Spectacles and Eyeglasses, their forms, mounting, and proper adjustment, by R. J. Phillips, M.D., ophthalmologist to Presbyterian Orphanage, etc. Fourth edition, revised, with 56 illustrations. Philadelphia: P. Blakiston's Son & Company, 1012 Walnut street. 1908. (Price, $1.00 net.)

A monograph of this kind is useful to the beginner in refraction as it is of convenient form to make of easy reference. Moreover, it is an inexpensive book and new editions, frequently appearing, keep the refractionist promptly advised of the improvements constantly making not only in the methods of proper adjustment of spectacles and eyeglasses, but of the advance in mechanical optics. In this edition we particularly note the description of "invisible" bifocals, and other devices of both benefit and convenience to the wearer of lenses. Phillips is an expert at this work and his book is both practical and scientific.

BOOKS RECEIVED.

By

Constipation and Intestinal Obstruction (Obstipation). Samuel Goodwin Gant, M.D., LL.D., Professor of Diseases of the Rectum and Anus, in the New York Post-graduate Medical School and Hospital; attending surgeon for Rectal Diseases at the New York Post-graduate and Saint Mary's Hospital, and the German Polyclinic Dispensary, with 250 original illustrations. Philadelphia and London: W. B. Saunders Company. 1909. (Price, $6.00 net).

American Practice of Surgery. A complete System of the Science and Art of Surgery by representative surgeons of the United States and Canada. Edited by Joseph D. Bryant, M.D, and Albert H. Buck, M.D., New York. Complete in eight volumes. Vol. IV. Imperial octavo, pp. 1010. Profusely illustrated. New York: William Wood

& Company. 1909. (Price, cloth, $7.00.)

Saunders's Pocket Medical Formulary. With an appendix containing many useful tables, and suggestions for treatment in emergency conditions. By William M. Powell, M.D., member of the Philadelphia pathological society, etc. Ninth editon, thoroughly revised, and enlarged. Philadelphia and London: W. B. Saunders Company. 1909. (Price, $1.75 net).

Report of the United States Commissioner of Education for the year ended June 30, 1907. Volume II. Washington: Government Printing Office. 1908.

The Urine and Clinical Chemistry of the Gastric Contents; the Common Poisons and Milk, by J. W. Holland, M.D., Professor of Medical Chemistry and Toxicology in Jefferson Medical College, Philadelphia. Forty illustrations. Eighth edition, revised and enlarged. Philadelphia: P. Blakiston's Son & Co. 1908. (Price, $1.00).

A Textbook of Genitourinary Diseases, including Functional Sexual Disorders in Man by Dr. Leopold Casper, professor in the University of Berlin. Translated and edited by Charles W. Bonney, B.L., M.D., Assistant Demonstrator of Anatomy in Jefferson Medical College, Philadelphia, etc. Second edition revised and enlarged with 23 illustrations and 24 full page plates, of which 8 are in colors. Philadelphia: P. Blakiston's Son & Co. 1909. (Price, $5.00).

BUFFALO MEDICAL JOURNAL.

VOL. LXIV.

A

MARCH, 1909.

ORIGINAL COMMUNICATIONS.

The Tuberculosis Problem in Buffalo'

BY JOHN H. PRYOR, M. D., Buffalo, N. Y.

No. 8

quarter of a century has passed since the medical profession. generally accepted the belief that tuberculosis is a curable, preventable and unnecessary disease. Recently the public has been sedulously taught these facts in every state, city and hamlet. Now the people have begun to ask awkward questions. They want to know how much this vaunted knowledge has benefited the mass of consumptives, and the honest answer is very little. They are inquiring insistently why the disease prevails so mercilessly, and why the appalling death rate with its awful results continues almost unabated? This is a tremendously encouraging sign. Education is at last arousing the public and the day of a new form of enlightened endeavor is near at hand.

At the present time there exists a strong probability that the public will assume the great task of checking, and gradually annihilating a communicable disease and its dire effects. There is a prospect that the medical profession will be compelled to perform its full duty or be relieved of its plain responsibility. The burning question today is this, shall the medical profession lead as of old in the crusade against disease or follow in the titanic struggle? For the demand that the frightful suffering. woe and devastation shall cease, and the righteous clamor for adequate protection from an uncontrolled enemy of mankind. will be irresistible in its gathering force. As yet the whole truth has not been told. The grim story of disgraceful neglect and apathy, and the consequent unparalleled hardship of the poor consumptive will sometime be recited in fitting language by the men who have grown ugly while they view the Carnival of Misery and listen to the unnecessary death rattle in the weary victim's throat.

The tuberculosis problem in Buffalo is somewhat dissimilar to that existing in other large cities. There are reasons why the disease can be attacked with greater promise of success than in

1. Read at the Buffalo Academy of Medicine, January 12, 1909.

most large centers of population. The death rate from tuberculosis is comparatively low. The mortality is lower in proportion to the population than most cities of its size. The death rate from tuberculosis, compared with the general death rate, is also surprisingly low in this city. Our climate is evidently maligned because theoretically it should be a powerful predisposing factor in its causation.. These conditions, so pleasant to contemplate, are certainly not due to special efforts intended to check the spread of an infectious disease, because no city of its size in this country has done so little in that direction. In the campaign against tuberculosis it has been a laggard, and smothering and evading facts will not help the censurable situation. We have a small percentage of the submerged. Buffalo is a city of homes and the population is spread over an unusually large area. The tenement house population is comparatively, still a slight and controlled factor. Foci of infection are scattered and easy to locate and control. Unsanitary homes and overcrowding, conditions which make an infected building hard to fight, are the exception here. Fresh air can still be obtained by the vast majority of people, if they have sense enough to desire that seeming necessity of life. Under all the circumstances there should be very little tuberculosis in Buffalo. The physical conditions are not favorable to its spread, and the field for a battle with the monster foe is technically strong. Let us examine the local situation.

During the year 1907, 554 deaths were reported as due to tuberculosis. Of this number 497 deaths were caused by tuberculosis of the lungs, and 57 from other forms of tuberculosis. All statistics of mortality are necessarily more or less inexact. There is opportunity for an error in diagnosis and an unknown number of false returns. Undoubtedly a certain percentage of deaths from tuberculosis are attributed to other diseases of the respiratory tract, particularly pneumonia. The belief is now widespread that the question of life insurance plays a part in causing false returns when tuberculosis happens, unfortunately, to be the cause of death. The actual number of those infected with tuberculosis cannot be known. Although tuberculosis is designated as an infectious disease only a small portion of the cases are reported to the Board of Health. We are compelled to estimate the number of tuberculosis victims by the usual method of multiplying the number of deaths by five. Thus we assume that there are 2,770 people fatally infected to maintain the ghastly number of deaths. If we include all infectious, surgical and medical in character, and could account for those who recover, the number would be much larger. Phillip believes that the number of deaths should be multiplied by at least ten. It seems

fair to state that about one person in each 140 of the population oi Buffalo is fatally infected with tuberculosis. It may be mentioned casually that these facts are in strange company with the stogan that tuberculosis is curable, preventable and unnecessary. There must be something wrong somewhere. Now the vast majority of consumptives are attacked during the years of greatest productivity. They succumb to a preventable disease when best prepared to struggle for existence and the welfare of those dependent. It is customary to estimate the loss of wealth to a community by illness and death due to the white plague. Several methods may be employed. They vary in the data included in technic and conclusions. However derived they are startling and are used to arouse the public and stimulate interest in questions of public health. The dose of statistics has been administered also to show that an expenditure to save human beings is a good investment, and also to justify some increased taxation in benighted regions where ideas of false economy prevail. Now the value of a human life cannot be estimated. The loss means one thing to the desolate and grief stricken family and another to the city or state.

There never has been a method devised to measure the incalculable value of character and its influence, though dwelling in the precincts of poverty, and failure to receive an education and a fair chance are inestimable. But from a cold, materialistic, commercial standpoint the average earning power, the loss of an expected duration of life and the cost of illness may form a basis for computing approximately, the loss of wealth caused by tuberculosis in Buffalo. The mean figure according to the method of Newsholme, Fisher, Phillip and Wilcox will be about $3.500,000 annually. A newspaper announcement that a new factory would be located in Buffalo whose employment would bring 500 workingmen to Buffalo might, perhaps, attract more attention. Would it not be wiser to join in an attempt to save a number of the 500 victims of tuberculosis who live here and would like to stay if they had a chance. I might dwell longer on the economic aspect of this subject if the belief had not grown strong that statistics used to stimulate interest and support will not win in this vast conflict. The people have become accustomed to the story of a terrible hidden scourge and the revelation must be brought closer so that they must see and feel. Appeals to sympathy, justice and fair play will accomplish more. If these are not successful then hard, rough facts must be driven home and clinched until the disgrace and shame cannot be esraped.

Exaggerated statements to show that the prevalency of tuberculosis has declined are sometimes employed to encourage a

hopeful view or used to palliate the effects of stupid apathy. There is room for discussion when the causes of an incontrovertible decrease in proportion to the population is analyzed. That it is due to special preventive measures I refuse to assent. The decline began twenty years before the cause was known and was apparently as rapid during that decade as it has been since. Kadical efforts to combat tuberculosis have never been employed but once. That was in Italy in the 15th Century. Suspicion aroused more through prevention than knowledge has accomplished since. This fact is not mentioned to recommend its repetition. It is extremely important at the present time to avoid the misleading conclusion that the actual number of deaths from tuberculosis has decreased. The proportion of deaths to the population has steadily declined but the number suffering from tuberculosis, and the number dying from that disease, is greater than ever before. There is more need of relief and succor because we claim to know how it can be accomplished. There is more intelligence, more people who can help, and more money if it can be reached. A few words concerning the remarkable regularity of the death rate in Buffalo seems necessary to reveal possible methods of attack. I am inclined to believe that the striking uniformity of the figures year after year can be partially explained. ·

The disease is distinctly endemic and largely due to infection in the home or workshop. To maintain the yearly average there must be four groups, one tottering on the edge of the grave, one advanced, one moderately advanced, and one freshly infected or incipient. For every death there must be one or more recently infected. The ghastly army moving slowly to the grave nust be constantly joined by recruits, and the drafting of new victims must be performed with striking accuracy to keep the ranks full. The chance for infection is strangely limited. Immediate and prolonged contact seems to be necessary as a rule. The predisposing causes are not underestimated but the direct source of infection is often overlooked. A dark, overcrowded home is one thing, but insufficient food and poor ventilation with one consumptive in the building is a more important one. amining those exposed is sure to be one of the most valuable methods we possess, when its importance is fully realised. When there is an advanced case look for an incipient. That is the place to find them and to learn how to detect them. If searched for they will be recognised in at least 20 per cent. of the homes of the poor. The advanced case must lead to the early one and the unwilling victim snatched from the horrid throng. Well what has been done in Buffalo to prevent disease and save life? Tuberculosis has never been attacked or treated as an infectious,

Ex