods 
of dealing with the infection are now better understood, and 
* It is not meant that everything relative to the infectivity of tuberculosis in Koch’s 
“Etiology” is new. Cohnheim, in his pamphlet, “Tuberculosis as an Infectious 
Disease” (1880), reasons out with as much clearness as was possible before the actual 
discovery of the infecting bacillus (Koch, 1882) many facts as to infection and its 
methods, especially inside the body. He first popularized the idea of infection as 
regards tuberculosis. 9 
have, in consequence, been greatly simplified. Their importance 
in relation to general hygiene is now seen in more just propor- 
tion. I have, in the interval since this Memorial was remitted 
to me, followed closely all these discussions and investigations, 
and have collected everything in the shape of reports and docu- 
ments which serves to show what is the general attitude of the 
administrative mind to this important subject, more especially 
in the country to which we owe the knowledge of the facts 
which we are told call for administrative action. 
Tuberculosis in General. 
What is Tuberculosis? 
The word tuberculosis, or tuberculous disease, is associated in 
the popular mind almost exclusively with phthisis or consump- 
tion of the lungs. This is by far the most frequent and most 
deadly form of tuberculosis ; but every organ and every tissue 
of the body may be the seat of tuberculous disease. Hydro- 
cephalus is tubercle in the membranes of the brain ; tabes 
mesenterica is tubercle in the lymphatic glands of the abdomen; 
scrofula, in the popular sense, is tubercle in the superficial 
lymphatic glands, most familar in the neck; lupus is tubercle 
in the skin; there is tubercle of the joints and of tbe bones, 
giving rise to suppurations in all sorts of places, and occasion- 
ing surgical operations almost as various in their nature as in 
their locality. 
Tuberculosis is a disease, not only of man, but of the lower 
animals. No warm-blooded animal is insusceptible when artifi- 
cially tested, but it occurs naturally with great frequency in 
those which are domesticated or confined, as the cow, the pig, 
the rabbit, in fowls, in monkeys, etc. 
The only cause of tuberculosis is the tubercle-bacillus. With- 
out the bacillus there can be no tuberculous disease. Therefore, 
to prevent tuberculosis, we must get rid of the bacillus. From 
our point of view, tuberculosis is a disease. From the point 10 
of view of the bacillus, it is a natural life-process. The bacillus 
has a plan of life laid down for it, providing, as usual, for the 
maintenance of the individual and the propagation of its kind. 
Clearly, it is necess&ry that we should understand this plan 
before we can hope to disconcert it. The prevention of tuber- 
culosis rests upon the biology of the bacillus. 
The Biology of the Bacillus 
The bacillus is not inherited. As regards pulmonary con- 
sumption, this statement may be taken as absolutely true. The 
bacillus may pass from a tuberculous parent into the body of 
the foetus, and be born with it; and thus the offspring may 
carry into independent life a tuberculous process, but this fact 
has merely an academic interest. Tuberculosis has been actually 
seen in the foetus with just sufficient frequency and certainty 
to prove that the inheritance of the bacillus is not impossible. 
For all practical purposes, the hygienic administrator is bound 
to regard every case of tuberculosis as caused by infection which 
has taken place so to speak in the open — within the sphere 
of his control. 
The tubercle-bacillus not being inherited, but passing into the 
body from the outside, how does it get there? Under what 
conditions does it exist there? Under what conditions does it 
pass from the outside to the inside of the body? Under what 
conditions does it live and propagate there? It is impossible 
to demarcate the answers to these questions as clearly as the 
questions themselves. In nature the facts are interlaced, but, 
at any rate, the questions so stated will promote clear thinking. 
The bacillus multiplies by subdivision and by the production 
of spores. As compared with other disease-producing organisms, 
it grows very slowly even under the most favorable circumstances. 
To be effective, therefore, these circumstances must be main- 
tained for weeks continuously. At a temperature of 86° F. 
growth is much enfeebled, and it entirely ceases below 82.4° F. 
It cannot grow at a temperature above 107.6° F. It flourishes 11 
at the natural deep temperature of the human body, viz., 99° 
to 100° F.* Moisture is absolutely essential to growth, with a 
limited supply of air and an absence of light. Obviously, we 
have here an aggregate of conditions which, in this country at 
any rate, can only be found in nature inside the animal body. 
The tubercle-bacillus cannot multiply outside the animal body; 
it can merely live, and live only under certain conditions, and 
under any conditions only for a limited time.f 
When the bacillus obtains access to the body of a warm- 
blooded animal, which it almost solely does by the great main 
entrance, the mouth, passing thence into one or other of the 
diverging channels, the windpipe and the gullet, it is not yet in 
a physiological sense inside the body. It must break through 
the mucous surface of these passages. This is a most impor- 
tant stage in the career of the bacillus from a preventive aspect, 
which must be dealt with at large further on. Meanwhile, let 
us assume that the bacillus has broken through, still it has 
enemies in the tissues and fluids of the body. These also have 
a supreme interest for us, but these also we shall meanwhile pass 
by. If every circumstance has proved favorable, the bacillus 
proceeds slowly to multiply, and in doing so to invade and break 
down the natural tissue around. It may be borne along the 
stream of lymph or blood, or be carried by wandering cells to 
other parts of the body. However it may be effected, in all 
movement the bacillus is passive. Wherever it establishes tuber- 
culosis, the process has products — irritated and disorganized tis- 
sue, pus, etc. These products have the relation of foreign bodies 
to the healthy tissues, and have therefore an eccentric or cen- 
trifugal bias. They may, however, be imprisoned and retained, 
sometimes changed in nature. If the process lies on the line of 
the great channels by which the bacillus gained entrance, then 
it has an equally patent exit — in consumption, by the expec- 
* The tubercle-bacillus of fowls has a somewhat wider range of temperature, 
t The bacteriologist produces those conditions artificially, and finds it a very 
difficult task. 12 
toration, or by the faeces, if the expectoration is swallowed. If 
the process is in the bowel or the kidney, or any organ having 
a natural exit for its products, then the morbid matter passes 
out thus. If the process is in bone or in lymphatic glands, or 
in any locality from which the nearest way outwards is through 
the skin, then we may have abscesses and a discharge of matter 
therefrom. To us this is a feature of disease. To the bacillus 
it is a phase in the cycle of its life. These discharges carry out 
bacilli and their spores; and these bacilli and their spores main- 
tain the stock of infecting material outside the animal body upon 
which the continuance of the tubercle-bacillus as an individual 
and of tuberculosis as a disease depends. 
What are the conditions which favor the continued vitality of 
the bacillus, and preserve the potential activity of its spores out- 
side the animal body?* Although the bacillus will not grow, 
excepting under the conditions of heat and moisture described, 
it is not killed either by natural cold or heat, or by drying. It 
is, indeed, one of the hardiest of all disease-producing germs. 
Freezing has no effect. It resists putrefaction for weeks, and 
endures in the dry state for months. The greater stability in 
resisting natural agents and conditions to which other germs 
speedily succumb is, no doubt, compensatory for the character 
istics of parasitism and slow growth. If the bacillus, being un- 
able to grow anywhere but inside a warm-blooded animal, were 
also unable to survive outside, it would be exterminated. On 
the other hand, from the animal’s point of view, the extremely 
sluggish growth of the bacillus, and its inability to grow outside, 
in a measure countervails its tenacity of life, otherwise the ani- 
mal would be exterminated. Still, in spite of this tenacity of 
life, the combination of hostile conditions outside the animal 
body ultimately proves fatal to the bacillus. Direct sunlight will 
kill the bacillus in a few minutes, and ordinary daylight in a few 
days, whether it be exposed naked in cultures, or in sputum or 
* It is impossible to speak separately of the bacilli and their spores. Observations 
and experiments really refer to the loss or the retention of the property of infectivity. 13 
in dust, and in each case free flowing air makes the light more 
active. The converse of these conditions — darkness and stag- 
nant air—favor the bacillus. 
Tuberculosis in Man. 
Hitherto we have dealt with tuberculosis in its general sense, 
without reference to the species of the animal in which it is 
found, or the locality of the body where it is seated. In har- 
mony with the general law of life, the bacillus is varied by the 
soil in which it grows, and the disease to which it gives rise 
derives characteristics both as to locality and nature from the 
physiological idiosyncrasies of the species. For these reasons, 
and since it is in man that we are directly interested, we shall 
now consider specially tuberculosis in man. 
Putting aside, as of no practical importance, the very rare case 
of inheritance of the bacillus, man, like other animals, suffers 
from tuberculosis only when he receives the bacillus from with- 
out. Putting also aside, as of no great practical importance 
from a sanitary aspect, cases which arise from direct inoculation 
by wounds or through scratches and other ruptures of the integ- 
rity of the skin, it may be said that the bacillus always enters 
by the mouth, that it is either inhaled or swallowed, that it is 
conveyed either in the air or the food, that it enters either by 
the lungs or the alimentary canal, or stops short in the struct- 
ures in and adjacent to the mouth. 
Every bacillus and spore thus inhaled or swallowed must have 
been produced in an animal, not merely derived from or de- 
scended from a bacillus or spore produced in an animal, but 
must itself have passed out from a diseased animal or been in- 
cluded in the flesh derived from a diseased animal. 
Tuberculosis in man is therefore caused by infection either 
(1) through the excretions or discharges from infected animals, 
including man himself, or (2) the milk of infected animals, in- 
cluding his own species, or (3) the flesh of infected animals. 14 
There is a remarkable consensus of opinion that persons 
suffering from phthisis or consumption of the lungs are the 
largest contributors to the stock of what is very aptly called 
the “floating infection” which exists in the environs of men. 
Physicians, bacteriologists and pathologists, each reasoning on 
the line of the facts best known to them, concentrate upon this 
opinion. The hygienist sees no reason to dispute it. Nearly 
three-fourths of the deaths ascribed to tuberculosis are caused 
by consumption.* Though the bacillus may reach the lungs by 
other paths than by the air, still the infection which establishes 
tuberculosis in the lungs and air passages is generally air-borne. 
Phthisis is the most frequent cause of phthisis. It is a sufficient 
cause. Phthisical persons are to be found in every place and 
in every condition and position in which healthy persons are to 
be found. Everywhere, therefore, tubercle-bacilli may be dis- 
tributed. For this reason, while all that has been said as to the 
discharge of bacilli in tuberculosis generally is correct, phthisis 
has been regarded by all authorities who have taken special 
steps for the prevention of tuberculosis as either pre-eminently 
or alone among all its forms demanding precautionary measures. 
It is necessary, therefore, to enquire exactly how the bacillus is 
discharged and distributed from a case of phthisis; in what 
sense phthisis is and in what sense it is not infectious. For a 
knowledge of the latter is of as much importance as of the 
former. If we understand how phthisis becomes dangerous, we 
shall also understand the nature of the risks arising from tuber- 
culosis generally. 
Infection by Sputum and other Discharges. 
The tubercle-bacillus is not “ ubiquitous.” It haunts the 
vicinity of the consumptive. It is not in the expired air. It 
is not in the cutaneous exhalations. It abounds in the sputum. 
It abounds in the dust of the apartment. It is a well-known 
physical law that fluid or moist surfaces will not part with solid 
* In Glasgow, 1890-94, exactly 73 per cent. 15 
particles by evaporation or to a current of air. Hence the ab- 
sence of bacilli in the expired air, and hence they are likewise 
imprisoned in the sputum. Even particles of sputum sprayed 
into the air by the violence of coughing, being gross, subside at 
once, and could only infect if coughed into the face of some 
one, and mixed with the actually in-going air. In order to be 
air-borne, the sputum must be dried and broken up into dust. 
If discharged into a handkerchief, it speedily dries, especially if 
it is put into the pocket or beneath the pillow. In the last 
stages of consumption the patient becomes weak, the sputum is 
expelled imperfectly, pillows, sheets, handkerchiefs are soiled. 
If a male, the beard or moustache is smeared. Even in the 
hands of the cleanly, without special precautions, such circum- 
stances all tend to the production around the patient of a halo 
of infected dust maintained by every process of bedmaking, or 
of cleaning which includes the pernicious process happily de- 
scribed as “ dusting.” In the hands of the careless and the 
dirty, the infectivity is, of course, greatly aggravated. It attains 
its maximum of intensity where the filthy habit of spitting on 
the floor prevails, especially if the floor is carpeted. 
The remedy is simply to spit into a spittoon containing a little 
water; and when a handkerchief must be used, to see that it 
never dries. Immerse it in water, and ultimately boil it. Bet- 
ter still, use a piece of cloth or paper, and burn it at once. 
Cornet found that where the spittoon was used, and cleanly 
habits prevailed, there were no bacilli in the dust; where hand- 
kerchiefs were used, even though there was no spitting on the 
floor, there the dust was infective. 
This is the golden rule in dealing not only with sputum but 
with all forms of tuberculous discharge, with the faeces when 
they are infected, the pus from tuberculous sores and abscesses, 
etc. Keep them moist. Especially do not allow any soiled linen 
or dressings to lie about and dry. Make it impossible for the 
discharges to pass into the condition of dust. 
It is not merely the dried substance of the discharge which 16 
determines the bulk of the danger. All dust must be regarded 
as suspicious in the neighborhood of consumptives. If there is 
any infection at all about, it is there. The ordinary constitu- 
ents of dust—the fibres of linen and cotton, the shreds of wool 
— all act as rafts on which the infective germs are borne about, 
and with which they rise when disturbed. 
The infected dust in apartments occupied or frequented with- 
out precautions by consumptives will subside indiscriminately 
upon any exposed surface, and may thus ultimately be swallowed, 
e. g., upon plates, cups, glasses, basins, etc., viands of all kinds 
and fluids, such as milk or water. The latter are the most dan- 
gerous. They present more or less moist surfaces. No dust 
which falls on them can be blown away again, nor can they be 
cleaned. 
The first person to suffer from carelessness with reference to 
sputum is the patient. He breathes an infected atmosphere, and 
in the struggle which is going on between his tissues and the 
bacillus, the latter is constantly reinforced, fresh territory is 
invaded, and the chance of recovery is destroyed. Auto-infec- 
tion is one of the unavoidable risks of phthisis. The chances 
of this occurring ought not to be knowingly increased. The use 
or misuse of handkerchiefs, and swallowing the sputum, are both 
likely occasions. These facts bring the precautions necessary in 
the public interest within the scope of the duties of the private 
physician in the treatment of a case of phthisis. 
Infection by Milk and Flesh. 
The other sources from which man may derive the infecting 
bacillus are the milk and the flesh of diseased animals. That 
infection through the stomach is possible, we know from the 
observed effect upon consumptives of swallowing their sputum, 
and from experiments with animals. The process of cooking 
tends to diminish the risk; but in the case of milk, there is no 
such safeguard interposed, owing to the habit of the country to 
consume it raw. The primary seat of tuberculosis in children 17 
is so frequently in the bowels and their related glands, and milk 
forms so large and essential an element in the food of children, 
that we cannot avoid the conclusion that it is to them a frequent 
source of infection. There is ample room for public interference 
to prevent the spread of tuberculosis by meat and milk, but, 
above all, by milk. 
The Conditions which Control Infection. 
Although without the bacillus there can be no tuberculosis, 
we cannot call it the sole cause of the infection in the individual 
case. The theory of infection has a profound influence upon 
the practical aspects of prevention. So long as we believe that 
infection is guided from person to person by supernatural agency, 
without regard to physical laws, we can do nothing. When we 
advance to the conception that the infecting element is material, 
and subject to physical laws, we have taken a great stride towards 
precision, both in preventing and curing the disease. As wre 
ascertain that the element is solid, then that it is organic, we 
become more precise, until with the knowledge that infection 
passes with the body of a microbe, a minute living being, we 
are ushered into the study of those complicated conditions which 
surround the maintenance and development of life. 
We have already learned something of the restrictions imposed 
upon the tubercle-bacillus by some of those conditions. It can 
grow only within warm-blooded animals. It retains vitality with 
considerable tenacity outside the body, especially when dried, but 
sunlight, free air, and other natural agents, which first kill and 
then disintegrate, wage steady war against it. In the long run, 
therefore, only a fraction of the total quantity of infecting ma- 
terial survives until it has the opportunity to infect. 
When at last the bacillus reaches its natural habitat, disease 
is not necessarily caused thereby. In other words, but a small 
proportion of all who are exposed to infection, who actually in- 
hale or swallow the bacillus, are infected. Every breath we 
inhale is loaded with particles of all kinds, organic and inorganic, 18 
dead or possessing the potency of life. A large proportion of 
this microscopic dust is caught in the nasal passages in the case 
of nose-breatliers. Tubercle-bacilli have been found in the dis- 
charge from the noses of the attendants in wards occupied by 
consumptives. The moist lining of the air-passages catches the 
dust which passes the nose. The breath we exhale is optically 
pure. There are arrangements for expelling such particles — 
for scavenging the air-passages. If there were not, our wind- 
pipes would get choked as surely as unswept chimneys. What 
may be called local health is more important as a protection 
from the tubercle-bacillus than any other of the species of dis- 
ease-germs, especially the integrity and vigor of the organs by 
which it enters the body. The bacillus is slow to develop, there- 
fore there is a longer interval for its expulsion ; but any catarrh, 
however local, anything which interposes a mechanical obstruc- 
tion, or weakens the expelling power, or hampers the movements 
of the lungs, or provides crevices as resting-places, interferes 
with the expulsion of the bacillus, as of every other sort of 
foreign matter. In like manner, any impairment of the func- 
tions or integrity of the stomach or bowels favors infection; but 
inasmuch as the business of the stomach is to resolve and break 
up, and its acid juice is inimical, while in the bowels there are 
swarms of competing microbes, and the struggle for life is keen, 
the bacillus is more likely to perish in these regions. Still, any- 
thing of the nature of indigestion or local irritation may give 
the microbe a chance. 
These are all obstacles to entrance within the substance of 
the tissues, for, as has already been said, the tubercle-bacillus 
is no more inside the body after it has passed the portal of the 
mouth than when it is floating in the dust of the air or in the 
milk of a tuberculous cow. It is nearer, but there has been no 
infection. When it has effected a lodgment in the tissues, the 
production of disease depends upon the defeat of the antagonistic 
forces which surround it. These amount to nothing more than 
constitutional vigor — tissue-health. A condition of perfect health 19 
is one of insusceptibility. In this condition the juices of the 
tissues are poisonous to microbic life, and their cells active 
agents of destruction. Depression of vital resistance by disease, 
debauchery, fatigue, want, even by mental causes, induces sus- 
ceptibility. Susceptibility may be constitutional, and may be so 
great and so marked as to amount to a predisposition. This it 
is which passes by inheritance, and, until the discovery of the 
bacillus, was regarded as hereditary tuberculosis. It is not the 
disease which is inherited. It is the pre-disposition — the feeble 
constitution, the low vitality, the tout ensemble of conditions, 
some of which are recondite and imperfectly understood, some 
obvious and capable of specification and comprehension. The 
outcome is a soil so congenial as to accept a delicate infection, 
from which the majority of mankind emerges absolutely scathe- 
less ; a soil which sustains and propagates the bacillus so vigor- 
ously that to popular observation the disease seems to be 
inherited. In such a person a blow or a sprain, a cold or sore 
throat, determines the local incidence. Nothing shows the reality 
of the antagonistic forces with which healthy animal tissues are 
endowed more strikingly than the numerous recoveries which 
take place, especially from pulmonary infection. In such cases 
there has been some temporary local susceptibility ; but the vital 
forces have rallied, have invested the detachments of invaders, 
have cut off their convoys and scouts, and ultimately starved 
them out. The fact is undoubted. There is nothing in the 
world to accomplish this result but the native forces of the 
tissues. The phrase sounds rather mystical and metaphorical; 
but the forces are real, and may very confidently be trusted as 
most important allies in any general campaign against tubercu- 
losis. 
In such a contest as that which we have depicted, and alike 
in both stages, the number of bacilli engaged must obviously 
have an important relation to the result. It is impossible to 
express oneself without appealing to the analogies of warfare. 
In the stage of endeavor to obtain a footing, numbers must tell 20 
as effectively as in storming a breach; in the stage of maintain- 
ing a footing, as effectively as in the resistance of a garrison 
or the progress of an invasion. This introduces the all-impor- 
tant preventive doctrine of dilution. Infection is fifty times more 
likely to occur if there are fifty bacilli in each breath of air or 
pint of milk than if there is but one. Apart, therefore, alto- 
gether from the wholesomeness of ventilation and the vital 
energy imparted thereby, the merely mechanical effect of dilut- 
ing or reducing the concentration of infective germs in air has 
an important protective and preventive power. 
What ought the Local Authority to do? 
Is Tuberculosis an Infectious Disease ? 
Now that we have come to the practical issue of this inquiry, 
it is well at once to raise the question— Is tuberculosis an “in- 
fectious disease?” The answer is — Yes and No. It must be 
apparent from what precedes that, while in the academic sense 
tuberculosis is infectious, in the popular sense it is not. Even 
in the language of the schools, where words are weighed and 
meanings are qualified to a nicety, hydrocephalus, although it 
is tuberculous, cannot in any sense be said to be infectious ; 
neither can many forms of tuberculosis of glands, bones and 
joints. Until a discharge is established, they cannot be infec- 
tious. Indeed, it is doubtful if even those cases of miliary 
tuberculosis of the lungs which have ended in recovery ever were 
infectious, and it is certain that no case of phthisis is infectious until 
the expectoration becomes specific. Tuberculosis, therefore, even 
in an academic sense, is a disease which, though in all cases caused 
by infection, is not in all cases infectious. There is no other 
infectious disease of which this can be said. The fact that it 
is not infectious in the popular sense is of much more impor- 
tance for our present purpose. The popular idea of an infectious 
disease is one from which there is no safety save in keeping 
away from it. Proclaim a disease to be “ infectious,” and the 
people will pay no attention to qualifications. It is very natural 21 
— don’t go near the person, and the conditions of safety need 
give no trouble ! Education makes no difference. The fear of 
infection is indiscriminating even to absurdity. Enteric fever 
scarlet fever, whooping-cough, small-pox, all entail the same 
social ostracism. 
There is a substantial excuse for the popular notion of an 
infectious disease in the fact that the law does not discriminate 
between one infectious disease and another. The words have a 
technical meaning, and every disease in the category is within 
the scope of every provision of the law applicable to infectious 
disease — compulsory isolation of the living and of the dead, 
compulsory disinfection, penalties for the use of public vehicles, 
for appearance in public places, whether streets or buildings, etc., 
etc. It may be said that the application of these laws is left 
to the discretion of authorities, which is true ; but one has only to 
study the opinions advanced by some medical officers of health 
to be convinced that, before placing tuberculosis officially among 
“infectious diseases,” it is necessary to understand quite defi- 
nitely what is to follow. There is not a single power of inter- 
ference with the liberty of persons suffering from small-pox, the 
application of which to consumptives has not been advocated. 
Indeed, one cannot avoid contrasting the studied caution and 
expressed solicitude to protect the consumptive from prejudice, 
which characterizes the application by the original German in- 
vestigators of their discoveries to prevention, with the rash 
utterances of many of those who seek to interpret those dis- 
coveries elsewhere. Koch himself showed the example in the 
closing words of his famous treatise, “ It seems to me the time 
has now come to adopt prophylactic measures against tubercu- 
losis. But, owing to the wide distribution of the disease all 
steps taken against it have to deal with social relations, and it 
must therefore be carefully considered in what way, and how far, 
we may proceed without neutralizing, by unavoidable disturbances 
and other disadvantages, the benefit obtained.” 
Push aside the proposal to extend such demands to everything 22 
that can be designated “tuberculosis” as condemned in the 
utterance. Consider them as applied to consumption alone. 
Recall all the representatives of that pale multitude one has 
known who bore the burden of their infirmity for years, few or 
many, who did good work in the world, earned honest wages, 
supported themselves, supported others ; all those one has heard 
of who lived more in the world’s eye, who have instructed or 
entertained mankind, consumptives who have enriched our book- 
shelves, given us paintings for our walls, and satisfied our ears 
with music; all the phthisical patients to whom Sir Andrew 
Clark preached from his favorite text—“Labor vitae vita, est 
— Work is the life of life,” with himself as the example, 
born of parents who both died of phthisis, and sent to Madeira 
at twenty-one to die.* They all suffer from an “ infectious 
disease.” They are all to be notified by the first physician 
who sees them. Each is to be “ furnished with a card bearing 
the date of notification,” which they are “required to pro- 
duce on application for disinfectants, etc.,” and which medi- 
cal men, wherever they may have to consult a doctor, are to 
ask for, so that they may not cause unnecessary expense by 
being reported again, for economy must not be lost sight of.| 
The announcement of the sad diagnosis is to be signalized and 
proclaimed to the world by a domestic ceremony of purification, 
conducted by the high priests of the sanitary department, to 
wipe out all the infection which has followed the unfortunate’s 
pestiferous steps while the taint was yet unrecognized. To put 
an end to this he must “ be thenceforward confined to certain 
parts of the house,” in which the ceremony of purification is to 
be carried out every two months. They are now known to all 
men as “ consumptive people,” and are in future to live up to 
a code. They must abjure pocket-handkerchiefs ; when “ attend- 
ing a workshop, assembly, or church,” they must “spit into a 
* “The Treatment of Fibroid Lung Disease:” a Clinical Lecture. — Lancet, 6th 
January, 1894. 
f Dr. Niven “On the Prevention of Phthisis.” — Lancet, 10th August, 1895. 23 
hand-glass spittoon,” which “ may be conveniently attached to 
the person;” their “eating utensils . . . should be kept sepa- 
rate from all eating utensils of other persons;” their “ clothing 
must be washed separately;” their “ bowel discharges should be 
disinfected.” * Even this is a compromise to which the sanitary 
puritan reconciles himself by the prospect of an ideal such as 
this: “In the wake of compulsory notification would follow 
a number of regulations all aiming at stamping out phthisis 
[surely a misprint for phthisics]. These subsequent regulations 
fall easily into three classes: (1) Prevention of patients with 
actual phthisis, or, indeed, with strong hereditary predisposition, 
from marrying. (2) Prohibition of patients wTith actual phthisis 
from frequenting churches, theatres, railway carriages, tram-cars, 
or any public places. (3) Disinfection of sputa, habitations, and 
all things coming in contact with phthisical patients. Isolation 
of the consumptive.” f 
Let us rapidly run over the various administrative procedures 
usually applied to infectious diseases, and consider them as 
applicable to tuberculosis. 
Compulsory Notification? 
Although this has been frequently recommended in expert 
reports, and was voted by the Parisian Congress in 1888, and 
again in 1893, as necessary in reference to tuberculosis in gen- 
eral, the fact is chiefly noteworthy as a warning of the direction 
in which science, without practical discrimination, is moving. 
This would cover an enlarged cervical gland, a lupus, a white- 
swelling, a hydrocephalus, a “cold abscess,” every form of local 
tubercle, as wrell as a case of phthisis. The question has in 
reality, as a rule, resolved itself into a discussion of the pro- 
priety of requiring the notification of consumption. Suffice it to 
* Memorandum of the N. W. Branch of the Society of Medical Officers of Health 
as to the prevention of phthisis or consumption ; also Dr. Niven’s Manchester leaflet. 
f “The Necessity for placing Tubercular Phthisis under Control.” — Article by 
Arnold Chaplin, M B., in the Medical Magazine, Yol. I., p. 1022. Exactly the same 
regimen is strenuously advocated in an article in the Forum for February, 1894. say, that I am not aware of any country or place where this 
has yet been done. I am not aware of any resolution in favor 
of compulsory notification having been passed by any body of 
medical practitioners. On the contrary, the subject has been 
discussed by the French Academy of Medicine, the College of 
Physicians of Philadelphia, and the Medical Society of Oldham, 
with an adverse result. Even the Incorporated Society of Medi- 
cal Officers of Health of England, when asked to l'esolve that 
“tuberculosis should be made a notifiable disease, notifiable 
under the same acts and under similar conditions to such dis- 
ease as scarlet fever,” passed instead a resolution to the effect 
that they, “ while accepting the view that phthisis is an infective 
disease, in the prevention of which active hygienic measures 
should be taken, think it premature to recommend the compul- 
sory notification of a chronic disease like phthisis ” At the same 
time a rider was added encouraging voluntary notification and 
disinfection.* 
Isolation ? 
Here again it may be mentioned the extremists have proposed 
that sanitary authorities should provide hospital accommodation 
for tuberculosis, but practically the question is one of providing 
for consumption. We must carefully distinguish between the 
humanitarian and the sanitarian aspect of this question. The 
conditions which determine infection from phthisis are, as we 
have seen, very narrow. With proper precautions, they are 
obviated merely by sleeping alone. In small-pox and in typhus 
they are so wide as to include almost every case; in scarlet 
fever they are sufficiently wide to make removal to hospital 
advisable in three-fourths of the cases; and in enteric fever in 
about the same proportion. From the present point of view, 
the essentially dangerous case of phthisis is the one which is 
in the last stage, confined to the house or bedridden. When a 
person in this condition cannot have a bed alone, especially if 
young children must share it, when the material accessories of 
* Public Health, September, 1893. 25 
the special precautions necessary are wanting, when the condi- 
tions are hygienically bad, then removal would, from a preven- 
tive aspect, be useful. But this is a task different from any 
hitherto undertaken by local authorities, and one not to be 
lightly assumed — to provide, not a hospital for curative pur- 
poses, but a shelter for incurables, a “ Friedensheim,” or “ home 
of peace,” a place in which to die without endangering the liv- 
ing. Consumption hospitals, in the ordinary sense, are not open 
to such cases. I confess to considerable sympathy with the 
opinion of Dr. Squire,* referring to this limited class of cases 
— “A sanitary district should provide a home for its own ad- 
vanced consumptives, where the sufferers should be received, 
without thereby incurring the brand of pauperism ; these inva- 
lids would thus be prevented from being unwilling dangers to 
others.” At all events, any provision which exists for the treat- 
ment of consumption ought to be patronized by the authorities. 
These doctrines give them a special interest in consumptives. 
We already, when asked by medical practitioners, wash and 
disinfect after fatal cases of phthisis, but we seldom are asked. 
Disinfection ? 
The circumstances which require precautions in carrying out 
the washings of consumptives or other persons having tubercu- 
lous discharges are restricted very much in comparison with 
the ordinary infectious diseases. Indeed, we must avoid creat- 
ing the impression that the bedding and clothing are necessarily 
infected. It is not so. They seldom are infected. It is the 
helplessness or carelessness of the patient which leads to infec- 
tion of his garments, etc. Here again the advanced case, the 
fatal case, is the dangerous one ; so that it would be well that 
washing and disinfection should, always after death, be under- 
taken by the authorities. If people possess the means of washing 
properly the clothing of the healthy members of their household, 
they can also wash the ordinary linen of a consumptive. I see 
* “ The Hygienic Prevention of Consumption,” 1893, p. 141. 26 
no reason for interference even in the use of a common wash- 
ing-house. If, however, people have not the requisite accommo- 
dation and appliances, if they are untidy and cannot be trusted 
to carry out any process of washing at all, then it might be 
carried out by the authorities, each case being considered in 
view of the circumstances. Whatever danger there is in any 
case emerges not from mere neighborhood or to mere touching 
of articles, or from the act of washing, but from the disturbance 
of dust when they are dry. The moment they are wet the risk 
is gone. 
Popular Instruction ? 
In Glasgow, for the last twenty years, the local authority has 
caused a paper, couched in simple language, entitled “ Hints 
about the Prevention of Scarlet Fever,” to be left at every house 
in which a case is known to exist. While it would be well to 
take similar means for the instruction of the people regarding 
tuberculosis, the dissemination of the knowledge of the facts we 
have been considering through the mass of the public must de- 
pend chiefly upon the medical profession. No doubt, every case 
of consumption will be made the occasion of some detailed 
instructions as to the nature of the risks entailed upon the 
family, and the method of obviating them. But there is room 
and use for popular instructions applicable to the special risks 
of consumption and of strumous sores. These might be sup- 
plied to public dispensaries, and given there to the appropriate 
patients; and, no doubt, many practitioners would welcome such 
papers for the more speedy and certain information of private 
patients. What ought to be in such pamphlets? We certainly 
do not wish any exposition of the whole etiology of tuberculo- 
sis. We do not wish to call names, and to run the risk of false 
impressions therefrom. We would meet the occasion of a case of 
consumption or a case of open tuberculous sores, and state as 
plainly as might be under what conditions the patients may live 
in the family, and follow the ordinary intercourses of life, with- 27 
out causing risk to anybody. We would preach the gospel of 
cleanliness, fresh air, and sunshine, from a new text. 
I have already remarked upon the tendency of the disciples 
of Koch, Cornet, and Heller, especially in this country, to out- 
Herod Herod in the application of their doctrines. One naturally 
looks to Cornet himself and to the city where he resides, where, 
in fact, the bacillus was discovered, and whence nearly all we 
know of it has been announced to the world, for guidance as 
to what it is expedient to teach the people as to consumption, 
and what it is necessary to require of consumptives by way of 
precaution for the safety of others. Here are (1) a leaflet 
which Cornet is in the habit of giving to his patients ; and (2) 
a leaflet issued by the municipal authorities of Berlin: — 
I. — Cornet. 
“ Protection from Consumption.* 
“The most destructive disease of the human race is consump- 
tion (tuberculosis). It carries off a seventh of the population. 
In Germany alone there die yearly of consumption well nigh one 
hundred and fifty thousand people. 
“ It has now been discovered that this disease is caused by the 
inhalation of a germ, a so-called bacillus. It is infectious, that is, 
it can be given by any person to another. But neither the breath 
nor the perspiration of the patient is at all dangerous, as used to 
be supposed. Infection generally takes place through the spit, 
and, according to the latest inquiries, especially when the spit is 
discharged by the consumptive upon the floor or in a handkerchief, 
where it dries and becomes dust, and some of the swarm of germs 
contained therein are inhaled by healthy people. 
“ Many other diseases, such as diphtheria, pneumonia, and vari- 
ous forms of catarrh, may be communicated in a similar way. 
“ Consumptives endanger not only those about them, but them- 
selves, through the drying of their spit, because they again inhale 
the discharged and dried bacilli, and thus infect hitherto sound 
parts of their lungs. 
“ Such infection may be avoided if consumptives, and, indeed, 
all who have a chronic cough with expectoration, keep this expec- 
toration always moist; if they give up spitting on the floor or into 
• “ XJeber Tuberculose,” etc., etc., von Dr. Georg Cornet, Leipzig, 1890, p. 145. 28 
a handkerchief, and always use a spittoon which is emptied down 
the water-closet. 
“ Spittoons must be placed wherever it appears necessary, in 
every inclosed space frequented by men. They ought not to be 
filled with sand or sawdust, but either left entirely empty or sup- 
plied with a very little water. They ought to be at hand in suffi- 
cient numbers in every apartment of houses, in workshops and 
factories, in counting-houses, schools, offices, public places, in 
corridors and on stairs, so as to give every one a convenient op- 
portunity of observing these injunctions. 
“In this way healthy people who have to remain within the 
same room as consumptives will be almost entirely protected from 
infection. 
“ Posters ought to be put up in factories, workplaces, etc., for- 
bidding most strictly spitting upon the floor or into a handkerchief. 
“On the street, where spitting can scarcely be prevented, cer- 
tain other circumstances diminish the risk of infection. 
“ Let every man, even though suffering from an ordinary cough, 
discharge his spit, not on the ground, nor in a pocket-handkerchief, 
but always in a spittoon. 
“Milk ought, as far as possible, to be used only after boiling, 
especially by children, invalids, and convalescents. 
“By the strict observance of these injunctions, consumptives 
are made almost harmless to those about them ; and all the more 
that the bacilli can live outside the body only for about six months, 
it may be hoped that, if these rules are followed out by the sick, 
consumption in general will diminish.” 
II. —Berlin. 
“ Measures against the Spread of Consumption. 
“Pulmonary and laryngeal consumption (tuberculosis) is com- 
municated to the healthy by means of the tubercle-bacilli contained 
in the expectoration of the sick, when the spit dries, becomes dust, 
and is thus inhaled. The discharges from the bowels of such per- 
sons may in like manner act injuriously. 
“ If those matters are rendered harmless, the spread of consump- 
tion is prevented; the healthy are protected from the sick. 
“In order to prevent drying and the production of dust, the 
consumptive, indeed every person who has a cough (people with 
a cough are often not aware that they are actually coughing up 
tubercle-bacilli), ought to spit in vessels containing a little water 
(spittoons of earthenware or glass). No person ought ever to spit 
upon the floor or into a pocket-handkerchief. For the reception 
of sputum, spittoons should be placed in the dwellings of all who 
are ill with a cough, and, indeed, in all houses, on the stair land- 29 
ings, but especially in such buildings and rooms as are used by the 
public (hotels, restaurants, places of amusement, meeting places, 
of all kinds, schools, etc.). These spittoons should be eight to ten 
inches in diameter, two inches in height, with smooth slightly in- 
verted edges, made of strong, smooth glass, porcelain, earthenware, 
or enamelled iron, containing water to the depth of half an inch 
or thereby. In places of public resort there should be a clearly 
legible inscription on the wrall ‘ Spittoon Jor the use of persons 
troubled with cough.’ The water must be renewed as it evaporates ; 
the spittoons to be emptied down the water-closet, and washed 
daily with boiling water. 
“ Cleanliness of all places is the first condition of a successful 
public health administration; consumptives ought especially to 
study cleanliness. 
“The sitting and sleeping rooms of consumptives ought to be 
provided with washable curtains, table covers, etc., with no car- 
pets on the floors, or woollen runners on the stairs, and contain as 
little furniture as possible, with washable, easily removable covers 
(dusters). Elastic iron garden seats, with washable covers or 
movable cushions, are the most suitable furniture, and facilitate 
cleaning and disinfection of the room and its contents. Bedmats 
should be made of washable jute material. 
“ Wipe the whole floor of every room over with a damp cloth 
daily to remove the dust, and even in winter ventilate thoroughly 
for at least an hour. The room should be thoroughly cleaned 
weekly, and every three months be disinfected, according to the 
directions of the Code of 7th February, 1887, prescribing the 
process of disinfection in epidemic disease. The fulfilment of 
these instructions, especially the harmless removal of the expec- 
toration, enables the intercourse of the healthy with consumptives 
to be carried on without scruple, and prevents the spread of this 
most destructive disease. 
“ May everybody, according to his circumstances, co-operate to 
this end.” 
It is characteristic of all official action in Germany in rela- 
tion to the person of the consumptive to concentrate attention 
upon his expectoration. Every detail of injunction, as well as 
express statement, has the effect of liberating the consumptive 
from all social disability, so long as he is able to go about, pro- 
vided he is careful to follow the simplest precautions as to ex- 
pectoration ; and when he is weak and bedridden, provided his 
attendants take up the role as to expectoration and are cleanly 
as to his other discharges. It is the same in France. Out of the periodic “ Congress for the Study of Tuberculosis,” sprang 
a “League for the Prevention of Pulmonary Phthisis and other 
forms of Tuberculosis,” the primary object of which was to 
educate the people of France by the circulation of popular 
literature, each member acting as a distributing centre in his 
own locality. Their first issue was the code- of instructions 
which received such drastic treatment at the hands of the Royal 
Academy. This was included in a pamphlet of twelve pages, 
which has been scattered broadcast over France. The code 
itself is prefaced by some facts to show the gravity of phthisis 
as a cause of ill health and death, and by an exposition of the 
modern doctrine, in the course of which this sentence is printed 
in emphatic type : — v 
“ We know further that the consumptive is not in the least dan- 
gerous by contact or proximity, that it is neither his body nor his 
breath which is hurtful, and that we can chat with him for hours, 
live with him for years, and even sleep in his room and give him 
the most constant care, without running any serious risk, provided 
we take certain precautions, the chief of which is to collect his ex- 
pectoration, and not to delay the destruction of his spittle until it 
becomes dry, and is disseminated as dust into the atmosphere.” 
This position is logical and unassailable. If you accept the 
doctrine as sound, the practice must be conceded as sufficient. 
Let there be spittoons handy for everybody; don’t put your 
spit in the way of drying and becoming dust; don’t anywhere 
stir up the dust in inclosed places. The remedy is so common- 
place that, after reading all that has been written and spoken, 
and proclaimed and enjoined, when we look at our notes and 
find nothing but sputum, spittoons, and dust, we are apt to show 
a little temper, like Naaman when he expected the prophet to 
hold a solemn function over his leprosy, and he merely told 
him to go and wash himself. No doubt, the very simplicity of 
the prescription will constitute the greatest difficulty in the way 
of its acceptance and observance. To the vulgar a “ spittle ” 
is symbolic of all that is insignificant and contemptible. To 31 
base a cardinal matter of sanitary practice and regulation upon 
the how, and the when, and the where, people are to spit, re- 
quires some moral courage. Only a clear apprehension of, and 
firm belief in, the doctrine that practically consumption is com- 
municable through dried expectoration, and nothing else, will 
save the practice from ridicule. 
How far it is to be explained by the fear of this — how far 
by the imposition of modern doctrines upon the top of the con- 
ception of a vague infection, instead of entirely substituting the 
one for the other—we cannot say; but the fact remains that 
in this country the advocates of the modern doctrines never 
seem to regard the consumptive with any more equanimity. 
They expound the modus operandi of infection ; they prescribe 
spittoons and proscribe dust, just as is done on the continent; 
but in place of manifesting confidence in the consumptive thus 
reformed in his habits, as they most expressly do abroad, the 
tendency here is to exhibit suspicion of him in all his ways. 
They would surround him with restrictions, and cover him with 
differential marks, which must make him almost as conspicuous 
in society as if he were clad in the gray gown and sounded the 
clapper of a mediaeval leper — 
“ They curse him in eating, they curse him in drinking, 
They curse him in coughing, in sneezing, in winking ” 
The jackdaw of Rheims was not “ a penny the worse,” but 
it would be far otherwise with the poor consumptive. Well 
may one say, “Show us your faith by your works;” but it is 
not the logical inconsistency, it is the cruelty, the inexpediency 
of these restrictions which moves our criticism. They are cruel 
and inexpedient, because unnecessary. They deprive the con- 
sumptive of the very advantage of the modern doctrine to 
which Cornet never tires of adverting, “ The consumptive in 
himself is almost absolutely harmless, and only becomes harmful 
through bad habits.” Setting out from this propostion, he says, 32 
prophylaxis is therefore simple. No more demands for legis- 
lative prohibition of marriage and other absurdities of restric- 
tion, which would consign consumptives to an island in the 
solitary ocean. No more demands for the separation of chil- 
dren from tuberculous parents, for their accommodation in insti- 
tutions, for abstinence from kissing them,* for avoidance of 
intercourse with consumptives, for exclusion of consumptive 
workmen from workshops, etc. Cornet thinks such prescrip- 
tions about the furnishing of rooms for consumptives as those 
in the Berlin leaflet, and as to special disinfection of sputum 
are futile for private houses; the hygienist must endeavor to 
make his demands consistent with the comforts and habits of 
civilized life, otherwise his voice will be as that of one crying 
in the wilderness. This is now possible. Prophylaxis had of 
late come to a standstill because of its impracticable demands. 
Koch’s discovery, the most fruitful in medicine, seemed to ex- 
haust itself in staining bacilli.f In short, Cornet has proved 
by experimental induction, if ever anything has been proved, 
that the sputum is practically the only source of infection in 
phthisis ; that where there is no sputum there is no infection; 
that the sputum is not infectious unless it dries; that it cannot 
dry excepting under certain conditions, perfectly easy to be 
avoided; that if these conditions are avoided, a consumptive 
is not a source of danger to any one in the ordinary intercourse 
of society and the home. If this is so, we must say so; and 
we must not act, or make others act, as if we did not believe it. 
Tuberculous Milk. 
There is no need for argument in reference to the milk of 
tuberculous cows. The facts are so universally accepted and 
so grave, that the administrative effect shines through them. It 
* He means kissing on the cheek or brow, which he advises in place of osculation, 
t “ Ueber Tuberculose, etc ,” 1890, pp. 130 el seq. He recurs to the same subject 
in his paper, “ Die Prophylaxis der Tuberculose, etc.” — Berliner klin. Woch, May, 
8195. 33 
is precisely the Glasgow position — that a tuberculous cow must 
not be retained in a dairy. There is a remarkable consensus of 
opinion as to the influence of milk in disseminating tuberculosis, 
especially amongst the young. The pathologist finds “that of 
the total deaths under ten years of age amongst the mass of 
the people, about a third are due to tuberculosis,"* and that the 
usual seat of the disease at that age points to food as the 
medium of infection. The prevalence of tuberculosis among 
dairy cows is notorious. Experiment shows that when the 
udder is affected the milk is virulent. Every authority on the 
prophylaxis of tuberculosis places the supervision of the milk 
supply next to the regulation of the expectoration of consump- 
tives in importance. I am inclined to think that it is at least 
of equivalent importance. It certainly is much more practicable 
as a matter of sanitary administration. If we remember the 
habits of the tubercle-bacillus, we cannot imagine a more favor- 
able nurture-ground than the typical byre (cow stable) — a dark or 
badly lighted space, with insufficient ventilating apertures, which 
are unhesitatingly closed when necessary to maintain a temper- 
ature of 60° to 70° F. by the heat of the animals ; the air con- 
sequently loaded with carbonic acid, with organic impurities and 
moisture, full of the dust of dried dung, never penetrated by 
a direct ray of sunlight, in winter never vacated either in country 
or town for weeks, and in cities never vacated at all.f The 
natural result is that dairy stock is ravaged with tuberculosis. 
Yet we never hear a farmer or a dairyman speak of tuberculosis 
without speaking of compensation. When he puts windows in 
his byre, and floods it with light, ventilates it, and ceases to 
use his cow as a heating apparatus, it will be time enough to 
* “Tuberculosis viewed as an Infectious Disease; its Prevalence and the Fre- 
quency of Recovery from it.” — Professor Joseph Coats, Sanitary Journal, 23rd 
November, 1891. 
t See valuable paper by J. MacMillan, M. B., D. Sc., Edinburgh. — “An Investi- 
gation into the Condition of the Atmosphere of Cowhouses and Stables in Edinburgh, 
Leith, and the County of Midlothian.” — Journal of Comparative Pathology and 
Therapeutics, 1892. 34 
speak of compensation. Meanwhile the children of the town 
are being infected wholesale, and it behooves the authorities, not 
only to take every means to eliminate tuberculous cows from 
dairy byres, but to enforce sanitary reform in the construction, 
use, and condition of byres. By-laws as to cubic space, ven- 
tilation, lighting, cleanliness, obtain from tuberculosis a direct 
interest to all men. 
But yet more is required. A competent veterinary inspector 
ought to be at once appointed, who could test with tuberculin 
the accuracy of the suspicions suggested by his skilled general 
examination. In this way only can we hope to detect and abol- 
ish, as milk-producers, animals which are, no doubt, at this 
moment contaminating the milk supply of Glasgow. At present 
our powers are lying dormant. After putting our own house 
in order, an occasional inspection of the cattle at dairy farms, 
chosen at random in various parts of the country, would have 
a most wholesome effect, not limited to the detection of a few 
unsound animals, but leading up to more stringent by-laws and 
better sanitation in country byres. County officials require a 
little help from the powerful commercial lever which the pur- 
chaser of country produce can apply whenever he chooses. 
General Hygiene in the Prevention of Tuberculosis. 
Statistics. 
Glasgow itself affords a remarkable illustration of the influence 
of general hygienic measures upon tuberculosis, as is shown in 
the following diagram : — 35 
Glasgow and Massachusetts — Death Rate per Million 
from Phthisis in Quinquennial Periods for Forty Years, 
1855-94. 
DEATH RATE PER MILLION FROM PHTHISIS 
IN QUINQUENNIAL PERIODS FOR 40 YEARS* 
GLASGOW. 
MASSACHUSETTS* 
1- 
2- 
3- 
4- 
5- 
6- 
7- 
8- 
Note. — For the purpose of comparison the foregoing diagram has been remodeled 
so as to include the figures for Glasgow and for Massachusetts for the same periods. 
A table containing the figures for each year may be found at the end of this paper. 36 
In the period 1860-64 phthisis reached its highest mortality, 
4,094 per million. In the period 1890-94 it was 2,315, so 
that in 25 years consumption has been reduced 44 per cent, 
in fatality without special treatment as an infectious disease. 
If we turn to “zymotics” for the same periods, we find that 
the combined effect of special efforts and general hygienic meas- 
ures has been to reduce their fatality 50 per cent. Enteric 
fever, which we are told tuberculosis most resembles as an 
infectious disease, was reduced 60 per cent. The proportion of 
the total deaths which took place in isolation rose from 7 per 
cent, to 66, which serves as an index of the extent to which 
every known special method was pushed. The reduction in 
phthisis is very notable even by the side of these figures. Un- 
fortunately, phthisis is the only form of tuberculosis which has 
been throughout consistently classified by the registrar-general 
as a cause of death. Prior to 1883 there was a class “ tuber- 
cular diseases ” comprising “ scrofula,” “ tabes mesenterica,” 
“ phthisis,” and “ hydrocephalus,” but in 1883 these were all 
transferred to “constitutional diseases,” as “tabes mesenterica,” 
“ tubercular meningitis (acute hydrocephalus),” “phthisis,” and 
“ other forms of tuberculosis, scrofula.” A table is appended 
giving the returns for‘the 40 years as published, but the sequence 
of the figures shows that after 1882 “hydrocephalus,” at any 
rate, does not represent the same thing; and information con- 
firms what the sequence suggests, viz., that “scrofula” also 
is not the same. We are, therefore, shut up to the 12 years, 
1883-94, for evidence of the movement of tuberculous diseases 
other than phthisis. Dividing them into two periods of 6 years, 
we find that the death rate from “phthisis” has fallen from 
2,849 per million to 2,316, and from “ other tubercular diseases ” 
from 1,090 per million to 884, in both cases 19 per cent. — a 
result which quite casts into the shade the improvement in 
Prussia and Saxony, quoted from Cornet, which he puts to the 
credit of special prophylaxis. Clearly, then, we are warranted 
in asserting that among infectious diseases, tuberculosis is the 37 
most amenable of all to general hygienic measures ; that, in fact, 
from these alone as good results are obtained as from hygienic 
measures plus isolation, disinfection, etc., etc., in the case of 
diseases popularly known as infectious. It is not implied that 
special measures directed against the infectivity might not have 
produced even better results ; but in view of what has been ac- 
complished, and in view of the difficulties in the way of special 
prophylaxis, it is contended that more is to be expected from 
general hygiene. 
We have already gone with some detail into the relation of 
local and general health to tuberculosis through their influence 
on the bacillus. Everything within the control of the indi- 
vidual which promotes and maintains soundness of body; every- 
thing within the control of the municipality or the State which 
improves the physical conditions beyond which the individual 
living in populous communities cannot go, which raises and 
maintains the standard of public health, comes within the scope 
of the prevention of tuberculosis. So that, to treat this aspect 
of prevention in its fulness, would be to write a treatise on 
private regimen and State medicine. Nevertheless, there are 
some of the elements of health which tuberculosis marks with 
special importance. 
The Dwelling and Consumption 
A copious supply of pure air and distribution of direct and 
diffused sunlight within and without the dwelling are not only 
wholesome to man, but are directly fatal to the bacilli distrib- 
uted outside the animal body. Sunlight is the only disinfectant 
which sustains the man while it kills the microbe. Therefore, 
whatever withdraws from the air we breathe impurity of smoke, 
or dust, or foul exhalation, and from the sky above us that 
canopy of smoke which reduces our sunshine to twilight; every- 
thing which promotes free motion of air without and within 
the house ; every by-law which regulates the width of streets, 
the height of houses, the arrangement of buildings, so as to 38 
offer no obstruction to the winds, and to secure as much light 
and as little shadow in the hours of daylight as possible, which 
promotes the access of the sun’s rays to dwellings, and helps 
to make the sky visible from the floor of all inhabited rooms, 
which widens and brightens lobbies and staircases in tenements, 
which prevents dampness of foundations and walls; every reg- 
ulation which checks overcrowding both in house and work place, 
which protects the artificer from irritating dust and fumes and 
secures to workers of every degree and kind natural light and 
pure air in the place of their employment, — all are precautions 
against tuberculosis. 
The lungs are like every other organ, their health is pro- 
moted by free and full use. Deep inhalation of pure air — 
especially the open air, the air which is moving freely in the 
great currents we call winds, which is clarified by sunshine — 
gives vigor to the lungs, and supplies the heart with well oxy- 
genated blood to be sent throughout the body, increasing the 
insusceptibility of every tissue. Therefore, every public park, 
and the flowers and music which attract people thither, every 
open space and children’s playground, every cricket and football 
field, every gymnasium and drill-ground, is a precaution against 
consumption. 
It is remarkable with what unanimity those who have studied 
consumption clinically testify that no diseases predispose to it 
more frequently than enteric fever, scarlet fever, measles and 
whooping-cough. Enteric fever produces a profound and long- 
continued depression of the vitality, which favors the lodgment 
of the bacillus. If, perchance, tuberculous milk should be given 
to such patients, who are practically sustained for weeks on 
milk and nothing else, it certainly would infect. Scarlet fever, 
in its severer forms, also reduces constitutional resistance. On 
the other hand, measles and whooping-cough create for the 
bacillus an opportunity chiefly by their influence on local health, 
producing debility in the lungs, to which whooping-cough fre- 
quently adds great general exhaustion. It follows from these 39 
facts that all hygienic measures which tend to prevent enteric 
fever, and whatever is done to limit the spread and prevent 
the complications of the infectious diseases of children, are 
precautions against consumption. 
In combating tuberculosis in the lower animals, hygienic meas- 
ures bear an equally important part. Indeed, the tuberculosis 
of animals is begotten of the domestication of animals by man, 
and the perversity of man in treating them as if fresh air and 
sunlight were less essential to their health than to his own. 
The fact is they are more essential. Tuberculosis prevails 
among the different species in proportion to the extent to which 
man has, for his purposes, made them denizens of closed spaces; 
and most of all in the cow, which he has entirely taken posses- 
sion of, and which he treats as if foul air and darkness were 
conditions of its being. Dogs and cats also share in the risks 
of the society of consumptives who are careless in their habits. 
The improvement of the hygiene of the domestic animals is a 
precaution against consumption in man. 
1. It is of supreme importance, first of all, to- lay in the 
mind, both of the profession and the public, a broad founda- 
tion of positive knowledge. The direct and indirect practical 
issues of the doctrine of tuberculosis are very various, and can 
only be effectively worked out through the intelligence of the 
community. They touch the business of administrative bodies 
of every kind, not merely municipal, but parochial, charitable, 
corrective, educational, and others both of a public and private 
character. They affect the personal habits of a considerable pro- 
portion of the citizens, and the duties of those about them, and, 
in certain circumstances, are responsible for them. They concern 
the health of all. 
Summary of Suggestions. 
2. The local authority ought to resolve that, in the interests 
of public health, it is necessary that washing and disinfection 
should be effectively carried out after every death from pulmon- 40 
ary consumption, and at the discretion of the medical officers 
in the course of illness from this or any other form of tubercu- 
lous disease. 
3. In my own opinion, the importance of taking immediate 
action in the direction of eliminating tuberculous cows from the 
dairies, first of all in Glasgow, and next from those sending 
milk into Glasgow, can scarcely be exaggerated. It is at least 
equivalent in promise of beneficial results to any part of the 
special action recommended in this report. Glasgow is in the 
unusual position of possessing ready to hand the legal powers 
to deal with this source of tuberculosis. We cannot take full 
advantage of these powers without a veterinary expert. Science 
has provided in tuberculin a test which overcomes that difficulty 
of diagnosis of tuberculous disease in the living animal which 
has hitherto made professional opinion uncertain or only equiva- 
lent to suspicion, and therefore insufficient to support decisive 
action. This test can be systematically applied only by a spe- 
cially qualified veterinary surgeon. 
4. The issuing of popular leaflets to be systematically dis- 
tributed from house to house, and otherwise put into the hands 
of those responsible for the care of the sick, may be remitted 
to the medical officers to be taken in due course. 
5. It is scarcely necessary to point out that many depart- 
ments of municipal management ought to be inspired with re- 
newed energy, and to receive increased precision of direction, 
each in its own special work, from this doctrine of tuberculo- 
sis, e. g.: — 
In the application of general and local powers to the sup- 
pression of damp, dark dwelling-houses; to the dissemination 
of light and air within and around tenements and work places, 
whether factories, workshops, warehouses, counting-houses, or 
offices; in the enforcement of ventilation, light, and cleanliness 
in byres; in the provision of open spaces and play places con- 
venient to tenements. 
In the suppression of smoke, and the energetic application of 41 
the law in all cases relating to overcrowding, cleanliness of the 
house, and other matters of domestic police, which, if not asso- 
ciated in the judicial mind with some large principle, are apt to 
sink to the rank of petty details, rather vexatious than otherwise. 
Parks are only useful in proportion as they are used, and 
therefore they must be made attractive. Flowers are wanted 
for some, music for others, but always space for the young. 
The youthful instinct to play and sport is accessory to growth 
and development, and suitable space for the gratification of that 
instinct, may powerfully aid in building up strong, resistant 
constitutions. 
The superintendents of railways, especially of street lines, may 
find moral courage to enforce their by-laws against spitting “in or 
upon any car,” which, in fact, means to compel the male sex to 
refrain, for hygienic reasons, from doing that which the female 
sex, from a sense of propriety, never does. 
6. The practical issues of this doctrine of tuberculosis, as 
regards the individual and the family, in matters which can 
only be touched by private effort, actuated by the growth of 
intelligence, are many and various, and must be trusted to the 
evolution of thought in the process of time. How to deal with 
domestic dust is, perhaps, the most important of these issues. 
It is to be desired that women should understand the impor- 
tance of dust in the causation of consumption, and should devise 
methods of dealing with dust which will end in its collection 
and destruction, not merely in its disturbance and redistribution. 
Not merely as housewives, but as sick nurses, women ought to 
study these modern doctrines. 
JAS. B. RUSSELL. 
Sanitary Department, 
1 Montrose Street, October, 1895. APPENDIX. 44 
APPENDIX. 
Death Rates per Million Inhabitants from Phthisis and Other 
Tuberculous Diseases— Glasgow and Massachusetts, 1855-94. 
PHTHISI8. 
Other Tuber- 
culous Diseases. 
All Tuberculous 
Diseases. 
Glasgow. 
Mass. 
Glasgow. 
Mass. 
Glasgow. 
Mass. 
1855, 
3,977 
4,195 
1,790 
786 
5,767 
4,981 
1856, 
3,411 
4,083 
1,536 
604 
4,947 
4.686 
1857, 
3,772 
3,950 
1,668 
630 
5,440 
4,580 
1858, 
3,738 
3,842 
1,813 
758 
5,551 
4,600 
1859, 
3,814 
3,886 
1,492 
655 
5,306 
4,541 
1860, 
4,327 
3,702 
1,670 
782 
5,997 
4,484 
1861, 
3,988 
3,653 
1,584 
805 
5,572 
4,458 
1862, 
4,116 
3,428 
1,651 
664 
5,767 
4,093 
1863, 
3,837 
3,726 
1,834 
708 
5,671 
4,434 
1864, 
4,200 
3,757 
1,742 
693 
5,942 
4,450 
1865, 
4,135 
3,678 
1,768 
634 
5,903 
4,313 
1866, 
3,928 
3,531 
1,672 
560 
5,600 
4,091 
1867, 
3,861 
3,255 
1,724 
538 
5,585 
3,794 
1868, 
3,965 
3,220 
1,701 
522 
5,666 
3,742 
1869, 
3,969 
3,288 
1,796 
520 
5,765 
3,808 
1870, 
4,306 
3,433 
1,911 
601 
6,217 
4,035 
1871, 
4,346 
3,393 
2,112 
695 
6,458 
3,988 
1872, 
3,955 
3,626 
1,871 
677 
5,826 
4,303 
1873, 
3,557 
3,536 
1,815 
703 
5,372 
4,240 
1874, 
3,374 
3,280 
1,567 
696 
4,941 
3,975 
1875, 
3,949 
3,474 
1,660 
688 
5,610 
4,161 
1876, 
3,836 
3,176 
1,607 
627 
5,443 
3,803 
1877, 
3,468 
3,204 
1,885 
543 
5,354 
3,747 
1878, 
3,676 
3,085 
1.906 
571 
5,581 
3,656 
1879, 
3,289 
2,975 
1.701 
612 
4,990 
3,586 
1880, 
3,153 
3,081 
1,603 
707 
4,756 
3,789 
1881, 
3,111 
3,245 
1,340 
720 
4,451 
3,965 
1882, 
3,064 
3,179 
1,547 
698 
4,611 
3,877 
1883, 
3,361 
3,160 
1,124 
696 
4,484 
3,856 
1884, 
3,054 
3,037 
1,111 
693 
4,165 
3,730 
1885, 
2,967 
3,066 
1,189 
704 
4,156 
3,771 
1886, 
2,878 
2.951 
1,131 
717 
4,009 
3,668 
1887, 
2,499 
2,856 
1,004 
763 
3,503 
3,619 
1888, 
2,336 
2,708 
980 
794 
3,316 
3,503 
1889, 
2,324 
2,565 
936 
754 
3,260 
3,319 
1890, 
2,499 
2,587 
969 
696 
3,468 
3,283 
1891, 
2,418 
2,396 
903 
738 
3,321 
3,134 
1892, 
2,187 
2,453 
769 
721 
2,956 
3,175 
1893, 
2,213 
2,310 
882 
771 
3,095 
3,082 
1894, 
2,257 
2,234 
846 
740 
3,103 
2,974 
Death Rate per Million from Phthisis in Five-year Periods 
Massachusetts and Glasgow. 
Mass. 
Glasgow. 
Mass. 
Glasgow. 
1855-59, . 
3,988 
3,792 
1875-79, . 
3,179 
3,644 
1860-64, . 
3,653 
4,094 
1880-84, . 
3,140 
3,149 
1865-69, . 
3,388 
3,453 
3,973 
1885-89, , 
2,822 
2,392 
2,601 
2,315 
1870-74, . 
3,908 
1890-94, . A CIRCULAR OF THE STATE BOARD OF HEALTH 
RELATIVE TO TUBERCULOSIS OR CONSUMPTION 
AND THE BEST MEANS FOR PREVENTING IT. 
The object of the State Board of Health in issuing the following cir- 
cular is to furnish information (1) as to the nature of pulmonary con- 
sumption, (2) the conditions which favor its spread, and (3) the best 
methods of preventing it. 
Consumption is the most destructive disease of New England, the num- 
ber of persons annually dying from this cause in Massachusetts amount- 
ing to nearly six thousand. Modern research places it among infectious 
diseases. 
The specific virus or poison of the disease consists of a minute germ, 
the “ bacillus of tuberculosis,” which exists in the tissues and expecto- 
ration of the sick, and which may in various ways enter the bodies of the 
well and reproduce the disease in them. In the proper care and disposal 
of the expectoration of the sick, it is probable, lies one of the chief 
methods of preventing the spread of the disease. 
1. — As to the Nature of Consumption. 
2. — Conditions which favor the Spread of Consumption among 
Human Beings. 
Defective ventilation. One of the chief conditions which is favorable 
to the production of consumption is the continuous and habitual breath- 
ing of unrenewed air. Consequently, in workshops, factories, school 
rooms, public buildings, halls, churches and the inhabited apartments 
of dwellings and tenement-houses the absence of adequate means of ven- 
tilation favors the spread of consumption. 
Dampness of soil on which the house stands and dampness of the 
immediate neighborhood are favorable conditions for the production of 
consumption. The occupancy as living or sleeping rooms of apart- 
ments which are constantly damp or are partly or wholly underground 
undoubtedly has a similar effect. 
Overcrowding in dwellings, in factories and in workshops where men 
and women work for several hours each day is also a favorable condi- 
tion for spreading the disease. Density of population increases the lia- 
bility to this disease. Observations in Massachusetts extending over a 46 
period of twenty years (1871-90) show that the deaths from consump- 
tion in densely settled districts, as compared with those in sparsely set- 
tled districts of the State, stood in the l'atio of 1,000 deaths in the former 
to 727 in the latter. 
Another factor which favors the spread of this disease is the presence 
of dust in the air of apartments, factories, mills and workshops. Hence 
occupations or trades in which men, women or children are exposed 
to the inhalation of irritating dust increase the liability to contract the 
disease among such operatives. An examination of the reports of the 
Registrar-General of England for several successive years shows that 
fishermen, who are of all classes the least exposed to dust inhalation, are 
also comparatively exempt from consumption. 
Insufficient and badly selected food. While the influence of improper 
and insufficient feeding upon the predisposition to consumption is not 
so directly proven as are the effects of certain other conditions, there is 
yet sufficient evidence to show that a restricted diet or one composed ex- 
clusively of single elementary constituents, as, for example, the starches 
alone, and these in too limited quantifies, probably predisposes to con- 
sumption. 
intemperance in the use of alcoholic stimulants has also been shown 
to act in the same direction. 
Undue physical or mental strain, overwork, worry and anxiety and 
the prolonged suckling of infants (beyond ten or twelve months) are 
conditions contributing to the same end. 
3. — Preventive Measures. 
Having the foregoing predisposing conditions in view, the measures 
which are essential for the pi'evention of this disease may he more clearly 
understood. 
1. The prevention of overcrowding. In tenements and in dwelling- 
houses the prevention of overcrowding diminishes the liability to con- 
tract tubercular diseases among the occupants, 
Hence the adoption of measures which shall counteract the effect of 
overcrowding is desirable. Ventilation is one of the most efficient of 
such measures. Adequate ventilation should be provided in all facto- 
ries, halls, school-houses and other buildings in which people assemble 
in considei'able numbers. Simple methods of ventilation in the living 
and sleeping rooms of dwellings are also essential to healthy living. 47 
Open fireplaces, movable transoms in sleeping-rooms, provision for ad- 
mitting fresh air at the windows by special means are all useful pre- 
cautions. 
2. Household as well as personal cleanliness is essential to the pre- 
vention of consumption. The removal of dust from floors should be 
practised, and care should be taken that such dust is removed by such 
means as will insure the least diffusion through the air of rooms during 
their occupancy. 
3. Occupations. The selection of a healthy occupation is a matter of 
no small importance. 
Sedentary occupations in ill-ventilated apartments and those which 
expose the workmen to the inhalation of dust should be avoided. Dif- 
ferent sorts of dust vary in hai-mful effects. The sharp dust produced 
in the grinding of needles and steel tools and in the mining of metals 
is especially irritating, and the mortality from consumption among 
opei*atives in such industries is high. Operatives engaged in such occu- 
pations may diminish the liability to harm by wearing “ respiratoi's ” 
over the mouth and nose, while at work. 
In several factories where consumption had made serious inroads upon 
the operatives, the adoption of measures for the prevention of a dusty 
atmosphere secured a marked diminution of the prevalence of this dis- 
ease among the workmen employed in them. 
Regular daily exercise in the open air is of the first importance for all 
persons who are engaged in sedentary occupations. 
The owners and superintendents of factories, mills and workshops can 
accomplish much toward the prevention of tuberculosis among the oper- 
atives by the introduction of adequate systems of ventilation and heating, 
and by the use of hard, smooth floors without cracks or crevices. 
The dust should be removed from the floors at night, after working 
hours, and not during the occupancy of the work-rooms. The use of 
moisture in the removal of dust, and careful wiping with damp cloths 
is prefex-able to sweeping up the dust when dry. Spitting upon the floor 
should be forbidden. 
4. Food. As an essential requisite to the prevention of consumption, 
a diet of sound, wholesome food, in which the chief elementary forms 
of nutriment are harmoniously combined (the fats, starches and proteids), 
is necessary. Such a diet should consist mainly of bread and the various 
cereals, with butter and other fats in generous measure, together with meat, fish and fruits. This does not imply a luxurious or expensive 
diet, but rather one that is nutritious and easily digested. 
The question of the effect of the use of the meat and milk of tubercu- 
lous animals does not yet appear to be so well settled as to admit of an 
unqualified conclusion. 
In the absence of absolute and definite evidence, it is therefore desira- 
ble that the meat of all suspected animals should be cooked thoroughly 
before using it as food. The milk of such animals should be entirely 
excluded from the food supply. 
5. Overwork, anxiety, worry and exhaustion should be avoided. 
Mothers should be advised to wean suckling infants by the end of the 
first year. 
Disposal of Sputa. 
6, With reference to those who are sick with consumption or tuber- 
culosis, and especially with reference to the possibility that their pi'esence 
among other human beings may prove a source of danger on account of 
infection, the following recommendation as to the disposal of the expec- 
toration of consumptives should be especially noted. 
Observation and experiments have demonstrated the fact that in this 
expectoration (especially when dried) lies the chief danger of infection 
and hence its proper disposal becomes a matter of prime importance. 
Therefore, sputa should never be allowed to become dry, and should be 
destroyed as quickly as possible. Consumptives should be instructed 
not to expectorate about rooms, in streets or highways, in railway or 
street cars, or in vehicles of any sort, but should spit into rags which can 
be burned, or into cups or other receptacles containing a little water or 
other material which may be thoroughly disinfected before the same is 
allowed to pass into the drain or sewer. Such receptacles should be 
cleansed with boiling water. 
A healthy person should not sleep in the same room with a con- 
sumptive. 
Disinfection. 
7. Sputa may best be burned when deposited upon pieces of cloth or 
rags; and when put into cups or receptacles holding water the whole 
should be disinfected with a saturated solution of carbolic acid, which 
may be obtained of any reliable druggist. 
Disinfection should be practised in the case of rooms or apartments 
which have been vacated by consumptives or those in which such per- 49 
sons have died. There is a growing belief, supported by observation, 
that rooms which have been inhabited by consumptive families may 
become permanently infected, and ought not to be occupied until radical 
measures have been taken to cleanse and disinfect them. Each room 
vacated by a tuberculous patient should be disinfected, and especially 
the floor and lower parts of the walls. For this purpose washing the 
floor and all woodwork with a corrosive sublimate solution, one part to 
one thousand (about one teaspoonful to a gallon of water), should be 
pi’actised, and the bed and clothing of the last occupant should be sub- 
mitted to steam disinfection or to boiling water. Strong soapsuds also 
have efficient disinfecting power, and may be used for washing floors 
and woodwork. The disinfection should be thoroughly done, but es- 
pecially so in cases where the habits of the consumptive in regard to 
disposal of his sputa have been careless. 
As a means of spreading information upon this important subject, local 
boards of health can undoubtedly accomplish much toward the preven- 
tion of consumption by issuing a circular like the following : — 
THE PREVENTION OF CONSUMPTION. 
Consumption is the most destructive disease of New England, the number of per- 
sons dying annually from this cause in Massachusetts amounting to nearly six 
thousand. 
The disease is infectious, and can be communicated from one person to another. 
The chief danger exists in the expectoration of the sick, and if this expectoration is 
carefully destroyed little danger need be feared. 
Consumptives should be instructed not to spit upon the floors of rooms, public 
halls, street and railway cars and other vehicles, nor in the streets, but into pieces 
of cloth or receptacles made for the purpose, containing water or a saturated solution 
of carbolic acid (one part of carbolic acid crystals to about fifteen parts of water). 
Such bits of cloth should be destroyed by fire before the sputa become dry, and 
other receptacles should be cleansed with scalding water, their contents having been 
destroyed or otherwise carefully disposed of. Handkerchiefs which may have been 
used from necessity should be boiled half an hour before washing. 
A healthy person should not sleep in the same room with a consumptive. 
Remember that sputa must never be allowed to become dry. 
Office of the State Board of Health, Boston.