[Reprinted from the Special Number 9f Toe PHILADELPHIA MepicaL
JOURNAL on Tuberculusis, December 1, 1900.]

WHERE THE DANGER LIES IN TUBERCULOSIS.

A Study of the Social and Domestic Relations of Tuber-
culous Out-Patients.*

Br ADELAIDE DUTCHER,
of Johns Hopkins Medical School, Baltimore, Md.

Dorina the past year I have visited in their homes
190 out-patients of the Johns Hopkins Hospital suffer-
ing from tuberculosis. These people represent the
poorer classes, who are ‘compelled to work on in their
illness to support themselves or their families. They
are scattered over all parts of the city, but about 85%
are limited to particular districts. One large area about
‘the hospital, within a radius of 10 to 15 squares, and
extending south-eastward along the harbor as far as
Canton. The other district, angular in shape, follows
West Baltimore and South Charles streets in a strip
from 6 to 8 squares broad and 10 to 15 squares
long. Throughout these two districts, which repre-
sent the oldest parts of Baltimore, we find the
greatest massing of the poor. According to their
social and domestic conditions our 190 patients di-
vide themselves naturally into blacks, whites, and
Russians. The Russians are distinguished from the
rest of the whites by their exaggerated unsanitary
condition.

T have tabulated the details of my observations on the
sanitary environment in the individual cases under the
following headings: location, crowding, cleanliness,
light, and ventilation. Of course, there is no absolute
standard that can be taken as a basis, yet according to
my impression of the now generally accepted ideas of
what would constitute a fair hygienic condition, I con-
sider this summary to be a reasonable estimate of the
existing conditions.

 

*Paper read at the Laennec,—a Society for the Study of Tuberculosis, Johns
Hopkins Hospital.
2

SUMMARY OF TABULATION.

Total number of patients. ....... 190 Sane. = ot
Number of houses occupied ...... 234 Russians, | | 20

RUSSIANS. BLACKS, WHITES.

Bad sanitary location 2. ....4- 69% 40% 30%
Insufficrent light and ventilation... . 83% 1% 46%
Overcrowding ..- 2... 1 ae 76% 504% 46%
Persunal and household cleanliness. ; : 75% 66% 43%

These statistics reveal a most distressing state of
affairs among the Russians, who are dangerous elements
in our midst as breeders and spreaders of this disease.
They are fairly well limited to a triangular area
bounded by Monument Street, Central Avenue and
Jones’ Fails. This represents one of the very oldest
parts of the city, and the houses now used as tenement
houses were originally built for private dwellings.
They are packed into these dark, unventilated tenement
houses, often families of from 6 to 10 in 2 small, filthy
rooms. The halls are never lighted, and seem to be’
never cleaned. Thus shut in from fresh air and sun-
light, living in filth sometimes absolutely beyond
description, their resistance to disease must naturally
be lowered. We can but fear, therefore, the danger of
infection that attends the reckless distribution of
tuberculous sputum about the halls and dirty rooms.

The blacks form an intermediate class between the
Russians and the rest of the whites. Sixty per cent of
them have at least fairly gpod locations. There is, how-
ever, a decided drop in the percentage of other elements
that go to make up hygienic environment. Seventy-one
percent have insufficient light and ventilation. The
houses in the narrow alleys and courts, where so many
of them live, are roughly and cheaply built, and have
not the facilities for proper light. Fifty per cent of the
negroes are overcrowded, and a much higher percent-
age (66%) are dirty. Their poverty in many instances
is extreme. Perhaps on this account there appears to
be among them a greater neglect of the sick. One man
was found who had been confined to his bed several
weeks with almost no care whatever. His father came
in daily to bring him a few scraps of food. The poor
fellow was spitting at random over everything within
reach. His bed and the walls and floor besmeared with
sputum were extremely unsightly. Some observations
3

in similar cases were still more disgusting, because made
in the season when swarms of flies were found crawling
over the walls and bed, feeding on the sputum. It
seems unnecessary for me to say here that such indi-
viduals should be removed to some hospital or sana-
torium, and that someone should be responsible for the
disinfection of such rooms.

The colored people seem to be especially careless
about smearing their sputum over their clothing. While
talking with them I have frequently had occasion to stop
individuals from depositing their spit on the corner of
an apron or some other garment worn.

Turning now to the whites, who form the most inter-
esting and most hopeful class for the trial of our methods
of prophylaxis, the statistics show that 70% have at
least fairly good location. In regard to light, crowd-
ing, and cleanliness, less favorable percentages present
themselves. This only emphasizes the greater need
of such prophylactic measures as have here been under-
taken.

Though in many cases the facilities for proper light
and ventilation are inadequate, yet a large number of
the 46% living with insufficient light and ventilation
do so because the houses are kept dark and close by
keeping the blinds and windows shut. Oftentimes the
crowding is not from want of room, but from a natural
tendency of the individuals of a household to huddle
together.

When the consumptive is ill enough to be confined to
the house, it is common to find that he has been given
a couch in the corner of the family living-room, which
is generally the darkest and closest room in the house.
Frequently if the patient finds difficulty in getting up
and down stairs, he prefers to spend his nights also on
his couch in the corner.

Where large families are crowded into two or three
small rooms, the kitchen must also serve as a bedroom,
and almost invariably, especially in winter time, the
one with a cough is favored with a place in the kitchen
close to the fire.

Occupation.—The occupation of some of these patients
has a practical bearing on their relation to society. In
the majority of cases their occupation confines them
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within doors. This means that rigid precautions need
to be taken to destroy the spit. Individuals at work
are prone to spit carelessly about them. When this
chances to be on the floor of closed rooms protected
from the sunlight, the germs may retain their virulence
for a long time. As these germs become stirred up
from time to time, they may infect other occupants of
the room, or be deposited on the materials worked upon.
As an illustration: In a filthy, unventilated room I
found four men working on willow ware. One of the
men, a consumptive, was spitting about the floor and
even onthe willows. I feel certain that the other three
men were in imminent danger of direct infection.

The sweatshops have a goodly representation among
these 190 individuals. Patients often tell me that
among the 20, or 30, or 40 individuals who work in the
room with them they can point to several who have
pulmonary troubles similar to their own.

Not a few of these patients have to do with the hand-
ling of food which might easily become contaminated
by contact with their soiled fingers. In our list we find
cooks, bakers. cracker packers, and keepers of little milk
and meat shops represented.

Following the studies of Flick in Philadelphis,
the Board of Health of New York City has demon-
strated, by the results of an investigation made to deter-
mine the distribution of tuberculosis in that city, that
much importance attaches to the idea of house infec-
tion. Their statistics show that tuberculosis is not
uniformly distributed, but that the bulk of the cases
are confined to narrow limits in certain streets and
houses. They have noted the development of cases of
tuberculosis in families that have successively occupied
these houses. A look at their maps shows that some-
times six or eight patients were in a house at one time.
I might state here that in several instances | learned
that patients had developed the disease subsequent to
occupation of houses previously occupied by tubercu-
lous patients. Several times 1 found two patients, and
on one occasion four patients, living in the same house
In all these cases they were members of the same family.

While my statistics are too limited to admit of any
conclusions, they do point to the rapidity with which
i)

Baltimore houses are becoming centers of infection.
During the brief period that these 190 cases were under
my observation they had occupied 234 houses. When
the tuberculous occupants move out new occupants
move in without any attempt at disinfection. In 58%
of these cases the family history was absolutely nega- -
tive, which suggests the possibility of a general source
of infection, and may we not look to infected houses as
one of the most important ?

My work has been to visit these tuberculous patients
in their homes and give them a few simple instructions
on the nature of their disease, the mode of its contagion,
and methods of its prevention by the cultivation of
habits of cleanliness, the destruction of the sputum, and
the admission of air and sunlight into their houses. In
many instances among these poor people the patient
can and will be given a sunny room in the house, in a
measure isolated from the rest, with very little incon-
venience, when they learn that any benefit may be de-
rived from such a step. Most of the patients and their
families as well are absolutely ignorant of the idea of
contagion. The few that have begun to look upon the
disease as communicable, because of their ignorance of
the mode of infection and methods of prevention, live
in deadly fear that they transmit or contract the disease.
To such the information that the elements of contagion
are in the sputum, and can be destroyed, is heralded
with gladness. Ifthe physician has not informed the
patient as to the exact nature of his disease, I have not
found it necessary to do so. It is enough for him to
know that it is transmissible, be it in his mind throat-
trouble, catarrh, or bronchitis.

The need of this kind of education of the public by
house-to-house visitation is intense, and I feel that most
of these individuals, unless it be the Russians, are
teachable.

When we have taught the tuberculous patient to de-
troy his sputum, to rid his room of carpets and other
germ catchers, and to throw open his windows to admit
the sunshine and fresh air, we may then begin to look
for a visible decrease in the tuberculous entries on our
dispensary records.

The statistics of the Board of Health of New York
6

City show a remarkable decrease in the death-rate from
tuberculosis since they began a systematic education of
the tuberculous poor, and the disinfection of tenement
houses occupied by tuberculous patients.

On account of limited time I can but feel that my
work lacks thoroughness. To really follow these cases
by repeated visits has been impossible. Nevertheless I
am happy to say that in the few cases in which sub-
sequent visits were made I found visible signs of an
effort to follow my directions. I recall one case in par-
ticular. At the first visit I found my patient, a young
man of 21 (the oldest of 5 boys, all at home), spitting
at random into his handkerchief, or into the sink, or
on the floor, just as he found it most eonvenient.
Dried sputum was in evidence all about the room,
which made it very disagreeable for the rest of the
family. Not one member of the family had had the
least suspicion of fear of contagion. At a second visit,
one week later, I found that the floor had been scrubbed
with lye, and the patient was carefully collecting his
spit in a vessel containing antiseptic fluid. The mother
showed herself to be especially grateful for my few
words of advice and warning.