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THE PREVENTION OF TUBERCULOSIS.

BY T. E. OERTEL, M.D., AUGUSTA.

Since Robert Koch in 1882, gave to the world his remarkable monograph, Die Aetiologie der Tuberkulose, there has been a progressive enlightenment of the minds of both profession and the laity in regard to the socalled "White Plague."

The movement against tuberculosis is daily increasing in momentum, and the most gratifying results have attended its efforts.

To-day the scientific world is agreed that tuberculous affections, whatever their nature, are the direct result of the entrance of tubercle bacilli into the animal tissues and their multiplication there.

It is entirely superfluous to present to the Society evidence to substantiate this fact.

It would seem that a paper upon the prevention of tuberculosis with a view of awakening interest in the subject should also be unnecessary, but unfortunately facts do not warrant such an assumption.

It is estimated that over 150,000 deaths occur in the United States each year from T. B. (1)

The census of 1900 gives for the State of Georgia 9.84 per cent. of the total deaths as the mortality from T. B. (2) The mortality statistics for 1901 from public health reports show 8.09 per cent. of the total mortality given for this State as due to T. B., but this is evidently a low estimate, as it represents a population

of only 151,601, many of our larger cities being omitted from the report. (3)

As has been shown elsewhere by myself, the death rate from T. B. is probably very much higher in our own State than would appear from our mortuary tables. (4)

But granting that we have a proportion of 10 per cent. of all deaths due to T. B., then, it there are any methods of prevention against the disease, surely we should avail ourselves of them, nor have we done our duty to the public unless we use our best endeavors with this end in view.

Between the ages of fifteen and forty T. B. causes one-third of all deaths that occur. (5)

If then, we consider that T. B. is preeminently a disease of young adult life, 42 per cent. of all deaths between the ages of twenty and twenty-four being due to it, while between fifty-five and sixty-four the mortality percentage of T. B. is reduced to 5.5 per cent. (6), we are confronted by the fact that tuberculosis chooses its victims from among those who are just reaching the productive age, so that from an economic standpoint alone the disease is a factor of no small import.

Infection of the animal body may take place in the following ways:

1. By transmission from mother to child in uterus. 2. By direct inoculation through trauma.

3. Through the alimentary tract from infected food. 4. By inhalation of infected material. (7)

Infection by either of the first two methods is rare. Regarding primary infection through the alimentary tract from infected food, much might be said, and a brief review of the subject will not be amiss.

Prior to 1901, when Koch read before the British

congress on tuberculosis the celebrated monograph (8) which caused such a stir in the scientific circles, it was quite generally accepted as a fact that bovine tuberculosis was frequently transmitted to human beings through the agency of milk and infected meat.

When Koch asserted, "I should estimate the extent of infection by the milk and flesh of tuberculous cattle and the butter made of this milk as hardly greater than that of hereditary transmission, and I, therefore, do not deem it advisable to take any measures against it" (9), he raised a storm of protest, and stimulated renewed effort in research in the endeavor to settle this question.

The result has been the accumulation of an overwhelming mass of evidence to prove that human beings. can, and frequently do, contract tuberculosis by infection with the bacillus of bovine tuberculosis.

Ravenel asserts that the "strongest proof of the transmission of T. B. to the human being through milk infected with bovine tubercle bacilli, is the finding of bovine tubercle bacilli in the intestines of children who have died of intestinal tuberculosis." (10)

The Committee on Animal Diseases and Animal Food of the American Public Health Association, after exhaustive review of the literature of the subject in concluding their "Third Report" say: "The subcutaneous infection of cattle with pure cultures of the tuberculosis bacillus from human sources, which according to Koch, yields quite specially characteristic and convincing results, has proved, in the hands of the German Commission, no less than in those of independent investigators, that bovine tuberculosis is communicable to man. It will require much work to decide with even approximate accuracy the proportion of human tuberculosis caused by animal infection; but the fact that

twenty-five per cent. of the cases in children investigated by the German Commission, and fifty per cent. of similar cases investigated by DeSchweinitz, showed by this test that they were caused by animal infection, is sufficient to convince us that measures should be taken and enforced at once to guard against infection from this source." (11)

Dorset, drawing conclusions from data gained by experimental inoculation by him of a series of rabbits and guinea-pigs, states that he believes, "that in bovine and human tuberculosis we have to do with organisms differing usually in virulence, but between which there is no other essential distinction." (12)

More final still is the statement that "bovine tubercle bacilli introduced into the human tissues by accidental inoculation have lived, multiplied and produced disease at the point of inoculation, and have been recovered after a considerable time with their vitality and virulence unimpaired." (13)

To illustrate the danger that may lurk in cattle apparently healthy, we would best consider the following conclusions of Mohler in his valuable and recent monograph:

1. The tubercle bacillus may be demonstrated in milk from tuberculous cows when the udders show no perceptible evidence of disease either macroscopically or microscopically.

2. The bacillus of tuberculosis may be excreted from such an udder in sufficient numbers to produce infection in experimental animals both by ingestion and inoculation.

3. "That in cows suffering from tuberculosis the udder may, therefore, become infected at any moment.

4. "Cows secreting virulent milk, may be affected

with tuberculosis to a degree that can be detected only by the tuberculin test.

5. "The physical examination or general appearanceof the animal can not foretell the infectiveness of the milk." (14)

It may be well here to emphasize the fact that cattleare in no wise injured by the tuberculin test. (15)

From such information as I can gather, I am led to believe that in Georgia, and in fact in the South as a whole, there is comparatively little bovine tuberculosis. But unfortunately, we have no data upon which to base conclusions, and it is high time that measures were inaugurated to remedy such a condition.

The most common mode of infection is through the respiratory tract by inhalation of material containing the T. B.

The tubercle bacilli come directly from a case of tuberculosis, and do not multiply outside the human. body as true saprophytes. (16)

The usual source of infection is the dried sputum, which comes from the mouth and nasal passages of a tuberculous subject during coughing, sneezing, and even when talking.

It has been shown that in the act of coughing, infected mist may be driven to the distance of 1.5 metres. (17)

Fortunately, the tubercle bacillus is soon killed by the direct sunlight, but under conditions even slightlyprotected, it may retain its vitality for a long time. Tubercle bacilli have repeatedly been found alive and virulent two years after leaving their human host, they having resisted successfully desiccation and the action of light for this length of time. (18)

But the facts relative to the transmission of tuber-

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