No. 4065

JULY 27, 1901.

An AddressON

THE COMBATING OF TUBERCULOSIS IN THELIGHT OF THE EXPERIENCE THAT HASBEEN GAINED IN THE SUCCESSFUL

COMBATING OF OTHER IN-FECTIOUS DISEASES.

Delivered at the Second General Meeting of the British

Congress on Tuberculosis on July 23rd,

BY GEH.-MED.-RATH PROFESSOR DR. ROBERTKOCH,

DIRECTOR OF THE INSTITUTION FOR INFECTIOUS DISEASES, BERLIN,AND MEMBER OF THE IMPERIAL SANITARY BOARD.

THE task with which this Congress will have to busy itseliis one of the most difficult, but it is also one in which labouris most sure of its reward. I need not point again to theinnumerable victims tuberculosis annually claims in all

.countries, nor to the boundless misery it brings on the

families it attacks. You all know that there is no diseasewhich inflicts such deep wounds on mankind as this. Allthe greater, however, would be the general joy and satisfaction if the efforts that are being made to rid mankind ofthis enemy, which consumes its inmost marrow, were

-crowned with success. There are many, indeed, who doubt thepossibility of successfully combating this disease, which hasexisted for thousands of years and has spread all over theworld. This is by no means my opinion. This is a conflictinto which we may enter with a surely-founded prospect ofsuccess, and I will tell you the reasons on which I base thisconviction. Only a few decades ago the real nature oftuberculosis was unknown to us ; it was regarded as a conse-quence, as the expression, so to speak, of social misery, andas this supposed cause could not be got rid of by simplemeans people relied on the probable gradual improvement ofsocial conditions and did nothing. All this is altered now.We know that social misery does indeed go far to fostertuberculosis, but the real cause of the disease is a parasite-that is, a visible and palpable enemy which we can pursueand annihilate just as we can pursue and annihilate other

parasitic enemies of mankind.Strictly speaking, the fact that tuberculosis is a preventable

-disease ought to have become clear as soon as the tuberclebacillus was discovered and the properties of this parasiteand the manner of its transmission became known. I mayadd that I, for my part, was aware of the full significanceof this discovery from the first, and so will everybody havebeen who had convinced himself of the causal relationbetween tuberculosis and the tubercle bacillus. But the

strength of a small number of medical men was inadequateto the conflict with a disease so deeply rooted in our

habits and customs. Such a conflict requires the coöpera-tion of many, if possible of all, medical men, shoulderto shoulder with the State and the whole population, and nowthe moment when such cooperation is possible seems to havecome. I suppose there is hardly any medical man now whodenies the parasitic nature of tuberculosis, and among thenon-medical public, too, the knowledge of the natureof the disease has been widely propagated. Anotherfavourable circumstance is that success has recently beenachieved in the combating of several parasitic diseasesand that we have learned from these examples howthe conflict with pestilences is to be carried on.

The most important lesson we have learned from thesaid experience is that it is a great blunder to treat pesti-lences according to a general scheme. This was done informer times. No matter whether the pestilence in questionwas cholera, plague, or leprosy, isolation, quarantine, useless- disinfection were always resorted to. But now we know thatevery disease must be treated according to its own specialindividuality and that the measures to be taken against it

’ must be most accurately adapted to its special nature, to itsetiology. We are entitled to hope for success in combatingtuberculosis only if we keep this lesson constantly in view

As so extremely much depends just on this point I shall takethe liberty to illustrate it by several examples.The pestilence which is at this moment in the foreground

of interest, the bubonic plague, may be instructive to us inseveral respects. People used to act upon the conviction thata plague patient was in the highest degree a centre of infec-tion, and that the disease was transmitted only by plaguepatients and their belongings. Even the most recent inter-national agreements are based on this conviction. Although,as compared with formerly, we now have the great advantagethat we can, with the aid of the microscope and of experi-ments on animals, recognise every case of plague withabsolute certainty, and although the prescribed inspection ofships, quarantine, the isolation of patients, the disinfectionof infected dwellings and ships, are carried out with theutmost care, the plague has, nevertheless, been transmittedeverywhere, and has in not a few places assumed gravedimensions. Why this has happened we know very well,owing to the experience quite recently gained as to themanner in which the plague is transmitted. It has been dis-covered that only those plague patients who suffer from

plague-pneumonia-a condition which is fortunately infre-quent-are centres of infection, and that the real trans-mitters of the plague are the rats. There is no longer anydoubt that in by far the majority of the cases in which theplague has been transmitted by ocean traffic the transmissiontook place by means of plague among the ship rats. It hasalso been found that wherever the rats were intentionally orunintentionally exterminated the plague rapidly disappeared ;whereas at other places where too little attention had been

paid to the rat plague the pestilence continued. This connex-ion between the human plague and the rat plague was totallyunknown before, so that no blame attaches to those whodevised the measures now in force against the plague if thesaid measures have proved unavailing. It is high time, how-ever, that this enlarged knowledge of the etiology of theplague should be utilised in international as well as in othertraffic. As the human plague is so dependent on the ratplague it is intelligible that protective inoculation and theapplication of antitoxic serum have had so little effect. Acertain number of human beings may have been saved fromthe disease by that, but the general spread of the pestilencehas not been hindered in the least.With cholera the case is essentially different; it may under

certain circumstances be transmitted directly from humanbeings to other human beings, but its main and most

dangerous propagator is water, and therefore in the com-bating of cholera water is the first thing to be considered.In Germany, where this principle has been acted on, we havesucceeded for four years in regularly exterminating thepestilence (which was introduced again and again from theinfected neighbouring countries) without any obstruction oftraffic.Hydrophobia, too, is not void of instruction for us. Against

this disease the so-called protective inoculation proper hasproved eminently effective as a means of preventing the out-break of the disease in persons already infected, but ofcourse such a measure can do nothing to prevent infectionitself. The only real way of combating this pestilence is bycompulsory muzzling. In this matter also we have had themost satisfactory experience in Germany, but have at thesame time seen that the total extermination of the pestilencecan be achieved only by international measures, becausehydrophobia, which can be very easily and rapidly suppressed,is always introduced again year after year from the neigh-bouring countries.Permit me to mention only one other disease, because it is

etiologically very closely akin to tuberculosis, and we canlearn not a little for the furtherance of our aims from itssuccessful combating. I mean leprosy. It is caused by aparasite which greatly resembles the tubercle bacillus. Justlike tuberculosis, it does not break out till long after infertion and its course is almost slower. It is transmitted onlyfrom person to person, but only when they come into closecontact, as in small dwellings and bedrooms. In thisdisease, accordingly, immediate transmission plays the mainpart ; transmission by animals, water, or the like is out ofthe question. The combative measures, accordingly, mustbe directed against this close intercourse between the sickand the healthy. The only way to prevent this intercourseis to isolate the patients. This was most rigorously done inthe Middle Ages by means of numerous leper-houses, andthe consequence was that leprosy, which had spread to analarming extent, was completely stamped out in Central

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Europe. The same method has been adopted quite recently hin Norway, where the segregation of lepers has been ordered o

by a special law. But it is extremely interesting to see how ’ s

this law is carried out. It has been found that it is not at n

all necessary to execute it strictly, for the segregation of b

only the worst cases, and even of only a part of these, bsufficed to produce a diminution of leprosy. Only so many tinfectious cases had to be sent to the leper-houses that the tnumber of fresh cases kept regularly diminishing from year tto year. Consequently the stamping-out of the disease has d’lasted much longer than it would have lasted if every leper r

’had been inexorably consigned to a leper-house, as in the s

Middle Ages, but in this way, too, the same purpose is s

gained, slowly indeed, but without any harshness. cThese examples may suffice to show what I am driving at, r

which is to point out that in combating pestilences we must Jstrike the root of the evil and must not squander force in a

subordinate ineffective measures. Now the question is a

’whether what has hitherto been done and what is about to Ibe done against tuberculosis really strikes the root of ftuberculosis so that it must sooner or later die. In order to 3answer this question it is necessary first and foremost toinquire how infection takes place in tuberculosis. Of course, tI presuppose that we understand by tuberculosis only those 1morbid conditions which are caused by the tubercle bacillus tIn by far the majority of cases of tuberculosis the disease has tits seat in the lungs, and has also begun there. From this 6fact it is justly concluded that the germs of the disease-i.e., i

the tubercle bacilli-must have got into the lungs by’inhalation. As to the question where the inhaled tubercle {bacilli have come from, there is also no doubt. On the i

contrary, we know with certainty that they get into the air (

with the sputum of consumptive patients. This sputum, iespecially in advanced stages of the disease, almost always icontains tubercle bacilli, sometimes in incredible quantities.By coughing and even speaking it is flung into the air in 1little drops—i. e., in a moist condition-and can at once infect ipersons who happen to be near the coughers. But then 1

it may also be pulverised when dry, in the linen or i

on the floor for instance, and get into the air in the form ofdust. In this manner a complete circle, a so-called eircitlitsfJitiOS1lS, has been formed for the process of infection fromthe diseased lung, which produces phlegm and pus containingtubercle bacilli, to the formation of moist and dry particles(which in virtue of their smallness can keep floating a goodwhile in the air), and finally to new infection if particlespenetrate with the air into a healthy lung and originate thedisease anew. But the tubercle bacilli may get to other

organs of the body in the same way and thus originate otherforms of tuberculosis. This, however, is a considerably rarercase. The sputum of consumptive people, then, is to be

regarded as the main source of the infection of tuberculosis.On this point, I suppose, all are agreed. The question nowarises whether there are not other sources, too, copiousenough to demand consideration in the combating oftuberculosis.

Great importance used to be attached to the hereditarytransmission of tuberculosis. Now, however, it has beendemonstrated by thorough investigation that thoughhereditary tuberculosis is not absolutely non-existent it isnevertheless extremely rare, and we are at liberty in con-sidering our practical measures to leave this form of origina-tion entirely out of account. But another possibility ofuberculous infection exists, as is generally assumed, in thetransmission of the germs of the disease from tuberculousanimals to man. This manner of infection is generallyregarded nowadays as proved and as so frequent thatit is even looked upon by not a few as the most important,and the most rigorous measures are demanded against it.In this Congress also the discussion of the danger with whichthe tuberculosis of animals threatens man will play animportant part. Now, as my investigations have led me toform an opinion deviating from that which is generallyaccepted, I beg your permission, in consideration of the

great importance of this question, to discuss it a little morethoroughly.

Genuine tuberculosis has hitherto been observed in almostall domestic animals, and most frequently in poultry andcattle. The tuberculosis of poultry, however, differs so muchfrom human tuberculosis that we may leave it out of accountas a possible source of infection for man. So, strictly speak-ing, the only kind of tuberculosis remaining to be consideredis the tuberculosis of cattle which, if really transferable toman, would indeed have frequent opportunities of infecting

human beings through the drinking of the milk and the eatingof the flesh of diseased animals. Even in my first circum-stantial publication on the etiology of tuberculosis I expressedmyself regarding the identity of human tuberculosis andbovine tuberculosis with reserve. Proved facts which wouldhave enabled me sharply to distinguish these two forms of’the disease were not then at my disposal, but sure proofs oftheir absolute identity were equally undiscoverable, and Itherefore had to leave this question undecided. In order todecide it I have repeatedly resumed the investigationsrelating to it, but so long as I experimented on small animals,such as rabbits and guinea pigs, I failed to arrive at anysatisfactory result, though indications which rendered the.difference of the two forms of tuberculosis probable werenot wanting. Not till the complaisance of the Ministry of’Agriculture enabled me to experiment. on cattle, the onlyanimals really suitable for these investigations, did I arrive.at absolutely conclusive results. Of the experiments whichI have carried out during the last two years along with Pro.fessor Schiitz of the Veterinary College in Berlin I will tellyou briefly some of the most important.A number of young cattle which had stood the tuberculin

test, and might therefore be regarded as free from tubercu-losis, were infected in various ways with tubercle bacillitaken from cases of human tuberculosis ; some of them gotthe tuberculous sputum of consumptive patients direct. Insome cases the tubercle bacillus or the sputum was injectedunder the skin, in others into the peritoneal cavity, in othersnto the jugular vein. Six animals were fed with tuberculoussputum almost daily for seven or eight months ; fourrepeatedly inhaled great quantities of bacilli, which were.distributed in water and scattered with it in the form ofspray. None of these cattle (there were 19 of them)showed any symptoms of disease and they gained consider-ably in weight. From six to eight months after thebeginning of the experiments they were killed. In theirinternal organs not a trace of tuberculosis was found. Only atthe places where the injections had been made small suppura-tive foci had formed, in which few tubercle bacilli could befound. This is exactly what is found when dead tuberclebacilli are injected under the skin of animals liable to

contagion. So the animals we experimented on were affectedby the living bacilli of human tuberculosis exactly as theywould have been by dead ones ; they were absolutely insus-susceptible to them. The result was utterly different,however, when the same experiment was made on cattle-free from tuberculosis with tubercle bacilli that came from.the lungs of an animal suffering from bovine tuberculosis..After an incubation-period of about a week the severesttuberculous disorders of the internal organs broke out mall the infected animals. It was all one whether the infect--ing matter had been injected only under the skin or intothe peritoneal cavity or the vascular system. High feverset in and the animals became weak and lean ; some ofthem died after from one and a half to two months ; others;were killed in a miserably sick condition after three months..After death extensive tuberculous infiltrations were found at,the place where the injections had been made and in the-neighbouring lymphatic glands, and also far-advancedalterations of the internal organs, especially of the lungs andthe spleen. In the cases in which the injection had beenmade into the peritoneal cavity the tuberculous growthswhich are so characteristic of bovine tuberculosis were foundon the omentum and peritoneum. In short, the cattle provedjust as susceptible to infection by the bacillus of bovinetuberculosis as they had proved insusceptible to infection bythe bacillus of human tuberculosis. I wish only to add thatpreparations of the organs of the cattle which were artificiallyinfected with bovine tuberculosis in these experiments araexhibited in the museum of pathology and bacteriology.An almost equally striking distinction between human and

bovine tuberculosis was brought to light by a feeding experi-ment with swine. Six young swine were fed daily for threemonths with the tuberculous sputum of consumptive patients.Six other swine received bacilli of bovine tuberculosis withtheir food daily for the same period. The animals that werefed with sputum remained healthy and grew lustily, whereasthose that were fed with the bacilli of bovine tuberculosissoon became sickly, were stunted in their growth, and half ofthem died. After three and a half months the survivingswine were all killed and examined. Among the animalsthat had been fed with sputum no trace of tuberculosis wasfound, except here and there little nodules in the lymphaticglands of the neck and in one case a few grey nodules in the

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lungs. The animals, on the other hand, which had eaten t

bacilli of bovine tuberculosis had, without exception (just o

.as in the cattle experiment) severe tuberculous diseases, i!

especially tuberculous infiltration of the greatly enlarged t

lymphatic glands of the neck and of the mesenteric glands, 1and also extensive tuberculosis of the lungs and the I

spleen. yThe difference between human and bovine tuberculosis I

appeared not less strikingly in a similar experiment with vasses, sheep, and goats, into whose vascular systems the two ckinds of tubercle bacilli were injected. iOur experiments, I must add, are not the only ones that t

havered to this result. If one studies the older literature of 1the subject, and collates the reports of the numerous experi-anents that were made in former times by Chauveau, t

Gimther and Harms, Bollinger, and others, who fed 1,calves, swine, and goats with tuberculous material, (

one finds that the animals that were fed withthe milk and pieces of the lungs of tuberculous cattle 1

.always fell ill of tuberculosis, whereas those that were fed 1

with human material did not. Comparative investigations I.regarding human and bovine tuberculosis have been madevery recently in North America by Smith, Dinwiddie,Frothingham, and Repp, and their result agreed with thatof ours. The unambiguous and absolutely conclusive resultof our experiments is due to the fact that we chose methodsof infection which excluded all sources of error, and carefully.avoided everything connected with the stalling, feeding, andtending of the animals that might have a disturbing effecton the experiments. Considering all these facts, I feel

justified in maintaining that human tuberculosis differs frombovine and cannot be transmitted to cattle. It seems to me

wery desirable, however, that these experiments should berepeated elsewhere in order that all doubt as to the correctnessof my assertion may be removed. I wish only to add that,owing to the great importance of this matter, our Govern-ment has resolved to appointment a commission to makefurther inquiries on the subject.

But, now, how is it with the susceptibility of man tobovine tuberculosis ’I This question is far more important tous than that of the susceptibility of cattle to human tuber-culosis, highly important as that is too. It is impossible to,give this question a direct answer, because, of course, theexperimental investigation of it with human beings is out ofthe question. Indirectly, however, we can try to approachit. It is well known that the milk and butter consumed in

,great cities very often contain large quantities of the bacilliof bovine tuberculosis in a living condition, as the numerousinfection-experiments with such dairy products on animalshave proved. Most of the inhabitants of such cities dailyconsume such living and perfectly virulent bacilli of bovine

tuberculosis, and unintentionally carry out the experimentwhich we are not at liberty to make. If the bacilli of bovinetuberculosis were able to infect human beings, many cases oftuberculosis caused by the consumption of alimenta con-

taining tubercle bacilli could not but occur among theinhabitants of great cities, especially the children. Andmost medical men believe that this is actually the case. In

Teality, however, it is not so. That a case of tuberculosishas been caused by alimenta can be assumed with certaintyonly when the intestine suffers first-i. e., when a so-called

primary tuberculosis of the intestines is found. But such.cases are extremely rare. Among many cases of tuberculosis.examined after death I myself remember having seen

primary tuberculosis of the intestine only twice. Among the.great post-mortem material of the Charité Hospital in Berlin10 cases of primary tuberculosis of the intestine occurred infive years. Among 933 cases of tuberculosis in children.at the Emperor Frederick’s Hospital for Children-Baginsky never found tuberculosis of the intestine withoutsimultaneous disease of the lungs and the bronchial glands.Among 3104 post-mortem examinations of tuberculous child-ren Biedert observed only 16 cases of primary tuberculosis ofthe intestine. I could cite from the literature of the subjectmany more statistics of the same kind, all indubitably show-ing that primary tuberculosis of the intestine, especiallyamong children, is a comparatively rare disease, and of thefew cases that have been enumerated it is by no meanscertain that they were due to infection by bovine tuber-- culosis. It is just as likely that they were caused by thewidely-propagated bacilli of human tuberculosis, which mayhave got into the digestive canal in some way or other--forinstance, by swallowing saliva of the mouth. Hitherto

nobody could decide with certainty in such a case whether

;he tuberculosis of the intestine was of human or of animalorigin. Now we can diagnose the two. All that is necessaryls to cultivate in pure culture the tubercle bacilli found inbhe tuberculous material and to ascertain whether theybelong to bovine tuberculosis by inoculating cattle with them.For this purpose I recommend subcutaneous injection whichyields quite specially characteristic and convincing results.For half a year past I have occupied myself with such in-vestigations, but owing to the rareness of the disease inquestion the number ot the cases which I have been able toinvestigate is but small. What has hitherto resulted fromthis investigation does not speak for the assumption thatbovine tuberculosis occurs in man.Though the important question whether man is susceptible

to bovine tuberculosis at all is not yet absolutely decided,and will not admit of absolute decision to-day or to-morrow,one is nevertheless already at liberty to say that, ifsuch a susceptibility really exists, the infection of humanbeings is but a very rare occurrence. I should estimatethe extent of infection by the milk and flesh of tuber-culous cattle and the butter made of their milk as

hardly greater than that of hereditary transmission, and Itherefore do not deem it advisable to take any measures

against it. So the only main source of the infection of tuber-culosis is the sputum of consumptive patients and themeasures for the combating of tuberculosis must aim at theprevention of the dangers arising from its diffusion. Well,what is to be done in this direction ? Several ways are open.One’s first thought might be to consign all persons sufferingfrom tuberculosis of the lungs whose sputum contains tuberclebacilli to suitable establishments. This, however, is not onlyabsolutely impracticable but also unnecessary. For a con-sumptive who coughs out tubercle bacilli is not necessarilya source of infection on that account so long as he takes carethat his sputum is properly removed and rendered innocuous.This is certainly true of very many patients, especially in thefirst stages, and also of those who belong to the well-to-doclasses and are able to procure the necessary nursing. Buthow is it with people of very small means’? Every medicalman who has often entered the dwellings of the poor, and Ican speak on this point from my own experience, knowshow sad is the lot of consumptives and their familiesthere. The whole family have to live in one or

two small, ill-ventilated rooms. The patient is leftwithout the nursing he needs because the able-bodiedmembers of the family must go to their work. How can the

necessary cleanliness be secured under such circumstances ?How is such a helpless patient to remove his sputum so thatit may do no harm ? But let us go a step further and picturethe condition of a poor consumptive patient’s dwelling atnight. The whole family sleep crowded together in onesmall room. However cautious he may be the suffererscatters the morbid matter secreted by his diseased lungsevery time he coughs and his relatives close beside him mustinhale this poison. Thus whole families are infected. Theydie out and awaken in the minds of those who do not knowthe infectiousness of tuberculosis the opinion that it is

hereditary, whereas its transmission in the cases in questionwas due solely to the simplest processes of infection, whichdo not strike people so much because the consequences donot appear at once, but generally only after the lapse ofyears. Often under such circumstances the infection is notrestricted to a single family, but spreads in densely inhabitedtenement houses to the neighbours, and then, as the admir-able investigations of Biggs have shown in the case of thedensely peopled parts of New York, regular nests or foci ofdisease are formed. But if one investigates these mattersmore thoroughly one finds that it is not poverty per se thatfavours tuberculosis, but the bad domestic conditions underwhich the poor everywhere, but especially in great cities,have to live. For, as the German statistics show, tuber-culosis is less frequent, even among the poor, when thepopulation is not densely packed together, and mayattain very great dimensions among a well-to-do populationwhen the domestic conditions, especially as regardsthe bedrooms, are bad, as is the case, for instance, amongthe inhabitants of the North Sea coast. So it is theovercrowded dwellings of the poor that we have to regard asthe real breeding-places of tuberculosis ; it is out of themthat the disease always crops up anew, and it is to theabolition of these conditions that we must first and foremostdirect our attention if we wish to attack the evil at its rootand to wage war against it with effective weapons. This

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

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made in almost all countries to improve the domestic con-ditions of the poor. I am also convinced that these efforts,which must be promoted in every way, will lead to a con-siderable diminution of tuberculosis. But a long time mustelapse ere essential changes can be effected in this direction,and much may be done meanwhile in order to reach the goalmuch more rapidly.

If we are not able at present to get rid of the dangerwhich small and overcrowded dwellings involve, all we cando is to remove the patients from them and, in their owninterests and that of the people about them, to lodge thembetter, and this can be done only in suitable hospitals. Butthe thought of attaining this end by compulsion of any kindis very far from me ; what I want is that they may be enabledto obtain the nursing they need better than they can obtainit now. At present a consumptive in an advanced stage ofthe disease is regarded as incurable and as an unsuitableinmate for a hospital. The consequence is that he is re-

luctantly admitted and dismissed as soon as possible. Thepatient, too, when the treatment seems to him to produce noimprovement and the expenses, owing to the long durationof his illness, weigh heavily upon him, is himself animatedby the wish to leave the hospital soon. That would be

altogether altered if we had special hospitals for con-

sumptives, and if the patients were taken care of there fornothing, or at least at a very moderate rate. To such

hospitals they would willingly go ; they could be bettertreated and fed there than is now the case. I know verywell that the execution of the project will have great diffi-culties to contend with, owing to the considerable outlay itentails. But very much would be gained if, at least in theexisting hospitals, which have to admit a great’ number ofconsumptives at any rate, special wards were established forthem in which pecuniary facilities would be offered them.If only a considerable fraction of the whole number of con-sumptives were suitably lodged in this way a diminution ofinfection, and consequently of the sum-total of tuberculosis,could not fail to be the result. Permit me to remind you inthis connexion of what I said about leprosy. In the com-

bating of that disease also great progress has already beenmade by lodging only a fair number of the patients in

hospitals.. The only country that possesses a considerablenumber of special hospitals for tuberculous patients is

England, and there can be no doubt that the diminution oftuberculosis in England, which is much greater than in anyother country, is greatly due to this circumstance. I should

point to the founding of special hospitals for consumptivesand the better utilisation of the already existing hospitals forthe lodging of consumptives as the most important measurein the combating of tuberculosis, and its execution opens awide field of activity to the State, to municipalities,and to - private benevolence. There are many peoplewho possess great wealth and would willingly giveof their superfluity for the benefit of their poor and heavilyafllicted fellow-creatures,*but do not know how to do this ina judicious manner. Here is an opportunity for them to irender a real and lasting service by founding consumptionhospitals or purchasing the right to have a certain number ofconsumptive patients maintained in special wards of otherhospitals free of expense.

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

municipalities, and rich benefactors will probably not be forth-coming for a long time yet, we must for the present resort toother measures that may pave the way for the main measure

just referred to and serve as a supplement and temporarysubstitute for it. Among such measures I regard obligatorynotification as specially valuable. In the combating of allinfectious diseases it has proved indispensable as a means ofobtaining certain knowledge as to their state, especially theirdissemination, their increase, and their decrease. In the con-flict with tuberculosis also we cannot dispense with obligatorynotification ; we need it not only in order to inform ourselvesas to the dissemination of this disease, but mainly in orderto learn where help and instruction can be given, and espe-cially where the disinfection which is so urgently neces-sary when consumptives die or change their resi-dences has to be effected. Fortunately it is not at all

necessary to notify all cases of tuberculosis, nor even allcases of consumption, but only those that, owing to thedomestic conditions, are sources of danger to the peopleabout them. Such limited notification has already beenintroduced in various places-in Norway, for instance, by aspecial law, in Saxony by a Ministerial decree, in New York,and in several American towns which have followed its

example. In New York, where notification was optional agmst and was afterwards made obligatory, it has provedeminently useful. It has thus been proved that the evilswhich it used to be feared the introduction of notification fortuberculosis would bring about need not occur and it isdevoutly to be wished that the examples I have named mayvery soon excite emulation everywhere.

There is another measure connected with notification-viz.,disinfection, which, as already mentioned, must be effectedwhen consumptives die or change their residence in orderthat those who next occupy the infected dwelling may beprotected against infection. Moreover, not only the dwellingsbut also the infected beds and clothes of consumptives oughtto be disinfected. A further measure, already recognised onall hands as effective, is the instructing of all classes of thepeople as to the infectiousness of tuberculosis and the bestway of protecting oneself. The fact that tuberculosis has

considerably diminished in almost all civilised states of lateis attributable solely to the circumstance that knowledge ofthe contagious character of tuberculosis has been more andmore widely disseminated and that caution in intercoursewith consumptives has increased more and more in con-

sequence. If better knowledge of the nature of tuberculosishas alone sufficed to prevent a large number of cases thismust serve us as a significant admonition to make the

greatest possible use of this means and to do more andmore to bring it about that everybody may know the dangersthat threaten them in intercourse with consumptives. It is onlyto be desired that the instructions may be made shorter andmore precise than they generally are, and that specialemphasis may be laid on the avoidance of the worst danger ofinfection, which is the Ube of bedrooms and small ill-ventilated workrooms simultaneously with consumptives. Ofcourse the instructions must include directions as to whatconsumptives have to do when they cough and how they areto treat their sputum. Another measure, which has comeinto the foreground of late, and which at this moment playsto a certain extent a paramount part in all efforts for thecombating of tuberculosis, works in quite another direction.I mean the founding of sanatoria for consumptives.That tuberculosis is curable in its early stages must be

regarded as an undisputed fact. The idea of curing as manytuberculous patients as possible in order to reduce thenumber of those that reach the infectious stage of con-

sumption and thus to reduce the number of fresh cases wastherefore a very natural one., The only question is whetherthe number of persons cured in this way will be greatenough to exercise an appreciable influence on the retro-gression of tuberculosis. I will try to answer this questionin the light of the figures at my disposal. Accordingto the business report of the German Central Com-mittee for the Establishment of Sanatoria for the Cureof Consumptives, about 5500 beds will be at the disposalof these institutions by the end of 1901, and then, if weassume that the average stay of each patient will be threemonths, it will be possible to treat at least 20,000 patientsevery year. From the reports hitherto issued as to the resultsthat have been acheived in the establishments we learn furtherthat about 20 per cent. of the patients who have tubercle bacilliin their sputum lose them by the treatment there. This is theonly sure test of success, especially as regards prophylaxis.If we make this the basis of our estimates, we find that 4,000consumptives will leave these establishments annually ascured. But, according to the statistics ascertained by theGerman Imperial Office of Health, there are 226,000 personsin Germany over fifteen years of age who are so far gone inconsumption that hospital treatment is necessary for them.Compared with this great number of consumptives the successof the establishments in question seems so small that amaterial influence on the retrogression of tuberculosis in

general is not yet to be expected of them. But pray do not

imagine that I wish by this calculation of mine to opposethe movement for the establishment of such sanatoria in anyway. I only wish to warn against the over-estimating oftheir importance which has recently been observable invarious quarters, based apparently on Jthe opinion that thewar against tuberculosis can be waged by means of sanatoriaalone and that other measures are of subordinate value. In

reality the contrary is the case. What is to be achieved bythe general prophylaxis resulting from recognition of thedanger of infection and the consequent greater caution inintercourse with consumptives is shown by a calculation ofCornet’s regarding the decrease of mortality from tuberculosisin Prussia in the years 1889 to 1897. Before 1889 the

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average was 31-4 per 10,000, whereas in the period named itsank to 21’8, which means that in that short space of timethe number of deaths from tuberculosis was 184,000 less than-was to be expected from the average of the preceding years.In New York, under the influence of the general sanitarymeasures directed in a simply exemplary manner by Biggs,the mortality from tuberculosis has diminished by more than.35 per cent. since 1886. And it must be remembered that.both in Prussia and in New York the progress indicated by<these figures is due to the first beginnings of these measures.- Considerably greater success is to be expected of theirfurther development. Biggs hopes to have got so far in fiveyears that in the city of New York alone the annual numberof deaths from tuberculosis will be 3000 less than formerly.

Now, I do indeed believe that it will be possible to render-the sanatoria considerably more efficient. If strict care betaken that only patients be admitted for whom the treatmentof those establishments is well adapted and if the durationof the treatment be prolonged it will certainly be possible tocure 50 per cent. and perhaps still more. But even then, and

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even if the number ef the sanatoria be greatly increased, thetotal effect will always remain but moderate. The sanatoriawill never render the other measures I have mentionedsuperfluous. If their number becomes great, however, and ifthey perform their functions properly, they may materiallyaid the strictly sanitary measures in the conflict withtuberculosis.

If now, in conclusion, we glance back once more to whathas been done hitherto for the combating of tuberculosis,and forward to what has still to be done, we are at

liberty to declare with a certain satisfaction that very promisingbeginnings have already been made. Among these I reckonthe consumption hospitals of England, the legal regulationsregarding notification in Norway and Saxony, the organisa-- tion:created by Biggs in New York (the study and imitationof -which I most urgently recommend to all municipalsanitary authorities), the sanatoria, and the instruction of- the people. All that is necessary is to go on developingthese beginnings, to test and, if possible, to increase their-influence on the diminution of tuberculosis, and wherever.anything useful has yet been done to do likewise. If weallow ourselves to be continually guided in this enterpriseby the spirit of genuine preventive medical science, if we- utilise the experience gained in conflict with other pesti-lences, and aim, with clear recognition of the purpose andresolute avoidance of wrong roads, at striking the evil atits root, then the battle against tuberculosis, which has’been so energetically begun, cannot fail to have a victoriousissue.

An AddressON

THE PREVENTION OF TUBERCULOSIS INTHE DIFFERENT CIVILISED

NATIONALITIES.Delivered at the Third General Meeting of the British

Congress on Tuberculosis on July 24th,BY PROFESSOR P. BROUARDEL,

DEAN OF THE FACULTY OF MEDICINE OF PARIS, MEMBER OF THEINSTITUTE.

MR. PRESIDENT, LADIES, AND G-ENTLEMEN,&mdash;Mortalityfrom tuberculosis varies according to the country. In some

oases it is accountable for a sixth, a fifth, and sometimes afourth of the total mortality. Havoc such as this makes it

compulsory that all nations and governments should strictlyinquire into and adopt measures to arrest the propagation of,a disease which in these days is the greatest enemy of thehuman race. The wonder is that the voice of alarm has beenso long in making itself heard and that for centuries our.ancestors have looked impassively on the disasters going on.around them. There were several reasons for this apparentindifference. The struggle was considered useless, thedisease incurable ; it was not known how it spread. Exag-gerating the import of some observations it was agreed thatphthisis was hereditary. They were lulled to sleep by this

tormula which served as a pillow for idleness and exemptedthem from investigating the origin of the mischief. Popularobservations were looked upon as old wives’ tales-e. g., thoseof Morgagni, who in the seventeenth century stated that inItaly it was customary to burn the bedding of persons whohad died from phthisis, and who declared that he was

frightened to make a post-mortem examination on cases ofphthisis.But when, on Dec. 5th, 1865, Villemin showed experiments

at the Academy of Medicine which proved the real presenceof the contagion, when our illustrious colleague ProfessorRobert Koch had discovered and demonstrated to the medicalworld the agent of this contagion, everyone felt that a newway was opened to humanity and every nation wished toprofit for the public good by the recent scientific discoveries.Before the men of science whom I have just mentionedhad actually made known their discoveries, you Englishpeople had already begun the struggle. Convinced byobservation that tuberculosis thrived in dark and dampdwellings, in 1836-nearly 70 years ago-you passed a lawproviding for the construction of healthy houses. And sincethat date your zeal has not abated. You have, withadmirable perseverance, passed more than 10 Acts of Parlia-ment, you have rendered salubrious the dwellings of the

poor, the workshop, the town, and the whole kingdom.This effort has been described by the name of the Queenwho presided over its direction-the Victorian Era. No

greater homage could be paid to Her Gracious Majesty, andin the name of all my countrymen I unite with my Englishcolleagues in adopting this characteristic name for thecrusade that was undertaken and for the success obtained.You have diminished mortality in England from tuberculosisby 40 per cent. Yours is the honour. It will be ours tofollow in your steps. I was asked by the committee tomake the subject of my address the measures adopted bydifferent nations for the prevention of consumption.This I agreed to do, but I must at the same time makea confession. I depended too much on my wish to

please my excellent colleagues whose request seemed sofeasible ; but, unfortunately, precise information is difficultto collect, and the time at my disposal for its verificationwas very short, so that there will, I fear, be lacunae, prob-ably even errors. I shall be pleased in either case to havemy attention drawn to them and I entreat my colleagues todo so ; if they comply, thanks to them and to you the wishexpressed by the committee will be .carried out and everynation may, by hearing what its neighbours have done, gaininstruction and be inspired by motives of emulation beneficialto all.

Gentlemen, the grounds for the prevention of tuberculosisare identical in every country. On this question the entiremedical profession of the world is united. Tuberculosis isavoidable and curable. The methods used to bring this aboutare the same in all countries, but according to the impetus givento the movement by the men of science in the different nationsand according to the customs and laws in force some nationshave taken the first rank. Allow me, gentlemen, to dwell amoment on legislation. It is only possible to bring a lawinto force that interferes with our daily life, that dis-turbs inveterate habits, and that has to be carried outin the bosom of the domestic hearth, when it is called for bypublic opinion-when all are convinced of its benefits and

everyone recognises the danger of his vicious habits and isready personally to reform them and to require his neighbourto do the same. This is the state of things in England.This system seems to me the only efficacious one and thefirst thing which is indispensable is to educate publicopinion. How is this anti-tnberculous education of publicopinion to be carried out? You founded in England in 1899,under the presidency of His Royal Highness the Prince ofWales, a National Association for the Prevention of Con-sumption and other Forms of Tuberculosis. Its object is tocarry out prevention by educating the masses. You drew upshort, practical pamphlets. As a model I may quote TheCrusade against Consumption" (48 pages, price 6d.), "Milkand Tuberculosis," "Fresh Air and Ventilation," "Howto prevent Consumption," &c., and distributed them freely. Atthe head of this association I find names that I recognisewith respect-those of the gentlemen who inaugurated thisCongress. Germany founded societies for the constructionof sanatoria and then societies for the propagation of theidea, to popularise sanitary ideas. These societies are

small and scattered in different localities, forming pro-vincial groups. They, too, publish popular pamphlets.