Three fundamental rules of action should be established as firmly as religious principles:

1. The public health authorities should be told of every known and every suspected case of tuberculosis.

2. For each case proved by examination of sputum to be tuberculous, the public-health officers should know that the germs are destroyed before being allowed to contaminate air or food.

3. Sick and not yet sick should practice habits of health that build up vitality to resist the tubercle bacilli and that abhor uncleanliness as nature abhors a vacuum.

Fighting Tuberculosis With A National Organization

All laws, customs, and environmental conditions opposed to the enforcement of these three principles must be modified or abolished. If the teachers of America will list for educational use in their own communities the local obstacles to these rules of action, they will see exactly where their local problem lies. The illustrations that are given in this book show in how many ways these rules of action are now being universalized. Three or four important steps deserve especial comment:

1. Compulsory notification of all tuberculous cases.

2. Compulsory removal to hospital of those not able at home to destroy the bacilli, or compulsory supervision of home care.

3. Examination of all members of a family where one member is discovered to be tuberculous.

4. Special provision for tuberculous teachers.

5. Protection of children about to enter industry but predisposed to tuberculosis.

6. Prohibition of dry cleaning of schools, offices, and streets.

7. Tax provision for educational and preventive work.

Compulsory notification was introduced first in New York City by Hermann M. Biggs, M.D., chief medical officer: 1893, partially voluntary, partially compulsory; 1897, compulsory for all. Physicians who now hail Dr. Biggs as a statesman called him persecutor, autocrat, and violator of personal freedom fifteen years ago. Foreign sanitarians vied with American colleagues in upbraiding him for his exaggeration of the transmissibility of consumption and for his injustice to its victims. As late as 1899 one British expert particularly resented the rejection of tuberculous immigrants at Ellis Island, and said to me, "Perhaps if you should open a man's mouth and pour in tubercle bacilli he might get phthisis, but compulsory notification is preposterous." In 1906 the International Congress on Tuberculosis met in Paris and congratulated New York upon its leadership in securing at health headquarters a list of the known disease centers within its borders; in 1906 more than twenty thousand individual cases were reported, ten thousand of these being reported more than once. To know the nature and location of twenty thousand germ factories is a long step toward judging their strength and their probable product. To compulsory notification in New York City is largely due the educational movements of the last decade against the white plague, more particularly the growing ability among physicians to recognize and to treat conditions predisposing to the disease. As in New York City, the public should provide free of cost bacteriological analysis of sputum to learn positively whether tuberculosis is present. Simpler still is the tuberculin test of the eyes, with which experiments are now being made on a large scale in New York City, and which bids fair to become cheap enough to be generally used wherever physical examinations are made. This test is known as Calmette's Eye Test. Inside the eyelid is placed a drop of a solution—95 per cent alcohol and tuberculin. If conjunctivitis develops in twenty-four hours, the patient is proved to have tuberculosis. Some physicians still fear to use this test. Others question its proof. The "skin test" is also being thoroughly tried in several American cities and, if finally found trustworthy, will greatly simplify examination for tuberculosis. Dr. John W. Brannan, president of Bellevue and Allied Hospitals, New York City, is to report on skin and eye tuberculin tests for children at the International Congress on Tuberculosis, mentioned later.

Fighting Tuberculosis By Organized Cooperative Dispensary Work

Fighting Bone Tuberculosis At Sea Breeze, Where Eye And Skin Tuberculin Tests Are Being Made