Tuberculo5i5 in Massachusetts Prepared by the Massachusetts State Committee for the International Congress on Tuberculosis, held in Washington, D. C, September 21 to October 12, 1908. «5 Edited by EDWIN A, LOCKE, A.M.. M.D. ^ WRIGHT & POTTER PRINTING COMPANY 18 Post Office Square, Boston 1908 674 Preface. This volume is published by the Massachusetts State Committee, as a supplement to the general exhibit prepared for the International Congress on Tuberculosis, in accord- ance with the provisions of the following resolve, and with the approval of the State Board of Health : — Chapter 140, Resolves of 1908. Resolve to provide for an exhibit at the international congress on tuberculosis. Resolved, That there be allowed and paid out of the treasury of the common- wealth a sum not exceeding thirty-eight hundred dollars, to be expended under the direction of the state board of health for the expense of collection, trans- portation, installation, care and return of a suitable state exhibit at the inter- national congress on tuberculosis to be held in the city of Washington in the District of Columbia from September twenty-first to October twelfth, inclusive, in the year nineteen hundred and eight. [Approved June 12, 1908. While designed primarily for general distribution at the Congress, the Committee has had in mind its special appli- cation to the many problems in the tuberculosis work arising within the Commonwealth. The past few years have wit- nessed such a general awakening throughout the State and the development of so many activities along various lines that it is difficult to get a proper perspective. The object of this memoir is therefore a practical one: namely, to make available for every section of the State information regarding the work done in every other, and to present the most essen- tial features of the general movement. With this object in view, a special effort has been made to give in consider- 60,'?4:8r^ iv PREFACE. able detail an account of the most important work, and to reproduce photographs and plans of the various types of institution. The lack of accurate and complete mortality, and, to a far greater degree, morbidity statistics regarding tuberculosis in the State has made it impossible to include any statis- tical investigation of the conditions in Massachusetts. Contents. PAGE List of Contributors, ......... ix Introduction, ......... . . xi Frederick I. Knight, M.D. Chapter I. The State and its Part in the Tuberculosis Movement, .... i Arthur T. Cabot, M.D. Chapter II. The Work of the State Board of Health, lo Charles Harrington, M.D. Chapter HI. The Work of the State inspectors of Health, . . . . . . i8 William C. Hanson, M.D. Chapter IV. Sanitation of Clothing Factories and Tenement-house Workrooms, . . 28 Harry Linenthal, M.D. Chapter V. Bovine Tuberculosis in Massachusetts, ....... 37 Austin Peters, M.R.C.V.S. Chapter VI. The Origin and Growth of the Sanatorium Treatment of Pulmonary Tuber- culosis in Massachusetts, ........ 65 Vincent Y. Bowditch, M.D. Chapter VH. Tuberculosis in the State Institutions for the Insane, .... 81 Charles W. Page, M.D. Chapter VHI. Tuberculosis in the Prisons of Massachusetts, ...... 94 Joseph I. McLaughlin, M.D. VI CONTENTS. Chapter IX. PAGE The Treatment of Surgical Tuberculosis in Massachusetts, ... 99 Edward H. Bradford, M.D. Chapter X. The Work of the Communities throughout the State, . . . .115 Edwin A. Locke, M.D. Chapter XI. The Work of the Anti-Tuberculosis Societies in the State, . . . 135 Arthur K. Stone, M.D., and Walter E. Kreusi, B.S. Chapter XII. Experimental Researches in Tuberculosis, with Special Reference to Eti- ology, Pathology and Immunity, . . . . . .158 Theobald Smith, M.D. Chapter XIII. Out-of-door Sleeping in New England, ....... 175 Charles S. Millet, M.D. Chapter XIV. On an Apparent Connection between Polluted Public Water Supplies and the Mortality from Pulmonary Tuberculosis, . . .181 William T. Sedgwick, Ph.D., and Scott MacNutt, S.B. Chapter XV. The Relation of the Industries of Worcester to Tuberculosis, . . . 187 Albert C. Getchell, M.D. Chapter XVI. Tuberculosis among the Granite Workers of Quincy, . . . • '93 John A. Gordon, M.D. Appendix. List of Articles on Tuberculosis by Massachusetts Authors, . . . 203 Massachusetts Committee of the International Tuberculosis Congress, . 221 List of Illustrations. State Sanatorium at Rutland, Frontispiece FACING State Hospital at Tewksbury. — Hospital for Consumptives, Hospital for Consumptive Men at Tewksbury. — Floor Plan, The Martin's Brook Sanatorium. — Front Elevation and Floor Plan of Open Shack, .......... The Martin's Brook Sanatorium. — Floor Plan of Closed Pavilion, Typical Tailor Shop, where Contract Work is done, . Corner of Shop where High-grade Custom Coats are pressed. Clothing Factory. — Showing ideal Conditions, Sharon Sanatorium at Sharon. — From the Southwest, Sharon Sanatorium at Sharon. — Sleeping Balcony, . State Sanatorium at Rutland. — Block Plan, .... The Millet Sanatorium at East Bridgewater, .... The Millet Sanatorium at East Bridgewater. — -Showing Shacks, Danvers Insane Hospital at Hathorne. — Special Ward Building for Tuber culous Patients, ........ Danvers Insane Hospital at Hathorne. — Special Ward Building for Tuber culous Patients, showing Interior of Ward, Danvers Insane Hospital at Hathorne. — Special Ward Building for Tuber culous Patients, showing Veranda, . ... Hospital Prison for Consumptives at Rutland, .... Hospital Prison for Consumptives at Rutland. — Floor Plan, Good Samaritan Hospital and Day-camp at Boston, . Convalescent Home of the Children's Hospital at Wellesley Hills. — Showing Shack Unit, .......... State Hospital-school for Crippled Children, at Canton. — Showing Unit, State Hospital-school for Crippled Children, at Canton. — Recreation and Education Centre of Unit, ...... State Hospital-school for Crippled Children, at Canton. — Interior of Educa- tion and Recreation Centre, ...... State Hospital-school for Crippled Children, at Canton. — Interior of Dor- mitory, .......... Day-camp at Cambridge, ....... Day-camp at Cambridge. — Floor Plan, ..... 29 30 32 66 68 72 77 78 84 86 90 97 98 102 107 109 "3 "3 117 116 Viii LIST OF ILLUSTRATIONS. FACING PAGE es, Chart I. — Showing Death-rate from Pulmonary Tuberculosis in Boston from 1846 to 1906 "8 Boston Consumptives' Hospital at Mattapan. — Elevation Plan of Ward Building '21 Boston Consumptives' Hospital at Mattapan. — Floor Plan of Ward Build- ing '20 Boston Consumptives' Hospital at Mattapan. — Day-camp, . . .122 Boston Consumptives' Hospital at Mattapan. — Floor Plan of Day-camp, . 122 Boston Consumptives' Hospital at Mattapan. — Dining-room of Day-camp, . 122 Boston Consumptives' Hospital at Mattapan. — Front Elevation of Cottage Ward 124 Boston Consumptives' Hospital at Mattapan. — Floor Plan of Cottage Ward, 1 24 Plan of Organization of the Municipal Campaign in Boston, showing the Relation of Various Institutions caring for Consumptiv Bulletins posted by the Boston Consumptives' Hospital, Cullis Consumptives' Home at Dorchester, Tuberculosis Exhibit of the Boston Association, Tuberculosis Exhibit of the Boston Association, Day-camp of 1907 at Mattapan. — Maintained by the Boston Association, Children's Day-camp at Parker Hill. — Maintained by the Boston Association Sleeping Balcony used by Class Patient in Haverhill, Polling Booths used for Consumptives at Haverhill, .... Day-camp at Holyoke, ......... Original Sleeping Balcony in Hanover. — Used since June, 1898, The Millet Sanatorium at East Bridgewater. — Shack used for Treatment of Tuberculosis, ....... The Millet Sanatorium. — Floor Plan of Shack, Map of Massachusetts, showing Distribution of Population, etc.. Following page 223 126 130 141 '43 142 144 144 149 '5' 152 176 '79 .78 Contributors. Vincent Y. Bowditch, M.D., Boston. Medical Director of the Sharon Sanatorium; formerly Medical Director of the State Sanatorium at Rutland. Edward H. Bradford, M.D., Boston. Professor of Orthopedic Surgery in the Harvard Medical School. Arthur T. Cabot, M.D., Boston. Chairman of the State Commission on Hospitals for Consumptives. Albert C. Getchell, M.D., Worcester. Member of the State Commission on Hospitals for Consumptives and of the Board of Trustees of the State Sanatorium at Rutland. John A. Gordon, M.D., Quincy. Charles Harrington, M.D., Boston. Professor of Hygiene in the Harvard Medical School; Secretary of the Mas- sachusetts State Board of Health. William C. Hanson, M.D., Boston. Assistant to the Secretary of the State Board of Health. Frederick I. Knight, M.D., Boston. Consulting Physician to the Sharon Sanatorium and the Free Hospital for Consumptives. Walter E. Kreusi, B.S., Boston. Secretary of the Boston Association for the Relief and Control of Tuber- culosis. Harry Linenthal, M.D., Boston. State Inspector of Health, District No. 5. Edwin A. Locke, M.D., Boston. Chief of Staff of the Boston Consumptives' Hospital. Scott MacNutt, S.B., Boston. Massacl usetts Institute of Technology. Joseph I. McLaughlin, M.D., Boston. Physician to the State Prison, Charlestown. X CONTRIBUTORS. Charles S. Millet, M.D., Brockton. Medical Director of the jMillet Sanatorium, East Bridgewater. Charles W. Page, M-.D., Danvers. Superintendent and Physician at the Danvers Insane Hospital, Hathorne. Austin Peters, M.R.C.V.S., Boston. Chief of the Cattle Bureau of the Massachusetts State Board of Agriculture. William T. Sedgwick, Ph.D., Boston. Professor of Biology at the Massachusetts Institute of Technology. Theobald Smith, M.D., Boston. George Fabyan Professor of Comparative Pathology in the Harvard Med- ical School. Arthur K. Stone, M.D., Boston. Vice-President of the Boston Association for the Relief and Control of Tuberculosis; Visiting Physician to the Good Samaritan Hospital. INTRODUCTION, Frederick I. Knight, M.D. The former high mortality from consumption in Massachusetts and other New England States is well known. It was at first attributed to the severity of the climate, but later rather to various unhygienic conditions, such as vitiated air, poor food and damp soil, and before the discovery of the active agent of the disease the mortality had been greatly diminished by im- proved hygiene. Having had such experience, it was not unnatural, when the value of closed sanatoria for the treatment of incipient tuber- culosis had been established, that Massachusetts should be the first State to erect such an institution. The establishment of sanatoria, public and private, has served not only to arrest the disease in many patients subjected to their strict regime, but has been of incalculable worth in teaching preventative measures to many others. Unfortunately, the reputation of the sanatorium treatment is suffering somewhat at present in this State, as in others, from exaggerated claims which were made for it, and on account of rather frequent relapses of patients (discharged as cases of arrested disease) after returning to their unhygienic homes and work. Supervision of patients discharged from sana- toria, and, as far as possible, the amelioration of adverse condi- tions of their lives, must be a part of the great movement against tuberculosis. The gradual inuring of patients to work, and in- struction in some healthy occupation before leaving the sanatoria, is a step in the right direction, especially since idleness, when long maintained, has been well called the curse of the consumptive. Since the discovery of the tubercle bacillus and the infectious- Xii INTRODUCTION. ness of the disease, the importance of special hospitals for patients with advanced tuberculosis, who cannot be properly cared for at home, is self-evident, and this State has authorized the erection of three such, and the city of Boston one. But the care of cases of tuberculosis, incipient or advanced, is only a small part of the work. When the discovery of the tubercle bacillus was announced, the thought came of the eradication of the disease, but the task seemed almost too great to be undertaken, considering the almost universal dissemination of the bacilli; but it was soon realized that the same building up of the human system which would arrest the disease when present, would also prevent its inception in the uninfected, and a movement was begun not only to prevent, as far as possible, the transmission of the germ, but also to put the individual in such condition of health as to prevent its develop- ment. So the movement is not merely a fight to combat the disease in those already affected, or even to annihilate the germ, but to make the people immune to it. When there are no sus- ceptible subjects, the germ will cease to exist. The present report will show how fully the people of this State appreciate the magnitude and at the same time the hopefulness of the task. They feel that every case of tuberculosis discovered should be followed to its home, not only to care for the patient, and insure, as far as possible, against his infection of others, but also to do everything possible to make others immune to the disease. To accomplish this, special organizations have been effected in Boston and other cities, special committees have been appointed from every district of the Massachusetts Medical So- ciety, and the State has been divided, largely on account of the tuberculosis problem, into fifteen health districts, with an in- spector in each, to insure as far as possible the hygiene of factories, workshops and tenements, as well as of the families of the working- INTRODUCTION. XIU men. The Boston Consumptives' Hospital Trustees have under- taken the most thorough following up of Boston cases. All these special agencies are obtaining more and more the active co-operation of our health boards, State and local, and of all our charitable institutions which have to do with the poor and their homes. How important all these means are, and how efficient they have already become, may be judged from the chapters which follow. In reading these chapters, one must feel that Massachusetts, with her special sanatoria, hospitals, dispensaries, laboratories, day- camps, prospective out-door schools, her control of bovine tuber- culosis, and the combined action of many general and special bodies in following up the disease, has made a most gratifying start in the struggle against this disease. Chapter I. THE STATE AND ITS PART IN THE TUBERCULOSIS MOVEMENT. Arthur T. Cabot, M.D. The State of Massachusetts exercises supervision over tuber- culous patients, and has endeavored to prevent and control tuberculosis by means of the following organizations and insti- tutions. The list covers the efforts made under direct state con- trol and also organizations which are not local but extend their activity over the whole Commonwealth. 1. The State Board of Health. 2. The State Board of Agriculture. 3. The State Board of Education. 4. The State Sanatorium at Rutland. 5. The special wards in connection with other state hospitals and reformatory institutions. 6. The Associated Committees of the Massachusetts Medical Society for the Prevention and Control of Tuberculosis. 7. The Commission to investigate Measures for the Relief of Consumptives, appointed in 1906. 8. The Massachusetts Commission on Hospitals for Consump- tives, appointed in 1907. 9. The state inspectors of health. 10. The Federation of Women's Clubs. 1. The Siaie Board of Health has been active in combating tuberculosis from the time of its foundation, in 1869. An account of its work is given in the succeeding chapter. 2. The Cattle Bureau of the State Board of Agriculture has general supervision over the inspection of cattle throughout the State, 2 TUBERCULOSIS IN MASSACHUSETTS. and power to properly dispose of tuberculous cattle that are dis- covered by or reported to it. 3. The State Board of Education is now, in compliance with recent legislation, issuing a pamphlet on the tuberculosis problem, for the purpose of informing the teachers throughout the State as to the essential facts about this disease, to the end that they may present them intelligently to their pupils. 4. The State Sanatorium at Rutland, for the treatment of tuber- culosis in the early stages, was built in the year 1896, and was the first state sanatorium in the United States. It is fully described in another chapter, and is only briefly mentioned here as one of the most important and successful agencies through which the State has sought to curtail the ravages of tuberculosis. 5. The various state hospitals for the insane, the pauper poor and the penal institutions have separated the tuberculous from the other inmates, and in many cases have built specially designed wards for them. The most important of these is at the State Hospital at Tewksbury, where accommodations for about two hundred tuberculous poor are provided in isolated, well-equipped buildings. Many of the patients in the State Hospital are advanced cases, which are brought there from poor and crowded quarters in which they would be certain to spread infection. In this way excellent preventive work has been accomplished where this work has been of the greatest importance. The following is a list of state institutions thus providing for the isolation of tuberculous inmates: State Hospital, Tewksbury; State Farm, Bridgewater; State Hospital-School for Crippled Children, Canton; Danvers Insane Hospital, Hathorne; West- borough Insane Hospital, Westborough; Medfield Insane Asylum, Medfield Junction; Massachusetts School for the Feeble-minded, Waverley. CABOT. 3 At Palmer, the Taunton Insane Asylum and the State Hospital at Foxborough there are no consumptive wards, but care is taken to separate such cases and to provide for open-air treatment. 6. Associated Committees of the Massachusetts Medical Society. — In 1905 the various district medical societies of which the Massachusetts Medical Society is made up appointed committees to consider the question of the control and prevention of tuber- culosis within the State. In some districts these committees were small, consisting of from three to five members, while in others they were larger, and, seeking to fully represent the various localities, they com- prised members from all of the considerable cities and towns in the district. It soon became evident that the enlargement of the committees was adding to the efficiency of the work, as it led to a more thorough understanding of the conditions and needs of the various localities. The districts having small committees were urged to enlarge them by adding members from all of the large places that were unrepresented. This has been done in most of the districts, so that at the present time these committees comprise one hun- dred and ninety-four members from one hundred and fifty-six cities and towns. To promote uniformity of action and of interest these commit- tees were called together at the first annual meeting of the state society after their appointment, and they then voted to join in an organization to be called "The Associated Committees of the Massachusetts Medical Society for the Relief and Control of Tuberculosis." They elected a chairman and secretary and voted to publish a report each year. The activities of the committees during the first year were di- rected to studying the conditions as they existed throughout the State, and a brief abstract of their reports was published in the 4 TUBERCULOSIS IN MASSACHUSETTS. first annual report. In this report the suggestion was made that efforts should be directed especially to four principal objects, namely : first, perfecting registration ; second, procuring thorough and general disinfection after the death or removal of a tubercu- lous patient; third, the formation of anti-tuberculosis associations; fourth, procuring hospitals for advanced cases. During that year a compulsory registration law was put on the statutes. An act providing for the establishment of three sana- toria for tuberculous patients was passed by the same Legislature. The Associated Committees did their part in promoting this legislation. The success of their efforts to procure thorough dis- infection has varied greatly in different localities. In some com- munities the practice of disinfection has been greatly improved, but it will evidently be a matter needing constant attention until the community is educated to understand its importance and demands it. The members of the Associated Committees have been active and successful in promoting the formation of voluntary anti- tuberculosis societies. In 1905 Boston, Cambridge, Springfield and Worcester were the only cities in the State having societies of this sort. During this year Dr. J. C. Pitta, a Portuguese physician of New Bedford, established an anti-tuberculosis society called the "Portuguese League of Assistance to the Consumptives," among his fellow-countrymen in New Bedford. Just prior to the formation of the committee in the Middlesex North District Medical Society, in 1906, an anti-tuberculosis as- sociation was formed in Lowell, with the assistance of Mr. A. M. Wilson, the efficient secretary of the Boston Association. In 1906-07 anti-tuberculosis societies were formed under the auspices of the local committee of the Associated Committees in Haverhill, Salem, Holyoke, Walpole, Brookline, Brockton and CABOT. 5 Fitchburg. Similar associations have been formed in Lawrence, Lynn, Northampton, Pittsfield and Qinton during the past year. Besides these associations in larger towns there are other places in which smaller committees for anti-tuberculosis work have been formed; physicians have started classes for the instruction of tuberculous patients, and visiting nurses have been taught and urged to give especial care in the oversight of their tuberculous cases. The local boards of health have been stimulated and sup- ported by the medical profession in carrying out preventive meas- ures. The first day-camp was inaugurated by the Boston Association, and proved so successful in economically dealing with the tuber- culous poor that the same treatment has been adopted in a number of places, including Cambridge, Springfield, Lowell, Holyoke, Brookline, Fitchburg, New Bedford and Salem. These are some of the more tangible results already brought about or greatly aided by the Associated Committees. An equally important effect has been that produced upon the medical profession itself. This organization within the Massa- chusetts Medical Society was formed to bring the medical men throughout the State into the closest possible touch with the cam- paign against tuberculosis, to make them acquainted with the work done in other places and to arouse their interest and their confidence in the hopefulness of this endeavor. It is plain that it is largely through the practising physicians that the patients must be reached and placed in proper surroundings for a cure. By them they must be taught how to get well and how to avoid spread- ing the disease. It is necessary, then, that the physicians be fully informed as to the various agencies that may be asked to assist them in curing their consumptive patients. They must know where to obtain and how to use the various appliances for sleeping in the open air, as plans for cheap sleeping balconies, and should 6 TUBERCULOSIS IN MASSACHUSETTS. be informed of the success which has attended this form of treat- ment, in order that they may themselves be encouraged to use it and may have arguments to convince their patients that it is worth the trouble and expense. They should also be intimately acquainted with the various sanatoria for consumptives, in order that they may judge of the appropriate place for a particular case, and may also know how most easily to obtain his admission. The Associated Committees, with their members scattered throughout the State, are an efificient means of spreading this information, and of keeping alive the in- terest of their communities in anti-tuberculosis work. It*is to be expected that, as it becomes more and more widely recognized that consumption in the incipient stage is curable, the physicians, becoming more and more interested in finding their cases while still curable, will make greater efforts to detect the disease in its early stages, and will avail themselves more fully of opportunities to have sputum examinations made in doubtful cases. The Associated Committees have already had a good effect in helping the medical men in Massachusetts to co-operate in the important field of preventive medicine. 7. Commission to investigate Measures for the Relief of Con- sum-ptives. — In the spring of 1906, in accordance with a legisla- tive resolve, Governor Guild appointed a Commission to investigate measures for the relief of consumptives and sites for state hospi- tals for consumptives. After a careful study of the conditions throughout the State this Comrrtission embodied its observations and recommendations in a report, of which the following is a summary: — I. As to the number of persons in the Commonwealth who are suffering from pulmonary tuberculosis, or consumption: — That the total number of cases of pulmonary tuberculosis reported to the Com- CABOT. 7 mission is 7,779; of these, 6,376 are private patients of physicians who answered the circular letter sent out by the Commission, and 1,403 are in either private or public institutions located in the State. The number of incipient cases reported is 2,792; the number of advanced, 2,339; ^nd the number of far advanced, 2,648. 2. As to appropriate and available sites for a hospital or hospitals for the treat- ment of such sufferers: — That many appropriate and available sites, such as have been described in the text, can easily be found in every county and in the neighborhood of nearly every municipality in the State. 3. As to the probable cost to the Commonwealth of erecting and maintaining hospitals adequate for such treatment: — That the probable cost of erecting such hospitals would be about $500 per bed; and of maintenance, from $7 to §9 per week per patient. 4. As to the advisability of the undertaking by the Commonwealth of the care and treatment of such sufferers, the Commission advises: — That the statutes relating to the public health be amended by inserting the word "tuberculosis" after the words "scarlet fever," in sections 49, 50 and 52, chapter 75, Revised Laws; and also by inserting the word "tuberculosis" after the word " smallpox " and after the word " diphtheria," in sections 1 and 2, chapter 213, Acts of 1902. That section i, chapter 165, Acts of 1906, relating to the prohibition of expec- toration in certain public places, be amended by inserting the words " in any mill or -factory, or in any hall of any tenement building occupied by five or more families, or in any school building," after the words "or music hall." That the State erect three hospitals for the treatment of tuberculosis, to be devoted principally to the treatment of cases in the advanced stages of the disease; one of these hospitals to be located somewhere in the Connecticut Valley, another in the northeastern part and a third in the southeastern part of the State; each of the hospitals to be built to accommodate not over one hundred and fifty patients. That proper legislation be enacted so as to provide for medical inspectors. (Signed) Henry P. Walcott, M.D., Chairman. Charles H. Adams. Jeffrey R. Brackett. Charles H. Porter. (Signed) Adams S. MacKnight, M.D. Charles S. Millet, M.D., Secretary. 8. Massachusetts Commission on Hospitals for Consumptives. — The Legislature of 1907, after considering tiie above report, passed an act to provide for establishing three sanatoria for tuberculous 8 TUBERCULOSIS IN MASSACHUSETTS. patients, and appropriated $300,000 for this object. Pursuant to this act the Governor appointed the following Commission: Charles H. Adams, Dr. Arthur T. Cabot (chairman), Alvah Crocker, Dr. Albert C. Getchell, William C. Godfrey, Mrs. Sylvia B. Knowlton, Dr. William D. McFee and Jeremiah Smith, Jr. This Commission was appointed in July, 1907, organized on September i, and has since that time been actively at work in- vestigating sites and studying plans for the three hospitals above mentioned. The act as first passed provided that no building should be begun until the plans for all hospitals were complete, but was later amended so as to allow the Commission to start the building of one hospital as soon as it had submitted plans satisfactory to the Governor and Council, which reasonable estimates showed could be built and equipped for $100,000. The difficulties in obtaining suitable sites have been greater than was anticipated. The obvious requirement of proximity to a railroad, both for economy of administration and to provide easy access to patients and their friends, greatly limits the choice. Economy in construction, necessitated by the small appropriation, makes it imperative to select land that is level and well cleared. A high and dry plateau, where water can be obtained cheaply and where sewage disposal can be safely arranged, is not easily found. One satisfactory site has been obtained and the plans for the first hospital are well under way. The act creating this Commission is designed to eventually put under its charge all of the state sanatoria and to consolidate all the state anti-tuberculosis work under one Board. While the Commission has been searching for sites and planning these hospitals it has been issuing bulletins at short intervals, each bulletin dealing with some phase of the tuberculosis problem. These bulletins have been distributed to the newspapers through- CABOT. 9 out the State and have been generally published, or in some cases made the basis of an article or "leader." The Commission has also constantly urged the importance of and assisted in the establishment of tuberculosis dispensaries or clinics, day-camps, anti-tuberculosis associations and visiting nurses in various parts of the State. 9. Health Districts and Inspectors. — The Legislature of 1906-07, following the recommendations of Dr. Walcott's commission, or- dered that the State should be divided into districts, and that a health inspector, appointed by the Governor, should be assigned to each district. The work of the inspectors is considered at length in a subsequent chapter. 10. The Massachusetts Federation 0} IV omen's Clubs. — Within the past year the Federation of Women's Clubs has taken an active interest in the matter of tuberculosis. It has had public meetings in various places, with the purpose of educating the community in regard to tuberculosis, and in certain localities has taken an active part in the effort to establish anti-tuberculosis associations, day- camps and dispensaries. It is greatly to be hoped that the active interest among the women of the State in this important work will increase, as their assistance in educational lines, in establishing societies and clinics for the care of the tuberculous poor, as well as in giving individual assistance to those needing it, can become a very powerful factor in the work. 10 TUBERCULOSIS IN MASSACHUSETTS. Chapter II. THE WORK OF THE STATE BOA.RD OF HEALTH. Charles Harrington, M.D. Massachusetts was the first of the States to estabhsh a State Board of Health, and this was done in 1869. Dr. Henry I. Bow- ditch, whose investigation of the influence of soil moisture on the prevalence of consumption in New England had given him an in- ternational reputation as an authority on pulmonary consumption, was appointed chairman, and in his opening address at the first meeting of the Board, in September, 1869, he laid down as one of the fundamental principles of a board of health that it is "bound to take care of the public health, to investigate the causes of epi- demic and other diseases, in order that each citizen may not only have as long a life as nature would give him, but likewise as healthy a life as possible." The Board's first secretary. Dr. George Derby, whose statistical work concerning pulmonary consumption had already attracted much attention, said in his first report: — If there is any one disease which more than another would seem to favor the views of the advocates of the predestined and the inevitable, it is that terrible scourge, far more to be dreaded than cholera, consumption. It has been regarded as a special mode intended by Providence to reduce a redundant population, as feeble trees in a forest are crowded out of existence by their more vigorous neigh- bors. And there is much in the history of the disease which makes such arguments plausible. It is found everywhere in civilized communities, in the South as well as the North, seeming to be generally distributed. Yet the kind of investigation of its natural history and of its causes which we are able to make in these latter days, through the aid of vital statistics, and by the comparison of great numbers of cases, shows that this is far from being true, and places us directly upon the path leading to a discovery of the conditions under which it originates, — conditions HARRINGTON. I I which, when fully recognized, may be avoided. That its causes are many is certain ; that some of them are obscure, and even quite unknown as yet, is very probable. But others are fully revealed, and are influencing practice and saving life. Dr. Derby stated that an examination of tiie 45,000 deaths from consumption that had occurred during ten years in Massachusetts showed that its distribution in the State was very unequal, in some of the communities the mortality from this dis- ease being two and even three times that of others of equal size and equally stationary population. He emphasized the importance of fresh air, and gave as an illustration the difference in the fate of two individuals with similar consumptive tendency, one choosing to make shoes in an ill-ventilated shop and the other to live the life of a lumberman in the open air, the latter living the longer. " But," he said, "our grandfathers did not know even that. They protected such persons from fresh air, fearing they would take cold, coddled them, nourished them imperfectly, and gave them medi- cine." At that time tuberculosis was already declining in Massachusetts, through the influence of private and public hygiene, and in support of his statement to that effect Dr. Derby presented a table showing that whereas in 1853 there were four hundred and twenty-seven deaths from consumption per 100,000 population, the curve showed an almost constant yearly fall, the total decline being about 20 per cent. Comparing the first and the last groups of five years, he called attention to the annual gain of six hundred and eighty- eight lives saved, and ventured the opinion that this saving was due to the advance of medical science, which had given to physicians a better knowledge of the nature of the disease, a better mode of treatment and a greater acquaintance with prophy- lactic measures. "Fresh air, by day and by night, strong and nourishing food, dry soil on which to live, sunlight and warm cloth- ing are the means of saving many lives which would have been 12 TUBERCULOSIS IN MASSACHUSETTS. hopelessly lost in the preceding generation. ... Let in the sun- light, and never mind the carpets; better they should fade than the health of the family." In the second report of the Board, issued in January, 1871, was presented an important paper on the ventilation of schoolhouses, emphasizing the necessity of a continuous supply of fresh air, and also an article on air and some of its impurities, in which the im- portance of dust as an agent in impairing the general health was dwelt upon. in the same report was presented a reply to the Legislature of 1870, which directed the Board to ascertain the whole number of minors employed in the textile industries of the State, to compare their mortality with that of all other persons of the same age, during the same periods of time, and to report upon the effect of the employment upon their general health in comparison with the effects of other employments upon the general health of other per- sons of similar ages. At this time it appeared that about 40 per cent, of all of the deaths between the ages of fifteen and nineteen, inclusive, in Massachusetts, were due to pulmonary consumption, and the Board reported that the mortality among minors in fac- tories, so far as could be ascertained from the returns received, was about the same as that of minors in the general population; but attention was drawn to the fact that, when unfit for work by reason of sickness, and particularly in the first stages of consumption, a certain proportion of the operatives withdrew and were lost sight of, and that, such being the case, the rate of mortality among minors in textile factories was really higher than that of those in the general population. The fourth annual report of the Board presented an analysis of a correspondence on some of the causes or antecedents of consump- tion with two hundred and ten physicians resident in Massachusetts and elsewhere. At this time consumption was the cause of about HARRINGTON. I3 one-fifth of the annual mortahty, and in the next report the chair- man again referred to it as the most important disease in New England, and dwelt upon the value of sanitary houses, proper food and clothing, and personal hygiene, including exercise, in combat- ing its ravages, devoting several pages to the consideration of each one of these important topics. The evils of damp homes, improper food and too much clothing in cold weather, and the value of long walks in winter, even for young girls, and of keeping the skin in good condition by daily bathing, all received their proper share of attention. The chairman deemed recreation as of the greatest importance at all stages of life, but particularly in childhood and youth. The open-air treatment of to-day was strongly advocated by him thirty- four years ago. In speaking of children with hereditary tendencies, he said: "Such a child should be compelled to find some recreation in the open air." He would make it a rule that every clerk should walk daily two or three miles, and for a few weeks annually he should leave the city and go to the woods or the seashore. Camp- ing in the woods, yachting excursions, pedestrian tours, — all were recommended as recreations which would be beneficial for all, and especially for those having consumptive tendencies. "Noth- ing can be worse," he said, "for all youths, especially those hered- itarily consumptive, than a too close and constant attendance at school, college or counting-room." Recognizing the fact above stated, that one-fifth of the deaths in Massachusetts were due to consumption, the Board in its earliest days made an effort to ascertain whether this high rate of mor- tality could not be lowered; and early in July, 1871, a circular was issued to the profession, not only in Massachusetts, but in the other New England States and elsewhere, for data bearing on the causes of the disease and the factors governing its spread. In each of the annual reports since 1884 have been presented I^ TUBERCULOSIS IN MASSACHUSETTS. charts and tables showing the weekly variation in the mortality from tuberculosis during the year. In the report for 1891 were given a chart showing the mortality from pulmonary consumption from 1883 to 1 89 1, inclusive, and for 1891 separately; a table showing the total deaths for each week of the year for the period of nine years; and a map which showed the extent to which each city and town had been afflicted with the disease during the twenty years ended with 1890. In the report for 1894 there was presented a chart showing the deaths from consumption per 10,000 living, from 185 1 to 1893. The curve is of great interest, and shows a decline from forty-three in 1853 to a fraction less than twenty-three in 1893. It gave also a table showing the annual percentage of the annual mortality, which percentage had fallen from more than 22.90 to 1 1.25; and the deaths by sex and ages, the seasonal distribution and the mortality with respect to density of population. It appeared that the mortality in dense, medium and sparse districts varied as 1,810 and 727; the term "dense" applying to districts having less than one acre per inhabitant; "medium," where there was more than one acre per inhabitant but less than four; and "sparse," where there were more than four acres per inhab- itant. In 1895 the Board issued a circular, which was distributed ex- tensively throughout the State, to furnish information to the pub- lic on: — 1 . The nature of pulmonary consumption. 2. The conditions which favor its spread. 3. The best methods of preventing it. Under the second were discussed defective ventilation, damp- ness of soil, overcrowding of dwellings, factories and workshops, the influence of dust, of insufficient or badly selected food and of intemperance. HARRINGTON. 1 5 Under the third were presented prophylactic measures, includ- ing prevention of overcrowding, household and personal cleanli- ness, proper selection of occupation, the choice of a well-balanced ration, the avoidance of overwork, anxiety, worry and exhaustion, the disposal of sputum, and disinfection. A short time after this circular was issued there appeared a monograph written by Dr. J. B. Russell, Senior Medical Officer of Health, of Glasgow, on the prevention of tuberculosis; and, having been brought to the attention of the Board, it was reprinted, with the consent of the author, and 5,000 copies were distributed throughout the State. As the report for 1896 says: "No publica- tion of the Board has been received and read with greater interest, and it is hoped that much benefit will be derived from its circula- tion." In 1896 was begun the free examination of sputum or other material for the bacillus of tuberculosis, suitable packages being furnished by the Board for transmitting the material. This work has grown more and more in importance, and during the past few years the number of specimens sent annually to the Board's lab- oratory has exceeded one thousand. These specimens come from all parts of the State, excepting from those cities and towns which maintain diagnosis laboratories or avail themselves of the services of local bacteriologists and pathologists. At the present time, however, interest in tuberculosis has led to such an increase in the number of specimens that it is impossible to forecast what figure will be reached. Possibly the recently increased resort to the laboratory of the Board may be, in part, attributable to the fact that in 1907 the Legislature passed an act amending certain sec- tions of chapter 75 of the Revised Laws, which made it incumbent upon the Board to declare what diseases should be regarded as dangerous to the public health, and hence notifiable under that chapter. On August i, 1907, the Board declared eighteen dis- l6 TUBERCULOSIS IN MASSACHUSETTS. eases to be dangerous and notifiable, and tuberculosis in all its forms was one of them. In 1905 the Legislature passed a resolve authorizing the State Board of Health "to cause a public exhibition to be made of the various means and methods used or recommended for treating and preventing tuberculosis, now recognized as a communicable and preventable disease;" and in accordance with the provisions of the resolve an exhibition was held in Horticultural Hall, Boston, from December 28, 1905, to January 7, 1906, inclusive. An aux- iliary committee was appointed in order to obtain the co-operation of persons interested in the general subject who would assist the Board in arousing public interest and advise concerning the man- agement of the exhibition. The exhibition was advertised throughout the Commonwealth by means of circulars and circular letters addressed to physicians, philanthropists, boards of health, managers of institutions, secretaries of labor unions, superin- tendents of schools, officers of all of the colleges and institutions of higher learning, manufacturers, owners of large mercantile establishments and trained nurses. Additional publicity was secured through posters and cards printed in Hebrew and Italian. The material shown was contributed by various health organi- zations, institutions and tuberculosis societies and associations, and was exceedingly valuable and interesting. It drew a total attendance of 25,953 persons, or an average daily of 2,359. Dur- ing the exhibition, a number of special meetings were held, which were addressed by men qualified to represent all classes concerned in this movement, — physicians, employers, workingmen, philan- thropists, health authorities, teachers, managers of public and pri- vate institutions, and others. These meetings were attended by a total of 5,275 persons. There was also given a series of seven lantern-slide demonstrations, which drew a total of 2,625 persons. The exhibition fulfilled the purpose for which it was held in a HARRINGTON. '7 very satisfactory manner, and led to the holding of many similar though smaller exhibitions in various parts of the State. In its report to the Legislature of 1906, on the sanitary condi- tion of factories, the Board laid especial emphasis on the influence of dust and lack of ventilation in causing the spread of tubercu- losis, and made a number of recommendations concerning the sanitation of factories and the protection of the health of em- ployees. These, with other influences, led to the division of the State into fifteen health districts and the appointment in each of a state inspector of health, one of whose principal duties is to gather all information possible concerning the prevalence of tuberculosis and other diseases dangerous to the public health within his dis- trict, and to disseminate knowledge as to the best methods of pre- venting their spread. Under the provisions of this act all minors employed in factories are subject to examination by the state in- spectors of health, who are required to call any condition of ill health or physical unfitness detected to the attention of the minor's parents or employers and also to the State Board of Health. The work of this department of the Board is considered in another chapter. TUBERCULOSIS IN MASSACHUSETTS. Chapter III. THE WORK OF THE STATE INSPECTORS OF HEALTH. William C. Hanson, M.D. On June 19, 1907, Governor Guild approved an act which pro- vided for the establishment of fifteen health districts and the ap- pointment of a physician as state inspector of health in each dis- trict. This act further provided that the state inspectors of health should be under the general supervision of the State Board of Health, and that they should perform such duties other than those specifically imposed upon them as the said Board from time to time should determine. Broadly stated, the duties of the state inspectors of health fall into four main groups: each inspector is required to inform him- self respecting, first, all influences which may be dangerous to the public health; second, the prevalence of tuberculosis and other diseases dangerous to the public health within his district; third, the health of all minors employed in factories within his district; and fourth, the sanitation of factories, slaughterhouses, public buildings and tenements in which clothing is manufactured. In performing the duties under the first and second, the inspectors act as intermediaries between the State Board of Health and the local health authorities. For example, in the matter of preventing, destroying or mitigating nuisances, which endanger human life or health, the local boards of health have almost absolute authority; but the function of the state inspectors of health is to investigate such nuisances for the purpose of notifying local health authorities of their powers and duties relative thereto, and of recommending such measures as may be deemed expedient for the promotion of HANSON. 19 the public health. At the same time copies of all written sug- gestions made by the state inspectors to the local health authorities are sent to the State Board of Health. In the matter of investigating contagious diseases, and all diseases dangerous to the public health, the inspectors have full power, but may only take steps toward the eradication of any such diseases after consultation with the State Board of Health and the local board. In performing the duties under the third and fourth, relating to the health of minors and the sanitation of buildings, the inspectors act independently of local health authorities and under the direction of the State Board of Health. It must be clear that the duties of these inspectors are manifold. There is, however, but one object in view, namely, to guard the public health. In this work their position is unique, for with their medical knowledge — which is indispensable to the proper en- forcement of the statutes — they may appeal to the medical pro- fession on the one hand and to the laity on the other, teaching all that the promotion of public health is a matter which concerns not only the medical profession but every profession and every indi- vidual. The one health problem which more than all others, at the pres- ent time, demands the services of all professions and of every per- son in his respective sphere, is that of diminishing the prevalence of tuberculosis. Now that the matter has been brought earnestly to public attention, it should be kept before the public, with ever- increasing emphasis upon the importance of sanitary education. Reform cannot be complete as long as sanitary science is considered inferior in interest and importance to any other branch of educa- tion. In this connection it is interesting to observe that the beginning of the state work marks the lapse of upwards of half a century since Lemuel Shattuck brought to the attention of the Massachu- 20 TUBERCULOSIS IN MASSACHUSETTS. setts Legislature the necessity for "particular observation and in- vestigation of the causes of consumption and the circumstances under which it occurs," on the ground that "if consumption is ever to be eradicated or ameliorated it can only be done by preventive means and not by cure." The report continues: — We cannot too strongly impress upon local boards of health, upon the members of the medical profession, and upon all others interested, the importance of making a united and energetic effort to obtain such observations concerning every case which occurs in every part of the Commonwealth. Nearly three thousand cases in this State annually terminate in death; and if they were properly observed, for a series of five, ten or more years, it is impossible to anticipate the good results which might follow. Possibly, — and even probably, — discoveries might be made which would reduce the annual number of cases, certainly by hundreds, and perhaps by thousands. We shall hereafter suggest a form of a register of cases adapted to this object; and the great importance of the disease, and the confident hope that some discovery can be made which will materially abate its melancholy ravages, should arouse us all to action.' Notwithstanding this valuable recommendation to the Massa- chusetts Legislature of 1850, it remained for the Legislature of 1907 to pass acts which made it possible for the State Board of Health to require the registration of all cases of tuberculosis, and, through the state inspectors of health, to gather all information possible concerning the prevalence of this disease. The authority given to the state inspectors for taking steps toward the prevention of tuberculosis is limited only by the many specific statute requirements relative to the sanitation of buildings, and by the express provision that the inspectors shall inform themselves concerning the health of all minors employed in fac- tories. These two spheres of specific duties are themselves im- mense, and it is easy to forecast a great advancement in sanitary science along the lines which they include; namely, the hygiene of occupation and the sanitation of public buildings, and the sanita- tion of tenement workrooms and workshops wherein clothing is ' Report of the Sanitary Commission of Massachusetts, 1850, page 181. HANSON. 21 manufactured. In all these phases of sanitary work the investi- gation of the prevalence of tuberculosis plays an exceedingly im- portant part. The inspector in a factory community bears in mind the hygiene of the town or city, especially in the workmen's quarters, and is ready to make an investigation of the existence of tuberculosis or of any other disease dangerous to the public health. Within the factory, the inspector, knowing that tuber- culosis of the lungs is a common consequence of overcrowding and exposure to vitiated air and dust, — including the various kinds of trade dust and other impurities injurious to health which are generated in the course of the manufacturing process carried on therein, — pays especial attention to ventilation. If, in his opinion, mechanical appliances are necessary for the protection of employees against dust, he may require that such appliances shall be provided, maintained and used. In order to properly inform himself concerning the health of minors employed in a given fac- tory, each inspector is required to ascertain of every minor if the family history discloses illness or death due to tuberculosis, or any disease to which the minor himself seems liable. Whenever the family history discloses illness or death of any member due to tuberculosis, the inspector makes a physical examination of the minor; and in every instance, whether or not a physical exam- ination is made, the inspector submits a concise report on the immediate sanitary conditions under which the minor works, apart from the general report which covers details relative to the lighting, ventilation and cleanliness of the entire factory. The tenement workroom problem is limited to those tenements and dwellings in which clothing is manufactured by members of the family working there. Persons doing such work must be licensed and the rooms in which the work is done must be kept clean. In case the inspector finds evidence of tuberculosis or other disease dangerous to the public health, as a contagious skin 22 TUBERCULOSIS IN MASSACHUSETTS. disease, in one of these dwellings, he may or may not revoke the license, as occasion requires; but whenever he does revoke a li- cense for such reason he is obliged to report his findings at once to the State Board of Health, which notifies the local board of health (unless notification has already been made) to examine said dwell- ing for the purpose of issuing such orders as the public safety may demand. Since the tuberculosis problem is closely connected with that of the tenement workroom and the workshops wherein clothing is manufactured, and since the majority of these work- rooms are situated in Suffolk County, the state inspector of health of this district. Dr. Linenthal, has made a careful study of the types of such dwellings and the sanitary conditions in them. For this reason, and because the types of dwellings and workshops described by Dr. Linenthal include those situated in other parts of the State as well, and because of the practical importance of the investigation, he has been asked to present the facts relative thereto in a separate chapter. The work pertaining to factory hygiene is of such magnitude and presents so many problems, some of which will require much time and patience for a proper solution, that it is impossible at present to give information which would add appreciably to that already contained in the recent " Report of the State Board of Health upon the Sanitation of Factories and Workshops." In the meantime, there are many things which the public can do and ought to do in order to make the work of the state inspectors of health more effective. if, for example, any citizen knows of a person suffering with tuberculosis who is not receiving proper care, or who, through carelessness and neglect, is endangering others, it is clearly the duty of that citizen to notify the state inspector for his district. In the same way private individuals, physicians, social service workers and organizations of various kinds may be of great as- HANSON. 23 sistance to the inspectors by calling to their attention any unsan- itary conditions, diseases or influences dangerous to the public health, or threatening to affect the same. Since the law requiring that every public building and every schoolhouse shall be ade- quately ventilated is to be enforced by these health officials, medical inspectors of schools and teachers should notify them of any vio- lation of this law. Notice of any ill-ventilated or overcrowded schoolhouse should be brought to the attention of the state in- spector in whose district the schoolhouse is located. It is of the greatest importance that factories and workshops should likewise be well ventilated and not overcrowded. Persons who work day after day in crowded rooms which are not properly ventilated must after a time suffer a loss of resistance to disease, and, in consequence, become more susceptible to tuberculosis. This is especially true of a workshop where many people work side by side, some of whom may be suffering with tuberculosis of the lungs. One of the most "important duties of an employer, therefore, is to provide fresh air for his employees. Another duty of the public, equally important with those men- tioned, is to remember that a tuberculous person whose personal habits are clean, and who properly disposes of his sputum, is not a source of danger to those about him. Failure to appreciate this fact is already causing many hardships which are both unnecessary and unjust. It is not at all uncommon to-day to hear of instances where the very means of obtaining one's livelihood have been taken away because the person was unfortunate enough to be afflicted with tuberculosis. To take away from such a person the means of obtaining his livelihood is to take it from the very person who needs it most. On the other hand, to meet the problem fairly, the healthy employees, both minors and adults, should be properly protected from all ignorant or careless consumptives. At the present time investigations are being made concerning the health 24 TUBERCULOSIS IN MASSACHUSETTS. and the influence of occupation upon the health of children and young persons, but there is no law by which adults working in factories may be examined, and such steps taken as may be deemed advisable or necessary for guarding the public health. The duties of the state inspectors of health relating to tuber- culosis may be stated briefly as follows: first, to gather all infor- mation possible concerning its prevalence; second, to disseminate knowledge as to the best methods of preventing its spread; third, to report to the State Board of Health any minor employed in a factory who is known to have any form of the disease; fourth, to report to the State Board of Health and to the proper local health authority every case discovered in a tenement workshop; fifth, to notify local boards of health of any person found to be endangering the public health; and sixth, to see that the notification laws, which require householders and physicians to report any known case to local health authorities, are enforced. Following are the names and addresses of the state inspectors of health who were appointed by the Governor on the tenth day of July, 1907: — District No. i. — Dr. Charles E. Morse, Wareham. District No. 2. — Dr. Adam S. MacKnight, 355 North Main Street, Fall River. District No. 3. — Dr. Wallace C. Keith, 237 North Main Street, Brockton. District No. 4. — Dr. Elliott Washburn, 50 Broadway, Taunton. District No. 5. — Dr. Harry Linenthal, 327 Blue Hill Avenue, Roxbury. District No. 6. — Dr. Albert P. Norris, 728 Massachusetts Ave- nue, Cambridge. District No. 7. — Dr. J. William Voss, i Dane Street, Beverly. District No. 8. — Dr. William Hall Coon, 70 Newbury Street, Lawrence. HANSON. 25 District No. 9. — Dr. Charles E. Simpson, Lowell Hospital, Lowell. District No. 10. — Dr. William W. Walcott, 32 West Central Street, Natick. District No. 11. — Dr. Melvin G. Overlock, 91 Chandler Street, Worcester. District No. 12. — Dr. Lewis Fish, 7 Highland Avenue, Fitch- burg. District No. 13. — Dr. Harvey T. Shores, 177 Elm Street, Northampton. District No. 14. — Dr. Richard S. Benner/ 10 Chestnut Street, Springfield. District No. 15. — Dr. Lyman A. Jones, 170 Main Street, North Adams. Under the rules, consideration was postponed until July 17, when the appointments were severally confirmed by the Council. The division of health districts was made on July 9, 1907. The districts are as follows: — Health District No. i. — Includes the counties of Barnstable, Dukes and Nantucket, and the town of Wareham. Health District No. 2. — Includes the cities of Fall River and New Bedford, and the towns of Acushnet, Berkeley, Dartmouth, Dighton, Fairhaven, Freetown, Marion, Mattapoisett, Rehoboth, Rochester, Seekonk, Somerset, Swansea and Westport. Health District No. 3. — Includes Plymouth County, exclusive of the towns of Marion, Mattapoisett, Rochester and Wareham, and, in addition, the towns of Cohasset and Weymouth. Health District No. 4. — Includes the cities of Quincy and Taun- ton, and the towns of Attleborough, Avon, Bellingham, Blackstone, Braintree, Canton, Dedham, Easton, Foxborough, Franklin, Hol- 1 Resigned in October, 1907. Succeeded by Dr. Herbert C. Emerson, 177 State Street, Springfield. 26 TUBERCULOSIS IN MASSACHUSETTS. brook, Hyde Park, Mansfield, Milton, Norfolk, Norton, North Attleborough, Norwood, Plainville, Randolph, Raynham, Sharon, Stoughton, Walpole, Westwood and Wrentham. Health District No. 5. — Includes Suffolk County. Health District No. 6. — Includes the cities of Cambridge, Ev- erett, Maiden, Medford, Melrose and Somerville, and the towns of North Reading, Reading, Stoneham and Wakefield. Health District No. 7. — Includes the cities of Beverly, Glouces- ter, Lynn and Salem, and the towns of Dan vers, Essex, Ipswich, Hamilton, Lynnfield, Manchester, Marblehead, Middleton, Na- hant, Peabody, Rockport, Saugus, Swampscott, Topsfield and Wenham. Health District No. 8. — Includes the cities of Haverhill, Law- rence and Newburyport, and the towns of Amesbury, Andover, Boxford, Georgetown, Groveland, Merrimac, Methuen, Newbury, North Andover, Rowley, Salisbury and West Newbury. Health District No. 9. — Includes the cities of Lowell and Wo- burn, and the towns of Acton, Arlington, Ayer, Bedford, Billerica, Boxborough, Burlington, Carlisle, Chelmsford, Concord, Dracut, Dunstable, Groton, Harvard, Lexington, Lincoln, Littleton, Maynard, Pepperell, Shirley, Stow, Tewksbury, Townsend, Tyngsborough, Westford, Wilmington and Winchester. Health District No. 10. — Includes the cities of Marlborough, Newton and Waltham, and the towns of Ashland, Belmont, Brookline, Dover, Framingham, Grafton, Holliston, Hopedale, Hopkinton, Hudson, Medfield, Medway, Mendon, Milford, Millis, Natick, Needham, Northborough, Sherborn, Shrewsbury, South- borough, Sudbury, Upton, Watertown, Wayland, Wellesley, West- borough and Weston. Health District No. 11. — Includes the city of Worcester, and the towns of Auburn, Brookfield, Charlton, Douglas, Dudley, Leicester, Millbury, Northbridge, North Brookfield, Oxford, HANSON. 27 Southbridge, Spencer, Sturbridge, Sutton, Uxbridge, Warren, Webster and West Brookfield. Health District No. 12. — Includes the city of Fitchburg, and the towns of Ashburnham, Ashby, Athol, Barre, Bedin, Bolton, Boylston, Clinton, Dana, Gardner, Hardwick, Holden, Hub- bardston, Lancaster, Leominster, Lunenburg, New Braintree, Oakham, Paxton, Petersham, Phillipston, Princeton, Royalston, Rutland, Sterling, Templeton, Westminster, Winchendon and West Boylston. Health District No. 13. — Includes all of Franklin County, and all of Hampshire County excepting the towns of Huntington, Middle- field and Worthington. Health District No. 14. — Includes all of Hampden County, and, in addition, the towns of Huntington, Middlefield and Worthington. Health District No. 15. — Includes all of Berkshire County. 28 TUBERCULOSIS IN MASSACHUSETTS. Chapter IV. SANITATION OF CLOTHING FACTORIES AND TENEMENT- HOUSE WORKROOMS. H. Linenthal, M.D. A great deal has been said and written about the crowded, badly ventilated, poorly lighted tenement houses of our large cities, and we are aware of the fact that these houses furnish con- ditions favorable to the spread of tuberculosis. Not quite so much is generally known, however, regarding the conditions of the factories or "tailor shops" where men's clothing is made. A brief statement of the conditions found in these shops may, there- fore, be of interest to those engaged in the crusade against tuber- culosis. It will also throw some light on the causes of the increase of tuberculosis among the operatives of a trade which, in itself, cannot be regarded as the direct cause of the disease. Although the majority of the tailors in Boston are Jews, who are supposed to possess a relative immunity to tuberculosis, yet — and this is the general impression of the physicians practicing among them — their number afflicted with tuberculosis is on the increase. Most of the tailor shops are located in the North and South Ends of the city. In some instances there are as many as eight or ten in the same building, while the number of workmen employed in each shop varies from ten to sixty. The buildings are for the most part in a neglected condition, and proper sanitation cannot possibly be maintained. For the cleanliness of the stairs, hallways and toilets, which are used by the occupants in common, no one seems to be responsible; they are consequently very dirty. The closets in many cases are foul and reek with filth. The land- lord, through a janitor, is supposed to look out for the cleanliness LINENTHAL. 29 of the public parts of the building; but the activity of the janitor, if he exists, is not manifest. The interiors of the shops are very unclean; the dirty walls and ceilings appear not to have received a coat of whitewash for years; and the windows are often so dusty " as to be almost opaque. In most of the shops the unsanitary con- ditions of the buildings are made worse by the slovenly, uncleanly habits of the contractors as well as of their employees. Dust, rags and other refuse are allowed to accumulate in the corners of the shops and under the tables. The habit of spitting on the floor is evident in almost every shop. To appreciate fully the signifi- cance of this disgusting and dangerous habit one need but visit the shop in operation. Various parts of the garment are made by different operators. When the operator has finished the part al- loted to him he throws it on the floor. The garment is then picked up by the foreman, who passes it to the next operator. The dried as well as the moist sputum may thus be freely circulated among the operators by the contaminated clothing. When the shop is swept, as happens on rare occasions, the sweeping is usually dry and helps to stir the dust. Is it surprising that people continually exposed to such conditions become tuberculous? The attitude of most of the contractors is that filth is a natural and necessary condition, and that it is unreasonable to expect a proper standard of cleanliness. "What do you expect? This is not a parlor or a ballroom." "Of course they spit on the fioor; where do you expect them to spit, in their pockets?" "Do you want us to make parlors of our workshops?" were remarks often heard when the unsanitary conditions were pointed out to the employers. In several instances I was told that the employees do not spit on the floor, but on heaps of rags in the corners. Inves- tigation showed that these rags are later sorted by hand in the rag shops. What is to be said of the possibility that clothing thus exposed 30 TUBERCULOSIS IN MASSACHUSETTS. to infection may be a factor in the spread of tuberculosis? There are on record well-authenticated cases where diphtheria was con- tracted by the wearers of garments manufactured in tenement houses where diphtheria existed. In a disease so widespread as tuberculosis, where the foci of infection are so numerous, it is im- possible to trace definitely any one case; but it is quite probable that tubercle bacilli are carried from the shops by the infected garments. In the opinion of the manufacturers, the conditions in the manu- facture of clothing have vastly improved in the last ten years. "At one time," one manufacturer told me the other day, "before the garments were put in the store, it was necessary to air them on the roof to rid them of vermin." This is no longer necessary, as he has "not seen a bedbug in the clothing for a number of years." The reader will undoubtedly feel that his clothing, at least, is not made under such unsanitary conditions. His clothing, or- dered perhaps from a fashionable tailor in the city, is custom- made. I regret to disillusionize him. The fashionable tailor does not make the clothing on his own premises; the cut material is sent out to the shops of custom tailors, most of which are very small, extremely filthy and far more unsanitary than the shops where ready-made clothing is manufactured. From one of these shops, consisting of a room not larger than five yards square, which I had ordered to be cleaned, four barrels of dirt, rags and other refuse were removed. So striking was the change produced in the shop that the owner sent me a letter of thanks for having ordered him to clean his premises. The expensive custom-made suit is thus manufactured under worse sanitary conditions than the cheaper ready-made suit. Another important factor of the clothing industry from the standpoint of public health is the tenement workroom. In the LINENTHAL. 3I making of trousers there is considerable sewing to be done by hand, and the contractors, the people who operate the tailor shops, find it cheaper to have this work done by outside finishers, who work for very little and thus set the rate of wage for those who do the same work in the shops. The work of finishing pants is carried on almost entirely by Italian women in the most congested district of Boston. In connection with these workrooms the question of public health becomes quite prominent, and the maintenance of proper sanitary conditions requires frequent inspection. Over- crowding, dark, poorly ventilated and dirty halls, bedrooms with windows opening into narrow, unclean alleys or airshafts, and rooms with no windows at all, are some of the conditions one meets. When confronted with these conditions one cannot help feeling how inadequate are our efforts to prevent the spread of tubercu- losis, and how far off we are from striking at the root of the evil. Among the tenement workrooms inspected I came across a two- room flat on the top floor of a building situated in a narrow, dirty street in the North End. In these rooms there lived a young man of twenty-five with his mother and grandmother. The two women finished pants at home, — their only means of subsistence. The young man was consumptive and unable to work. A small, low-studded room, used as kitchen and workroom, served at night as a bedroom for the consumptive. When I visited the place a kerosene stove was burning and the family dinner cooking. The windows were tightly closed, and the air in the room was suffo- cating. The young consumptive stayed at home, as he was "in- disposed" to go out. He subsequently went to the Rutland Sanatorium for several months, and the disease was apparently arrested. But what chance has he of remaining well when he has to live now in the same two-room flat, under the same unsanitary conditions? In all probability a relapse will occur, and the time. 32 TUBERCULOSIS IN MASSACHUSETTS. money and energy spent to arrest the disease must be duplicated, and with smaller chances of success. The children living in the tenement workrooms are pale and many of them show evidences of impaired nutrition. The infants, however, look surprisingly plump and well nourished. So long as the child receives its nourishment from its mother's milk it thrives. Life to these children is quite a serious affair; they know not of childhood, since at a very early age household responsibilities are thrown upon them. On several occasions 1 have seen girls of ten or eleven years of age doing the family washing, while the mother was finishing pants. The finishing of pants, crocheting on ladies' undervests, making children's dresses, nightgowns, overalls, etc., does not include all the work carried on in tenement workrooms. There is a consid- erable number of other industries carried on in dwelling houses, among which may be mentioned the making of artificial flowers, baseballs, paper boxes, cigars and cigarettes and home laundries. In one house 1 found an old Italian engaged in cracking nuts for fruit stands. The condition and appearance of the little closet- like room were not calculated to whet one's appetite for fruit- stand nuts. Of all the above-mentioned tenement-house indus- tries, that of wearing apparel is the only one which is carried on under supervision. Protective legislation in the line of regulating hours of work and employment of minors cannot be enforced in these home indus- tries. The amount of work done by the women is regulated only by the quantity they can get and by their physical endurance. One woman, for example, in addition to her housework and the care of three children, has to work from fourteen to fifteen hours a day on the sewing machine in order to make one dozen pairs of overalls, for which she gets seventy-five cents. Out of this pit- tance she pays for the delivery of the goods both ways. Her 1 LINENTHAL. 33 earnings support the whole family, consisting of an alcoholic, shiftless husband and three children. Not only do the women work excessively long hours, but in the evening other members of the family are drafted into service. The vitality and powers of resistance of the tenement workers are thus lowered by the un- sanitary conditions of the homes and by the excessively long hours of work. They fall an easy prey to all forms of disease, and es- pecially to contagious diseases, and become a public menace. To protect the public against the spread of contagious diseases that may occur in any of the tenement workrooms, the bulletins of contagious diseases reported to the Boston Board of Health are examined daily. In case disease occurs in any of these workrooms, the premises are visited and steps are taken to guard against its spread. There is always, however, the danger of unreported cases. For example, a mild case of scarlet fever or diphtheria may run its course without a physician being called in and the case may re- main unreported. Moreover, unreported cases of tuberculosis un- doubtedly exist among many of the families of tenement workers. There is also the danger of exposing clothing, in tenement work- rooms, to the contagious matter of certain skin diseases which are quite common among the tenement dwellers. As these are not reported there is no way of detecting them, unless accidentally found in the course of inspection. As a matter of fact a number of such diseases have been found, and in every instance work on the premises has been stopped until all danger from their spread has ceased. From July 25, 1907, to May i, 1908, 1,455 visits were made to tenement workrooms. During that period sixty-three cases of contagious diseases reported from these workrooms were investigated. I have briefly described the general conditions under which men's clothing is manufactured, both in the shop and in the tene- ment workroom, and have indicated the dangers to the operatives 34 TUBERCULOSIS IN MASSACHUSETTS. as well as to the public from clothing exposed to infectious ma- terial. I have also indicated in a general way the methods used to guard the public health against the spread of diseases occurring in the tenement workroom. As regards the improvement of sanitary conditions in tailor shops, it may be stated that efforts are made to enforce strictly the requirements of the law. Many of the shops have been re- plastered, whitewashed and renovated in other ways, and a large number have been cleaned. To May i, 1908, four hundred and forty-one visits were made to two hundred and seventy work- shops where clothing is manufactured, and three hundred and sixty-seven written orders were issued. In one hundred and seventy-three reinspected before May i, the orders had been complied with. The law in regard to spitting and providing receptacles for spitting is receiving special attention. All this, however, is not sufficient. What is of far greater importance is the education of the employers as well as their employees to the necessity of the simplest sanitary measures. This is by no means an easy task. One meets with a general indifference and apathy, quite frequently with obstinacy and antagonism to the enforce- ment of sanitary measures. Of still greater importance is the need of interesting the wholesale manufacturer, and creating in him a sense of responsibility as to the conditions under which his clothing is manufactured. The contract system which prevails in the clothing industry is at the root of the evil. The clothing manufacturer has the goods cut on the premises by people in his employ. After the cut ma- terial is handed over to the contractor the manufacturer concerns himself but little with the conditions under which the goods are made. In fact, this system puts a premium on the filthy tailor shop. In the close competition existing among the small con- tractors, the one who has his shop in an old, neglected building LINENTHAL. 35 can, in consequence of smaller expenses, make the goods for a smaller compensation, and have the advantage over the one who is in a clean building, with a higher rental. The competition among the contractors is extremely keen; they earn a mere pit- tance, often less than some of their employees. It can hardly be expected that in the struggle to eke out a mere existence any at- tention will be given to matters of sanitation. A shifting of the responsibility from the contractors to the wholesale manufacturers would vastly improve conditions. This can best be accomplished by acquainting the public with the existing conditions and by creating a demand for cleaner clothing. To summarize briefly: the inadequate rate of wages, the exces- sive hours of labor, the unsanitary state of the shops, make of our clothing industry a sweating industry, with all the predisposing factors of tuberculosis in full operation. Before concluding I desire to call attention to the present inad- equate methods of supervising persons ill with tuberculosis. Every person so afflicted who is reported to the Boston Board of Health is visited by a physician of the Board, and the family is instructed as to what measures should be taken to guard against infection. But the supervision of the patient at his work, though fully as impor- tant, is entirely omitted. Every tuberculous employee should be visited at his work in the factory, and the employer or foreman instructed as to what precautions should be taken to guard the health of the other employees. The great difficulty at present in carrying out such a supervision is one of our own making. We have been emphasizing the contagious nature of tuberculosis and thus creating a dread of the disease. A person afflicted with it, however clean he may be, is regarded as a pest by both employer and employees, and they do not want him in the shop. Consider- ing that the largest number of consumptives have to remain at their work, this unwarranted dread of having them in the factory 36 TUBERCULOSIS IN MASSACHUSETTS. or workshop is a tremendous hardship. Moreover, it is a very powerful motive to conceal the disease, and prevents the person afflicted from taking any precautionary measures which would in any way indicate that he is tuberculous. As long as he spits on the floor, for example, he can remain quietly at his work without being molested; should he, however, take any precautions, such as using a sputum cup, or having a separate receptacle for spit- ting, suspicion is immediately aroused, and he is in danger of losing his position. in our preaching about the dangers and contagiousness of tuberculosis let us emphasize a little more the fact that a person ill with this disease, who has clean personal habits, may attend to his work without endangering his fellow workmen. The education of the public along these lines will not only render justice to the consumptive, but will enable us to supervise him at his work in the factory and workshop. PETERS. 37 Chapter v. BOVINE TUBERCULOSIS IN MASSACHUSETTS. A HISTORY OF THE EARLIER AGITATION CONCERNING IT, AND EFFORTS OF THE STATE FOR ITS ERADICATION AND CONTROL. Austin Peters, M.R.C.V.S. To the late Noah Cressy, M.D., V.S., Ph.D., of Hartford, Conn., is due the credit of the first attempt to call the attention of the farmers of Massachusetts to the nature, importance and serious- ness of bovine tuberculosis. As a speaker at several farmers' institutes in the western part of the State in the winter of 1879 and 1880, held in western Worcester, Hampshire and Hampden counties, he first started the agitation against this disease. His addresses created quite an excitement for the time being among the farmers in the localities where these institutes were held, and were reported quite extensively in the "Springfield Republican" in January and February, 1880, but attracted very little attention beyond this, and the excitement soon subsided. The report of the first farmers' institute at which Dr. Cressy (who at that time resided at Amherst) spoke is in the "Springfield Republican" of January 30, 1880. The article is headed "A Rural Sensation," and is an account of a meeting held at Warren the previous day, where he gave a lecture on "The Diseases of Farm Animals," among which he included tuberculosis in cattle. Among other things he said that the herd of cattle at the Massa- chusetts Agricultural College was infected with tuberculosis, and that the trustees were allowing cattle of various pure breeds to be bred there, and permitting the progeny to be sold to the farmers of the State for the purpose of improving their stock, whereas in reality animals were being sold that were infected with a dangerous 28 TUBERCULOSIS IN MASSACHUSETTS. disease, which in this way was being disseminated among the herds of the Commonwealth. A sensation was created during the lecture by the appearance of a Mr. Paige of Hardwick, in a wheeled chair, who told how he bought three Ayrshire heifers from the Agricultural College in the spring of 1877, that in November, 1879, ^^ ^^^ ^^^ killed for beef and found her badly diseased, and that he attributed his paralysis and also a blood poisoning in his children to the use of the milk from these heifers. He also showed specimens from the side of one of these heifers, which Dr. Cressy said were lesions of tubercu- losis of long standing. He also gave it as his opinion that Mr. Paige's paralysis and the sickness in his children might have been caused by the use of milk from tuberculous cows. Dr. Cressy also referred to an auction sale of cattle at the Agricultural College during the previous summer, and the possible harm to the herds of the State by the dissemination of these animals. The report of the meeting also conveys the idea that Dr. Cressy, who had formerly been Professor of Veterinary Science at the Agri- cultural College, had severed his connection with the institution on account of differences of opinion between himself and some of the members of the faculty upon the question of bovine tuberculosis. The "Springfield Republican" of January 31, 1880, quotes Prof. Levi Stockbridge, who had been at the college thirteen years, as saying that the college never bred an animal that had tuberculosis there or developed it within two years of the time it was sold; furthermore, that the statement that Dr. Cressy left the college because he disagreed with some of the faculty on the presence of tuberculosis in the college herd "is an unmitigated and outrageous falsehood." Professor Stockbridge is also reported as saying that "the disease is only consumption, and may attack any breed of cattle in any part of the country; that the milk is healthy until the animal's constitutional vigor is utterly reduced; and that PETERS. 39 Mr. Paige's statement that the milk gave him paralysis is pre- posterous." The "Springfield Republican" of February 4, 1880, has a short interview with Dr. Cressy, in which he speaks of a cow sold to a farmer at South Amherst, at the auction held early in the sum- mer of 1879, afterward killed at the slaughterhouse and found to be badly diseased with tuberculosis. It also mentions that two other Amherst farmers, who were at the auction with the intention of buying, did not bid on any animals because Dr. Cressy, who was present, advised them not to. In another column on the same date is a short editorial, advising that the college authorities should court a most searching investi- gation, with a view to either disproving Dr. Cressy's assertions, or, if true, to setting matters right. The "Springfield Republican" of February 5, 1880, has a report of a farmers' institute at East Longmeadow, at which Mr. W. H. Bull of West Springfield read a paper on "The Farmers' Duty to the Massachusetts Agricultural College," after which Mr. Phineas Stedman of Chicopee, a trustee of the college, spoke of the Paige cattle, saying they were sold to Mr. Paige in 1877 and might have become diseased since; that he had bought cattle from the Agricultural College and put them in his own herd and never found any that were not healthy. An account of a farmers' institute held at the town hall in Brook- field, February 5, 1880, is contained in the "Springfield Republi- can" of February 6, 1880. This meeting was largely attended, as Dr. Cressy's previous lecture at Warren had attracted a good deal of attention. Professor Stockbridge, then Professor of Agriculture at the Massachusetts Agricultural College, was present and took the platform early in the proceedings. He had a newspaper with a report of Dr. Cressy's previous lecture in his hand, and read passage after passage of Dr. Cressy's statements concerning the 40 TUBERCULOSIS IN MASSACHUSETTS. college herd and the sale of diseased animals from it, and asked him as he read each sentence if he (Dr. Cressy) ever made any such statement, and as each question was asked, Dr. Cressy would shake his head. As a matter of fact, Dr. Cressy's state- ments concerning the condition of the college herd and the danger to other herds by the introduction of cattle from it into them were correct. At that time a cat could not be kept in the cattle barn at the Massachusetts Agricultural College without de- veloping a cough, becoming emaciated and pining away in a few months. Dr. Cressy should have maintained the position he took at first, but evidently lacked the courage to do so. After Professor Stockbridge finished his remarks Dr. Cressy gave a very good talk on bovine tuberculosis, its nature and the danger from it to the herds of the State, refraining, however, from any allusion to the condition of the herd at the State Agricultural College. This seems to have been the end of the agitation regarding bovine tuberculosis in Massachusetts so far as Dr. Cressy was concerned. What he said did not carry a great deal of weight for the reason that the farmers thought him a disgruntled individual, who was endeavoring to injure the college because he had been dismissed from the faculty a few years before, at a time when the trustees of the college had to economize and decided that the position he held could better be dispensed with at the time than any other. If it had not been for the prevailing idea that he was airing a grievance, which discredited his endeavors, much good might have come from the agitation he started. Cressy's ideas were evidently largely taken from Walley's "Four Bovine Scourges," and were decidedly in advance of the times. In his " Four Bovine Scourges," published several years before Koch's famous dis- covery, Walley includes tubercle with the other three great con- tagious diseases of cattle, viz., contagious pleuropneumonia, foot and mouth disease, and rinderpest. In the preface to his work he PETERS. 41 speaks of these four diseases as being of "more importance to the stock owner than all the other ills to which bovine flesh is heir." He also says that, while "the three first-mentioned diseases are only too well known, the last (tubercle) is less perfectly so, even, it may be said, to the veterinary surgeons." He further expresses his belief in the communicability of tuber- culosis from one animal to another, the danger to man from the use of milk and meat from tuberculous animals, and his opinion that tuberculosis is identical in man and the lower animals. He quotes from the experiments of Villemin, Gerlach, Viseur, Grad, Zundel and other veterinary and medical authorities in support of his views. In his lectures at the farmers' institutes Dr. Cressy simply voiced Walley's opinions, and the views he then expressed were no less true, nor did they differ from the views held by many scientific men at the present time, but they were not then generally accepted as true by the medical profession, because they lacked the conclu- sive proof later furnished by Koch when he announced to the world his discovery of the tubercle bacillus. There were a few faint echoes following the agitation started by Cressy, although nothing more was heard from him personally. The "Springfield Repub- lican" of February 9, 1880, mentions the report of the trustees of the Massachusetts Agricultural College for the year. The part relating to the college herd reads in part as follows: — That from the most thorough investigation we have been able to make, the statement that disease has been propagated by the sale of cattle from the college farm is absolutely false, and we ask that the matter be referred to the commis- sioners of contagious diseases for a most rigid investigation. There are two or three other references to the matter in later is- sues of the " Springfield Republican," only one of which it is necessary to quote. The "Springfield Republican," February 12, 1880, reports a farmers' institute at Northampton, at which 42 TUBERCULOSIS IN MASSACHUSETTS. Professor Stockbridge spoke. At the close of the meeting resolu- tions endorsing the work of the college were passed, one of which was as follows : — Resolved, We believe the reports of the disease, tuberculosis, exaggerated, and the attempt to connect the college with it unjust. The Cattle Commissioners in their report to the Legislature of Massachusetts, January 7, 1881, refer to bovine tuberculosis as follows : — Owing to a prevailing feeling that we are liable to an outbreak of contagious pleuropneumonia, or from ignorance of its mode of propagation, the Board are frequently notified of supposed cases of this disease; but they have always proved to be simple lung fever, or tuberculous consumption. Some of these cases are very severe and fatal, and cause no inconsiderable loss to stock owners. A nar- rative of one of them will suffice for all, and may indicate some of their causes and means of prevention. Early in October we were notified by the selectmen of Grafton, in Worcester County, that cattle at a designated locality in that town were suffering from a supposed contagious disease. Visiting the farm we found a large herd of generally very fine looking and highly prized cows. The owner in- formed us that some of them had indicated disease for many months. One had already died; two more were much emaciated, and probably past recovery; and three or four others coughed more or less severely. The symptoms of the sick animals were such as might exist in the contagious form of the disease; but the herd had been on the farm for a long time, and it was not known that any of them had been in contact with or infected by cattle from abroad. To make the matter certain, one of the sickest cows was appraised and slaughtered. Both lungs of the animal were found packed and solidified with tubercles; but there was an entire absence of those peculiar tissue characteristics always found in the contagious form of lung disease. The facts elicited by careful inquiry respecting the history of the herd and its management satisfied the Commissioners that the disease was engendered on the premises. There were about forty animals in all, practically in one stable, and, except in the daytime in the summer season, they had little exer- cise in the open air. Throughout the cold portion of the year the stable was closed front and rear; the barn doors were shut at all times; and in the coldest weather the temperature of the stable was maintained at between sixty and seventy degrees, and practically no ventilation provided, in all other respects the herd was cared for in the best manner; but in the opinion of the Board proper sanitary conditions had been systematically disregarded for a long time, and this was a sufficient cause for the condition of the herd. The fact that this disease had been found in three PETERS. 43 or four isolated localities within the last year has been the occasion of much excite- ment and alarm by sensational statements of its contagiousness. That it is so, the best authorities are not agreed. Youatt in his work on cattle, published in 1840, says: "Animals which exhibit decided symptoms of consumption should be removed from the dairy, not because the disease is contagious, but because it is undeniably hereditary." Recent experiments have been made to test the con- tagiousness of tuberculosis, both by inoculation and the ingestion of tuberculous matter; and Fleming says: "The facts elicited affirm that it may be thus com- municated." Several investigators in this direction have failed to produce corrobo- rating results, and others say that no results have yet been reached of any value in this direction. The question of the contagiousness and virulence of tuberculosis is still under consideration, and further researches are necessary to elucidate and establish certain important points respecting it. We have, therefore, declined to consider it within the intent of the law which prescribes our duties and obligations. During the excitement occasioned by the supposed prevalence of this disease, a report reached the Board of Agriculture that the cattle on the Agricultural College farm at Amherst were infected with it, and the members, in their capacity as overseers of the college, passed a re.solve requesting the Commissioners to make a careful examination of the stock and its condition. Complving with this request. Dr. E. F. Thayer, the veterinarian of the Board, made the examination, and reported to the overseers that " the appearance of the animals, without exception, was that of perfect health. Not one could be found that required physical examination; percussion and auscultation were tried on one without eliciting other than a normal and healthy condition. This portion of the Cattle Commissioners' report for 1880 is here given in detail because it seems to be the first official recognition of, or a declination to recognize, tuberculosis among cattle in Massa- chusetts, and this communication from the Cattle Commissioners was in reality the result of Dr. Cressy's agitation of the matter during the previous winter. The late Professor Stockbridge, and also the late Dr. Josiah H. Stickney of Boston, have informed the writer that during the cam- paign against contagious pleuropneumonia in 1860-66 occa- sionally cases of bovine tuberculosis were met with, but little attention was given to them; the Cattle Commission was stamping out contagious pleuropneumonia, and this disease 44 TUBERCULOSIS IN MASSACHUSETTS. was not contagious pleuropneumonia, was not known to be contagious, and therefore little thought was given to the few cases met with. In their report to the Legislature dated January lo, 1882, the Cattle Commissioners, speaking of lung diseases in connection with contagious pleuropneumonia, write as follows: — Inflammation of the lungs or tuberculosis may be engendered in the stock of any farm by undue exposure, want of ventilation or confinement in damp and filthy enclosures. But contagious pleuropneumonia, which has symptoms resem- bling those diseases, is the result of contact with an animal possessing the infection, or with some object he has infected, and is disseminated from animal to animal, like smallpox or measles in the human family. The appearance of lung disease on remote and isolated farms, unless it can be traced to contact with animals from abroad, should cause no alarm, but should prompt the owners to a careful hygienic examination of their premises, and methods of stock management. There is no further mention of bovine tuberculosis by the Mas- sachusetts Cattle Commissioners in their reports for four years, but a lecture was read at the public winter meeting of the State Board of Agriculture, at Framingham, in December, 1885, upon "Tuberculosis in Cattle," prepared by Dr. Frank S. Billings of Boston. Dr. Billings was, unfortunately, not present to deliver it in person, hence there was little discussion of the paper. As this lecture was given after the discovery of the tubercle bacillus by Koch it was more in accordance with modern ideas than the statements in the former reports of the Cattle Commission. Space will not permit a resume of this paper, but it can be found in the report of the secretary of the Massachusetts State Board of Agri- culture for 1885. In June, 1885, the personnel of the Massachusetts Board of Cat- tle Commissioners was changed; Dr. Thayer and Mr. Jordan re- tired and Mr. A. W. Cheever, agricultural editor of the "New England Farmer," and Dr. J. F. Winchester, a young veterinarian of Lawrence and a graduate of the Massachusetts Agricultural PETERS. 45 College, were appointed to replace them. Professor Stockbridge was continued in office. At a special meeting of the State Board of Agriculture, held at the town hall at Barre, Mass., November 29, 1886, called at the request of the Cattle Commissioners, Dr. Winchester addressed the meeting, calling attention to the presence of bovine tubercu- losis in the State, its hereditary nature, transmissibility and in- sidiousness, the difficulty of diagnosis, and his inability to assist owners of infected herds under existing laws. He was followed by Professor Stockbridge, who stated that the Board of Cattle Commissioners had long known of the existence of bovine tuber- culosis in Massachusetts, but that the veterinary colleges had never agreed upon the question as to whether it is contagious or not. "There has been a long and acrimonious dispute in relation to it, and the consequence has been that the Cattle Commissioners have never recognized it or treated it as a contagious disease." After considerable discussion it was decided that if additional legislation regarding it were necessary, the Cattle Commissioners were the ones to recommend it to the Legislature and to attempt to procure it. The Cattle Commission in its report to the Legis- lature, January 7, 1887, refers to tuberculosis among cattle, its nature and dangers, and in conclusion says: — Notwithstanding all that is certainly known of the disease and the great losses it entails, yet it is surrounded with such obscurity and uncertainty, and presents such apparently insurmountable obstacles to its eradication, that we have made no direct attempts to combat it; but some of our citizens, to rid their herds and premises of the pest, have, during the past year, destroyed many thousands of dollars' worth of cattle. If the Cattle Commission made any attempt this year to obtain legislation on bovine tuberculosis nothing came of it. In their report 6f January 6, 1888, for the year 1887, the Cattle Commis- sioners again speak of the prevalence of tuberculosis among cattle. 46 TUBERCULOSIS IN MASSACHUSETTS. its peculiarities and the difficulty of eradicating it "by force of our present statutes or any appropriation the Legislature would make." It says the disease prevails to about the extent of the previous year, but suggests that as the veterinary profession increases in number "attention is called to it more and more, and there is a call for more active work." In the report of the Cattle Commission of January 7, 1889, for the year 1888, there is a special report by Dr. J. F. Winchester upon tuberculosis, showing by tables its prevalence and losses in certain herds to which his attention had been called. In 1889 Dr. Winchester's term expired and the late O. B. Hadwin of Worcester was appointed to the vacancy. Bovine tuberculosis is briefly referred to in the report for that year, and it is stated that: — Should the disease materially increase in those sections of the State where milk is produced for town or city markets, as a measure to guard the public health it may become the duty of the Commissioners or of local boards of health to cause the inspection of herds producing market milk, and the removal therefrom of all animals exhibiting the slightest symptoms of this disease. Messrs. Stockbridge, Cheever and Hadwin continued on the Board of Cattle Commissioners until the spring of 1892, and as the public interest had now been thoroughly aroused on the question, their reports for 1890 and 1891 give the subject a certain amount of consideration, although the position taken is rather one of not unduly alarming the public or of exaggerating the danger. In the report for 1890 it is stated, in reference to tuberculosis: — Careful observation during the past year fails to convince us that this disease is becoming more prevalent; but the published experiments of sundry investigators, the zeal of veterinarians for the public welfare or their own personal interests, have pointed out the methods by which it is propagated, and newspaper reporters have aroused public attention to the matter by sensational or erroneous reports of a very few special cases. The disease has been here ever since white men or cattle occupied the land. PETERS. 47 The report for 1891 exhibits considerable ire against the State of Maine for prohibiting the shipment within her borders of neat cattle from Massachusetts because of the prevalence of bovine tuberculosis within the latter Commonwealth, and remarks that the action of Dr. George H. Bailey, veterinarian to the Maine Cat- tle Commission, is unconstitutional, and quotes a decision of the United States Supreme Court in support of this view in reference to Missouri forbidding bringing cattle infected with Texas fever within her limits, "because it attempted to interdict or control commerce between the States, which was a power conferred by the Constitution only upon Congress." Since then there have been other opinions of the United States Supreme Court, that a State can take measures to protect itself from the introduction of a disease that may endanger the health of its people or live stock. Late in 1886 or early in the winter of 1887 the writer of this chapter, who v^as at that time investigating contagious bovine abortion for the Massachusetts Society for Promoting Agriculture, remarked to the late Ebenezer Francis Bowditch of Framingham, one of the trustees of the society, that it would be very interesting to investigate the danger from the use of milk from a tuberculous cow. While it was generally conceded that a cow with tubercu- lous udder gave off tubercle bacilli in the milk, it was suggested that an investigation to show how slightly diseased a cow might be and yet be dangerous might be of value. The trustees of the society decided that such an investigation would be of value, and determined to undertake the work. The writer, while he was the society's veterinarian, advised that in order to make the results of the work carry the greatest possible amount of weight the services of a man who had already made a name as a scientist, and whose signature to a report would secure immediate recognition, should be secured to direct the experiments and prepare a report of the results. The services of Dr. Harold C. Ernst of Boston, Professor 48 TUBERCULOSIS IN MASSACHUSETTS. of Bacteriology at the Harvard Medical School, were secured for this purpose. A committee of the trustees of the Society for Pro- moting Agriculture, consisting of the late Thomas Motley, its president, the late E. F. Bowditch, the late Jacob C. Rogers, and Gen. Francis Henry Appleton, was appointed to have charge of the work. A farm was rented at Mattapan, a suburb of Boston, as an ex- periment station, in the spring of 1887, where a herd of tubercu- lous cows was kept for over three years, and feeding and inoculation experiments conducted and bacteriological examinations of the milk and cream made at the Harvard Medical School. Dr. Ernst supervised much of the work and wrote the report, but a great deal of the actual work was performed by Dr. Henry Jackson, Dr. Langdon Frothingham and the writer of this chapter. A report of the results of these researches was presented to the trustees of the society in the autumn of 1890, and was later published in book form at its expense under the title of " Infectiousness of Milk." It was found that milk from a herd of tuberculous cows contained tubercle bacilli, as demonstrated by both microscopical examina- tion and inoculation experiments, and that milk from these cattle was capable of producing tuberculosis in calves and pigs fed upon it in from 33 to 50 per cent, of cases. Milk-feeding ex- periments were tried on rabbits, but with much less positive re- sults, due no doubt to the fact that these little animals drink pro- portionately less milk than calves and pigs. Examinations made of city milk taken in Boston and Lowell, and inoculation experi- ments tried on rabbits, showed it to be infected in a few instances. Beside the results of the experiments at Mattapan and examina- tions of milkmen's milk the report contains a voluminous corre- spondence, elicited by letters written by Dr. Ernst asking the views of members of the veterinary and medical professions on the in- fectiousness of milk, and reports from veterinarians upon the prev- PETERS, 49 alence of bovine tuberculosis in various localities. Dr. Ernst con- cludes the report as follows: — I have presented, in the preceding pages, the evidence that we have been able to collect upon the points in regard to which information seemed to be especially needed. This evidence is sufficient, it appears to me, to warrant certain definite conclusions, as follows: — 1. While the transmission of tuberculosis by milk is probably not the most important means by which the disease is propagated, it is something to be guarded against most carefully. 2. The possibility of milk from tuberculous udders containing the infectious element is undeniable. 3. With the evidence here presented, it is equally undeniable that milk from diseased cows with no appreciable lesion of the udder may, and frequently does, contain the bacillus of this disease. 4. Therefore all such milk should be condemned for food. The Massachusetts Society for Promoting Agriculture presented the results of these investigations to the Legislature of 1891, on January 13, by petition asking for legislation to secure an inspec- tion of cattle in Massachusetts. After a delay of several months the Legislature passed the following: — Chapter ii8, Resolves of 1891. Resolve providing for an investigation by the state board of agriculture into the dangers arising from tuberculosis in the food products of CATTLE. Resolved, That the State board of agriculture be instructed to investigate and ascertain the best methods to be adopted in order to protect the citizens of this Commonwealth against the dangers to human life and health which may arise from the presence of tuberculosis in the food products of cattle, with power to employ expert assistance, and report in print the result of their investigations to the next general court, with such recommendations as they may deem advisable. And for the purpose aforesaid they may expend such sum, not exceeding twenty- five hundred dollars, as they may deem necessary, which sum shall be allowed and paid out of the treasury of the Commonwealth. [Approved June 1 1, 1891. The appropriation provided was much less than was recom- mended, and was so small as to negative the purpose of the resolve, 50 TUBERCULOSIS IN MASSACHUSETTS. as shown by the following report of the State Board of Agriculture to the Legislature of 1892: — In compliance with the requirements of the foregoing resolve the State Board of Agriculture begs leave to submit the following report: — This resolve seems to look to a report on two distinct subjects: first, as to the danger to human life and health from the food products of cattle; and second, as to how best to protect the public from such danger. First. Much attention has been bestowed by scientists on this branch of the subject, and many thousands of dollars by individuals, institutions and societies in investigation. The Massachusetts Society for the Promotion of Agriculture has expended a large sum in experiments to prove how great is the danger to human life and health from the use of milk of tuberculous cows. The results of these experiments were made known to the Legislature of 1891, as were also the discov- eries of other scientists in our own and foreign countries. In view of the results of the experiments obtained at such large expense, the State Board of Agriculture believes that any further experiments and investigations that could possibly be made with the sum appropriated ($2,500) could throw very little light upon the subject. For this reason no expense has been incurred. That there is danger to human life and health in the food products of animals affected by this disease seems to be a proved fact. There is also danger to the life and health of our do- mestic animals, arising from the presence of these diseased animals among them. How great the danger is depends upon the proportion which the number of tuber- culous animals bears to the number of those in health. It must not be forgotten that the danger to life and health is not alone from food products. Many investi- gators believe that the greatest danger is from the germs of the disease floating in the air. These germs come from the dried sputa reduced to powder. The same danger comes from the presence of human beings affected with the disease. Many alarmists have stated that the proportion of tuberculous cattle is very large, — some place it as high as 25 per cent, of the whole number in our State. However, careful estimates from all sources of information show that the percentage of tuberculous animals is very much less than that figure, probably not more than 3 or 4 per cent. It is known that the cattle of all countries are subject to this disease, and have been so subject for thousands of years; but it is only recently that it has been recognized as the same as consumption in man. It is not believed that the proportion of infected cattle in Massachusetts is much greater than in other thickly populated countries. Second. How best to protect the public against the danger to human life and health, arising from the presence of tuberculosis in the food products of cattle. As there is danger, it is highly proper that the Legislature should provide for re- ducing the danger to a minimum. The trade brings large numbers of cattle from other States into Massachusetts, and there is alwavs a likelihood of infected cattle PETERS. 51 being brought in. Cattle are always liable to get the disease from consumptive attendants. Consequently we cannot hope to eradicate this disease from among our cattle. So long as the human family suffer from it our cattle will be liable to it; but it may be reduced to a minimum. The meat of cattle affected with this disease should not be used for food; the milk from tuberculous cattle should not be sold in the market; it is not safe to breed from such animals, and they are con- sequently worthless. The owners of such animals would only be too glad to be rid of them were they prevented from selling their food products, and if it were not for the possibility of selling the animal to some one who was not aware of its condition. So the only value a tuberculous animal can have is from the possibility of imposing upon some one by the sale of unhealthy food products or worthless animals. Thus the practical solution of the problem seems to be to find means to prevent the trade in such cattle. Many of the milk farmers of the eastern portion of the State, where all admit tuberculosis to be the most prevalent, procure their cows at the Brighton and Watertown markets. There are gathered for sale the surplus cows of western Massachusetts, Vermont, New Hampshire and Maine, as well as many from New York and farther west. A law providing for the inspection of all cattle sold in these markets by a state inspector is recommended. Along with this provision should go an amendment to the contagious disease law, requiring the Cattle Com- mission to order the slaughter and burial, without appraisement, of animals found to be infected with tuberculosis, in the same manner in which glandered horses are disposed of. Provision should be made for a post-mortem examination of all cattle thus slaughtered, sufficiently thorough to determine whether or not they were tuberculous, and in case the post-mortem failed to show the presence of the disease, provision should be made for remuneration to the owner for the damage suffered. While the above includes all that the Board desires to recommend, if further provision be deemed advisable it is suggested that state inspectors might be ap- pointed in different parts of the State, not less than one to each county, whose duty it should be to examine neat cattle on application from the owner, party desiring to purchase, or town or city authorities, and give certificates that such animals were free from tuberculosis when the examination warranted. Provision should be made for the pay of such inspectors from the State treasury per diem for the time spent, or by a stated sum per head of cattle examined. In order to make the work of these inspectors most effectual, they should be appointed by and work under the direction of the Cattle Commissioners. The above report is thus given in full because many of the recommendations made in it were incorporated into law by the Legislature of 1892, and have continued in force, with occasional modifications, until the present time. Primarily to the Massa- 52 TUBERCULOSIS IN MASSACHUSETTS. chusetts Society for Promoting Agriculture belongs the honor of bringing to public attention the prevalence of bovine tuberculosis, and the dangers from the use of meat and milk from tuberculous animals, and it largely deserves the credit for final legislative action. The Massachusetts Legislature of 1892, ten years after the dis- covery by Koch of the tubercle bacillus, declared tuberculosis to be one of the contagious diseases of animals recognized by the statutes of the Commonwealth, and provided for the killing of diseased cattle without appraisal or payment. It also made the law providing for the appointment of inspectors of animals in the various cities and towns of the State mandatory; prior to this it had been permissive since 1876, but only a few municipalities had availed themselves of it. Later the law was amended to provide that these appointments should be subject to the approval of the Cattle Commissioners; it also provided that the Board of Cattle Commissioners could appoint inspectors of animals where cities or towns refused or neglected to do so, and that they could remove inspectors for incompetency or just cause. In 1893 the Legisla- ture also enacted a law providing a penalty for any city or town that refused or neglected to appoint an inspector or inspectors of animals and provisions. In 1908 the Legislature passed a law that one of the inspectors of animals annually appointed in cities shall hereafter be a registered veterinary surgeon. As a matter of fact nearly all the cities and larger towns already had veteri- narians for inspectors of animals. In the spring of 1892, at the request of Gov. Wm. E. Russell, the Cattle Commissioners, Messrs. Stockbridge, Cheever and Had- win, resigned, and the Governor reappointed Professor Stockbridge, and named to serve with him two veterinarians. Dr. Charles P. Lyman, Dean of the Faculty of the Harvard Veterinary School, and Dr. Maurice O'Connell, a veterinarian living in Holyoke, who qualified May 12 and immediately entered upon the dis- PETERS. 53 charge of their duties. During their first year in office eighty- one head of tuberculous cattle were killed without appraisal or payment. The Cattle Commission of three members continued as above until June, 1894, when the Board was increased to five; owing to the increasing interest in bovine tuberculosis, and the demand for a greater amount of work, it was decided that three men were not sufficient and that the Board ought to be larger. Dr. Frederick H. Osgood, a professor at the Harvard Veterinary School, and Leander F. Herrick of Worcester were appointed. The act of the Legislature increasing the Commission to five members also pro- vided that one-half the value of neat cattle killed as tuberculous by state authority shall be paid by the Commonwealth, the ap- praisal to be based on the value of the animals for food or milk. In October, 1894, Charles A. Dennen of Pepperell was appointed a member of the Board, to fill the vacancy caused by the retirement of Professor Stockbridge, after twenty-seven years' service, who resigned at the end of his term of office. In September, 1894, the Board of Cattle Commissioners first in- troduced the use of tuberculin as a method of diagnosis, and immediately instituted its use upon a large scale. The tuberculin test was applied to all the cattle quarantined on suspicion by the local inspectors of animals, also upon cattle brought into Massa- chusetts from adjoining States, and a systematic testing of entire herds was undertaken, the Commissioners stating that it was their intention to test all the herds in the State and kill reacting animals, starting in the southeast corner. This season the entire bovine population of Nantucket Island was tested, only .9 per cent, of the cattle reacting. The assertion that the Commission intended a compulsory test of all the cattle in the State aroused a great deal of opposition in some quarters. During the autumn the local inspectors quaran- 54 TUBERCULOSIS IN MASSACHUSETTS. lined 3,295 cattle on suspicion of being affected|with tuberculosis, of which eight hundred and ten were found to be tuberculous by means of the tuberculin test and killed; 1,432 head were tested at Brighton, of which eighty-nine, or 6.21 per cent., were killed and found tuberculous, but there were also twenty-one killed in which no lesions were found. Of six hundred and sixty-five tested on Nantucket, only six reacted, and the lesions in some of these were so slight as to be questionable. During 1895 the personnel of the Commission remained as it was in October, 1894, after the appointment of Mr. Dennen, and the policy adopted the previous autumn continued unchanged in most respects. The payment of half compensation for tuberculous neat cattle destroyed was found to be unsatisfactory to the farmers, and the law was changed to allow the full appraised value for each animal killed, not exceeding sixty dollars for any one creature, provided the condemned animal had been owned in the Common- wealth for six consecutive months prior to the date of condemna- tion. The Cattle Commission continued to test all cattle brought to Brighton, Watertown and Somerville stock yards from without the State, and also all Massachusetts cattle offered for sale at these markets, except beeves for immediate slaughter, calves under six months old and cattle intended for export, until April 30, when the work was relinquished for lack of funds. In July an order was adopted that cattle could be brought in from without the State on permits issued by the Board, except to the stock yards at Brighton, Watertown and Somerville, where they could be brought without permits, as these yards were con- sidered quarantine stations, and cattle accompanied by satis- factory certificates of tuberculin test, made by veterinarians in other States approved by the Board, were released. This method continued for several years, and soon became a farce and fraud PETERS. 55 upon the public, as much of the work was done dishonestly, to please the cattle dealers, particularly for the drovers attending the weekly market for milch cows at Brighton. The systematic testing of herds started in Nantucket the pre- vious year was continued, and completed in Dukes (the island of Martha's Vineyard) and Barnstable counties, including 2,856 animals, of which nine reacted to tuberculin and were killed and found to be tuberculous. In addition, seven hundred and ninety- five head were condemned as tuberculous that were quarantined by the local inspectors. The Cattle Commission continued in 1896 as organized in Oc- tober, 1894, with Dr. Osgood as chairman and Dr. Lyman as sec- retary, until October. The Commission's position on tuberculosis was very radical and expensive. The inspectors of animals during the first half of the year, before an appropriation was made for the year's work, con- tinued to quarantine cattle on suspicion of having tuberculosis, and the law provided that after ten days from the date each ani- mal was quarantined the State should assume the expense, and the Commission would not kill any until an appropriation was made. The result was that when the Legislature made an appro- priation, early in June, there were 1,043 head of neat cattle in quarantine, upon which the State owed a board bill of 128,223 .43, nearly as much as the appraised value of the animals in quarantine. The avowed intention of the Board of Cattle Commissioners to enforce a compulsory tuberculin test of all the neat cattle in the State aroused a great deal of opposition among the farmers. Tu- berculin was a new agent, and as such could not be forced upon cattle owners until more was known about it by them, as many statements were in circulation concerning injurious effects pro- duced by it, such as causing tuberculosis in healthy cattle, abortion and the like; furthermore, many owners of cattle were unable to 56 TUBERCULOSIS IN MASSACHUSETTS. comprehend that an animal with a nodule or two in a bronchial or mediastinal gland was a source of danger to other cattle or to human life, or that the flesh of such an animal was unhealthful for human food. As the result of this opposition Dr. John M. Parker of Haverhill was appointed a member of the Board by Governor Wolcott, at the expiration of Dr. Lyman's term of office, in October, 1896. In December Dr. F. H. Osgood resigned and Dr. Austin Peters of Boston was appointed to fill the vacancy, and elected chairman, with Dr. Parker as secretary. The excitement over bovine tuber- culosis reached high-water mark in 1896, when the Legislature appropriated $300,000 for the use of the Cattle GDmmission. Early in the winter of 1897 an appropriation of $250,000 was secured for the eradication of contagious disease among animals. During the spring of 1897 many farmers in Middlesex County had their herds tested by veterinarians, at their own expense, and the veterinarians reported reacting animals to the Cattle Commissioners, who had the animals appraised and killed. This led to a raid on the appro- priation as a result of tests made on cattle over which the Com- mission had no control. Another extravagant feature of the law then in force was that animals killed as diseased were deemed unfit for food, and hun- dreds of animals were thrown into the rendering tank and made into fertilizer, which, under an intelligent system of meat inspec- tion, might have been passed as fit for beef. The farmers who had the testing done in most cases had no in- terest in an attempt to diminish the amount of bovine tuberculosis in the State, but simply did it as a matter of speculation, with the idea of selling a lot of old milked-out cows to the Commonwealth for more than they were worth. In this they were disappointed to a certain extent, as more cows reacted than the owners expected, and also in many instances the best ones, so as to almost wipe out entire herds. This condition of affairs attracted the attention of PETERS. 57 certain members of the Legislature, and resulted in the appoint- ment of a special joint committee, April 9, 1897, ^o investigate the work of the Cattle Commission, with power to employ experts to make autopsies on the cattle from certain herds in Dracut, con- demned after private tests made by veterinarians, the committee to report to the Legislature later. The committee selected as experts to make autopsies on con- demned cattle, and also the few remaining non-reacting cattle in certain herds, Harold C. Ernst, M.D., of Boston, Theobald Smith, M.D., of Boston, George N. Kinnell, M.R.C.V.S., of Pittsfield, Dr. Frank Billings of Grafton, a graduate of a German veterinary school, and Charles R. Wood, veterinary surgeon, of Lowell. Each wrote an independent report. The legislative committee from the Senate and House reported May 25, 1897. There were two reports, one signed by most of the members, and a minority report, signed by two members of the House. The majority report favored more conservative methods, stated that the Cattle Commission should pay more attention to disinfecting barns and stables where tuberculous animals had been kept, immediately upon their removal, and before new animals were introduced. The majority report continued as follows: — From our observations at the investigation we hold that the Board of Cattle Commissioners should at once take into consideration modifications of the law relative to the condemnation of cattle by tuberculin test alone, that is, upon the request of owners of cattle for such testing of their herds. If cattle are to be con- demned or regarded as suspicious animals only after they show signs of disease, it is a question as to the propriety or equity of the State paying full value for those that are actually diseased. This proposition we respectfully refer to the considera- tion of the next General Court, trusting that the Board of Cattle Commissioners will, in the meantime, consider the same question and offer recommendations in their annual report. We believe that the Legislature should at once deal with the matter of indis- criminate tuberculin tests. We recommend that all testing of cattle with tuberculin when compensation is expected be limited to the Cattle Commissioners or their authorized agents. The Board of Cattle Commissioners have already expended more than $160,000 of the total appropriation of $250,000, made earlier in the 58 TUBERCULOSIS IN MASSACHUSETTS. session. If they are compelled to kill all reacting animals and allow full compen- sation for the diseased cattle the remainder of the appropriation will soon be ex- hausted. There will then be no money for the prosecution of the regular work of the Commission or the slaughter of those animals reported by the local inspectors as suspicious cases, and which are really the most dangerous animals to the health and comfort of the general public. The Commissioners are not allowed to exceed their appropriation, hence all their work must stop when their money gives out. We earnestly recommend the immediate passage of the following act: — COMMONWEALTH OF MASSACHUSETTS. In the Year One Thousand Eight Hundred and Ninety-seven. An Act relative to the payment of compensation from the state treasury on ac. COUNT OF cattle INFECTED WITH TUBERCULOSIS. Be it enacted by the Senate and House 0/ Representatives in General Court assembled, and by the autJiority of the same, as follows: Section i. No person or persons having animals tested with tuberculin shall be entitled to com- pensation from the state for any animals that react to the tuberculin test unless such testing be done by the state board of cattle commissioners or their authorized agents acting as such at the time of the test, and such testing must be subject to the supervision and control of the state board of cattle com- missioners. Section 2. This act shall take effect upon its passage. We submit with this report the reports made by the experts attending the post- mortem examinations of these cattle. The above proposed legislation was immediately acted upon, and became law June lo, 1897, insuring a complete control of its appropriations to the Cattle Commission in the future. The Legislature had already earlier in the season passed an act re- stricting the use of tuberculin, which provided as follows: — The use of tuberculin as a diagnostic agent for the detection of the disease known as tuberculosis in domestic animals shall be restricted to cattle brought into the Commonwealth from any point without its limits, and to all cattle at Brighton, Watertown and Somerville: provided, however, that tuberculin may be used as such diagnostic agent on any animal or animals in any other portion of the State upon the consent in writing of the owner or person in possession thereof, and upon any animals condemned as tuberculous upon a physical examination by a com- petent veterinarian. This was approved March 17, 1897. This clause in the law was first enacted in April, 1896, to continue in force until June i, 1897, PETERS. 59 but in March, 1897, it was made permanent upon the statute book. This was due to the opposition of the farmers to the unrestricted compulsory use of tuberculin by the Cattle Commission. The minority report of the committee favored continued radical action, and considered that if the Cattle Commissioners had made mistakes the fault was with them, and not with the law. In 1898 the Legislature gave the Cattle Commissioners "power to make and issue rules and regulations for the guidance of in- spectors of animals and provisions in the inspection of meat, which shall conform with the rules and regulations of the United States Bureau of Animal Industry for the inspection of meat for export and for interstate commerce." This was approved May 23, 1898. This put an end to the folly and extravagance of making fertilizer out of meat fit for food. The Legislature of 1898 appropriated only |20,ooo for the use of the Cattle Com- mission. Governor Wolcott called the attention of the Legis- lature to the fact .that this appropriation was insufficient to carry out existing laws, and the House then voted to abolish the Cattle Commission, in which, however, the Senate refused to concur. The Governor then again wrote the Legislature a message, recom- mending a further appropriation. The House again voted to abolish the Cattle Commission; the Senate again stood by it. The Commissioners decided to do what they could as individuals during the remainder of the year, and in this way examined and caused to be killed glandered horses, and kept up the quarantine against out-of-the-state cattle, requiring all those brought in to have certificates of tuberculin tests, except beeves for immediate slaughter or calves under six months old. The Legislature of 1899 passed a deficiency appropriation bill sufficient to pay the members of the Commission the arrears in their salaries. The Legislature of 1899 also passed an act recodifying the laws ,1 6o TUBERCULOSIS IN MASSACHUSETTS. «' relating to contagious animal diseases, reducing the Cattle Com- mission from five members to three, and giving it an appropria- tion of 175,000 for the current year. The limit of value on a bovine with tuberculosis Vv'as reduced from |6o to $40, and the law providing for the annual appointment of inspectors of animals and provisions by the various cities and towns of the State was changed to provide for the annual appointment of inspectors of animals. The inspection of live animals at the time of slaughter and provisions was turned over to the local boards of health, the inspectors of animals only having to inspect live animals for con- tagious diseases, quarantine suspected cases, and make a general inspection of farm animals and premises where they are kept when ordered to do so by the Cattle Commission, which has been or- dered annually in the autumn since 1899. This act was approved May 25, 1899, and Governor Wolcott appointed Charles A. Dennen, Leander F. Herrick and Dr. Austin Peters members of the Board. The Commission continued thus until 1902, when, at the sug- gestion of Gov. W. Murray Crane, who thought that the State had too many cbmmissions, the Legislature abolished the Board of Cattle Commissioners and established in its stead a Cattle Bureau of the State Board of Agriculture, with a chief appointed annually by the Governor with the advice and consent of the honorable Executive Council, who, by virtue of his office, shall be a member of the State Board of Agriculture. The Governor then appointed Dr. Austin Peters chief of the Cattle Bureau. As there is no one in the Cattle Bureau except the chief, who has the powers and duties formerly vested in the Cattle Commis- sion, it practically replaces a commission of three with a single commissioner. This arrangement has remained in force since April, 1902. During the winter of 1902-03 the market at Brighton was closed because of an outbreak of foot-and-mouth disease, but PETERS. 6i since it was reopened in July of the latter year all out-of-the- state cattle brought to Brighton, Watertown and Somerville for the weekly market upon which a test is required have been tested by the agent of the Cattle Bureau in charge of these yards, and his assistants, as it was found that much of the testing outside of the State, which was done by the veterinarians for the drovers, was not honestly performed, and the certificates in many instances were of no value. About thirteen or fourteen thousand cattle, chiefly milch cows, are tested at the Brighton barn each year, and reacting animals, about two hundred usually, are killed. Recently it has been decided not to accept any certifi- cates of test from veterinarians outside of the State on cattle coming in on permits to points outside of the stock yards at Brighton, Watertown and Somerville, but to have all cattle upon which a test is required tested after arrival at their destina- tions by agents of the Cattle Bureau. These tests are made free of charge to citizens of Massachusetts, and at cost to others, as required by chapter 332 of the Acts of 1903. The following shows the amounts appropriated for the use of the Cattle Commission or Cattle Bureau since 1895, and the number of cattle killed: — YEAR. Amount appropriated. Number of Cattle killed. Amount paid for Cattle. 1896, $300,000 00 5.748 $189,216 60 1897, . . 250,000 00 5,529 188,534 00 1898, 20,000 00 297 8,057 61 1899, 75,000 00 785 17.277 69 1900, 50,000 00 1,423 30,870 22 1901, ■ • { 50,000 00 3,408 I 1 ' 1 '.341 27,424 50 1902, I 58,000 00 73,000 00 1,001 1 21.137 75 1903. . 4,500 00' ■.843 42.454 32 40,000 00^ J J Deficit appropriation. 2 Additional appropriation, foot-and-mouth disease. 62 TUBERCULOSIS IN MASSACHUSETTS. YEAR. Amount appropriated. Number of Cattle killed. Amount paid for Cattle. '904 I '905 { 1906, .... 1 '907 1 $65,000 00 9,500 00' 67,000 00 5,000 00* 66,416 66 1 1,560 24 77,000 00 8,432 60 1 } .,658 } .,625 } '.737 1 2,030 $35,456 45 34. '33 58 35.952 75 42,326 60 Totals, $1,233,817 61 25,017 $672,842 07 It will be seen by the foregoing table that for the twelve years ending December 1, 1907, the State of Massachusetts has appro- priated the sum of $1,233,817.61 for the eradication and control of contagious diseases among domestic animals, and that a large item of expense is the cost of paying owners of tuberculous ani- mals for neat cattle slaughtered by the state authority as suf- fering from this disease. During twelve years 25,017 head of tuberculous cattle have been killed, for which the State has paid $672,842.07, an average of $26.89 P^'* head. It is also shown how the pendulum has swung one way and then the other; that in 1896 the limit was reached when $300,000 was appropriated, and in two years the Legislature went to the other extreme and appropriated but $20,000, and that the House then voted to abolish the Cattle Gjmmission; how later an even keel was reached, and since then the appropriation has ranged from $50,000 to $75,000 per year. The combined appropria- tions for the years 1896 and 1897 were nearly half of the sum of the appropriations for the twelve years, and $377,750.60 was paid for 11,277 diseased cattle in 1896-97, which is more than half of the sum total paid for 25,017 head. The average price paid per head for condemned animals in 1897 ' Deficit appropriation. PETERS. 63 was a little over I34, which was the maximum average price per head reached; since then it has been diminished, until the last few years the average price paid per animal has been between |20 and |2i. The reason for the high prices paid in 1896-97 was due to the fact that all animals quarantined by the local inspectors and many large herds were tested with tuberculin, and all reacting animals killed, no matter how slightly diseased they might be, and many of these animals were apparently in good physical con- dition, while at the present time only animals that show marked physical evidence of disease, or that have nodulated udders, are killed, and nearly all are condemned on a physical examination. In 1896-97 there must have been, counting private tests, fully ten thousand head of cattle tested with tuberculin in each year, over half of which reacted, and were killed and found to be diseased. The present methods give the State a tolerably good system of dairy inspection as far as protecting the public health from the milk of tuberculous cows in Massachusetts is concerned, but it does not protect them from the milk of tuberculous cows in Maine, New Hampshire, Vermont, Connecticut or New York State. While much has been done towards diminishing bovine tuberculosis in some of the adjoining States, notably Vermont, there are, on the other hand, localities from which milk is shipped into Massachu- setts where the conditions are exceedingly bad. It is doubtful if the work at present being carried on against bovine tuberculosis in Massachusetts accomplishes much in the direction of decreasing the percentage of tuberculosis among the herds of the State, as a fresh crop of badly diseased cattle, mostly cows, is harvested year after year; if anything, it would appear that there is a slight increase, as the number of condemned cattle has gradually increased a little, varying somewhat from year to year, from 1,423 in 1900 to 2,030 in 1907. To do more work and 64 TUBERCULOSIS IN MASSACHUSETTS. gain greater headway, larger annual appropriations for the use of the Cattle Bureau will be needed. The greatest possible amount of work is being done with the means available at the present time. If public opinion demands more than is at present being done, there is no doubt but what the appropriations will be increased so as to allow more active and extensive measures being adopted for the eradication and control of bovine tuberculosis than are at present in force, but it is not at all likely that the Commonwealth of Mas- sachusetts will ever return to annual appropriations for this pur- pose of from 1250,000 to $300,000. BOWDITCH. 65 CHAPTER VI. THE ORIGIN AND GROWTH OF THE SANATORIUM TREAT- MENT OF PULMONARY TUBERCULOSIS IN MASSACHU- SETTS. Vincent Y. Bowditch, M.D. THE SHARON SANATORIUM AT SHARON. The Sharon Sanatorium in Sharon, was the first institu- tion of its kind in New England to be estabHshed in accordance with the ideas of Brehmer and Dettweiler in Germany and later of Trudeau in the Adirondack Mountains in New York State. In certain particulars the sanatorium was for several years unique. Previous to its establishment in 1890 it had been thought neces- sary to place such institutions at a comparatively high altitude, at considerable distance from the sea, and in climates less subject than the coast of New England to sudden changes of temperature and humidity. The idea that patients could be successfully treated not far from home had hitherto been thought, if not abso- lutely impossible, at least of such doubtful nature that the sug- gestion was at first regarded by many as almost chimerical. In spite of this skeptical attitude on the part of both the medical profession and the laity, and following the teachings of the late Henry Ingersoll Bowditch, who for many years had constantly taught the value of fresh air as the most important feature in the treatment of pulmonary disease, an appeal was made to private citizens of Boston, and the sum of about 130,000 was raised. The town of Sharon, approximately eighteen miles from Boston and ten miles from the seacoast, was selected on account of its favor- able situation on the watershed between Boston and Providence, and because of its porous soil and abundant supply of excellent 66 TUBERCULOSIS IN MASSACHUSETTS. water. Through the bounty of a lady deeply interested in the plan, a small farm of twenty-three acres was bought, and upon a high knoll at an altitude of only about two hundred and fifty feet above sea level, sheltered by woods on the north, east and west, a commodious but simple building, suitable for nine patients and the administrative staff, was erected in the autumn of 1890. As necessary adjuncts to the sanatorium, a pumping engine and tank for the water supply were installed and a simple but thorough method of cesspool drainage was arranged, to be changed in later years to a perfected form of sewage filter-beds. The cost of these essentials for a sanatorium, in addition to a small amount of grad- ing and road-making, amounted to about $20,000. The sum of $10,000 was therefore left for current expenses until the object and aims of the sanatorium should become generally known. The institution was opened on the 9th of February, 1891, and the first patient was received on February 16. It was formally incorporated in March, 1891, with the legal title of the "Sharon Sanitarium." ' The following directors and officers were elected : — • Board of Directors: Alfred Bowditch, President, N. H. Stone, Treasurer, Reginald Gray, L. Vernon Briggs, Miss Olivia Y. Bow- ditch, Miss Alice M. Curtis, Secretary, Miss M. H. Denny, Mrs. Horatio A. Lamb. Medical Directors: Vincent Y. Bowditch, M.D., Robert W. Lovett, M.D. Consulting Physicians: Henry I. Bowditch, M.D.,- Frederick 1. Knight, M.D. Assistant Physician, John J. Moran, M. D. Matron, Mrs. M. E. Small. As the sanatorium was intended only for women in the early stages of tuberculosis, of very limited means, a uniform charge of $5 a week, exclusive of personal laundry, was established. This sum included all medical services, medicines and board. The same charge is still adhered to, in spite of the great increase in the 1 This name was legally changed in 1903 to " Sharon Sanatorium," as being the more correct and usually adopted title. 2 Died in 1892. BOWDITCH. 67 cost of living in the past few years, and in spite of the fact that the annual deficit is much larger than formerly. The Sanatorium has been dependent chiefly upon the public for its support, and in consequence of certain bequests has made notable additions to its buildings. In 1897 ^ small infirmary was built not far from the main building, for the reception of patients who should become very ill, or in case of an outbreak of any acute infectious disease requiring absolute isolation. In 1900, by the bequest of Thomas T. Wyman, a large wing was added, providing separate rooms for ten patients, attic rooms for the servants, a large treatment room, and a heating plant in the basement. Be- tween this wing and the infirmary, and connected by a subway, a cottage with apartments for the matron-superintendent and for the resident physician was also added. The capacity for patients has thus been increased during the past few years to twenty-three beds. During the past year extensive but simple alterations have been made. Sleeping balconies have been added to the main building and wing, so that every bed can be rolled out at night, the patients sleeping in the open air under a canvas canopy even in the coldest winter weather. The dining-room has been much enlarged, with marked increase of light and air by the insertion of a larger number of windows than before. To the small farm, upon which the buildings now stand, more than one hundred acres of beautiful woodland have been added to the property by gift and by purchase. By this the buildings are shielded from the harshest winds and the woods are being slowly developed as a park for the patients' use, the sale of timber being made a source of income to the sanatorium. A few acres of farm land are used for the production of vegetables sufficient for the patients' needs throughout the summer season, the supply of pota- toes usually being sufficient for the whole year. Milk is obtained 68 TUBERCULOSIS IN MASSACHUSETTS. from an excellent herd of cows on the Town Farm near by, which is in charge of an excellent Superintendent, the animals being occasionally examined by the State Inspector. The cost per patient is one of the difficult problems of such an institution. All sanatoria of this nature are naturally compara- tively expensive. If good results are to be obtained, a much larger outlay is required for provisions than in ordinary hospitals. The fact that a prolonged stay is necessary for each patient means that the surroundings must be attractive, though not necessarily luxu- rious, and entertainment must be afforded to relieve monotony as essentials in treatment. The class of patients received at Sharon is also a factor in the expense. People of refinement, even if of very limited means, naturally require more than the lowest class of the poor. All these considerations have to be taken into account in estimating the comparative cost of different institutions. The price of board thus far charged (I5 a week) barely covers one-third of the outlay, and in spite of earnest endeavor to use economy it has hitherto been impossible to lessen the expense per capita. The number of people in the working staff of the sanatorium is as follows: a Superintendent and Matron (since May, 1901, Miss Alice R. Hodges), who has charge of the general administration and of the nurses; a Resident Physician (Dr. Walter A. Griffin since 190 1), who, with the Medical Director, has charge of the medical department; two nurses; seven maids; and two men-of- all-work for the stable and farm. The experiment has been tried in times past of employing the patients in the general work of the household; but for various reasons this has been found impracticable, chiefly because not only is it apt to interfere with the course of treatment, but because of the liability to illness, thus crippling the management. Each patient, however, is supposed to have the care of her own room, unless the physical condition contraindicates it. I ^^^HkMM, m ^3?*4fc. m ^W 'Lr- "^'^i. #11111 -*. Bil CCT| I BOWDITCH. 69 The institution is free of any debt, but is in constant need of funds to supply the annual deficit. An Auxiliary Committee of ladies and gentlemen has been of invaluable service in adding large sums to the treasury by bazaars and other entertainments. An attempt is being made to establish an endowment fund, and thus far about |20,ooo has been obtained for that purpose. The results obtained at Sharon have long since shown that what was started as an experiment over seventeen years ago has justified the belief that much more can be done near the patients' homes than was thought possible a comparatively few years ago. Since the development of the method of fresh-air treatment, by which the patients are practically in the open air nearly every minute of the twenty-four hours, summer and winter, the results are even more satisfactory than in the earlier days, when less rigorous methods were in use. A few statements are appended, showing the results of treatment. The Medical Report for March, 1907, prepared in accordance with the plan used by the National Association for the Study and Prevention of Tuberculosis, gives the following results: out of forty proven cases of tuberculosis treated during the year, nine- teen were discharged "apparently cured," nine were discharged "arrested," ten were discharged "improved," two were discharged "progressive." In a paper entitled "Subsequent Histories of One Hundred and Sixty 'Arrested Cases' ^ of Pulmonary Tuberculosis treated at the Sharon Sanatorium, 1891-1906," by Vincent Y. Bowditch, M.D., and Walter A. Griffin, M.D., ^ the following facts are given: — 1 This use of the term " arrested " is in accordance with the former method of nomenclature adopted at Sharon. It comprises all those cases who at the time of discharge were free of all abnormal out- ward symptoms of disease, viz., cough, sputa, fever, etc., the general aspect and condition being one of apparent good health. By this method, the term " cured " or even " apparently cured " is not used until, after a period usually of many months, the patient under ordinar>' conditions of life has shown no sign of relapse. 2 Transactions American Climatological Association, 1907, printed in igo8. 70 TUBERCULOSIS IN MASSACHUSETTS. Summary of the Total Number of "Arrested" Cases, 189 1-1906 inclusive. Total number " arrested," . . . . . . .160 Number still living and well, most of them wage-earners or house- keepers, 133=83.0-1-% Number who have not recently been heard of, but who at last ac- counts were doing well, many of them in robust health, . , 6=3.7% Number who have since died, . . . . . . .21 = 13.0-1-% It should be added that, of those who died, the majority were advanced cases in which arrest of the disease was not expected. Two, at least, died from some cause other than tuberculosis, and others returned against advice to unhygienic surroundings, and relapsed. The present list (1908) of Directors and Officers of the Sanato- rium is as follows : — Board of Directors: Prof. William T. Sedgwick, President, N. H. Stone, Treasurer, 614 Sears Building, Boston, Mrs. Charles A. Porter, Secretary, Augustus Hemenway, Rev. Edmund F. Mer- riam, Arthur Dehon Hill, Mrs. Henry P. King, Mrs. Wm. T. Sedg- wick, Vincent Y. Bowditch, M.D., Robert W. Lovett, M.D., L. Vernon Briggs, M.D. Medical Director, Vincent Y. Bowditch, M.D. Consulting Physician, Frederick I. Knight, M.D. Resident Physician, Walter A. Griffm, M.D. Superintendent and Matron, Miss Alice R. Hodges. THE STATE SANATORIUM AT RUTLAND. On June 5, 1895, pursuant to the provisions of chapter 503 of the statutes of 1895 of the Massachusetts Legislature, a bill was approved for the establishment of a so-called "Massachusetts Hospital for Consumptives and Tubercular Patients," and a Board of five Trustees was appointed by the Governor and Council. This is the first instance in America of the founda- tion of a state institution for the treatment of tuberculosis. BOWDITCH. 71 The sum of 1150,000 was appropriated for the purpose of purchasing suitable land and for the erection of buildings there- upon. The Board of Trustees, composed of Fred B. Percy, M.D., of Brookline, Alfred Worcester, M.D., of Waltham, and Messrs. John C. Hammond of Northampton, A. W. Esleeck of Holyoke and W. E. Parkhurst of Clinton, held their first meeting for or- ganization on August 15, 1895. After much individual study of the question, and after obtain- ing the opinion of many physicians throughout the State as to the best location for such a hospital, a farm of about two hun- dred acres in Rutland, in Worcester County, fifty miles from Boston, at an elevation of about eleven hundred feet, was pur- chased, as having many of the essentials for the location of such a hospital, and buildings, planned by the architect, W. Chester Chase of Boston, were erected. In December, 1897, the first report of the Trustees was issued. It speaks of the unforeseen difficulties of drainage and of laying out a long road to reach the Sanatorium, both requiring a larger outlay than was at first supposed. The drainage was carried through a rocky cut to the west of the hospital to a point about one mile distant onto lands six acres in extent acquired for the purpose of filtration beds. At the time of opening, therefore, no administration building had been put up, owing to lack of sufficient funds, and in consequence, the Superintendent was obliged to occupy a portion of the hospital intended for other purposes. This left a capacity of about one hundred and seventy- five beds for men and women, instead of two hundred as originally intended. The price of board and treatment was fixed at 50 cents a day (I3.50 a week). This price was not long afterwards raised to I4 a week, this being the present charge to all patients. At first no distinction was made as to race, creed or age, although 72 TUBERCULOSIS IN MASSACHUSETTS. there was a somewhat tacit agreement that no child under twelve should be admitted. At this time the question was mooted of changing the name of the institution and of converting its purpose from that of a hospital for advanced cases to that of a sanatorium for the treat- ment of incipient and moderately advanced cases. In the Trus- tees' report for 1898, the success obtained at the Sharon Sana- torium was cited as an instance of what could be done for the successful treatment of incipient tuberculosis in Massachusetts, and the decision was made to so change the original purpose of the bill as to make the institution a sanatorium for hopeful cases, rather than a hospital for advanced cases. The wisdom of the Trustees in making this decision can only be fully estimated when one realizes the intense interest which was soon shown by other communities throughout the United States, who have since followed the example of Massachusetts in erecting state sanatoria. Two specialists on pulmonary diseases were chosen to act as attending physicians, who should represent respectively the regular and the homoeopathic schools of medicine, in accordance with the terms of the original bill. Drs. Vincent Y. Bowditch and Herbert C. Clapp of Boston were selected to fill the positions. Their duties consisted in making weekly visits to Rutland; in taking full charge of the medical departments, with the privilege of having assistants who should reside in the hospital; and in making weekly examinations of applicants at the Boston office of the hospital. On September 23, 1898, the hospital was formally opened by Governor Roger Wolcott. The first patient was received October 3, and Drs. Bowditch and Clapp began their service. Dr. Walter J. Marcley had been previously chosen as Superin- tendent, and Miss Mary E. Thrasher as Matron. In 1900, by an I BOWDITCH. 73 act of Legislature (statutes 1900, chapter 192), the name of the hospital was changed to that of the "Massachusetts State Sana- torium" in accordance with the decision of the Trustees to ex- clude all far-advanced and hopeless cases from the institu- tion. During the year 1901-02, at the suggestion of the State Board of Charity, five new buildings were added, — an administration building, a recreation hall, a large dining-room and two new wards, — thus increasing the capacity of the institution to two hundred and fifty beds. In consequence of the larger number of patients, a second medical assistant for the regular service was appointed at this time. By statutes enacted in June, 1903, chapter 445, and under chapter 75 of Resolves of 1904, after a careful study of the ques- tion by the State Board of Charity, provision was made for the addition of "four brick cottages," two to be used as general wards, one as a possible "probation ward" and another as an "infirmary" for twenty or thirty patients who might require special nursing during severe illness. These wards were com- pleted in 1905, with the exception of one spoken of as a "proba- tion ward," which, owing to the unexpected expense of estab- lishing a new heating plant, was omitted. The infirmary was finished later. The capacity was thus increased to about three hundred and eighty beds. At this time, in 1905, the expense per capita was $8.83 per week, as against $9.36 in 1904. In 1904 the Boston office was removed from 181 Tremont Street to the Out-Patient Department of the Massachusetts General Hospital, the duty of examining patients for admission falling upon the resident assistant physicians of the Sanatorium, instead of the attending physicians. Examining offices were also established in Worcester, Lowell, Springfield, Fall River and 74 TUBERCULOSIS IN MASSACHUSETTS. Pittsfield, special examiners having been appointed to these positions. In 1905 two women members of the Board of Trustees were appointed, making the number seven in all. In the same year, at the suggestion of the State Board of Charity, an out-patient department was established at the Sanatorium, for the benefit of patients who were boarding in the surrounding farm-houses but not connected with the Sanatorium. Two local physicians in Rutland kindly consented to take charge gratuitously of this department; but thus far, according to the Superintendent, in his eleventh annual report (1907), their ser- vices have not been in such demand as was at first thought would be the case, there being on an average only eight or ten calls weekly. Most of the work of this department now consists of laryngeal examinations and treatments done by the assistant physicians in the Sanatorium. In 1906 the Trustees decided to change the form of admin- istration by abolishing the positions of attending physicians, and by placing the whole medical department under the charge of a Medical Superintendent and his assistants. Following this decision. Dr. E. O. Otis of Boston (who had been chosen to fill the place of Dr. Bowditch after the latter's withdrawal on January I, 1906) and Dr. H. C. Clapp ceased to be attending physicians and were made consulting physicians, to serve without salary. Dr. Frederick L. Hills was also chosen as Medical Superintendent, in.the place of Dr. Walter J. Marcley, who resigned to take charge of the Minnesota Sanatorium. The cost per capita during this year again increased to I9.38, largely due, doubtless, to the general increased cost of living everywhere. In 1907 this cost was increased to |i 0.07, probably due to the same cause as before. The report for 1904 contains an interesting statement as to the BOWDITCH. 75 effect of the Sanatorium upon adjacent real estate values and upon the health of the native population of Rutland. On the assessor's books the total valuation of the town in 1904 was 1704,183; in 1895, before the Sanatorium acquired any land, it was 1518,180, — a gain of $186,000. The number of deaths from tuberculosis (ex- clusive of those who came to the town to be treated for the disease) for the whole time since patients were first received, viz., 1899 to 1904, inclusive, — six years, — was eight; for the six years imme- diately preceding (1893 to 1898 inclusive), eleven; for six years 1887 to 1892 inclusive, eleven; for six years 1881 to 1886 inclusive, fourteen. The town has thus averaged for the last twenty-four years two deaths per year from tuberculosis in a population averag- ing about one thousand. During the six years previous to 1904, with increased population, the deaths from this cause were less than before. A table of comparative results expressed in percentages during the first eight years of the Sanatorium is hereby appended. It is taken from the tenth annual report of November 30, 1906. Comparison of Percentages in the First, Second, Third, Fourth, Fifth, Sixth, Seventh and Eighth Years. QfC e * 9 a © M 9 9 9 9 9 9 9 9 9 e a f4 9 ft 9 9 M 9 9 9 9 9 Per cent, of " arrested " or " appar- ently cured " cases. 34-28+ 42-35 46.12 48.31 48-97 44-8 33-7 39-1 Per cent, of all classes of " improved " 39-36+ 44.70 47.64 44.S1+ 43 -00+ 47-7 58.9 52.1 cases. Per cent, of "not improved " cases, 26.04+ 12.9s 5-74 6-73+ 7.90+ 7-4 7-4 8.8 Percentage of Incipient Cases " arrested" or " apparently cured " 9 9 i *4 9 9 9 9 9 9 9 9 9 « 9 9 p« 1 PM 9 9 M 9 9 9 9 9 9 •N M 9 9 9 9 4 9 9 PN 9 9 9 M 1 FOR THE HOSPITAL YKAR. 1906-07. Under one month, From 3 to 6 months, From I to 2 years, ........ From s to lo years 1 I PAGE. 89 Table showing the Percentage of all Deaths due to Tuberculosis in the Massachusetts Institutions for the Insane. ~ V OJ 1 i ■ 1 u V c ffS (Jn c C B V B s s . c 2 c •"• s c c •^'S ^- C .■^r HH ^ 3 O-'ra 11 3 ^■5. 5 s i 2! 2S oK C ~ > 5K s^ ■2^ 0, C c ^ H ^s Q ;s IS S CA w fa Based upon deaths in 5 -year periods : — 1840-45, 9.2 - - - - - - - - - - 1850-53, 13-8 - - - - - - - - - - 1S60-65, 24.8 25-5 33-9 - - - - - - - - 1870-73. 5.8 5-6 28.2 - - - - - - - - 18S0-85, 12.5 8.6 22.0 10.3 - - - - - - - 1890-^3. 10.7 10.7 I2.0 II. I 10.0 - - - - - - iqoo-03. 12-3 10. 1 7-7 9-3 9-7 21.4 13. 1 14-9 23-5 - - For the hospit al ye ir igc )6-07 8.6 4.0 7.0 '5-3 15.0 27.8 19.5 18.6 56-5 26.6 - Of the seventy-three deaths reported from the five insane hos- pitals, fourteen died within one year from the date of their com- mitment. In our northern dimate, few cases of tuberculosis terminate in death within a period of twelve months from incep- tion, hence it is fair to infer that these persons contracted the disease prior to their hospital residence. But three-fourths of the whole number had spent two years or longer within the hospital walls. A majority of these no doubt died from hospital tubercu- losis. It seems unnecessary to tabulate the hospital residence of eighty-five others who died in the various state asylums. Each patient had experienced a more or less prolonged hospital residence before being transferred to asylum care. Such individuals can reasonably expect a change of environment only by death, and it seems to be a law of nature that terminal infections shall ultimately arrest a majority of human lives. In a series of one hundred autopsies performed in the Danvers Hospital Laboratory, it was found that terminal infections had invaded the heart's blood 90 TUBERCULOSIS IN MASSACHUSETTS. in sixty-four cases, and the cerebro-spinal fluid in seventy-five cases. The high tuberculosis mortality reported from Danvers Insane Hospital during the past year calls for further analysis. While the special wards for tuberculous cases were under construction, methods calculated to prevent or arrest this disease were less actively enforced than at present, and the use of tents was aban- doned. Then the state care act, through the pressure of local economy in town and city management, operates to increase the commitment of some patients already infected with tuberculosis. As the public conception of the old forbidding lunatic asylums has been gradually brought into harmony with the new christening, — state hospitals, — candidates for the wards, as well as their friends, more readily assent to the suggestion that they resort to institutions of this class when health is broken. Patients have been received at Danvers when the sole evidence of insanity was the deUrium incident to the terminal stages of tuberculosis. Of those who died at Danvers last year, seven had been in the hospital less than twelve months, and six of these died within six months of their entrance. Again, the misleading possibihties of statistics when employed in connection with limited time or restricted circumstances should be borne in mind. This sugges- tion may be emphasized by noting that while for the hospital year ending November 30, 1907, Danvers had twenty-six deaths from tuberculosis, — a mortality per cent, of 15.3, — for the first half of the succeeding or present year, /. e., the six months ending May 30, 1908, but three cases of tuberculosis have died in the hospital, — a mortality per cent, of only 2.5. The shack, or special ward for male patients with tuberculosis, has been in use eighteen months at Danvers, but this fact does not explain the reduced mortality from tuberculosis, although favorable results are being accomplished through the aid of this ward. Already it has re- DANVERS INSANE HOSPITAL AT HATHORNE. —Special Ward Building for Tuberculous Patients, showing Veranda. PAGE. 91 ceived thirty-four men by transfer from the wards of the main hospital. Of this number, nine have died, seven of the nine having shown physical signs of tuberculosis when admitted to the hos- pital. Of the thirty-four so far treated, sixteen are still inmates; thirteen of the number have gained in weight, — an average of twenty-one and one-half pounds; the other three have lost, — an average of six and one-third pounds. As a rule, open cases of tuberculosis are still cared for in certain parts of the main hospital, and a few have been too unreliable for residence in the special wards. In order to give tuberculous inmates the benefit of special treatment in the incipient stages of the disease, a routine tempera- ture examination, four times daily, of all chronic demented pa- tients, and others as circumstances suggest, is repeated several times each year. A continuous rise in temperature or a marked loss in bodily weight suffices for an order of transfer to the tuber- culosis ward, unless the patient is too irritable or excitable for continuous residence there. The continued use of the tuberculin test in a large series of cases covering a period of several years gave such unsatisfactory results in differentiating incipient cases that it has been discarded at the Danvers Insane Hospital. Although tuberculin has failed to identify early tubercular lung disease, faith in its reliability, when properly used, to demonstrate the presence without regard to location of infected foci, is not diminished. The ophthalmic reac- tion has also been found to be unreliable in detecting incipient tuberculosis, and has been discarded. In addition to the many phases of the tubercular problems which arise in connection with the insane, the state hospitals have to contend with bovine tuberculosis, as each hospital has a farm with a herd of milch cows. For the past twenty years this disease has been so common in the hospital dairy stock as to occasion serious Q2 TUBERCULOSIS IN MASSACHUSETTS. _ concern. For a time it was feared that the milk from the diseased cows might be communicating tuberculosis to the patients. Later, when new theories modified such views, there still remained the great annual financial loss to the State from the steady inroads of this disease. The experience at Danvers probably duplicates that at all the other state hospitals. In 1888, when the first official examination of horned cattle belonging to the hospital was made, out of the sixty-one animals, twelve were condemned as worthless, twenty-five were classed as probably diseased, and twenty-four only were given a clean bill of health. Since that time animals manifesting this disease have been discarded and fresh stock brought in. Measures to insure the disinfection of the stable and to improve the sanitary conditions of the barn have been enforced, and yet no abatement of the infection has been evident. From time to time the tuberculin test has been em- ployed. In the year 1900, 64 per cent, of the whole herd reacted. The Bon system of removing diseased animals from the barns has been steadily practised and thorough disinfection carried out, but without appreciable effect in diminishing the prevalence of the disease. In April, 1906, the Danvers Hospital Trustees decided to adopt von Behring's method of immunizing dairy stock to pre- vent infection from tubercle bacilli. This practice consists in giving two injections, three months apart, of a special quality of human tubercle bacilli into the blood current through the jugular vein. The Northampton State Hospital began to treat young animals in this manner at about the same date, and thirty calves had been thus immunized at the close of the last hospital year. To date, Danvers has seventy-eight on the list of immunized animals. Time alone can satisfactorily demonstrate the value of this system of fighting bovine tuberculosis, but in Europe von i Behring's Bovovaccine has been in extensive use twice as long as in the United States, and all reports seem to support the original PAGE. 93 claims that by this treatment horned animals are rendered com- paratively immune. No injurious results from the operation have been observed at Danvers. The tuberculin tests so far made on immunized stock have been generally negative, but it is recognized that the vaccination sensi- tizes the animals for a period of at least seven to twelve months. (Von Behring and Romer.) How much credit for such results as have been obtained at the Danvers Insane Hospital should be attributed to the immunizing process may remain a question, for a time at least; but such favorable evidence, constantly accumulating, stimulates courage to believe that a certain means for checking bovine tuberculosis has been discovered. And if bovovaccination proves successful, it is not too much to expect that there will be at our command, in due time, equally efficient methods for checking human tuber- culosis. 94 TUBERCULOSIS IN MASSACHUSETTS. CHAPTER Vin. TUBERCULOSIS IN THE PRISONS OF MASSACHUSETTS. Joseph I. McLaughlin, M,D. The Massachusetts Board of Prison Commissioners have the control and management of the three large prisons of the State, the Women's Reformatory at Sherborn, the Reformatory at Con- cord for young male adults and the State Prison at Charlestown. In addition, they have a general supervision over the twenty-one jails or houses of correction or both in the various counties. As the latter, with two or three exceptions, have no appointed hos- pitals and issue no tabulated report of the sick inmates, it is possible to consider in this study only the measures in use for the care, and more particularly the prevention, of tuberculosis in the larger institutions named above. The two reformatories, being of more recent construction and situated in the open country, with a wide area of land adjoining which is owned by the State, ^| present far less difficulty in carrying out appropriate measures for the control of tuberculosis than does the State Prison, the oldest of the three. It is intended, then, to speak but briefly of the former institutions and more at length of conditions at the State Prison. At the Women's Reformatory in Sherborn tuberculosis has not gained a very strong foothold, and this can be attributed to a great extent to the measures employed at this excellent institution to maintain the general health of the prison, such as gymnastic ex- ercises, a liberal amount of work in the open air, light gardening and farming, etc. From the product of the fields the table of the inmates is constantly supplied with a generous quantity of fresh fruit and vegetables. The good results following such manage- Mclaughlin. 95 merit are shown in the yearly medical reports. During the last twelve years only two deaths occurred from tuberculosis, with an average population of nearly two hundred and fifty. The Reformatory at Concord, established in 1884, for the im- prisonment of young male adults with sentences ranging from twelve months to five years, has a very low general death-rate, with tuberculosis as the principal cause of death, as seen from the following: from 1855 to 1907 inclusive, the average yearly popu- lation was eight hundred and thirty-seven. The average yearly number of deaths from all causes was three, of which one was due to tuberculosis. Tuberculosis is a community disease, and develops and spreads most readily in places where the accepted rules of sanitation are not enforced. Cleanliness, proper ventilation, good food and exercise are of the greatest importance in protecting the individual from infection. In a state prison, however, it is most difficult to observe these requirements, inasmuch as the community is largely composed of physical and moral degenerates, and society demands that it shall be surrounded by such safeguards as shall make escape impossible. It is not to be wondered at that in the Massachusetts State Prison the physician in former years waged a losing fight against tuberculosis, when we read of the conditions existing at that time. The prisoner spent the greater part of his time in a cell three and one-half feet wide, seven feet long and seven feet high, having a solid iron door with a small grating at the top, which served, or was supposed to serve, the purpose of admitting a sufficient quantity of light and air. In the lower part of the encircling prison wall there were no windows, and even in the hospital with its fourteen cells there were but three small windows. This criti- cism does not apply, however, to cells built in later years. For instance, some are nine and one-half feet long by six feet wide, 96 TUBERCULOSIS IN MASSACHUSETTS. with the windows in the outer wall extending almost from floor to roof, while others are sixteen feet long, twelve feet high and eight feet wide, all the cells in addition being supplied with a suitable means of ventilation. The larger cells have two windows at the top opening directly into the outer air. At the present time the physician sees each prisoner when com- mitted, and if there is a suspicion of his having a communicable disease he is kept under special observation until all doubt is removed. All others are assigned work, commensurate with their abilities, by the warden. The clothes worn during imprisonment, except in certain cases, are destroyed, and a new outfit is given them at the time of their discharge. Each prisoner's clothing and bed clothes are marked with his name, which reserves them for his wear only, and these also as a rule are destroyed when the prisoner is discharged. In the case of a prisoner who is suspected of having a communicable disease, all danger to others is avoided by the separate washing and sterilization of his clothing. The regular prison fare is nourishing, generous and varied, and consists of milk with cereals or meats and bread and coffee for breakfast; stews, fish or meats with vegetables and bread fo*- dinner; and bread, coffee, prunes or apple sauce, etc., for suppe". Each prisoner is also given the privilege of ordering enough fruit in season once a week to furnish a daily supply for the remainder of the week. As an extra precautionary measure, all food or clothing coming from friends or relatives is withheld from the prisoner. The workshops are well lighted and ventilated, and the character of the work is healthful. The dark punishment cell ("solitary con- finement," so called), with its deprivation of light and the diet limited to bread and water, as time goes on is less frequently called into use in dealing with refractory prisoners. The number of punishments of this nature in one year at the State Prison has for jlllTiiilTE HOSPITAL PRISON FOR CONSUMPTIVES AT RUTLAND. Mclaughlin. 97 a considerable period exceeded by only a small margin the number of punishments of this type given in one week in penal institutions in other States. Bodily cleanliness is rigidly enforced, each pris- oner being compelled to bathe the whole surface of the body at least once a week. The present administration having practically extended over a period of fifteen years with a view to comparative results, the records of the two preceding corresponding periods were looked up, and this brief summary is presented: — PERIODS. Average Yearl}' Number of Prisoners. No. of Deaths from All Causes per loo Prisoners. Percentage of All Deaths Due to Tuberculosis. 1861-75 inclusive, 1876-90 inclusive, 1891-05 inclusive, 524 638 771 '•74 1.68 0.57 54 49 32 The average age at death from tuberculosis during the last period was twenty-eight, exclusive of two whose ages were forty, one at forty-eight and another at fifty-one. The average duration of imprisonment at time of death was three years, exclusive of two terms of six years each, and two others, one of whom was in prison sixteen years, the other twenty-four years. PRISON HOSPITAL AT RUTLAND. Although the statistics of tuberculosis in our reformatories and prison compared most favorably with those of similar institutions in this and other countries, the Board of Prison Commissioners, through its chairman, Mr. Frederick C. Pettigrove, keeping in touch with the best thought of the day, looked for better results, and effected the passage of a law in 1905 establishing a hospital for the reception of prisoners ill with tuberculosis from the various prisons and jails of the State. A site was selected about five miles 98 TUBERCULOSIS IN MASSACHUSETTS. from the State Sanatorium at Rutland, on land with an elevation of about one thousand feet above the sea level, and the hospital built thereon received its first patient in the latter part of Septem- ber, 1907. When a prisoner receives his court sentence and is committed to a jail or prison, as the case may be, and is then found to have tuberculosis, the attending physician fills out a certificate and forv^ards it to the Prison Commissioners, who then order the prisoner transferred to the Prison Hospital at Rutland. This hospital is built on the pavilion plan and consists of two large wings, placed parallel, which run directly north and south; an administration building joins the northern ends of the two ward pavilions, the three buildings forming three sides of a large rec- tangular area. This area on its fourth side will be enclosed by a stockade wall so placed on the slope of the hill as to offer no ob- struction to the view or the warm, pure southern breezes. Keep- ing in view the necessity of an abundance of pure air and light, the buildings are so arranged that the patient gets the full benefit of both when conditions permit. The walls of the east dormitory are made of corrugated iron on a wooden frame, the walls of the west dormitory of cast stone, the administration building of rubble stone. The dormitories or wards are large, with double tiers of windows, suitably grated, extending to the roof, and at the north- erly end of each, adjoining the administration building, are rooms for the more advanced or special cases. Long, open iron-grated verandas at the sides and ends of the dormitories afford the oppor- tunity for open-air treatment day and night. I BRADFORD. 99 CHAPTER IX. THE TREATMENT OF SURGICAL TUBERCULOSIS IN MASSACHUSETTS. Edward H. Bradford, M.D. In the publications of the various associations engaged in com- bating tuberculosis, as a rule more attention is paid to the attempts to check the pulmonary form than to the surgical efforts against it. This is to be explained by the fact that public attention has been turned more especially to the medical rather than the surgi- cal features of tuberculosis, and also because the surgical type is not as threatening a source of contagion as that more common form, — phthisis. Bone tuberculosis is in its most aggressive form to be seen in childhood, and is usually cared for in the family home. In adult life the active phase of the disease has terminated, if not fatally, in some form of crippling deformity which may im- pair individual activity but does not endanger public health. In the severer cases cripples are objects of pity and charity but not of medical care, and are to be found either in the almshouse or in private homes, where they do not endanger the health of the community. The distressing nature of bone tuberculosis, and the severe in- fliction it often entails, however, justifies every effort, surgical as well as medical, to eradicate or check it. The closest study of every feature and manifestation of one of the chief maladies crippling mankind is a public duty. Surgical tuberculosis is a broad subject, and in this chapter attention is paid chiefly to that form affecting the bones, not only because it presents one of the most common forms of surgical tuberculosis, but because the osseous system plays so important 100 TUBERCULOSIS IN MASSACHUSETTS. a part in human activity that special arrangements are often needed to meet the indications of treatment demanded. The therapeutics of an infection depend in a great measure upon the accepted theory of the nature of the disease. What is now classed as bone tuberculosis has passed through various phases of medical classification. In the past medical generation it was still classed as scrofula, and a survival of the old "humoral path- ology" persisted. When this was overthrown by the acceptance of the theory of "cellular pathology," bone tuberculosis was at- tacked chiefly as an affection of a definite tissue which demanded eradication. With the advance of the germ theory and the demon- stration of the tuberculous nature of this form of caries, treatment was directed to the destruction of the germ; and more recently, since the theory of antitoxins and immunity has been developed, the chief aim has been to develop a condition of the tissues which would resist the invasion of the specific germs-. Corresponding to these different theories, the treatment of bone tuberculosis has ranged from the employment of issues, setons, the cautery, radical surgical intervention {i.e., excision and am- putation), the use of apparatus, the administration of drugs and antitoxins, to the employment of fresh air and activity for the development of normal and healthy metabolism. In New England, and especially in Massachusetts, the facilities for the surgical treatment of bone tuberculosis were, until within the last fifty years, confined chiefly to counter-irritants, blisters, and to the relief of pain and discomfort. Hospitals were not equipped for chronic cases; where patients demanded admission, it was for amputation or the radical removal of diseased bone. The application of braces was left largely to instrument makers and empirics. Those suffering from these affections were aided chiefly by such advice and oversight as counseled good nutrition and the administration of tonics. In this respect New England BRADFORD. . lOI was in no way behind other communities. There was a general skepticism both in the minds of the community and in that of the profession as to the advisabiUty of any attempts at treatment for what were termed the "scrofulous diseases." At present leprosy in Japan is popularly considered a divinely decreed blight, and not within human power to control; and, according to popular opinion of the past generation in this community, all attempts to cure children with hip disease and tuberculosis of the spine were re- garded as futile and little more than palliative. It was even regarded by many as wrong to attempt to prolong the life of scrofulous children. Later, as the medical tradition of scrofula and the belief in the "humoral pathology" passed, direct surgical interference seemed to offer a hope of cure by the eradication of the diseased cellular tissue. Excision of the ends of the bone was commonly attempted at the hospitals where such cases were re- ceived. As rest was essential in the painful stages of tuberculosis of the larger joints, some form of fixation of the joint was regarded as advisable; and patients suffering from Pott's disease and disease of the knee and ankle were, when under medical care, kept in bed. Avoidance of fresh air and the administration of alcohol were commonly advised. A few even at this period recognized the advantages of country air, but organized efforts for climatic cure were not attempted. Later, much attention was paid to furnishing patients with mechanical appliances which would correct deformity or protect the limb from jar. The treatment by counter-irritation, by long periods of enforced rest, followed, combined with radical surgical intervention where other measures failed. These constituted for many years the recognized methods of treatment for bone tuber- culosis. The pathology of these affections was not well under- stood. Authorities discussed whether scrofulous bone affections were in reality tuberculous. As all doubts on this subject were 102 TUBERCULOSIS IN MASSACHUSETTS. ended by the advance of pathological knowledge, the importance of some form of treatment which would directly check and over- come the tuberculous germs became apparent, and the efforts to develop a healthy condition of the body, and in that way overcome the tuberculous condition, seemed justified. HOUSE OF THE GOOD SAMARITAN. The beginning of a systematic attempt to treat those afflicted with bone tuberculosis, in Massachusetts, was made through the efforts of a noble woman, Miss Anne Robbins of Boston, who devoted not only her small fortune, but her life, to the establish- ment of the House of the Good Samaritan. This institution was founded in 1861 to receive patients who could not be admitted to the Massachusetts General Hospital, then the only large hospital in Boston. An especial ward was provided for children with hip and spine disease. Dr. Buckminster Brown, who in his early youth suffered from caries of the spine, and, recovering after years of suffering with a severe deformity, became a successful practi- tioner in orthopedic surgery, was placed in charge of this ward. Painstaking care was given to those admitted to the hospital, with the aid of such appliances as were then in use. The treatment was thorough, and those leaving the hospital were followed with charitable interest for years by Miss Robbins and her nurses. The advantages of country air were manifest, and those patients who were able to be moved and who did not require constant surgical attendance were placed in country homes in many instances, and later a farmhouse in the suburbs of Boston was utilized as a con- valescent home for the institution. A tribute of respect and admiration is due to the memory of Miss Robbins, who, alone and without the guidance of precedent and unsupported by the experience of others, more than fifty years ago founded a work which brought not only relief from suffering I BRADFORD. IO3 and favored the ultimate cure of hundreds, but also developed an institution which, for skill and economy of administration, breadth of charitable effort and value of the work accomplished, might serve as a model even now to a generation which is enjoying the benefit of all that experience has taught in the last half- century. The work so wisely begun by Miss Robbins did not cease with her death, but by the co-operation of her friends has continued. The institution grew into the admirable Samaritan Hospital, at present maintained in Boston for the treatment of all chronic affections. BOSTON CHILDREN'S HOSPITAL. When the Boston Children's Hospital was established in 1869 it became evident that the treatment of bone tuberculosis would be demanded in the institution, and the results have justified this original opinion. The treatment of surgical tuberculosis, and especially of the larger joints and of the spine, has been an im- portant feature of the work of the institution. As a continued and systematic treatment of these affections has been made at the Boston Children's Hospital for a number of years under the same direction, the improved results enable the observer to esti- mate the great advance that can be recorded in the treatment of bone tuberculosis. The progress in the treatment of bone tuberculosis can be well illustrated by a comparison of the results now obtained with those recorded twenty or thirty years ago. For example, the mortality of hip disease at the hospital in Tiibingen was 40 per cent.; at Kiel, 48 per cent, non-operative cases, 53 per cent, operative cases; at Marburg, 35 per cent, non-operative cases, 40 per cent, operative cases; at Heidelberg, 46 per cent, non- operative cases, 58 per cent, operative cases; in Zurich, 37 per cent, non-operative cases, 54 per cent, operative cases; in 104 TUBERCULOSIS IN MASSACHUSETTS. Vienna, 17 per cent, in all cases; in Gbttingen, a mortality of 40 per cent.; at the Alexandra Hospital in London the mortality was 26 per cent. These statistics represent the mortality of hip disease from twenty to forty years ago, i.e., before the introduction of the modern methods of treatment in seashore sanatoria and conva- lescent homes. From such meager statistics as exist, the American mortality from hip disease twenty years ago was estimated as from 12 per cent, to 25 per cent. This included death from various causes connected with the original tuberculous coxitis; namely, tuberculous meningitis, septicaemia, septic nephritis, etc. In con- trast to this, the latest statistics in the Boston Children's Hospital, giving the ultimate results of cases treated ten years ago, show a mortality of only 4 per cent, from all causes. This diminution of the death-rate may be fairly attributed in large part to improved methods in surgical treatment, as well as to better opportunities for out-door life, fresh air and activity. Statistics of mortality, however, do not indicate the only benefit which has followed surgical treatment in these forms of bone tuberculosis; even more marked are the limitations of the ravages of the disease, and the securing of ultimate results which ensure freedom from deformity and great disability. Those who have observed the gradual advance in the success in treatment can testify further to the less formidable character of the affection as it is now brought for treatment. This is in part due to the general improvement in public health, but largely to the earlier recognition of the disease and the better facilities for early and thorough treatment. This fact, so noticeable in this community, is confirmatory of what has been observed in other places where careful attention is paid to the care of this class of cases. A similar statement can be made in regard to Pott's disease, which, next to pulmonary tuberculosis, is the most formidable of all the tuberculous affections. It may be said that at present. BRADFORD. IO5 under proper medical care, there should be no hump-backs, and that the mortality, which in the hands of the surgeons of the past generation was formidable, is now reduced to what may result from an attack of another disease or the entrance of a complication. The advances in the methods of treatment consist not only in improvement in surgical intervention and in improved methods in the correction and prevention of deformity, but also in better methods in the treatment of the local condition and in the care and nurture of the patient. When it was generally believed that diseased bone could not heal and was a foreign body causing irritation, the surgeon's re- course to the knife was necessarily extensive. Now that repara- tive power in diseased bone tissue under certain circumstances has been recognized, not only is there a greater reliance upon conservative measures, but operative procedures are less commonly and more carefully performed. The use of the Roentgen rays has given both greater precision to operative interference and a sounder judgment in having recourse to it. Experience with appliances and in the use of plaster bandages, a more thorough knowledge of the nature of bone tuberculosis, when rest should be enforced, when activity is safe, have given the surgeon greater elasticity in his methods, and enabled him to employ with greater freedom the general methods of proved ad- vantage in combating the tuberculosis and therefore in promoting a cure. The advance in the therapeusis of bone tuberculosis will be best understood if, not forgetting earlier pathological teachings, the present theory of treatment is explained. While it is universally admitted that the best treatment for tuberculous affections is fresh air and such an environment as promotes healthy nutrition, — in other words, those conditions which aid in the development of sound tissue, — yet, in bone tuberculosis other factors of almost equal importance cannot be I06 TUBERCULOSIS IN MASSACHUSETTS. overlooked. While tuberculosis of bone, if undisturbed, heals as does tuberculosis elsewhere, it is evident that, owing to the rigid nature of the bone and the inability of the cicatricial tissue to shrink the previously diseased structure into a small cicatrix of fibrous tissue, an extensively diseased bone, if the detritus of dis- organized tissue is thrown off, leaves a gap which must be filled by resistant bone before a healthy bone substance capable of with- standing tuberculous invasion is established. This latter process needs an adequate amount of time; and time, therefore, becomes an important element in the care and cure of bone tuberculosis. Again, where a tuberculous tissue is exposed to constant bruising, the impaired cell development which follows, as well as the con- tused tissue, furnishes an excellent nidus for the development of tuberculous germs. This is well shown by the fact that tubercu- losis of the upper extremities is less destructive and more easily arrested than the same infection of the larger joints of the lower extremities or in the spinal column. It is important, therefore, that all injury to the diseased tissue be avoided. It is for this reason that Pott's disease and hip disease were for many years considered incurable. The surgeon was unable, on account of the faulty means at his disposal, to prevent the patient from being subject to repeated injury of the diseased structure, except by retention in bed or close confinement. Protection from injury which involved the retention of the patient in bed for years, or for a long period, was not favorable to the proper metabolism, and was in itself an evil. With improved methods of fixation, the surgeon, however, is enabled with safety to take advantage of both therapeutic agencies, — protection from jar and freedom from confinement. I BRADFORD. IO7 WELLESLEY CONVALESCENT HOME OF THE BOSTON CHIL- DREN'S HOSPITAL. Cases of bone tuberculosis are especially benefited by the fresh- air treatment, as has been shown in many instances. The ex- perience of the Wellesley Convalescent Home will serve as an admirable illustration. For several years the Convalescent Home consisted of a comfortable, well-arranged building, with the health- ful surroundings found in a well-aired and well-drained farm. All the children showing constitutional enfeeblement were sent from the Children's Hospital to the Convalescent Home when active surgical treatment was not needed. The fresh air furnished was simply that which was to be obtained from the out-of-door play, and in rooms well aired by window ventilation. After some years the management of the Convalescent Home determined to give children suffering from surgical tuberculosis the advantage of fresh-air treatment in shacks. Circumstances delayed the first attempt until the winter months, and the patients were therefore placed in the shacks during the cold weather. The results have been so gratifying that the open-air method of treatment has become the established one for suitable cases of surgical tuber- culosis for both summer and winter. Tabulation of the increase in the percentage of haemoglobin and weight in thirteen cases of tuberculosis of the knee, hip and spine thus treated shows very striking results. It was found that cases suffering from open abscesses did not show the improvement that was seen in cases where no surgical irritation existed.' It is evident that in the surgical treatment of bone tuberculosis the indications for surgical interference must vary with the locality attacked. The treatment of tuberculosis of the vertebral bodies will necessarily be different from that of tuberculosis of the 1 Dr. John L. Adams, " A Report of Seventeen Cases in Open-air Treatment for Surgical Tuber- culosis in Children." Bost. M. & S. J., 1906, CLIV, 71. I08 TUBERCULOSIS IN MASSACHUSETTS. — Sternum. Tuberculosis first attacks the spongy portion of the bone and by preference that portion of the spongy portion where the development of new cells is likely to take place, namely, the epiphyses or the juxta-epiphyseal line. Hard, dense bone is resistant to the tuberculous invasion. The spreading of tuber- culosis in bone is probably not rapid, and is usually accom- panied by the development of cicatricial bone tissue surrounding the focus or the portion invaded. The constructive cicatricial osteitis in the majority of cases establishes a cure by the encysting of the tuberculous mass, and by the gradual substitution of dense cicatricial bone for the diseased spongy bone tissue. The surgical treatment should therefore be directed toward aiding this natural tendency to cicatrization, rather than interrupting it. In ex- tensive bone tuberculosis the periarticular tissues of the capsules of the synovial membrane usually become involved and at times all motion of the joint is painful. When, however, cicatrization and cure have been nearly established, some motion at the joint is not only harmless but may be beneficial. The danger of mixed infection is not to be overlooked in bone tuberculosis. It has been shown that in the majority of fatal cases of joint tuberculosis death does not result from tuberculous generalization, but from a septicaemia due to secondary infection of the tissues previously affected by tuberculosis. The application of this fact to operative treatment is evident. The special surgical procedures and appliances to be used in the tuberculous affections of different joints do not come within the scope of, and are not described in, this article, but the absence of any description here need not be construed as indicating a lack of the sense of importance of surgical measures. In bone tuber- culosis constitutional treatment alone is but partially curative. Where surgical measures are thoroughly carried out, the best results can be anticipated. BRADFORD. IO9 The subject of the general treatment of tuberculosis will also not be considered here, for the reason that bone tuberculosis as considered in this chapter is to be regarded as amenable to the same general treatment that is found of advantage in tuberculosis elsewhere in the body. The present surgical treatment of bone tuberculosis may be regarded as having developed over that of the past to the extent of retaining the essence of that which was useful in past surgery, with the addition of what modern science has taught us. The fixation and protection of the joints are important at certain stages, namely, the stage of acute invasion and of progressive disease; but they are not indicated in all stages, and greater freedom should be allowed in the convalescent stages, where the exercise and hyperzemia of slight motion is found to be of ad- vantage in restoring function to the cicatrized periarticular tissues. Counter-irritants, which were formerly regarded as of so great value, are now replaced by hyperaemia treatment, which is of benefit in reducing the sluggish congestion of swollen periarticular tissue. Operative interference is of proved value in advanced cases with marked necrosis, and the usefulness of perfected mech- anisms in the prevention of deformity has been abundantly shown. Little need be said here regarding the tuberculous invasion of other tissues which frequently come under the surgeon's care. Tuberculous periosteitis, tuberculous involvement of the glands, tuberculosis of the kidney, of the testes and the prostate, of the mesenteric glands and larynx may all be classed as surgical tuber- culosis. But, like bone tuberculosis, the surgical treatment varies with the locality invaded, and needs special surgical consideration as to the question of surgical interference. In these, as in all forms of tuberculosis, the treatment of the patient's general con- dition should be the first consideration. no TUBERCULOSIS IN MASSACHUSETTS. GENERAL CONSIDERATIONS. The subject of bone and joint tuberculosis needs, in addition to the study of the results of treatment of individual cases, the broader consideration of the subject, especially the relation of the affected individual to the community, and what steps the com- munity should take, not only for the care of the individual afflicted, but also for the protection of other individuals-, especially among the poorer classes. The first and most important consideration is: Should cases with bone and joint tuberculosis be isolated, or to what extent are they to be isolated? The fear of tuberculosis which has recently be- come so evident in our communities is such that the doors of many charitable institutions are closed against even bone tuberculosis. It is important, therefore, to learn to what extent there is danger to the inmates of such an institution from the presence of patients with bone tuberculosis. There can be no doubt that the danger of contagion from bone tuberculosis is greatly exaggerated, if any danger at all exists. It is not conceivable that a patient suffering from a tuberculous focus in one of the vertebral bodies, that is, in the anterior portion of the spinal column, without a discharging sinus, can serve as a source of infection. There would appear to be no danger in the admission of such patients into the wards of a general hospital or convalescent home. All these affections differ entirely from pulmonary tuberculosis, where the sputum is a ready carrier of contagion. It is to be remembered that in bone tuberculosis, where abscesses have developed, with discharg- ing sinuses, the tuberculous process is usually accompanied by the complication of streptococcic bone involvement, which largely transforms the tuberculous osteitis into a septic osteomyelitis. It is possible that the pus-forming organisms in septic osteomye- litis may destroy the virulence of the tubercle bacillus to such an BRADFORD. 1 1 I extent that the danger of contagion is small. If any danger does exist, it can be easily overcome by the use of ordinary surgical dressings. In fact, it may be said that where common surgical care is provided there can be no danger to the inmates of an insti- tution from the admission of patients suffering from bone tuber- culosis. It is undoubtedly of advantage in most institutions to separate children from adults, especially from those with pulmonary tuber- culosis; and it is for these reasons that the surgical treatment of bone tuberculosis properly falls within the province of the chil- dren's hospitals, as by far the greater number of patients suffering from bone tuberculosis are children, and need different surround- ings from those necessary for adults. Home Care Versus Institution Care. — As the majority of these cases occur in childhood, there can be no doubt that home sur- roundings, when favorable, furnish the best environment for children and are much preferable to institution care. These conditions are not always possible among the poor, or even the well-to-do, and for this reason a large number of cases of bone tuberculosis need institution treatment for a portion of the time during the active stage. It must be admitted that efficient care of the patient suffering from caries of the spine or tuberculosis of the hip involves a considerable tax upon the nursing resources of the home. A compromise is possible in most instances, where a short period of institution care may be followed by intelligent home care under direction and supervision. Convalescent Homes. — The value of these institutions in the treatment of bone tuberculosis can hardly be exaggerated. Few private homes furnish the requirements of fresh air and activity which can be given in properly regulated convalescent homes, where the conditions can be made to conform to the requirements demanded by the surgical indications of the patients. Residence 112 TUBERCULOSIS IN MASSACHUSETTS. in a convalescents' home should be limited to those cases where proper home care cannot be carried out, it being an aphorism in all charitable work that it is an unwise policy to remove children from home influences. Seashore Versus Country Convalescent Homes. — There has existed a general feeling that the sea air is especially beneficial to bone tuberculosis, which may be likened to the former belief as to the superiority of mountain air over that of sea air for pulmonary tuberculosis. It is difficult to state definitely what foundation exists for the belief in the superiority of sea air over that of pure air of internal localities. It is probable that the benefit to be derived from seashore homes is that during the hot season the heat is tempered by sea breezes, and the patients are not obliged to remain housed for protection from the intense heat. It would appear reasonable to suppose that the question of a country convalescent home or a seashore convalescent home is a geographical rather than a theoretical one. A convalescent home should be so located as to enable the patients to enjoy the benefit of pure air and a maximum of sunshine for as long a period as possible. There can be no question of the advantages of sea- shore homes during the hot season of the year, provided they are well protected, and allow the proper amount of freedom from any source of tuberculous contagion. School Hours for Patients with Bone Tuberculosis. — As bone tuberculosis in its usual form requires for its complete cure a long period of time, children would be deprived of educational ad- vantages if during the convalescent stage they were unable to attend school. Such children should not only be free from any tax upon their constitutional strength, but also from the rougher play incident to large schools. It is for this reason that special arrangement of school work is advisable for children who are suffering from bone tuberculosis in the acute or the convalescent I o H iz; < H 3 6 1907. 4 '3-7 The ages of those dying from tuberculosis in Oxford during 1907 were twenty-six, forty-seven, sixty-three and seventy-seven respec- tively, and of these four individuals one was only a temporary resident. This shows strikingly how few new cases are appearing in the town. Although this decrease was undoubtedly the result in a large measure of such factors as the general improvement in the living conditions of the poor, it seems fair to attribute the very marked fall in the death-rate during the past seven years to the vigorous campaign carried on against the disease on the part of the au- thorities of the town and some of its citizens. The A. P. Joslin 1 Best. Med. & Surg. Jour., 1905. CLIII, 436. Il8 TUBERCULOSIS IN MASSACHUSETTS. Company has been especially active in investigating conditions in its factory, and in caring for any cases found among the em- ployees. Various notices, calling attention to the prevalence of the disease, the proper measures to be taken to control it, describ- ing the symptoms of the disease and urging all employees with suspicious symptoms to consult a physician, are posted in the factory. Relief to the families of the consumptives is given, and the firm agrees to pay the board in a sanatorium for at least three months of any case appearing among those employed. THE ANTI-TUBERCULOSIS WORK ORGANIZED BY THE CITY OF BOSTON. Boston is the only city in the entire State which has inaugurated a comprehensive municipal anti-tuberculosis movement. A full account of this organization was recently published in the second annual report of the Consumptives' Hospital Department of the City of Boston, 1907, and a further account in the Transactions of the National Association for the Study and Prevention of Tuberculosis, 1908, of which the following is an abstract. The assumption of this work by the city is a direct outgrowth of the many years of splendid activity in this community on the part of many private agencies and the efforts of individual phy- sicians. The needs of this broader work become more evident if the con- ditions in Boston are briefly considered. According to the latest estimates, Boston has a population of 609,757. For the year 1907 the general death-rate per 10,000 inhabitants was 191 .67, of which 9| per cent., or 18.42 per 10,000, were due to tuberculosis. Chart I shows, in terms of the number of deaths per 10,000 inhabitants, the decrease in the death-rate from consumption since 1846. It will be seen that the past twenty-one years marks a diminution iS£^C:i?:^g-S8^^^ fc •^^^fi? -s i.Tr [ 1 1 j ♦.^ lUl, ' -^ /?¥7 *-=. /IVf 1 ^ 3> A^fr /r^* ^ r /fJ7 '2 /?^A > /tS3 f' i ItS^ • ^ ifSS "j> /U(t J( /fsn itSK _,r- /ts^ 7 Ifho I il^l I l%ki. ^■^ I'ii'i I'iltHr 15 ^ l%itS k I1^ « «;"" I'ii'l i ~T itut *,, Ifif "^v. ItTo ^s Itll s H itnA ^ itH g _j /«9r J' itji. ^^ ' itfl t /«n _ Jiff I M ■""■'■ ■ ' ~ ^^^ ^ l^ol f I'ipln. it ikoi J J$a± ^ licKS" J I3j>(t ::.,.■ >1 1 1 1 , J^C7 CHART 1.- SHOWING DEATH-RATE FROM PULMONARY TUBERCULOSIS IN BOSTON FROM 184* TO 1906. LOCKE. 119 of approximately 55 per cent, in the number of yearly deaths from this single cause. This decrease represents an actual saving of 14,412 lives. In spite of this gratifying fall in the death-rate, the total num- ber of deaths from all forms of tuberculosis in 1907 was 1,358. As is well known, this occurred largely among the poorer class. In the absence of any reliable morbidity statistics, the exact number of cases of tuberculosis in the city cannot be stated, but 1 believe we have sufficient basis for the estimate that there are at least 10,000 and probably 15,000 consumptives in the city of Boston. For the care of these cases, the total number of beds in all institu- tions for consumptives previous to the beginning of the present work was 775; 2,131 patients were treated in these beds during the year 1907, and approximately 800 were examined in the four special tuberculosis clinics. The urgent need of greater hospital accommodations for those affected with tuberculosis has for many years been apparent, and in 1901 an appropriation of 1150,000 was finally made by the city government. This sum seemed so inadequate, however, that for many years it was not made available. The real beginning of the present work was made five years later, in the creation of a Consumptives' Hospital Department by the City Council, and the appointment of an unpaid Board of seven Trustees by Mayor Fitzgerald, who were empowered to purchase land and to erect and maintain a hospital for consump- tives. As a means of affording immediate relief, pending the erection of the hospital, the Board of Trustees were authorized by a special act of the State Legislature to "hire not more than one hundred beds in private hospitals and to pay not more than five dollars a week per patient for the use of needy tuberculous patients who are residents of said city." Up to the present time 120 TUBERCULOSIS IN MASSACHUSETTS. the city of Boston has appropriated $307,000 for buildings. For the maintenance of the work thus organized, the city has for the present year made an appropriation of 1 100,000. I Realizing the magnitude of the task and the ineflFectiveness of individual efforts, the trustees have sought to build up a compre- hensive organization which shall so co-ordinate all factors in the work, both public and private, as to effectively deal with all phases of the problem. Success demands sustained efforts along many lines for a long period of years. The Boston Board of Health, the various hospitals for the care of advanced consumptives, sana- toria, special tuberculosis clinics, convalescent homes and many | other agencies, such as the volunteer associations. Associated Charities (comprising over sixteen hundred different societies), churches, women's clubs, labor unions, etc., have co-operated in the fullest degree in the development of this plan of campaign. Since the State Sanatorium at Rutland provides ample accom- modations for all incipient cases, no special provision for the treatment of this class has been made. Our efforts have thus been directed along two main general lines: first, the protection of the well against infection ; and second, the care of the various classes of advanced consumptives. The work undertaken may perhaps be best described under five heads: First. Clinical. Second. Edu- cational. Third. Social. Fourth. Sanit-ary. Fifth. Study and investigation. I. CLINICAL WORK. Obviously the most urgent need has been for facilities for the care of the advanced cases, and the first efforts of the trustees have been directed toward providing such. In the spring of 1906 the trustees purchased an estate of fifty-eight acres in Mattapan, and immediately started the development of plans for a municipal hospital for advanced consumptives. The site chosen is within city limits, in a quiet suburb approximately seven miles from the bo a 2 '3 C J vj 4 LOCKE. 121 center of the city, and is readily accessible by trolley from any part of the city. The land is admirably adapted for the develop- ment of a hospital plant, and is undoubtedly the most favorable of any vacant tract situated within city limits. The general hospital scheme as planned comprises the following buildings: six ward buildings, administration, domestic and pathological buildings, chapel, laundry, nurses' home, central power station, permanent day-camp and a group of cottage wards ; but because of the lack of funds, only the central power station, two ward pavilions, the day-camp, one cottage ward and a temporary do- mestic building can at present be built. The administration of all these institutions, as well as the Out- Patient Department, to be described later, is in charge of one executive head, and the medical work under a single staff, con- sisting of a Chief of Staff, a First Assistant, a Visiting Pathologist, a Laryngologist and a corps of Assistant Physicians. A uniform system in the keeping of clinical records will be installed in all departments, and by a simple system of transfers these will be cross-referenced. A. Hospital for Advanced Cases. — This hospital is designed to furnish accommodations for the care of consumptives in the last stages of the disease. Although this class represents but a small percentage of all consumptives, the building of this hospital is of the first importance, for the reason that they are the class most dangerous to the community and the type most needing hospital care. It is our purpose so far as possible to permanently detain all cases once admitted to the hospital. The ward buildings are of the two-story, pavilion type, placed sixty-five feet apart, connected by open corridors, and are so placed as to permit of extension by the addition of more wards to the limit of four hundred beds. Each ward building is to cost roughly $62,000, and will contain fifty-eight beds. They are of fire-proof 122 TUBERCULOSIS IN MASSACHUSETTS. construction throughout, two stories high, and are arranged with a view to economy and efficiency of administration, absolute cleanliness and comfort for the patients. Their position is such as to afford a maximum of sunshine. It is expected that these wards will be completed by the end of the present year, and the accommodations which they will aflford, together with those in the various institutions in the city which receive advanced cases, will, we hope, be sufficient for all destitute cases. B. The Sanatorium Day-camp. — German statistics show that but from ten to fifteen per cent, of all consumptives are of the incipient type, and those in the most advanced stage of the dis- ease probably comprise a no larger percentage; hence the greatest demand is constantly felt for provisions for the moderately ad- vanced or ambulatory cases. Experience has taught us that the great majority of consumptives cannot be induced to enter a hospital, and, even were it possible, the expense in caring for so large a number would render it impossible to make provisions for them. For three years the Boston Association for the Relief and Control of Tuberculosis has successfully maintained a sanatorium day-camp for consumptives during the summer months, and their success in this special work has led us to attempt the same thing on a larger and more comprehensive scale, and for this purpose we have erected a permanent structure immediately adjacent to the main hospital. This building, which was opened early in July, 1908, is one story high, one hundred and fifty feet long, thirty-six feet wide, of rough but solid wooden construction, and unfinished on the inside. Along the south side is an open veranda one hun- dred by sixteen feet, provided with an overhanging roof of eight feet and awnings. The building contains a well-equipped kitchen, capable of furnishing food for a maximum of five hundred patients a large storeroom with refrigerators, a patients' dining-room seat- ing one hundred and eighty, a small nurses' dining-room, two rest Q O -J S^i^2S2o5g^CoS^< 1 i LOCKE. 123 rooms for patients, one for men and one for women, a thoroughly equipped laboratory, a laryngological room, a linen room, a nurses' office, a medical office and one large examining room. Steam and electricity are to be furnished from the central power station. Its beautiful situation on the edge of a small grove of oaks and sheltered to the north by high rocks and trees gives the most ideal opportunity for the rest treatment for patients. At least two hundred patients can be accommodated in this single institution. The routine of treatment is strictly the accepted sanatorium type. Patients are required to report at the camp at nine a.m., and are allowed to return to their homes not earlier than five p.m. or later than six p.m. The medical work is in charge of a Director and an Assistant, both of whom are assistant physicians to the Boston Consumptives' Hospital. At least one of these assistants is required to be in constant attendance. A head nurse and two assistant nurses are also assigned to the work. One of the latter will devote her entire time to the members of the camp in their homes, and especially to the following up of delinquents. The same exact records are to be kept as in the main hospital. As a routine, the patient must first be registered and investigated at the Out-Patient Department before admittance to the camp. C Cottage IV ards. — Immediately adjacent to the day-camp is being erected a somewhat different type of building, to which we have given the name of "cottage wards." This type is much like the "improved lean-to's" at Liberty and other sanatoria, though of somewhat more permanent construction. It is of one story, and consists of a central portion containing a large assembly room, two locker-rooms, two shower-baths and one tub-bath, lavatories, a wash-room, an emergency ward of two beds and a nurses' room. On each side is a large open ward sixty by eighteen feet, facing to the south, the floor of which is continuous with a wide veranda 124 TUBERCULOSIS IN MASSACHUSETTS. on the south side, extending the entire length. The front of each ward is closed by large windows of three sashes, which can be raised, thus opening the entire front of the ward. Likewise along the end and north side is a row of sliding windows. The entire cottage is about one hundred and fifty feet long and provides for twenty-six beds. The estimated cost is |8,ooo. ■ Exactly the same type of ambulatory cases will be treated here as in the day-camp, and precisely the same hygienic-dietetic regime will be followed. It is designed to care for those patients without homes, or with only such as do not oflfer proper conditions for the patient at night. Depending upon the success obtained in this form of treatment and the demands for hospital accommodations, it is the purpose of the Trustees to build a series of these cottages about the day-camp building as the administrative center. In our opinion, no form of home treatment, however carefully super- vised, can give as good results as can be obtained with this method. D. JVork for Patients. — The plan for the care of patients in both the day-camp and cottage wards includes provision for gradu- ated work. This will be made possible by the routine daily work to be done in the institutions and on the farm which constitutes a considerable portion of the estate. We have in mind not only to prevent the patient from acquiring habits of idleness during his treatment, but to give him the benefit of regular occupation of such nature and length of time each day as his condition permits. In other words, work will be used therapeutically. E. The Out-patient Department {Dispensary). — The first de- partment of the Consumptives' Hospital to be opened was the Out-Patient Department, the first clinic day being September ii, 1907. At present a clinic is held four mornings each week, Satur- day morning being reserved for children. An evening clinic will soon be opened. The place of the dispensary in any properly organized municipal tuberculosis campaign and the best methods f I i LOCKE. 125 to be employed are so well known that I shall not dwell upon these subjects. A suitable four-story house, centrally located and accessible to the poorer sections of the city, where the greatest number of cases of tuberculosis are found, was chosen, thoroughly renovated and adapted to the needs of a tuberculosis clinic. In keeping with the idea of Philip and others, we have made this clinic the center of all activity, as will be seen from the accompany- ing diagram. This diagram is designed to show the close relation existing between our Out-Patient Department and all other in- stitutions receiving tuberculosis patients. Those under our control are drawn in full line, those under other control but still associated with our work, in broken line. In a general way, the size of the circle is intended to represent the relative number of cases which each can accommodate, and the depth of line the relative importance of the individual factors. All cases except the few bed patients must first be registered and studied at the central bureau, then assigned, so far as the accommodations will permit, to the type of treatment best suited to the stage of the disease, the social and financial conditions of the patient, and the individual. The double arrows indicate that cases are not only sent from the dispensary to various other institutions, but when discharged from these are referred back to the same center. In this manner a permanent record will be kept of the patients' whereabouts and condition. I am convinced that this close supervision of tuberculosis patients is the first essential to suc- cessful control. No intelligent efi"ective work in controlling the spread of the disease is possible without it. A list of all cases of contagious diseases with addresses is sent to the office of the dispensary daily by the Board of Health. All members of the family of a tuberculous individual are sys- tematically sent or brought to the clinic for examination. This work is principally done by the visiting nurses from our clinic. 126 TUBERCULOSIS IN MASSACHUSETTS. During the past two years especially, work of this nature has been done among the children under the direction of the committee from the Associated Charities, Boston Association for the Relief and Control of Tuberculosis, and the Boston Consumptives' Hos- pital. For the purpose of this work the city was divided into four districts, each with its tuberculosis clinic to which the children of that district were taken. A record of all cases was sent to the Out-Patient Department of the Consumptives' Hospital as a cen- tral bureau. In consequence of the better facilities for the work and the special clinic for children maintained there, the majority of the children have been sent to the Out-Patient Department. By the application of the newer exact methods of diagnosis, we have found a surprising number of children to be infected. All these methods above mentioned comprise what 1 have termed "aggressive work." Experience has convinced us that by the ordinary methods of an out-patient department, where the patients are left to come voluntarily, only a small percentage of cases is ever discovered. A considerable portion of the time of our nurses is spent in following up delinquents and in bringing in- dividuals to the clinic for examination. Besides the visiting physician, there are nine nurses on duty at the dispensary, four of whom are in attendance at the Out-Patient Department on clinic morning. The routine work of history tak- ing, etc., is done by these nurses. Besides her duties at the clinic, each of the nurses is assigned a definite section of the city, and under the direction of a Superintendent of Nurses she carries out the line of work most necessary. Nothing has been so gratifying and encouraging to us as the success which these nurses have at- tained in their work, and we regard them more and more as the all-important agents in the work. In spite of every provision for suitable institution treatment and the exercise of every possible influence, the majority of con- at yr]^JtcLfUi,m._ Cotk^lX^i^ -^U^^J^jr^ *y..WJw^ 0/a*A^t4 Armorers, . •3 Agents, 10 Cooks, 10 Domestics, 9 Farmers, . 9 Gardeners, 8 Nurses, 7 Porters, 7 Screw-workers 7 Wood-workers 7 GETCHELL. I9I The figures of these two groups of cases pointed to no definite industry as productive of tuberculosis. Still, in order to investi- gate the question more directly, I visited personally most of the largest plants and many of the smaller ones. I was given every opportunity to thoroughly inspect them, in several instances my guide being the superintendent of the place. I found the owners of the mills and superintendents generally interested in the sub- ject, and in some instances particularly so. The hygienic character of the buildings varied directly with their age, the newer ones being always better, — in many instances models of proper mill construction. Some of the plants were the growth of more than half a century. In one of them I was shown a room in which the old overshot wheel was first installed, still used for manufacturing purposes, — a dark, ill-ventilated room. I particularly inspected all factories in which either wet or dry grinding is done. In some of the factories the grinding was done in large, light, above-ground rooms; in others, in darker basements. But everywhere I found an efficient system of exhaust pipes, through which the dust of the grinding was removed, and the air in the vicinity of the grinding machines was apparently as free from dust as that in other parts of the same factory. The foremen of these factories talked very freely with me about consumption among their employees, and from their experience, as well as from my own investigations, I could not attribute to grinding a causative factor. In these visits I was impressed with the care taken to keep the factories clean; in some places men or boys were constantly employed sweeping the floors and removing the dirt. The histories of the thousand cases which form the basis of this paper were taken on similar printed forms. One of the questions related to the source of infection. Personally, this subject has very much interested me, and I have laid stress upon it in exam- inations. But I can recall only one instance in which an operative thought he contracted the disease at his work. That was an op- 192 TUBERCULOSIS IN MASSACHUSETTS. erative in a hat shop, who said that a fellow workman had had a cough for some time and freely spat on the floor. From this study my conclusions are that no industry in Worces- ter stands in any particular causative relation to tuberculosis. If it shows anything, it emphasizes the belief that the disease im- plants itself in the home; that it develops most readily in those who follow a sedentary life (note the large number of clerks and students) ; that it occurs more often in the unskilled workman, who earns small wages, and consequently cannot house and feed himself adequately. There can be no question that certain occupations are worse for the already tuberculous than others; and there can be no question as to the duty of the community to insist that all work places be as healthy as the requirements of the particular industry will allow, that the well may keep well, and that those predisposed to tuberculosis or having the disease may not be so weakened by un- hygienic surroundings that they will succumb to it. An efficient campaign against tuberculosis means clean streets, clean, light and well-ventilated stores, offices, public places, schools and factories; but in this community at least, we must look to the home as the main breeding-place of the disease, and it is upon the home that we must concentrate our main energies for its extermination. GORDON. '93 CHAPTER XVI. TUBERCULOSIS AMONG THE GRANITE WORKERS OF QUINCY. John A. Gordon, M.D. It has long been recognized that the proportion of deaths from pulmonary tuberculosis among the granite workers of Quincy was relatively very large; but it was not until a careful investigation of the vital statistics of the city was made that the extent of the disease became fully evident. For twenty years there have been on an average twenty-five hundred men employed in the Quincy granite works. Of these, about five hundred are quarry men, twelve hundred granite cut- ters, three hundred polishers, one hundred and fifty paving cutters, and the remainder are made up of tool sharpeners, boxers, teamsters, carriers and others whose occupation is inci- dental to the business. In this report only the causes of death among the granite cutters, quarry men and paving cutters will be considered, as it was found that the causes of death among polishers, sharpeners, boxers, teamsters and carriers are essentially the same as among men employed in other occupations. On careful examination of the records of death in Quincy for the ten years, i.e., from 1897 to 1906 inclusive, it was shown that the total number of deaths among granite cutters from all causes was two hundred and three, of which ninety-three, or 46 per cent., were from tuberculosis. The average age was fifty-nine. The following table shows the relation of the number of deaths from tuberculosis to the total number of deaths among granite cutters by years for the same period: — 194 TUBERCULOSIS IN MASSACHUSETTS. ^.T, \ Total Number Total Number of Deaths from Percentage of Total Number of YEAR. of Deaths from All Causes. All Forms of Tuberculosis. Deaths due to Tuberculosis. ■897 '9 9 47 1898, 26 10 38 1899, 20 6 30 1900, 17 10 59 19OI, 23 12 52 1902, 23 9 39 1903, 18 7 39 1904. '7 1 1 65 1905, 25 10 40 1906, ■5 9 60 203 93 46 Of these ninety-three deaths from tuberculosis, forty-six, or nearly 50 per cent., occurred between the ages of forty and sixty, as will be seen from the following table: — AGE. Number of Deaths. Under 20, 20-30, 30-40, 40-50, 50-60, 60-70, Over 70, . 2 II >3 23 23 18 3 93 Twelve deaths occurred among the paving cutters, of which five, or 41.5 per cent., were due to tuberculosis, and the average age was fifty-four years. Nine, or 22.5 per cent., of the forty deaths among the quarry men were due to tuberculosis. The average age was forty-eight. The largest proportion of deaths from tuberculosis, or 15 per cent. GORDON. 195 of the whole number, occurred between the ages of forty-five and fifty years. The number of deaths from tuberculosis among the polishers, boxers and tool sharpeners averaged only about 1 5 per cent., and is essentially the same as that from tuberculosis in other occupa- tions found in Quincy. The whole number of deaths in Quincy during the above-men- tioned period, i.e., the years 1897 to 1906 inclusive, was four thou- sand two hundred. Of these, but four hundred and fifty-four, or 1 1 per cent., were from tuberculosis. If we deduct the fourteen hundred deaths in children under five years from this number, very few of which were from tuberculosis, leaving twenty-eight hundred deaths in persons over five years of age, in ten years we get an average death-rate from tuberculosis which is only 16 per cent, of the total death-rate. It will thus be seen that the number of deaths from tuberculosis among granite cutters and quarrymen is relatively very large. It is interesting to note that in the two hundred and fifty-five deaths among granite cutters, quarrymen and paving cutters, eighteen, or 7 per cent., were from pneumonia, and fifty-four, or 21 per cent., were from disease of the circulatory system (heart disease, thirty-six; arterio-sclerosis, seven; apoplexy, eleven). In my experience of thirty-seven years among the granite cutters of Quincy I have found that a large number were affected with chronic bronchitis and emphysema, and in almost all cases the bronchitis preceded the development of tuberculosis by a consider- able period. There is one feature which somewhat lessens the serious aspect of the condition under consideration. The deaths from tubercu- losis occurred generally somewhat late in life, differing materially in that respect from the usual history of the disease. But it is deplorable, inasmuch as in nearly 50 per cent, of the cases the men 196 TUBERCULOSIS IN MASSACHUSETTS. were infected during the active working period of life, and at an age when their time is most valuable. in investigating the causes of this large proportion of deaths from tuberculosis among the granite workers of Quincy, it is im- portant to examine the peculiar conditions attending the quarrying and cutting of granite as carried on at the present time. The granite from these quarries is a syenite, consisting of quartz, felspar and hornblend, with an occasional mixture of mica, and is in consequence very hard, cutting with difficulty. The granite is quarried by drilling holes in the face or surface of the rock about one and one-half inches in diameter and several feet deep. These holes are charged with powder, which, when exploded, breaks off large masses of the rock. These masses are subdivided into blocks by drilling smaller holes in them and splitting with ingeniously devised wedges inserted in these holes. The drill for the large holes is a steel bar one and one-quarter inches in diameter, with a flat cutting point. It is operated by two men. One man holds the drill and turns it about in the hole, while the other man hits it on the head with a heavy sledge hammer. Every blow forces from the hole a quantity of fine dust from the disintegrated granite, which is liable to be inhaled by the man who holds the drill. The smaller holes are drilled by one man, who holds and turns the drill with his left hand while he hits it with a heavy hammer held in his right. This also sets free a large quantity of fine dust. In many cases these drills are worked by compressed air, when a much larger amount of dust is produced. In most cases the quarries are from twenty-five to a hundred and fifty feet deep, and, as there is no air stirring, the quarrymen are almost constantly enveloped in a cloud of this fine dust. The cutting sheds where the granite is finished are built about a semi-circular or rectangular yard, usually of boards, with a tight roof to keep out the rain. They are from twenty to thirty feet GORDON. 197 wide and about twenty feet high, and vary in length according to the size of the yard and the number of men employed. Each man has a ground space of about fifty square feet. There are doors along the front and back of these sheds about eight feet high, which can be raised or lowered by pulleys. Some of the sheds have closed windows in the walls above these doors, others have ventilators of slanting boards along the ridge pole. These venti- lators are of little use, however, in removing the dust. In the very hot season the front and back doors are usually open, and there may be a current of air in the sheds. In cold or windy weather the back doors are usually shut, and in the winter season both front and back doors are kept closed and the sheds heated by stoves. In this case the sheds are always full of dust. The workmen are frequently exposed to draughts not sufficiently strong to carry off the dust, yet sufficient to chill the body after perspiring. The blocks of granite are brought into proper shape and trimmed by clipping off the superfluous parts with a sharp- pointed chisel and heavy mallet. They are then finished or cut with the bush hammer, which consists of a handle about two feet long and a head made up of from three to twelve blades of hard steel two and one-half to three inches square, with one side double-bevelled to a cutting edge. These are bolted together to the head of the hammer so as to form parallel grooves on the cut- ting face. By hitting the block of granite with these bush ham- mers the surface is gradually disintegrated and thrown off in the form of a very fine, almost impalpable powder, which floats about the cutter in the form of a cloud of fine dust. It is inevitable that the dust should be inhaled with every breath. In some cases the bush hammer is operated rapidly by compressed air, and in these cases a still greater amount of dust is produced. The particles of dust are very fine and float in the air for a con- 198 TUBERCULOSIS IN MASSACHUSETTS. siderable time. When seen under the microscope they present the appearance of elongated flattened masses, with numerous sharp angles and pointed spiculae. The injurious effects of the constant inhalation of the pulverized granite on the lung tissue is well known. The granite cutter usually works in a stooping posture, with the upper part of the body bent over the stone; and this position seriously interferes with the breathing capacity of the chest. This is particularly the case with the letter cutters and carvers, who have to look closely at their work. We find, then, that the granite worker is exposed to three peculiar conditions: dust of a particularly irritating character; constrained position of the upper part of the body; and excessive draughts. The determining factors in the development of tuberculosis are the state of health and the susceptibility of the individual, the vulnerability of the lungs and the duration and intensity of the exposure to the dust and abnormal posture. The remedy is difficult to apply, but not impossible. We must first inaugurate a crusade of enlightenment in the matter. It is found, generally, that the granite manufacturers and the granite workers themselves are very unwilling to believe that the occu- pation is extra-hazardous, or that the dust is a dangerous element. If the facts were brought forcibly to their minds, there is every reason to believe that both the manufacturers and the workmen would voluntarily do a great deal to ameliorate the condition under which the work is done. In the first place, larger and better ven- tilated sheds should be provided, so that each workman would have more room, and would not be exposed to the dust produced by his fellow workman. Each workman should exercise more care in the management of the dust which he produces. Instead of sweeping the dust from the stone on which he is working and scattering it into the air again, he should gather it up carefully GORDON. 199 with a brush and deposit it in a receptacle for the purpose. The sheds should be provided with windows sufficient to give abundance of light, so that it would not be necessary for the workman to bend so closely over the stone in order to follow his marks and lines. Proper appliances should be used to place the stones at a suitable height, so that the cutter could work in an upright position, and he should be taught to appreciate the importance of working in this position. He should understand the importance of protecting himself, when perspiring, from exposure to the cold air, while the position of his stone is being changed. He should be made to understand his susceptibility to tuberculosis, and the danger he incurs from sleeping and living with others who are suffering from the disease. He should change his occupation when the symptoms of chalicosis or dust poisoning begin to show themselves, before the destructive processes in the lungs have become advanced. Respirators made of wire netting and containing a suitable sponge to cover the mouth and nose have been recommended, and used in some cases, but they are unsightly and inconvenient. The sponge soon becomes moistened by the breath and clogged with dust, thus requiring frequent washing and cleaning. It further interferes with speaking. It seems possible that a contrivance for aspirating the dust might be made similar to those employed in shoe factories, wood- turning shops and other dust-producing works, the use of which is obligatory in many cases. This would involve considerable ex- pense, especially for the smaller sheds, and might make the work of granite cutting unprofitable. But if the several smaller man- ufacturers would combine and build more commodious and more suitably constructed sheds and equip them with contrivances for handling and placing the stone for convenience in working, and install in them large aspirating pipes with adjustable funnels that could be brought in front of each cutter, into which the dust 200 TUBERCULOSIS IN MASSACHUSETTS. would be drawn as soon as made and carried out of harm's way, this would be made possible. It does not seem that the expense would be very excessive, as in all the large manufactories they al- ready have powerful machinery for the production of compressed air for operating the pneumatic appliances and surfacing ma- chines, and the dust itself might even be used as a by-product for various useful purposes. f I APPENDIX. t i List of articles on Tuberculosis by Massachusetts authors.' Abbott, J. Case of Abscess of the Lung, with Enlarged and Tuberculous Liver. Bost. M.&S. J., 1842, XXVL 77. Abbott, S. W. Consumption: an Indoor Disease. Bost. M. & S. J., 1898, CXXXVIH, I. The Decrease of Consumption in New England. Quart. Pub. Am. Statist. Ass., 1904, IX, I. Adams, J. D. A Report of Seventeen Cases in Open-air Treatment for Surgical Tuberculosis in Children. Bost. M. & S. J., 1906, CLIV, 71. Adams, J. F. A. The Segregation of Consumptives. Med. Com. Mass. Med. Soc, 1907, XX, 397. Austin, A. E. Some Observations on Tubercular Meningitis. Bost. M. & S. J., 1894, CX XX I, 637. Ayer, J. B. Cerebral Symptoms Connected with Phthisis. Bost. M. & S. J., 1889, CXXI, 129. Bartlet, E. Fatal Pleurisy in Tuberculosis Patients and Chronic Tubercular Peritonitis, etc. Am. J. M. Sc, 1836, XVIII, 325. Bates, E. A. A Case of Tuberculous Pericarditis with Enormous Effusion: Gen- eral Tuberculosis: Autopsy. Bost. M. & S. J., 1894, CXXX, 7. BoARDMAN, W. S. The Treatment of PulmonaryTuberculosis by the Subcutaneous Use of the Chloride of Gold and Sodium with the Iodide of Manganese. Bost. M. & S. J., 1894, CXXX, 492. Borland, J. N. Cases of Tuberculosis. Bost. M. & S. J., 1868, II, 145. Both, C. A New and Effective Method for Treating Consumption (Phthisis Pul- monalis) through Artificial Calcification. Pamphlet, 46 pp., Boston, 1868, E. P. Dutton & Co. A Sketch of the Theory and Cure of Phthisis (Tuberculosis, Consumption). Pamphlet, 32 pp., Boston, 1864, A. Williams Co. Method for the Radical Arrest of Tuberculosis of the Lungs by Artificial Calcification. Ztschr. f. prakt. Heilk. u. Med.-Wes., Hannover, Mar. 3, 1871. Consumption and its Treatment in all its Forms. Boston, 1873, G. Lee & Shepard. Method for Treating Tubercular Consumption. Pamphlet, 20 pp.. New York, 1877, Cherundy & Kienlo. 1 References to surgical tuberculosis, with a few exceptions, arc not included. 204 TUBERCULOSIS IN MASSACHUSETTS. BowDiTCH, H. I. Pathological Researches on Phthisis. Revision of Cowan's Translation of Louis on Phthisis, Boston, 1836. Paracentesis Thoracis. Am. J. M. Sc, 1852, XXIII, 103. Am. M. Month., 1854, I, 7. Cases of Anomalous Development of Tubercles. Am. M. Month., 1855, IV, I. Thoracentesis. Host. M. & S. J., 1857, LVl, 349. Topographical Distribution and Local Origin of Consumption in Massachu- setts. Med. Com. Mass. Med. Soc, 1862, 59. Paracentesis Thoracis, a Resume of Twelve Years' Experience. Am. J. M. Sc, 1863, XLV, 17. Is Consumption ever Contagious or Communicated by One Person to Another in any Manner? Host. M. & S. J., 1864, LXX, 329. Consumption in America. Atlantic Monthly, Jan., Feb., and Mar., 1869. Thoracentesis and its General Results. N. Y. Acad. Med., Apr. 7, 1870. Thoracentesis. Lond. Practitioner, Apr., 1873. The Isles of Shoals as a Summer Resort for the Invalid and as Presenting a Specimen of One of the Three Climates of New England. Bost. M. & S. J., i88i,CIV, I. A Case of Arrested Phthisis. Bost. M. & S. J., 1883, CIX, 569. Open-air Travel as a Cure for Consumption. Trans. Am. Clim. Ass., 1889, VI, 194. BowDiTCH, V. Y. The Treatment of Pulmonary Diseases by means of " Pneu- matic Differentiation." Bost. M. & S. J., 1885, CXIII, 55. A Case of Phthisis with Numerous Bacilli. Complete Arrest of the Disease. Bost. M. &S. J., 1885, CXIII, 558. Ten Months' Experience with Pneumatic Differentiation. Trans. Am. Clim. Ass., 1886, III, 47. Comparative Importance of Different Climatic Attributes in the Treatment of Pulmonary Consumption. Trans. Am. Clim. Ass., 1888, V, 44. Two Cases of Phthisis Treated by Intrapulmonary Infections. Bost. M. & S. J., 1889, CXX, 455. Comparative Results in Ninety Cases of Pleurisy with special reference to the Development of Phthisis Pulmonalis. Trans. Am. Clim. Ass., 1889, VI, I. The Establishment of Sanitaria for Pulmonary Diseases in the Vicinity of our Great Cities. Bost. M. & S. J., 1892, CXXVI, 191. Three Years' Experience with Sanitarium Treatment of Pulmonary Diseases near Boston. Trans. Am. Clim. Ass., 1894, X, 254. A Plea for Moderation in our Statement Regarding the Contagious- ness of Pulmonary Consumption. Bost. M. & S. J., 1896, CXXXIV, 637. APPENDIX. 205 BowDiTCH, V. Y. The Treatment of Phthisis in Sanitaria near our Homes. Bost. M. &S. J., 1896, CXXXV, 125. Suggestions: the Result of Recent Experiences with Phthisical Patients. Trans. Am. Clim. Ass., 1898, XIV, 28. State Sanatoria for Tuberculosis. Providence M. J., 1900-01, I, 5. The Massachusetts State Hospital for Consumptives at Rutland; its Pur- poses and the Work Accomplished during the First Year. Bost. M. & S. J., 1900, CLXII, 127. The Home (Sanitarium) Treatment Versus the Climatic Treatment of Con- sumption. Bost. M. & S. J., 1901, CLXV, 328. The Care of Consumptives in State and Private Sanatoria in Massachusetts. Maryland M. J., 1902, XLV, 97. Subsequent Histories of Seventy-nine Arrested Cases Treated at the Sharon Sanitarium, 1891-1902. Trans. Am. Clim. Ass., 1903, XIX, 64. Origin and Growth of Sanatoria for Tuberculosis in Massachusetts. J. of Tuberculosis, Nashville, 1903, V, 147. ■ Arrested Tuberculosis, Subsequent Histories of Cases Treated at the Sharon Sanatorium. Bost. M. & S. J., 1904, CL, 309. Pulmonary Tuberculosis and Sanatorium Treatment. Bost. M. & S. J., 1904, CLI, 589. and Dunham, H. B. Six Years' Experience at the Massachusetts State Sanatorium for Tuberculosis. J. Am. M. Ass., 1905, XLIV, 1973. The Treatment of Phthisis in Sanatoria near our Homes. Med. Com. Mass. Med. Soc., 1906, XVII, 10 1. The Scope and Aim of State Sanatoria for Tuberculosis. Trans, of the Nat'l Ass. for the Study and Prevention of Tuberculosis, 1906, II, 287. and Griffin, W. A. Subsequent Histories of One Hundred and Sixty "Arrested Cases" of Pulmonary Tuberculosis Treated at the Sharon San- atorium, 1891-1906. J. Am. M. Ass., 1907, XLVIII, 2016. The English Sanatorium. Jour, of the Outdoor Life. 1907,111,461. Bowen, J. T. 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Considerations on a Change of Climate by Northern Invalids, and the Climate of Aiken, South Carolina. Bost. M. & S. J., 1851, XLV, 269. A Consideration of some of the Relations of Climate to Tubercular Disease. Bost. M. & S. J., 1852, XLV, 449. BuRRELL, H. L. Surgical Tuberculosis. Bost. M. & S. J., 1903, CXLVII, 685, and CXLIX, I. , CusHiNG, H. W., and Stone, J. S. Tuberculous Ulceration of the Lower Ileum. Perforation. Peritonitis. Operation. Death at the End of Five Weeks. Bost. M. & S. J.. 1904, CLI, 685. Cabot, A. T. Remarks upon the Proper Surgical Treatment of Tuberculous Bone Disease. Bost. M. & S. J., 1898, CXXXVIII, 79. The Physician's Duty towards Tuberculosis. Bost. M. & S. J., 1905, CLIII, 657. Call, E. L. Acute Tuberculosis in Puerperal Women. Bost. M. & S. J., 1897, CXXXVII, 343. Channing, W. Softening of the Brain, with General Tuberculosis. Bost. M. & S. J., 1863, LXIX, 9. Tuberculosis in Mental Disease. Bost. M. & S. J., 1894, CXXXI, 63. The Importance of Frequent Observations of Temperature in the Diagnosis of Chronic Tuberculosis. Bost. M. & S. J., 1895, CXXXI II, 609. Cheney, F. E. A Case of Tuberculosis of the Conjunctiva, Probably Primary, Followed by General Infection and Death. Bost. M. & S. J., 1896, CXXXV, 490. Chute, A. L. Urethral Tuberculosis, with Report of a Case. Bost. M. & S. J., 1903, CXLIX, 361. Clapp, H. C. Is Consumption Contagious and can it be transmitted by Means of Food? Boston, 1880, 178 pp., Otis Clapp & Son. Phthisis Pulmonalis. Amdt's System of Medicine, Vol. I., Phila., 1885-6, F. E. Boericke. Tuberculosis. Arndt's System of Medicine, Vol. Ill, Phila., 1885-6, F. E. Boericke. The Dangers of the Microscope in the Early Diagnosis of Pulmonary Tuber- culosis. Am. Med., 1904, VIII, 1010. What Cases are suitable for Admission to a State Sanatorium for Tubercu- losis, especially in New England? Am. Med., 1905, X, 148. and Lapham, G. N. Basic Pulmonary Tuberculosis. N. E. Med. Gazette, 1905. XL, 343. On the Importance of Early Diagnosis in Cases of Pulmonary Tuberculosis. Bost. M. & S. J., 1906, CLIV, 65. APPENDIX. 207 Clapp, H. C. Treatment of Pulmonary Tuberculosis in New England, the Home and Sanatorium. N. E. Med. Gazette, 1907, XLII, 54. Cold Air in Incurable Consumption. Bost. M. & S. J., 1907, CLVI, 850. Pulmonary Tuberculosis: Some of the Details of its Modern Hygienic Treat- ment which can be applied in treating the Patient at his own Home. N. Y. Med. Record, 1907, LXXI, 718. Diet in Pulmonary Tuberculosis. N. Y. Med. Record, 1907, LXXI, 1074. Clark, J. P. Tubercular Tumors of the Larynx. Am. J. M. Sc, 1895, CIX, 525- The Condition of the Nose in Phthisical Patients. Bost. M. & S. J., 1895. CXXXIII, 343. Clarke, A. B. Case of Co-existence of Cancer and Tubercle. Bost. M. & S. J., 1863. LXVn,474. Clarke, A. P. Pelvic Tuberculosis. Bost. M. & S. J., 1899, CXLI, 87. Clarke, E. H. Phthisis and Pleurisy with Pneumohydrothorax, treated by Para- centesis Thoracis; Iodine Injections into the Pleural Cavity. Bost. M. &S. J., 1859, LXI, 249. Hydrate of Chloral, with Cases illustrating its Action. — Phthisis. Bost. M. & S. J., 1870, LXXXII. 455 and 456. Cobb, F. Pseudo-tuberculosis of the Peritoneum. Report of a Case. Bost. M. &S. J., 1907, CLVI I, 861. Coffin, A. On Climate in the Treatment of Pulmonary Tuberculosis, etc., with . special Reference to that of Aiken, South Carolina. Bost. M. & S. J., 1868, II, 321. CooTE, C. T. A Case of Cancer of the Stomach associated with Tubercular Disease of the Lungs. Bost. M. & S. J., i860, LXI I, 204. Copp, O. What should be the State Policy regarding Tuberculosis in Insane Asy- lums? Bost. M. & S. J., 1906. CLIV, 63. Cornell, W. M. Consumption Forestalled and Prevented. Boston, 1846, 120 pp., James French. Consumption Curable and its Treatment. Boston, 1850, loi pp., Wm. Crosby & H. P. Nichols. 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Cutler, E. G. Record of Two Cases of Beginning Pulmonary Tuberculosis • Treated with Subcutaneous Injections of Koch's Tuberculin T. R. Bost. M. &S. J., 1897, GXXXVII, 571. DeBlois, T. a. The Rapid Fatality of Tuberculosis when involving the Pharynx. Bost. M. & S. J., 1885, CXIII, 397. Sub-glottic Tubercular Lesions of the Larynx. Bost. M. & S. J., 1904, CLI, 321. DiLLENBACH, H. P. Medicated Inhalation in the Treatment of Pulmonary Con- sumption, Bronchitis, Asthma, Catarrh and Clergymen's Sore Throat. Boston, 1857, 214 pp., G. C. Rand. Donaldson, F. The Influence of City Life and Occupations in developing Pulmo- nary Consumption. Pamphlet, 20 pp., Cambridge, 1876, Riverside Press. Dunham, H. B. Contractile Processes in the Lungs as a Result of Phthisis with Reference especially to their Production of Permanent Dextrocardia. Bost. M. & S. J., 1905, CLI V, 1 55. Some Observations on Tuberculin. Am. Med., 1901. Pulmonary Gymnastics in Tuberculosis. Bost. M. & S. J., 1906, CLV, 61. Favorable and Unfavorable Climates for Tuberculosis. Colorado M. J., March, 1904. Dunn, C. H. Recent Advances in the Knowledge of Tuberculosis in Early Life. Bost. M. & S. J., 1907, CLVII, 389. Durrant, G. M. On the Nature, Diagnosis and Treatment of Incipient Phthisis. Bost. M. & S. J., 1843, XXVI 1 1, 409 and 449. Edes, R. T. Acute Tuberculosis Simulating Typhoid Fever. Bost. M. & S. J., 1872, X, 326. Edson, G. E. The Pulmonary Invalid in Colorado. Med. Com. Mass. Med. See., 1896, XVII, 91. Elliott, J. L. The Bacillus Tuberculosis and the Busy Practitioner. Phila. Med. Times, 1886, XVII, 662. Ellis, G. Tubercle — Its Pathology and especially its Relation to Inflammation. Am. J. M. Sc, i860, XXXIX, 203. Recent Views of Tubercle. Bost. M. & S. J., 1870, V, 166. Ernst, H. G. A Contribution to the Study of the Tubercle Bacillus. Bost. M. & S. J., 1883, CIX, 100, and 121. Some Observations on the Bacillus of Tuberculosis. Am. J. M. Sc, 1884, LXXXVIII, 367. APPENDIX. 209 Ernst, H. C. How far may a Cow be Tuberculous before her Milk becomes Dangerous as an Article of Food? Congr^s pour I'Etude de la Tuber- culose, Paris, 1890. Am. J. M. Sc, 1889, XCVill, 439. Koch's Treatment of Tuberculosis. Bost. M. & S. J., 1891, CXXIV, 23, 77, and 105. Preliminary Report on the Clinical Use of Tuberculin. Bost. M. & S. J., 1891, CXXV, 5, 25, 55, 76, and 131. Tuberculin and Tuberculosis. Trans, of Ass. of Am. Phys., 1891, VI, 15. Carosso's Treatment of Pulmonary Tuberculosis. Trans, of Ass. of Am. Phys., 1895, X, 237. Infectiousness of Milk (Tuberculous). (Result of Investigations made for the Trustees of the Massachusetts Society for Promoting Agriculture.) Boston, 1895. Mass. Soc. for Promoting Agriculture. and Smith, T. Report on Cattle treated with Tuberculin. Mass. House of Representatives, No. 1341, 1897. FiTz, R. H. The Theory of Tuberculosis. Med. Com. Mass. Med. Soc, 1871, X, 30. Tuberculosis of the Genito-urinary Organs and Caries of the Vertebra. Bost. M. & S. 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J., 1901, CXLIV, 53. 212 TUBERCULOSIS IN MASSACHUSETTS. Knight, F. I. The Association of Tuberculosis and Syphilis. Trans. Am. Clim. Ass., 1901, XVII, 142. What shall we do with Patients having Pulmonary Tuberculosis? Bost. M. &S. J., 1904, CLI. 257. Discussion of the Report on Early Diagnosis of Tuberculosis. Bost. M. & S. J., 1905, CLII, 665. Climate as a Factor in the Treatment of Tuberculosis. Trans. Nat'l Ass. for the Study and Prevention of Tuberculosis, 1906, II, 437. The Importance of Supervision of Patients after leaving Sanatoria Appar- ently Cured of Tuberculosis. Trans. Am. Clim. Ass., 1907, XXIII, 180. Langmaid, S. W. The Treatment of Laryngeal Phthisis. Bost. M. & S. J., 1894, CXXXI, 59. Lapha.m, G. N. Early Symptoms of Pulmonary Tuberculosis. N. Eng. M. Gazette, 1906, XLI, 109. Leen, T. F., and Bottomley, J. T. Tuberculous Ulcer of the Ileum. Perfora- tion. General Peritonitis, Operation. Death. Bost. M. & S. J., 1907, CLVII. 605. Locke, E. A. 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J., 1887. CXVI,628. Pulmonary Tuberculosis with Special Reference to its Prophylaxis, Hy- gienic and Climatic Treatment. Bost. M. & S. J., 1893, CXXIX, 337 and 365. Climatic Therapeutics in the Treatment of Pulmonary Tuberculosis. Bost. M. &S. J., 1894, CXXXI, 51. Some Methods of Chest Examination, Supplementary to Auscultation and Percussion. Bost. M. & S. J., 1895, CXXXII, 355. Treatment of Advanced (Hopeless) Cases of Phthisis. Bost. M. & S. J., 1895, CXXXII, 609. The Value of Respiratory Gymnastics in maintaining the Integrity of the Lungs as an Aid in the Treatment of Diseases of these Organs. Bost. M. &S. J., 1896, CXXXIV, 525. The Sanatorium or Closed Treatment of Phthisis. Bost. M. & S. J., 1896, CXXXV, 241. 214 TUBERCULOSIS IN MASSACHUSETTS. Otis, E. O. Are Especial Hospitals or Homes for Consumptives a Source of Danger to their Neighborhood? Bost. M. & S. J., 1897, CXXXVI, 305. The Causes and Conditions of Pulmonary Tuberculosis, and how to avoid them. Am. J. M. Sc, 1898, CXVI, 532. Hospitals and Sanatoria for Consumption Abroad. Bost. M. & S. J., 1898 CXXXVIII,265, 313 and 329. Some Modern Methods of the Treatment of Phthisis and its Symptoms Bost. M. & S. J., 1898, CXXXIX, 31 and 55. The Value of the Tuberculin Test in the Diagnosis of Tuberculosis. Bost M. &S. J., 1899, CXLI, 21. Some Notes upon the Tuberculin Test. Bost. M. & S. J., 1899, CXLI, 247 The Struggle against Tuberculosis. Bost. M. & S. J., 1899, CXLI, 280. Especial Hospitals for Consumptives Among the Poor in Large Cities Phila. M.J.. 1900, V, 1468. The Duty of the State and Municipality in the Care of Pulmonary Tuber- culosis among the Poor. Albany M. Ann., 1900, XXI, 198. Further Notes upon the Diagnostic Test of Tuberculin. Med. News, N. Y., 1901, LXXIX, 281. State Sanatoria for Tuberculosis. Providence M. J., 1901, I and 11, 8. Measures for stamping out Consumption. Proc. Am. Invalid Aid Soc, § 1 90 1. The Home Treatment of Tuberculosis versus the Climatic Treatment. Bost. M. & S. J., 1901, CXLIV, 609. The City Consumptive Hospital and the Duty of the Municipality and People Regarding Consumption. Bost. M. & S. J., 1902, CXLVI, 461. The Struggle Against Consumption. Bost. M. & S. J., 1902, CXLVI, 625. Dispensaries for Tuberculosis with a Description of the Tuberculosis De- partment of the Boston Dispensary. Trans. Am. Clim. Ass., 1903, XIX. 71. The Significance of the Tuberculosis Crusade and its Future. Bost. M. & ' S. J., 1904, CL, 694. ; Dispensaries for Tuberculosis. Charities, 1904. ^ The Tuberculosis Problem and some Suggestions in dealing with it. Bost. k M. &S. J., 1905, CLII. 127. f Home Treatment of Tuberculosis either in favorable or unfavorable Climate. |- Trans. Nat'l Ass. for the Study and Prevention of Tuberculosis, 1905, ; 1.389- The Municipal Control of Tuberculosis. Bost. M. & S. J.. 1905, CLII I, 716. Workshops and Tuberculosis. Bull. No. 5 of the Civic Federation of N. Eng., May, 1906. The Use and Abuse of Pulmonary Gymnastics in Tuberculosis. Bost. M.&S. J.. 1906. CLV. 59. APPENDIX. 215 Otis, E. O. The Tuberculosis Dispensary; Its Methods, Value and Limitations. J.Am. M. Ass., 1906, XLVII,2i54. The Blood Pressure as a Guide in the Treatment of Tuberculosis. Bost. M. &S. J., 1907, CLVII, 211. Public Provision for Advanced Cases of Tuberculosis. J. Am. jM. Ass., 1907, XLIX, 818. The Early Diagnosis of Pulmonary Tuberculosis for the General Prac- titioner. Bost. M. & S.J. , 1907, CLVII, 361. Palmer, S. E. A Case of Tuberculosis Contagion. Bost. M. & S. J., 1904, CL, 588. Parker, W. T. Should the State treat Tuberculosis? Bost. M. & S. J., 1896, CXXXIV, 427. Peters, A. Prevalence of Bovine Tuberculosis. Bost. M. & S. J., 1894, CXXXI, 525- The Suppression of Tuberculosis in our Dairy Herds. Bost. M. & S. J., 1906, CLIV, 67. Pratt, J. H. The "Home Sanatorium" Treatment of Consumption. Bost. M. &S. J., 1906, CLIV, 210. The Organization of Tuberculosis Classes. Bost. M. & S. J., 1907, CLVII, 285. Prescott, W. H., and Goldthwait, J. E. Observations on Tuberculosis of the Kidney, with a Report of Cases. Bost. M. & S. J.. 1891, CXXIV, 61. Rand, I. Observations on Phthisis Pulmonalis and the Use of Digitalis Purpurea in the Treatment of that Disease. Pamphlet, 26 pp., Boston, 1804, the Repertory Office. Richards, G. L. What should be the Attitude of Public Sanatoria toward Cases of Tubercular Laryngitis; with Suggestions as to the general Plan of Treatment of such Cases in Sanatoria. Bost. M. & S. J., 1906, CLV, 145. Richardson, O. Autopsy in Dr. Townsend's Case of Tuberculosis in an Infant. Bost. M. &S. J., 1905, CLIII, 18. Rogers, A. E. The Successful Treatment of Tuberculosis. Bost. M. & S. J., 1906, CLIV, 291. Rogers, O. F. Should the Tuberculosis Insane in Hospitals be Segregated? Bost. M. & S. J., 1906, CLIV, 62. RoTCH, T. M., and Floyd, C. The Opsonic Index and the Tuberculin Test. J. Am. M. Ass., 1907, XLIX, 633. Russell, J. B. On the Prevention of Tuberculosis. Pub. by the State Board of Health, 1896. Sabine, G. K. Home Treatment of Phthisis. Bost. M. & S. J., 1894, CXXXl, 61. Scudder, C. L. a Case of Tuberculosis of the Breast. Am. J. M. Sc, 1898, XVI, 75. 2l6 TUBERCULOSIS IN MASSACHUSETTS. Sears, G. G. Four Cases of Phthisis treated by Inhalations of Hot Air. Bost. M.&S. J., 1889, CXXI, 33. Remarks on Two Hundred Cases of Phthisis. Bost. M. & S. J., 1895, CXXXII, 323. The Tuberculin Test in Ten Cases of Acute Pleurisy. Bost. M. & S. J., 1897, CXXXVl, 121. Sessions, W. R. The Agricultural Aspect of Tuberculosis. Bost. M. & S. J., 1894, CXXXI, 531. Shattuck, F. C. Recent Progress in the Treatment of Thoracic Diseases. The Use of the Hypophosphites in Phthisis. Expectoration in Phthisis. Bost. M. & S. J., 1877, XCVI, 462. Pulmonary Consumption. Cycl. Pract. Med. (Ziemmsen), N. Y., 1881, Supplement, 318. Tuberculosis. Cycl. Pract. Med. (Ziemmsen), N. Y., 1881, Supplement, 334. The Home Treatment of Consumption. Bost. M. & S. J., 1885, CXII, 576. Some Hospital Cases of Phthisis, marked Improvement under General Treatment, with special Reference to Alimentation. Bost. M. & S. J., 1887, CXVI, 580. Clinical Notes on Bergeon's Methods of treating Phthisis. Bost. M. & S. J., 1887, CXVI, 612. Prognosis and Treatment of Tubercular Peritonitis. Am. J. M. Sc, 1902, CXXIV, I. The Past, Present and Future of Tuberculosis. Bost. M. & S. J., 1907, CLVII, 133. Shattuck, G. B. Acute Miliary Tuberculosis. Bost. M. & S. J., 1886, CXIV, 1 56. Pleurisy with Effusion, Tuberculous Peritonitis. Addison's Disease. Bost. M. & S. J., 1905, CLII, 551. Shl'Mway, H. L. a Hand-book of Tuberculosis among Cattle. Boston, 1895, '77 PP' Roberts Bros. Smith, T. A Comparative Study of Bovine Tubercle Bacilli and of Human Bacilli from Sputum. J. Exper. M., 1898, III, 451. Notes on a Tubercle Bacillus having a Low Degree of Virulence. J. Bost. Soc. M. Sc, 1898, HI, 33. Comparative Studies of Bovine Tubercle Bacilli and of Human (Sputum). Bost. M. & S. J., 1898, CXXXVl II. 497. The Thermal Deathpoint of Tubercle Bacilli in Milk and some other fluids. J. Exper. M., 1899, IV, 217. The Relation between Bovine and Human Tuberculosis. Med. News, N. Y., LXXX, 343. Studies in Mammalian Tubercle Bacilli. Bost. M. & S. J., 1903, CXLVIII, 645. A Study of the Tubercle Bacilli Isolated from Three Cases of Tuberculosis of the Mesenteric Lymph Nodes. Trans. Ass. Am. Phys., 1904, XIX, 373. APPENDIX. 217 Smith, T. Studies in Mammalian Tubercle Bacilli. 111. Description of a Bovine Bacillus from the Human Body. A Culture Test for Distinguishing the Human from the Bovine Type of Bacilli. J. M. Research, 1905, XIII, 253- The Reaction Curve of Tubercle Bacilli from Different Sources in Bouillon Containing Different Amounts of Glycerine. J. M. Research, 1905, XIII. 405. What is the Relation between Human and Bovine Tuberculosis, and how does it affect Inmates of Public Institutions? Bost. M. & S. J., 1906^ CLIV, 60. The Parasitism of the Tubercle Bacilli and its Bearing on Infection and Immunity. J. Am. M. Ass., 1906, XLVI, 1247 and 1345. Note on the Stability of the Cultural Characters of Tubercle Bacilli with special Reference to the Production of Capsules. Trans. Nat'l Ass. for the Study and Prevention of Tuberculosis, 1905, I, 212. and Brown, H. R. Studies in Mammalian Tubercle Bacilli. IV. Bacilli Resembling the Bovine Type from Four Cases in Man. J. M. Research, 1907, XVI, 435. The Channels of Infection in Tuberculosis together with some Remarks on the Outlook concerning a Specific Therapy. Med. Com. Mass. Med. Soc., 1907, 449. The Vaccination of Cattle against Tuberculosis. J. M. Research, 1908, XVIII, 451. Smith, W. E. A Study of Phthisis and Pneumonia in Massachusetts; Statistical and Climatological. Med. Com. Mass. Med. Soc, 1887, XIV, 245. Stevens, C.W. Is Phthisis Contagious? Bost. M. & S. J., 1872, IX, 168. Stone, A. K. Clinical Value of the Bacillus of Tuberculosis. Bost. M. & S. J., 1890, CXXIII, 515. Why the Sputa of Tuberculous Patients should be Destroyed. Am. J. M. Sc, 1891, CI, 275. Impressions of the British Congress on Tuberculosis. Bost. M. & S. J., 1901, CXLV, 258. and Wilson, A. M. The Geographical Distribution of Tuberculosis in Boston in 1901-03 as compared with the Distribution in 1885-90. Bost. M. &S. J., 1905, CLII, 6. and Floyd, C. The Daily Care of Consumptives at a General Hospital as an Aid to solving Local Tuberculosis Problems. Bost. M. & S. J., 1907, CLVII, 141. A Case of Intestinal Tuberculosis, with Psychoneurotic Symptoms. Bost. M. &S. J., 1907, CLVII, 560. Strong, L. W. Immunity against Tuberculosis. Bost. M. & S. J., 1906, CLIV, 140. Stuart, F. W. Syphilis or Tuberculosis? Bost. M. & S. J., 1888, CXIX, 574. 2l8 TUBERCULOSIS IN MASSACHUSETTS. WEETSER, W. A Treatise on Consumption; embracing an Inquiry into the Influence exerted upon it by Journeys, Voyages, and Change of Climate. Boston, 1836, 254 pp., T. H. Carter. Thorndike, p. Genito-Urinary Tuberculosis. Bost. M. & S. J., 1902, CXLVI, 607. and Bailey, W. T. Tuberculosis of the Testicle. Bost. M. & S. J., 1902, CXLVIII, 13. Tileston, W. Passive Hyperaemia of the Lungs and Tuberculosis. J. Am. M. Ass., 1908, L, 1 179. Tower, C. C. A Case of Tuberculosis of the Pericardium and Bronchial Lymph Glands. Bost. M. & S. J., 1889, CXXl, 57. TowNSEND, C. W. An Unusual Case of Tuberculosis in an Infant. Bost. M. & S. J., 1905, CLIII, 17. Townsend, D. Results obtained at the Boston Day-Camp for Tuberculous Patients. Jour, of Outdoor Life, Dec, 1905. Day Sanatorium for Consumptives, Parker Hill, Boston. Bost. M. & S. J., 1906. CLIV, 69. "Mattapan Day-Camp." Bost. M. & S. J., 1908, CLVIII, 246. McCarthy, F. P., a^id Houghton, R. Mattapan Day-Camp for Con- sumptives, Boston. Bost. M. & S. J., 1908, CLVIII, 575. Verhoeff, F. H. Tuberculous Scleritis, a Commonly Unrecognized Form of Tuberculosis. Bost. M. & S. J., 1907, CLVI, 317. VicKERY, H. F. Pulmonary Tuberculosis as a Sequel to Ordinary Pleurisy with Effusion. Bost. M.& S.J. , 1887, CXVII, 521. The Prevention of Tuberculosis. Bost. M. & S. J., 1894, CXXX, 5. ViETOR, A. C. A Plan for the Municipal Control of Tuberculosis in Boston. Bost. M.&S. J., 1902, CXLVI, 131. Warren, I. Consumption and its Treatment. Bost. M. & S. J., 1851, XLV, 449. Waterhouse, H. Phthisis Pulmonalis. N. Eng. M. J., 1823, XII, 261. Watson, F. S. A Case of Tuberculosis of the Bladder, Prostate and Kidneys, Originating in Tuberculous Epididymitis; Autopsy. Bost. M. & S. J., 1888, CXIX, 5. The Surgical Treatment of Renal Tuberculosis. Bost. M. & S. J., 1907, CLVI, 263. Wheeler, L. Laparatomy for Tubercular Peritonitis. Med. Com. JMass. Med. Soc, 1890, XV, 231. White, C. J. The Modern Conception of Tuberculosis of the Skin. Bost. M. & S. J., 1905, CLIII, 291. White, F. W. The Diagnostic Value of Tuberculin. Bost. M. & S. J., 1897. CXXXVII. 123. White, J. C. Clinical Aspects and Etiological Relations of Cutaneous Tubercu- losis. Bost. M. & S. J.. 1891. CXXV, 509. APPENDIX. 219 Whitney, W. F. The Etiology of Tuberculosis. Pamphlet, 16 pp., Cambridge, 1882, Riverside Press. Whittier, E. N. Persistent High Temperature in Tuberculosis with Tubercular Pharyngitis. Bost. M. & S. J., 1885, CXIII, 513. Wilder, C. W. Pulmonary Consumption, its Causes, Symptoms, and Treatment. Med. Com. Mass. Med. Soc, 1843, ^''' 77- Wiley, H. Pulmonary Consumption. Bost. M. & S. J., 1838, XVIII, 85. WiLKiNs, G. C. Tuberculosis at the Long island Hospital. Bost. M. & S. J., 1902, CXLVII, 579. Williams, A. H. An Unusual Family History of Tuberculosis. Bost. M. & S. J., 1902, CXLVI, 433. Williams, F. H. Notes on X-rays in Medicine. Trans. Ass. Am. Phys., 1896, XI, 375- A Study of the Adaptation of the X-rays to Medical Practice and some of their Uses. Med. & Surg. Reports Bost. City Hosp., 1897, 8 s., 134. The Roentgen Rays in Thoracic Diseases. Am. J. M. Sc, 1897, CXIV, 665. Some of the Medical Uses of the Roentgen Rays. Brit. M. J., 1898, I, 1006. X-ray in Medicine. Med. News, 1898, LXXIl, 609. An Outline of the Clinical Uses of the Fluoroscope. Med. Com. Mass. Med. Soc, 1898, XVII, 857. An Outline of some of the Medical Uses of the Roentgen Light. Am. J. M. Sc, 1899, CXVII, 675. Observations on Pneumohydrothorax and Pneumothorax. Med. & Surg. Reports Bost. City Hosp., 1899, 10 s., 191. Roentgen Ray Examinations in Incipient Pulmonary Tuberculosis. Bost. M.&S. J., 1899, CXLI, 196. X-ray Examinations an Aid in the Early Diagnosis of Pulmonary Tuber- culosis. Bost. M. & S. J., 1899, CXL, 513. X-ray Examinations of the Chest as illustrated by Two Cases of Pneumo- hydrothorax and Two of Pneumothorax. Phila. M. J., 1899, IV, 575. Roentgen Ray Examinations in Diseases of the Thorax. Yale M. J., 1900, VI, 233. X-ray Examinations in Diseases of the Chest. Phila. M. J., 1900, V, 1 1. Note on X-ray Examinations of the Lungs. Bost. M. & S. J., 1900, CXLI I, 555- The X-rays in Medicine. Allbutt & Rolleston's System of Med., London, 1905, 2d ed., I, 473. Methods for determining the Density of Various Parts of the Body, especially the Lungs, by Means of the X-rays. Bost. M. & S. J., 1906, CLV, 185. The Use of X-ray Examinations in Pulmonary Tuberculosis. Bost. M. & S. J., 1907, CLVIi, 850. Williams, H. The Climatic Treatment of Phthisis. Bost. M. & S. J., 1885, CXIII, 313. 220 TUBERCULOSIS IN MASSACHUSETTS. Williams, Mrs. R. P. Can Consumption be Cured? A State's Experiment. N. Eng. Magazine, May, 1901. Winchester, J. F. Diagnosis and Prevention of Bovine Tuberculosis. Bost. M. & S. J., 1894, CXXXI, 526. WoLBACH, S. B., and Ernst, H. C. Observations on the Morphology of Bacillus Tuberculosis from Human and Bovine Sources. J. M. Research, 1903, X,3>3- Experiments with Tuberculins made from Human and Bovine Tubercle Bacilli. J. M. Research, 1904, XII, 295. Worcester, A. The Treatment of Tuberculosis with Tuberculin and its Deriva- tives. Bost. M. & S. J., 1896, CXXXV, 177. Young, J. H. A Case of Acquired Dextrocardia associated with Advanced Phthisis. Bost. M. & S. J.. 1907, CLVII, 791. APPENDIX. 221 Massachusetts committee of the inter. NATIONAL Tuberculosis congress, Arthur T. Cabot, M.D., Boston, Chairman. John B. Hawes, 2d, M.D., Boston, Secretary. J. F. AUeyne Adams, M.D., Pittsfield. Charles H. Adams, Boston. Carl A. Allen, M.D., Holyoke. Edward A. Andrews, Cambridge. P. Challis Bartlett, M.D., Rutland. Albert M. Belden, M.D., Northampton. Vincent Y. Bowditch, M.D., Boston. John T. Bottomley, M.D., Boston. Edward H. Bradford, M.D., Boston. Jeffrey R. Brackett, M.D., Boston. Wilford G. Brown, M.D., Plymouth. Herbert L. Burrell, M.D., Boston. Richard C. Cabot, M.D., Boston. Charles G. Carleton, M.D., Lawrence. H. Lincoln Chase, M.D., Brookline. Herbert C. Clapp, M.D., Boston. Israel J. Clarke, M.D., Haverhill. William T. Councilman, M.D., Boston. Simon F. Cox, M.D., Boston. John W. Cram, M.D., Colrain. Alvah Crocker, Fitchburg. Eugene A. Darling, M.D., Cambridge. Hon. William L. Douglas, Brockton. Samuel H. Durgin, M.D., Boston. Richard Dutton, M.D., Wakefield. 222 TUBERCULOSIS IN MASSACHUSETTS. Herbert C. Emerson, M.D., Springfield. Ernest B. Emerson, M.D., Tewksbury. Harold C. Ernst, M.D., Boston. John W. Farlow, M.D., Boston. Reginald H. Fitz, M.D., Boston. Cleaveland Floyd, M.D., Brookline. Mrs. Lilias Folger, Medford. Langdon Frothingham, M.D., Boston. Miss Emily C. Fisher, Norwood. George W. Gay, M.D., Boston. Albert C. Getchell, M.D., Worcester. Joel E. Goldthwait, M.D., Boston. Walter A. Griffin, M.D., Sharon. Charles Harrington, M.D., Boston. Thomas F. Harrington, M.D., Boston. Henry B. Hart, M.D., East Dennis. Ashton E. Hemphill, Holyoke. Frederick L. Hills, M.D., Rutland. Henry Jackson, M.D., Boston. Fred R. Jouett, M.D., Cambridge. Elliott P. Joslin, M.D., Boston. Mrs. Mary Morton Kehew, Boston. Frederick I. Knight, M.D., Boston. Walter E. Kreusi, Boston. Edwin A. Locke, M.D., Boston. George N. Lapham, M.D., Rutland. Robert W. Lovett, M.D., Boston. Edward F. McSweeney, Boston. Ernest P. Miller, M.D., Fitchburg. Charles S. Millet, M.D., Brockton. James J. Minot, M.D., Boston. John L. Morse, M.D., Boston. f APPENDIX. 223 John H. Nichols, M.D., Tewksbury. Edward O. Otis, M.D., Boston. Austin Peters, M.D., Boston. Joas C. De S. Pitta, M.D., New Bedford. Joseph H. Pratt, M.D., Boston. Charles A. Pratt, M.D., New Bedford. Silas D. Presbrey, M.D., Taunton. Frederick B. Percy, M.D., Brookline. George L. Rice, M.D., North Adams. Frederick J. Ripley, M.D., Brockton. Maurice H. Richardson, M.D., Boston. Thomas M. Rotch, M.D., Boston. George L. Richards, M.D., Fall River. Prof. William T. Sedgwick, Boston. Charles E. Simpson, M.D., Lowell. Theobald Smith, M.D., Brookline. Jeremiah Smith, Jr., Boston. Arthur K. Stone, M.D., Boston. Frederick C. Shattuck, M.D., Boston. George B. Shattuck, M.D., Boston. David Townsend, M.D., Boston. Mrs. C. H. Thomas, Cambridge. Henry P. Walcott, M.D., Cambridge. J. Collins Warren, M.D., Boston. John F. Welch, M.D., Quincy. , Arthur H. Wentworth, M.D., Boston. Frank G. Wheatley, M.D., North Abington. Francis H. Williams, M.D., Boston. Mrs. Rufus P. Williams, North Cambridge. Alfred Worcester, M.D., Waltham. William H. Watters, M.D., Boston. 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