In respect to the treatment of the class of cases to which our patient belonged, I wish to impress upon you the futility of therapeutic measures unless the amount of exertion made by the patient can be controlled and absolute rest can be enforced if necessary. Absolute rest of the body and stomach is a factor of the utmost importance in these cases, as illustrated in this patient; and, if declined by the patient, the physician may not be warranted in assuming the responsibility of treatment.

THE NECESSITY FOR ISOLATION AND HOSPITAL

CARE FOR POOR CONSUMPTIVES.

BY J. C. WILSON, M.D.,

Professor of Medicine in Jefferson Medical College, Philadelphia.

TWENTY-FIVE years ago Ruehle, a famous physician of Germany, Director of the Medical Clinic at Bonn, wrote concerning pulmonary consumption the following words: "The importance of laboring to check the spread of this deadly disease and to diminish the number of its victims has never seemed to be so urgent as at the present time, when there is a growing demand for more attention to the preservation of health and when the conviction is gaining ground that this is the main function of medical science." These words are emphatically true to-day; yet the learned writer, in his elaborate article upon pulmonary consumption in Ziemssen's Cyclopædia, immediately added, "It were idle to suppose. . . that we shall ever be able to extirpate consumption from the human race."

Fortunately for mankind, this gloomy prediction has, with advancing knowledge, lost its impressiveness. In 1882, seven years later, Robert Koch revealed to the world the actual cause of the tuberculous diseases, including pulmonary consumption, in the tubercle bacillus. This discovery marked a new era in medical history. With it bacteriology assumed an established position among the medical sciences. With it the mystery that surrounded pulmonary consumption came to an end. Doubts and uncertainties remained and still remain, but the matter passed from the region of uncertain hypothesis to that of scientific fact. Pulmonary consumption ceased to be an unknowable scourge, due to manifold, adverse, obscure conditions, and presented itself in the simple aspect of a chronic infection caused by a definite pathogenic principle, transmissible from individual to individual.

As this view concerning the nature of the disease became more clear, the three great stumbling-blocks which had stood in the way of the advance of knowledge relating to the disease were removed.

These were, first, the doctrine that pulmonary consumption is essentially hereditary; second, that it is incurable; and, third, that as a scourge of the human race it is ineradicable.

The medical profession is to-day in the position to assert, first, that the disease, except under rare and unusual circumstances, is not hereditary, and that in fact the vast majority of cases arise in consequence of infection by the tubercle bacillus,—that is to say, the transmission of the exciting cause of the disease from the sick to the well; second, that the tuberculous diseases, including pulmonary consumption, cannot in the present state of knowledge be regarded as incurable, but that a majority of the cases are, if seen early and placed under favorable conditions, amenable to treatment and capable of being restored to health; under these circumstances the individual case ceases to be a focus or source of infection; and, third, it naturally follows that the tuberculous diseases, which cause one-seventh, or fourteen per cent., of the deaths in the civilized world, may, by the general enforcement of proper sanitary regulations, be stamped out, or at all events enormously restricted in their prevalence. Facts familiar to the student of medical history in regard to the plague in Western Europe, to leprosy in the British Islands, and to typhus fever justify this assertion. There are those who will address you to-night who not only believe that pulmonary consumption and the other tuberculous diseases may be ultimately stamped out, but who are even sanguine enough to hope that this blessing to humanity may be brought to pass during, and constitute the crowning achievement of, the coming century. I cannot say that I wholly share in this sanguine expectation, but the time has arrived when the civilized world should be aroused from its apathy in regard to the subject.

The individual suffering from pulmonary consumption becomes a focus of infection, and in a very definite way. Whether the case be acute or chronic, so soon as necrosis of the lung occurs, that is, so soon as ulcerative processes develop,-tubercle bacilli are thrown off with the sputum. This organism is practically an obligate parasite, growing and developing freely within ranges of temperature not very greatly exceeding that of the bodies of animals, and requiring moisture and oxygen. Nevertheless, under favorable circumstances, outside of the body it preserves its vitality and capacity for new growth for a considerable period. While the expectoration

remains moist or when it is discharged into vessels containing water, it is innocuous, for the conditions in which the expectoration in the moist form is conveyed to the interior of the bodies of susceptible individuals are exceedingly limited. When, however, the expectorated matters are allowed to dry in handkerchiefs or upon the clothing of the patient, or upon the floor of the room which he occupies, they are ultimately converted into particles of dust, and floating in the atmosphere are inhaled by other individuals in the vicinity. These are familiar facts. They of themselves suggest practical measures of prophylaxis. The people must be taught that the disease is a transmissible one, and that in the vast majority of instances transmission is indirect by means of particles of dried sputum containing the tubercle bacilli and floating as dust in the atmosphere. They must be taught that the chief measure of safeguarding those in the neighborhood of the consumptive consists in the collection and destruction, preferably by fire, of the sputa. They must be taught that the disease is not necessarily an incurable one, but that if taken in time a majority of the cases, probably a large majority, are amenable to treatment. They must be taught that it is better for a man suffering from a beginning consumption to give up his work and place himself under proper conditions to be cured than to struggle on, working until he breaks down beyond hope of cure. The consumptive in the mill, in the factory, in the office, in the school, in the sweat-shop, in the church, in public places of amusement and recreation, and in his home is a menace to the health of those surrounding him. He infects localities, he renders baleful the atmosphere in which float the dried particles of his expectorated matter.

The period of incubation of pulmonary consumption is often a long one. It is rarely possible to trace the direct connection between the infecting sick person and the well person who receives the infection; hence arise difficulties that surround the question of transmissibility. But the closer the matter is studied the less important these difficulties become.

It is worse than useless to teach the people, especially the working people, the facts concerning the spread of tuberculosis and not to point out the remedy. It is cruel.

The remedy is a very simple one. It is based upon the simplest principles of preventive medicine. It demands the fulfilment of a

public duty. State and local governments provide and maintain institutions for the care of the poor, and especially for the care of the sick poor. But the consumptive of the laboring classes, when he most requires help for himself and safeguarding for the public, is usually neither sick nor poor. Before long he is both and also the cause of sickness and poverty in others. Then he is commonly past help. At no time is the almshouse or the general hospital the place for him.

Asylums are provided for the insane, in order that the curable cases may be properly treated, the incurable suitably detained, and society protected against the violent or homicidal. The danger from the lunatic at large is an episode; that from the consumptive a scourge. Hospitals are established for contagious diseases, incidentally that the sufferers may be cared for, primarily for the protection of the people and the prevention of epidemics. The welfare of the people has made it proper to throw around these institutions and those who are proper subjects for admission to them the protecting arm of the law. Yet the consumptive, whose need is sorer as his number is greater, turns in vain for help. If in any great community small-pox or diphtheria or yellow fever were to prevail to the tenth part of the ordinary number of cases of consumption, depopulation would at once take place; the people would not stay.

Among well-to-do people the danger is comparatively slight. Education, refinement, and decent ways of living are safeguards. Such people can avail themselves of travel, of health resorts. For them long journeys and favorable localities are practicable. They can go to Görbersdorf, Falkenstein, or Nordrach. For them the regular supervision of competent medical men is possible, with constant attention, proper diet, courses of medicine, treatment in emergencies, hygienic conditions, and agreeable surroundings. For the poor consumptive all these are wanting. For him there is only the daily struggle to the end, with disaster not only to himself but to those about him.

The establishment of special sanitariums to which the incipient cases can be sent, and special hospitals for advanced cases, is the solution of the problem. A patient within the curable period should be sent to such an institution, not on commitment but voluntarily, for in such a plan only is his hope-hope for himself and for those around him. The earlier he goes the greater the hope of cure.