SHALL ANYTHING BE DONE BY LEGAL AUTHORITY 
TO PREVENT THE SPREAD OF 
TUBERCULOSIS? 
Read at the Meeting1 of the American Climatological Association 
at Washington, May 30, 1894. 
BY 
FREDERICK I. KNIGHT, M.D., 
Boston, Massachusetts. 
Reprinted from the International Medical Magazine for July, 1891. SHALL ANYTHING BE DONE BY LEGAL AUTHORITY 
TO PREVENT THE SPREAD OF TUBERCULOSIS ? 
It is now twelve years since the infectious nature of tuberculosis, at 
various times before suspected or believed, was put beyond question, and 
yet very little has been done in this country to prevent its spread. Physi- 
cians recently graduated, and a few older ones who have kept themselves 
informed of progress in medicine, have enjoined care in the disposal of the 
sputa, and recently a few have had bulletins of information printed for the 
use of the sick, or those exposed to them, or both, notably the Pennsylvania 
Society for the Prevention of Tuberculosis, and Dr. De Lancey Rochester, 
of Buffalo, New York. In 1889 the Board of Health of New York City 
issued circulars, which were widely distributed, setting forth the communi- 
cability of tuberculosis and measures for its prevention. In 1893 the 
American Public Health Association and the Public Health section of the 
Pan-American Medical Congress adopted resolutions in favor of the report- 
ing and registration of all cases of tuberculosis. In September of last year 
the State Board of Health of Michigan resolved that " hereafter, consump- 
tion (and other diseases due to the bacillus tuberculosis) shall be included 
in the official list of 'Diseases dangerous to the public health,'requiring 
notice by householders and physicians to the local health officer as soon as 
such a disease is recognized." "The purpose of this resolution," as ex- 
plained by the secretary of the board, " is to secure to the local health au- 
thorities and to the State board of health information of the location of 
each case of well-developed consumption; with the view of placing in the 
hands of the patient reliable information how to avoid reinfecting himself 
or herself, and how to avoid giving the disease to others; with the view of 
placing in the hands of the patient's family, or others most endangered, 
information how to avoid contracting consumption; also with the view of 
instructing superintendents of public buildings how best to restrict the 
spread of the disease." In February of this year the Board of Health of 2 
FREDERICK I. KNIGHT, M.D. 
New York City took similar action, but the regulation is not quite so 
stringent. The circular declares that "the [health] department will here- 
after register the name, address, sex, and age of every person suffering from 
tuberculosis in this city, so far as such information can be obtained, and 
respectfully requests that hereafter all physicians forward such information 
on the postal cards ordinarily employed for reporting cases of contagious 
disease. This information will be solely for the use of the department, nor 
will the department assume any sanitary surveillance of such patients, un- 
less the patient resides in a tenement-house, boarding-house, or hotel, or 
unless the attending physician requests that an inspection of the premises 
be made; and in no case where the person resides in a tenement-house, 
boarding-house, or hotel will any action be taken if the physician requests 
that no visits be made by inspectors, and is willing himself to deliver circu- 
lars of information, or furnish such equivalent information as is required 
to prevent the communication of the disease to others." The resolution 
provides for the official visitation of tenement-houses, boarding-houses, and 
hotels where cases of tuberculosis are known to exist, unless the attending 
physician has assumed the responsibility as above stated. In all cases 
where it comes to the knowledge of the department that premises which 
have been occupied by a consumptive have been vacated by death or re- 
moval, an inspector will visit the premises and direct proper disinfection. 
Rugs, carpets, bedding, etc., are sent away and disinfected without charge. 
No other persons than those residing there at the time will be allowed to 
occupy the premises till the order of the board has been complied with. 
The order also provides for free bacteriological examinations, and that all 
cases in public institutions shall be reported. 
The College of Physicians in Philadelphia held a special meeting in 
January of this year to consider the proposed act of the board of health 
of that city in reference to the registration of tuberculosis. After a long 
discussion participated in by a number of the prominent members of the 
College, the resolution of Dr. Flick, looking to the registration and disin- 
fection of houses which have been infected by tuberculosis, and recom- 
mending the establishment of a municipal hospital for the treatment of the 
disease, was rejected, and the following resolutions offered by the council of 
the College were passed : 
" Resolved, That the College of Physicians believes that the attempt to 
register consumptives and to treat them as the subjects of contagious disease 
would be adding hardships to the lives of those unfortunates, stamping them 
as the outcasts of society. In view of the chronic character of the malady, 
it could not lead to any measures of real value not otherwise attainable. 
"That strict attention on the part of physicians in charge of the indi- 
vidual cases, insisting on the disinfection of the sputum and of the rooms, 
on adequate ventilation, and on the separation of the sick from the well as 
far as possible, will meet the requirements of the situation so far as they PREVENTION OF THE SPREAD OF TUBERCULOSIS. 
3 
practically can be met, and better than any rules that, for diseases so chronic, 
can be carried out by a board of health. 
"That the College of Physicians respectfully requests that no official 
action be taken in the matter by the board of health, except the insisting on 
the disinfection of rooms in which consumptives have lived and died, in 
instances in which such procedure is not likely to have been adopted under 
the direction of the attending physician." 
During the past winter a committee was appointed by the chairman of 
the Section on Clinical Medicine, Pathology, and Hygiene, of the Massa- 
chusetts Medical Society, of which committee I had the honor to be chair- 
man, to consider what means could be adopted to prevent the spread of 
tuberculosis in our State. The members of this committee felt that it 
would be unwise to attempt too much at first, but that the time had cer- 
tainly come for some kind of an entering-wedge, which could be driven 
deeper as circumstances and the temper of the people seemed to warrant or 
demand. So we decided to respectfully request the State board of health 
to consider the propriety of issuing a circular declaring the infectious nature 
of the disease, that the chief danger was from the sputum, and how to take 
care of this, copies of this circular to be distributed in large numbers to 
the physicians of the State, and by them placed in the hands of every 
family where a case of tuberculosis was known to exist. The committee 
also took the opportunity of expressing their opinion of the desirability of 
isolating tuberculous patients in hospitals, and the ultimate erection of 
special hospitals for them. The board of health acceded very willingly to 
the wishes of the committee, and have issued a bulletin setting forth the 
prevalence of the disease, its nature and mode of prevention, and also a 
small leaflet of information, which they suggest local boards of health to 
issue for the use of the patient and his family. 
This is about all that has been done. How can this apparent indiffer- 
ence to the most fatal disease in the world be accounted for? Is it that 
there lingers any doubt about the infectiousness of the disease? I think 
not on the part of any one who has looked at the evidence of it. Though 
every one might not admit that every case came from a previous case, he 
would not in the face of the evidence deny such a possibility. It is hard, 
in the wide-spread prevalence of the disease, to get convincing clinical sub- 
stantiation of what has been so abundantly proved experimentally. The 
experience of the nurses at Brompton Hospital is quoted over and over 
again to prove that the attendants of consumptives have no special lia- 
bility to contract the disease. The statistics are certainly remarkable, but 
equally so on the other side are the statistics of Cornet, who examined the 
records of thirty-eight nursing societies for twenty-five years, examining 
the causes of over four thousand deaths, and found that over sixty-two per 
cent, died from tuberculosis. It seems to me that it is to the magnitude of 
the case that one must look for the cause of the hesitation in grappling 4 
FREDERICK I. KNIGHT, M.D. 
with it. The disease is not only wide-spread, but pursues such a long 
course that a satisfactory treatment of it (such as we would give a short, 
acute infectious disease) seems out of the question. 
It stands to reason, however, that the State, if it is to take any interest 
in the health of its people, must not ignore the infectious nature of tuber- 
culosis because it cannot do all it would, but must begin at once, and do 
what it can to limit its spread. 
Let us consider for a moment what the State can do at once: 
1. It can proclaim the infectious nature of the disease, assuring the 
people that, inasmuch as the chief danger is from the sputum, if that be 
destroyed they need have little fear. It can inform them of the best 
methods of disposal of the sputum, and urge that all sputum in consump- 
tives' houses, and in public buildings, be so cared for. By this alone prob- 
ably thousands of lives will be saved. Knowing the danger, people will 
devise new plans of avoidance for themselves and thus benefit the State. 
Surely our people do not wish to be kept in ignorance, but have estab- 
lished boards of health to keep them informed of and protected against 
danger to their health, as far as possible, and if they find that the authori- 
ties have been remiss in this great matter they may not feel in a liberal 
mood when asked for future appropriations and concessions. If the procla- 
mation of the nature of this disease had been longer pressed in its true light 
in the State of New York, I doubt if a tuberculous herd of cattle would 
have been recently released for want of funds to dispose of it. 
2. The State can use the weight of its authority and recommendation 
for the establishment of special hospitals, whither thousands, who are now a 
burden at home, or improperly cared for at almshouse hospitals, are will- 
ing and anxious to go. The class of patients which would voluntarily 
enter the hospital is just the class which, out of the hospital, is most con- 
ducive to the spread of the disease. It includes those who are too sick to 
work, and often too sick to care for themselves personally, and who fall 
back upon their friends, who are unable to provide for them except by 
sharing their already overcrowded lodgings, and overtaxing themselves in 
such a way as to make them easy victims to contagion. That we cannot 
isolate all affected subjects is no reason why we should not isolate a part, 
especially when those left in the community will be those most willing and 
most able to take care of themselves. 
Other methods of combating the disease will come naturally, and be de- 
manded by the people when once they appreciate the gravity of the situation. 
Whether our boards of health should at once require notification of 
cases is a question about which opinions will differ. The object of notifi- 
cation, of course, is to insure that from the first every case is surrounded 
by every known safeguard by one competent and interested to do so. The 
objection to it has been, first, that it would unnecessarily alarm the patient 
himself, and, secondly, that it would so alarm the family and friends that PREVENTION OF THE SPREAD OF TUBERCULOSIS. 
5 
they would treat him as an outcast. In regard to the first objection it will, 
I think, be admitted by those familiar with the treatment of these cases 
of tuberculosis that those patients have always done best who have been 
apprised of the gravity of their condition, especially when this was done 
early. The late Dr. Henry Bennet, of Mentone, insisted upon this, and 
then encouraged his patients to make a hard, intelligent fight. In regard 
to the second objection, that it would create a panic among the relatives and 
friends, I do not think this need be seriously considered, if they are told 
that the careful following of the rules laid down will remove danger almost 
wholly. Leaving the whole matter in the hands of the family doctor, both 
in regard to the amount of information to be given and what precautions 
shall be taken, cannot be as efficacious as if this was done by an officer of 
the board of health. Unless the family physician thoroughly believed and 
was personally interested, it would not be properly done. 
It seems unnecessary and unwise to attempt too much at first. It is 
not necessary in the beginning to even mention all the minor sources of in- 
fection, but there is no doubt the State must soon attempt the destruction 
of tuberculous cattle, for though meat, being usually cooked, is not a great 
source of danger, milk certainly is. 
This Association was founded for the study of climatology and the dis- 
eases of the respiratory and circulatory systems. We have more to do 
with tuberculosis than any other association. We all know that something 
ought to be done to give the people the benefit of modern research, and it 
is our duty to so recommend. Therefore I shall propose in the business 
meeting a resolution calling upon all boards of health to issue bulletins of 
instruction in regard to the nature of tuberculosis, and the best methods of 
combating the chief sources of its dissemination, hoping and believing that 
this will prove an easy entering-wedge to more thorough and effectual means 
of controlling this most destructive disease.1 
1 At the business meeting on the day following the reading of this paper, the 
Association unanimously passed the following preamble and resolution: 
"Whereas, The American Climatological Association was founded, among 
other objects, to promote the study of the nature and treatment of diseases of the 
respiratory organs, and 
" Whereas, Tuberculosis is the most fatal cause of such diseases, and 
" Whereas, Modern research has placed this disease among the communicable, 
and hence, to some extent at least, among the preventable diseases, 
" Resolved, That this Association do strongly recommend the medical profession 
of this country to promote measures tending to its prevention." International 
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