infection, such as by the mucous membranes of the eye, genitals, wounds, and even through the unbroken skin, have been reported. There is little or no evidence to show that the disease is ever inherited, but we may assume that in children of consumptive parents we are dealing with the transmission of vulnerable anatomical elements, and this, together with the fact that they are constantly exposed to the germs, renders them peculiarly liable to the disease.

From what has been said it is evident that the tubercle bacilli are widely scattered; the modes of invasion are also numerous; and yet there is a certain proportion of those exposed who do not contract the disease. This shows that in addition to the germ there must also be a suitable soil for its growth and development. Such a soil is usually found in persons of feeble physique, victims of malnutrition, whose body has been weakened from any one or more of numerous causes, whether it be a previous attack of sickness, loss of sleep, dissipation, morbid habits, insanitary houses, lack of pure air, cleanliness, sunlight and outdoor exercise or of proper food.

Clinical experience indicates that faulty nutrition, debility, loss of blood, anemia, mental anxiety, diabetes, whooping cough, measles and other diseases favor the development of tuberculosis. We also know that a predisposition may be inherited, as evidenced by a delicate physique, narrow chest and general vulnerability of the tissues. A vulnerability of the tissues to the disease may also be acquired by dustproducing occupations, and here the amount of dust seems less important than the character of the particles which compose it. For this reason, no doubt, the hard, sharp and angular particles of iron and stone dust are more liable to produce injuries of the respiratory passages, thus favoring the invasion of the bacilli.

Uffelmann believes that what we call inherited or acquired predisposition to tuberculosis may amount, in many instances, only to a local susceptibility of the respiratory passages, a weakness of the membranes and greater vulnerability, and refers to the fact that some individuals, otherwise healthy, show a greater liability to laryngeal and bronchial catarrhs, and later to tuberculosis, whilst in others repeated attacks of tonsilitis predisposes to diphtheria.

The observations of Dr. Bowditch, of Boston, and Buchanan, of England, indicate that damp soils and habitations are important predisposing causes to tuberculosis, and we know positively that a decided reduction has been observed everywhere coincident with the introduction of sewers. The only reasonable explanation is that sewers have helped to purify the air and rendered otherwise damp soils and houses dry and more

healthful. It is well known that a damp soil is liable to make a house damp by capillary attraction, and the injurious effects of damp air have already been pointed out on page 99.*

As in other infectious diseases, the question as to whether the germs are introduced directly, and in sufficient numbers, is of importance. The observations of Humphrey, Pollock and Leudet conclusively show that in well ventilated wards, of chest and consumption hospitals, the disease is not usually found to spread. In private practice the results are different. A French committee of investigation presents two hundred and thirteen cases of tuberculosis in which the communicability of the disease was clearly established. In sixty-four of these cases the disease was conveyed from husband to wife; in forty-three from the wife to the husband; in thirty-eight it was transmitted to brothers or sisters; in nineteen from parents to the children; in sixteen to distant relatives; and in thirty-two to outsiders. The communicability was most marked among the poorer classes. Another collective investigation by a German medical society revealed the fact that of nine hundred and thirty-eight married persons who died of acquired tuberculosis, in one hundred and one instances either the husband or the wife also contracted the disease. In 8.1 per cent of these cases the husband contracted the disease from his wife, and in 13.2 per cent the wife was infected from the husband. Other statistics might be adduced in favor of the communicability of the disease, but Zasetzky's observation is of special interest. He reports the case of a tuberculous woman who married, between 1872 and 1883, three husbands, all previously healthy; the first husband died in 1879 of tuberculosis; the second in 1881, and the third husband, at the time of the report in 1884, was also a victim of the disease, the wife in the meantime having died of consumption.

We can only explain the greater contagiousness in such cases by a more intimate contact, the occupation of the same room and bed, common use of eating and drinking utensils, mouth to mouth contact, and the vitiated and infected air of private rooms.

EARLY SYMPTOMS OF CONSUMPTION.

The early symptoms are by no means clearly defined; we have, however, a steady loss in weight, with a slight amount of fever, especially in the afternoon or evening; the heart's action is quickened upon the slightest exertion, there is a general feeling of progressive weakness with loss of appetite, or disturbed digestion. There may or may not be a cough in the early stage of the disease. The symptoms referred to

*Kober's "Industrial Hygiene."

are sufficiently serious to call for the advice of a physician, and should never be neglected. Every child should learn to know that prompt treatment in the incipient stage offers the best chances for recovery, and that by proper care 80 per cent may be permanently cured.

Consumption is a curable disease, and the chief remedies, such as fresh air, wholesome food and living quarters, suitable clothing, systematic bathing and hardening of the skin are also the best preventive measures. Patients should not waste money on patent medicines or advertised cures for consumption. No reputable physician ever advertises his skill, and persons unable to pay for medical services will always find competent men at the dispensaries.

PREVENTION OF TUBERCULOSIS.

The facts presented in the foregoing pages justify the following conclusions:

(1) Tuberculosis is an infectious disease caused by a microbe, transmissible to healthy persons under certain favorable conditions.

(2) Inherited and acquired predisposition play an important role in the invasion and multiplication of the bacilli.

(3) The germs may enter the system by the respiratory and alimentary passages, and by the skin and mucous membranes, if there be an abrasion.

(4) While the bacillus may be transmitted through the milk, flesh and blood of animals and man, the most common and effective way of distributing the disease is by the sputum and droplets of tuberculous patients.

(5) The habitations of consumptives as well as their personal effects, clothing, etc., are infected and liable to convey the disease to others.

Space will not permit me to consider in detail the measures for the prevention of this disease, but I desire to emphasize a few which may be resorted to in the control of the sources of infection and the diminution of the predisposing causes.

(1) Compulsory notification of cases to the health authorities as soon as the disease is recognized. This is of vital importance for the location and control of the sources of infection, and for the protection of the family and others. It has been urged that the depressing effect of such information would be too great for the patient, but this will surely be counterbalanced when we inform him that it is a curable and preventable disease, and that his chances for recovery are especially favorable if he does not reinfect himself.

The health authorities, apart from distributing proper printed directions for the use of the family and the patient, as regard the care, disinfection of sputum and avoidance of droplet infection, should also resort to disinfection of the home and personal effects, especially upon the death of the patient or vacation of the premises. It is a good plan to receive the expectoration into paper spitting cups, paper napkins or moist saw dust, which should be burned. Cuspidors should contain a carbolic acid solution (6 ounces to a gallon of water). The patient, when out-doors, should use pocket spitting flasks, and during coughing or sneezing hold a handkerchief over mouth or nose. Under no circumstances should patients spit into spaces where the expectoration may be dried, and as pulverized dust, gain access to the air. The same directions about disinfection apply to cases suffering from pneumonia, influenza and diphtheria. The public should not cultivate an exaggerated fear of such cases, but has a right to insist upon clean and decent precautions.

(2) The enactment and enforcement of laws against promiscuous expectoration and coughing into the faces of persons where the sputum is liable to infect, and provisions for suitable spittoons and their proper disinfection in all public places are called for. The streets should be sprinkled and swept at night so as to reduce the inhalation of germ-laden dust to a minimum.

(3) The supervision of the sanitary condition of hotels, theaters, churches, schools, ambulance service, sleeping cars, etc., should likewise be under the control of the health department, and house-cleaning should be accomplished as far as practicable by the vacuum system.

(4) Marriage with a tuberculous person should not only be discouraged, but absolutely prohibited by law. A tuberculous mother should not nurse her infant, and in the selection of a wet nurse a certificate of health should be demanded.

(5) Isolation of tuberculous patients should be insisted upon in hospitals, asylums and public institutions. In private life the patient should occupy at least a separate bed, use separate eating and drinking utensils and neither receive nor give kisses.

(6) Government inspection of dairies and of dairy and meat products, and the extermination of bovine tuberculosis, are called for. Until this is accomplished or as an additional precaution, milk should be heated to 150 F. for 10 minutes, cooled quickly and kept cold, and all meats should be well cooked.

Having considered the sources of infection and the indications for their control, it is well to refer to what may be done towards diminishing the predisposing causes to consumption. Many of these questions have

been considered under personal hygiene, habitations, ventilation, food, alcohol, tobacco, clothing, bathing, etc., and it remains to sum up the duties of the State in this direction.

Reference has already been made to the good effects of sewers in preventing air pollution, and in the removal of dampness by drainage. When we recall the influence of sewers upon the prevalence of the disease, and remember that only about 30 per cent of the population in the United States live in sewered towns, and about 41 per cent live in towns having public water supplies, we see at once the necessity that a system of public sewerage should go hand in hand with the public water supply. The neglect on the part of the State not only increases the dampness of the soil, but compels recourse to the various make-shifts for the collection and removal of excreta, and leads to pollution of the air, soil and

water.

INSANITARY DWELLINGS.

The influence of insanitary dwellings on the prevalence of tuberculosis has already been emphasized. In addition to what has been said on page 99,* it should be remembered that the tubercle bacillus clinging to floors and walls in carelessly expectorated sputum or droplets would be destroyed by a few hours of sunlight, but finds in damp and gloomy rooms a suitable environment for its vitality and growth; and the other insanitary factors alluded to vastly increase the susceptibility to the disease. For all these reasons I consider the condemnation of houses unfit for human habitation, and substitution of sanitary homes, only second in importance to the destruction of the germs.

The State may not be in position to provide sanitary houses, but it can at least regulate and supervise the construction of all new houses with reference to the exclusion of dampness, sanitary plumbing, amount of air space, light, heating and ventilation of dwellings, and clearly define what constitutes an unsanitary tenement, offered for rent, and provide a suitable penalty. The State should also interdict the erection of tall buildings, and of all buildings covering over 66 per cent of the lot, since they shut out light and air, thus destroying the very object for which broad streets and avenues were created, and bringing us back to the insanitary era of the medieval towns with their narrow and winding

streets.

PHYSICAL CULTURE, PUBLIC PLAYGROUNDS AND BATHS.

The State should pay attention to the physical development of our youth, and this is best accomplished by proper training, preferably in the open air, in connection with the public schools and playgrounds.

*Kober's "Industrial Hygiene."