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H.-31

Speaking of the disabilities under which the poor soul suffering from this disease labours, the Director of the Phipps Institute for the Study, Treatment, and Prevention of Tuberculosis, Philadelphia, says,— The poor consumptive already is beyond the pale of rights. His rights were wrenched from him when he got the disease. His inalienable right of protection of life was violated when he was driven by conditions over which he had no control into an environment which gave him the disease and fostered its growth. Registration cannot save him; but it can save those who are near and dear to him from a similar fate. The objects which can be obtained by registration are, first, to educate and help the consumptive and his family; second, to protect the people against the danger from contaminated houses into which the}' may innocently move. With regard to the source of contagion he states, — It becomes more and more evident that family relationship is the most important factor in the spread of tuberculosis. Next to this comes association in employment, and third in order comes house infection. These deductions are in harmony with conclusions reached on the same subject along other lines of investigation. As a corollary, comes a slight change in our views upon the relative part which wet sputum and dried sputum play in the spread of tuberculosis. We gradually are driven to the conviction that contamination of food with the sputum of consumptives while the sputum is still in a moist state must be reckoned with as a factor in the spread of tuberculosis, and that sputum in a dried, powdered form is somewhat less dangerous than we formerly believed it to be. The lesson to be drawn from all this is that sputum must be disposed of immediately when given off, in such a way that nothing can be contaminated. As showing the good influence of institutions for the treatment of tuberculosis, he states :— Tuberculosis is a very chronic disease, and the more intimate our acquaintance with it, the longer the time which we assign to it for running its course. We also are beginning to find out that first attacks frequently are recovered from, and that the lung which has stood this first brunt after recovery has more resistance than the opposite lung. In this light it is quite conceivable that the lung in which the disease is most advanced may not be the place of beginning of the disease, nor was it so determined in these statistics. A most interesting and striking fact which stands out prominently in the topographical study in the death-rate from tuberculosis in Philadelphia is that every ward in which an institution for the treatment of tuberculosis exists has had a reduction in the death-rate from tuberculosis, while some of the adjoining wards have had an increase. This is especially interesting in view of the opposition which exists to the establishment of institutions for the treatment of tuberculosis on the score of danger to the neighbourhood. The location of the Hush Hospital in the Twenty-fourth Ward has been strongly opposed in that ward. One of the arguments most frequently used against its location there is the menace to residents from contagion. The Twenty-fourth Ward has a reduction in the death-rate from tuberculosis, while its neighbour, the Thirty-fourth Ward, with exactly the same kind of population, has had an increase. In fact, the only West Philadelphia wards which have had a reduction in the death-rate from tuberculosis during the two years are the two which have institutions for the treatment of tuberculosis. Another very interesting fact is that the reduction in the death-rate from tuberculosis during the three years is among the poor in the crowded parts of Philadelphia rather than among the well-to-do in the sparsely built-up parts of the city. The greatest reduction has been in the slum district, the foreign district, the coloured district, and the manufacturing districts. These are just the parts of Philadelphia in which tuberculosis was most rife formerly. The wards in which the wealthy and well-to-do live either have had .an increase in tuberculosis or very little decrease. A corollary springs from these facts that the superficial instruction given to the wealthy and well-to-do for the prevention of tuberculosis as advocated by many is insufficient for the prevention of tuberculosis. His remarks on the nursing question are also of very great value: — By the founding of the school, the problem of nursing in the Institute has been solved in a way that has proved increasingly satisfactory. At present the work of the training school presents a most interesting phase of the crusade against tuberculosis. The pupils are drawn almost without exception from young women who have been tuberculous cases themselves, who have taken a full course of treatment at the White Haven Sanatorium and have been discharged with the disease arrested. The employment of these young women as pupil-nurses is of benefit from many points of view. They have an absorbing interest in the disease from which they themselves have suffered; they have sympathy with the advanced cases that they are called upon to nurse; they present to their patients an inspiring object-lesson of what may be accomplished in the arrest of the disease; they come to the Institute after having had a valuable preliminary training at .White Haven; and, most important of all from the point of view of prevention, they are given an opportunity on their discharge from the sanatorium of immediately entering an occupation in which they have a present livelihood, and the prospect of a respectable earning-capacity after graduation. In this way a partial solution is offered to the problem —perhaps the most perplexing one in the struggle against the disease among the poor —of providing profitable employment for arrested cases.