IV. Besides the educational propaganda, the houses of rest, the hospitals for incipient cases of tuberculosis, or, as it is better to say, for lung diseases or for diseases of the throat and lungs, there is indicated still a fourth line of action. We need far more knowledge than is at present available as to the relation between overcrowding and tuberculosis, not only in living and sleeping rooms, but in business offices, printing establishments, and similar places of employment ; as to the relation between occupations and the disease ; as to the extent to which the disease is really what the Germans call it, a house disease ; espe cially as to the infection of the cheaper tenements where, of course, the most advanced cases among the poor gravitate, since with the duration of illness they naturally move into cheaper and cheaper rooms as wages are reduced and finally cut off entirely, and as savings are then grad ually exhausted.
That there is frequently direct infection in business offices, even where salaries are high, hardly admits of question. That in the cities there are many rooms in basements, where the direct sunlight never enters, where ventilating systems, if they are provided, are apt not to be in working order, or at least not to be working, and where employees are in too close contact, is also suscep tible of easy demonstration. But these things need to be made matters of record, and a basis established, first, for voluntary reform by proprietors and managers of these offices, who are often merely ignorant or thoughtless ; and then, so far as the evil is not remedied voluntarily, for restrictive legislation by health boards or by local or state legislative bodies. It may be also that the erection of high office buildings will be found to have some direct bearing upon the prevalence of tuberculosis. The primary task will be an inquiry as to the number of persons whose usual supply of light and air in working hours does not reach a carefully determined minimum, and as to the existing safeguards against direct infection.
When plans were submitted in a large city recently for new public bath-houses, many were quick to express surprise that they were to be only one story in height to permit use of skylights. That the architect and the charity expert who had planned them had been deter mined above all to be sure that bathers should be amply supplied with air and sunlight, as well as with water, is a cause for congratulation, and that the wonder of the aldermen and others who objected to the plans is typical of uneducated public sentiment in general is equally cause for regret.
We need also far more experience and knowledge than we now have as to the wisdom of aiding individual patients to remove to a more favorable climate, and as to the means of supporting them at a distance from their homes. The
ethics of aided transportation of consumptives are still rather crude and undeveloped, and the complementary ethics and public policy of restricting immigration and interstate migration of consumptives also need further elucidation. This fourth suggestion is, therefore, that there is need of investigation of certain social aspects of the disease, in which there is fully as much opportunity for cooperation between the medical profession and lay societies and individuals interested in the social welfare as in other lines that have been indicated.
In New York City, in the light of the extraordinary success of the Tenement-House Committee of the Charity Organization Society in its movement for tenement-house reform, it was in 1902 decided to inaugurate a committee on the prevention of tuberculosis in the same society in which there should be ample representation of physicians, of men of business experience, and of men and women who were identified with other movements for social reform, thus affording that combination of scientific knowl edge, of medical experience, of business efficiency, and of social enthusiasm that will permit some real contribution to the application of our existing knowledge to our recog nized existing evils. This committee has been energeti cally and successfully at work.' In Chicago, Boston, Wash ington, Buffalo, and St. Louis similar plans have been inaugurated, and other cities are taking steps to crystallize public sentiment on the There is another field in which the next step in reform appears to await an impetus from outside the medical profession. The practice of midwifery is virtually with out regulation, except in five or six states, chiefly for the reason that physicians are reluctant to assume any responsibility for it, and have apparently cherished the hope that it would either die out altogether from natural causes or that public sentiment would eventually call for legislative prohibition.
In a period of six years, from 1891 to 1896 inclusive, there appears to have been in New York City a slight de crease, probably about 3 per cent, in the number of cases attended by midwives. It is known, however, that many cases are not reported. It has been estimated again that 1 The first annual report of this committee, published in 1903, is expanded into a " Handbook on the Prevention of Tuberculosis," 388 pages, with important contributions on many aspects of the subject, including a valuable statistical study, by Lilian Brandt, of such social phases of the disease as are referred to in the preceding paragraphs.