specimens of physical manhood, having gained many pounds in weight and would never be suspected of ever having been tuberculous. The results were obtained by close observation, dieting, sanitation, open air, and prohibiting the use of tobacco in any form on the wards.

The duty of the State is to establish consumptive cottages at every public institution, where the insane, epileptic or convict, is confined and cause the closest scrutiny, and isolation to be practiced, then we will soon eradicate the disease from the public institutions. There should be established under State care, sanitariums for the treatment of tuberculosis as a protection to its citizenship; and these institutions should be conducted along purely scientific lines, politics having no part in its management. It is truly said by Dr. H. M. Bracken, secretary of board of health, St. Paul, Minn., that "it rests upon physicians in this country, through their various medical organizations, to transform the great body of medical sanitariums into medical specialists beyond and above the influence or control of politics."

PREVENTION OF TUBERCULOSIS IN PRIVATE

PRACTICE.

J. W. MCLAUGHLIN, M. D.,

GALVESTON, TEXAS.

Since the discovery of the bacillus tuberculosis in 1882 by Robert Koch, the possibility that tuberculosis of man may be finally exterminated has become a reasonable hope. Already the death rate from this disease has been markedly reduced in sections of country and in cities where repressive measures have been faithfully carried out along proper lines. But much remains to be done: the public must be educated, and the co-operation of the people must be had everywhere before complete success can be obtained.

In the war that is now being waged against this the most common and fatal disease of man, as in all other measures seeking to prolong human life and to lessen human suffering, members of the medical profession have been the initial and principal movers, but they alone can not carry forward this work to a successful issue, government authority and aid must be had and doubtless will be forthcoming when the purpose, importance and value of the work is more generally understood by the public. It is therefore the duty of the medical profession particularly, as its members are informed, to see to it that the people at large are informed of the concealed danger of contracting tuberculosis, to which they are constantly exposed.

The part assigned me in this symposium on the prophylaxis of tuberculosis is to indicate what particular part in the crusade belongs to the family physician. The relation existing between the doctor and his patient, and especially between the family physician and his clientele, is of that intimate, confidential and responsive character that the doctor in a great number of matters can secure the intelligent co-operation of the people, particularly in matters looking to the betterment of public health, better than can

29-Trans.

be done by any one else. Now the great mass of the people know nothing of the infectious nature of consumption, but little of the danger of its being transmitted from the sick to the well, and nothing of the means whereby this may be avoided. Here, then, is a fallow field of labor and the family physician is the best man to do it. He is the family adviser in medical matters, he has the confidence and can command the attention of his patrons and his opinions in matters of health are respected and usually followed. Besides, he is familiar with the physical diseases, hereditary tendencies, individual predisposition and habits of life of his people. Does not his attitude in the community, his technical education and his professional influence, make it the moral duty of the family physician to become a public instructor in the prophylaxis of tuberculosis? However this may be, there is no doubt but that he of all others can more successfully perform the labor.

The following statement of a few accepted facts of tuberculosis, its etiology, prevalence and mortality will enable one to more fully and clearly appreciate not only the supreme importance of prophylaxis and its possibilities in the saving of human life and in lessening human suffering, but will also indicate the work of individual prophylaxis that particularly falls upon the family doctor to see to.

The bacillus tuberculosis of Koch is the one essential etiological factor in the production of tuberculosis of man. Inherited predisposition or tendencies, vulnerability of the tissue soil, catarrhal inflammations, simple or infections, of the respiratory passages, and non-tuberculous adenites are important contributory causes of tuberculosis, but neither one of these factors nor all combined are capable alone of producing the disease; the germ, the tubercle bacillus is absolutely essential to the development and growth of tubercle and it is as impossible for the disease to develop without its germ as it is for an oak tree to spring from the soil without its seed, the acorn.

THE FREQUENCY OF TUBERCULOSIS IN MAN.

Taking the mean death rate of the whole population to be twentytwo per thousand, and the average of deaths from phthisis, or con

sumption, to be three per thousand, we find that the deaths from phthisis are nearly one-seventh of the entire mortality. (Hirsch.)

This mortality exceeds the combined deaths from war, famine, plague, cholera, yellow fever and smallpox. "Estimating the total yearly mortality of the world to be 35,000,000, we find that about 5,000,000 deaths are referable to this cause, being the greatest number reported by reliable observers as due to any single disease." (Evans.)

The United States census report for 1890 gives 102,181 deaths due to consumption. Basing his estimates on the census reports, Vaughn concludes that the total number of persons suffering from tuberculosis in the United States is 1,050,000, or one in every sixty of the population. In New York State more than 13,000 deaths occur annually from pulmonary consumption. In the city of New York more than 8000 deaths; in Paris over 11,000, and in London over 10,000 annually are attributed to this cause.

"Tubercle in its various forms at the present day carries off annually nearly 70,000 persons in England. In the form of phthisis, at ages between fifteen and forty-five-the most useful stages of human existence--it kills one-third of the people who die at these ages, and nearly half between fifteen and forty-five."-Ran

som.

According to the official returns for Germany (1893) out of a total of 268,500 persons dying between the ages of fifteen and sixty, of whom the cause of death was reported, 88,654 died from tuberculosis-a mortality of thirty-three per cent. for these ages. Leyden estimates the annual death rate from phthisis in that country to be 170,000, and the total living tuberculous patients to be 1,300,000. Statistics show that of a mortality of 850,000 in France, fully 150,000 deaths are due to tuberculosis.-Lartigue.

DISTRIBUTION OF THE BACILLUS TUBERCULOSIS.

That tubercle bacilli are widely distributed and have been found in the dust, adhering to the walls, floors and furniture, to the bedding, carpets and hangings in dwellings, hospitals, prisons and sanitaria where consumptives have resided need excite but little sur

prise, when one considers the great number of cases of chronic ulcerative phthisis who, either from ignorance or indifference, daily and nightly expectorate from their lungs germ-laden sputum containing millions upon millions of virulent bacilli. Nuttall estimates that the twenty-four hours sputum of a consumptive patient may contain from 3,000,000 to 4,000,000 bacilli. Furthermore, it has been established that sputum containing bacilli expectorated, dried and divided into a fine dust may retain its virulence for seveal weeks. The best-known experiments with dust and infectious tubercle bacilli are those carried out under the direction of Koch by Cornet. Dust gathered from various places, as hospital wards, asylums, sanitaria, prisons and private dwellings where tuberculous people had lived, perhaps died, was injected into guinea pigs and proved infectious in a large proportion of the cases. We may learn from this that the tubercle bacilli contained in the sputum of tuberculous patients may retain their virulence for weeks, possibly months, after it has been dried, divided into a fine powder and scattered to the winds. In the light of this evidence the astonishment that is excited by reading the frightful array of mortality statistics of tuberculosis is changed into wonder that any one breathing air polluted by teeming millions of virulent tubercle bacilli should escape infection. In fact, recent observations indicate that a very much larger per cent. of the population are attacked than has heretofore been known. "The statement has been made by Bouchard that, of the post-mortems of the Paris morguegenerally upon persons dying suddenly-the percentage found with some evidence of tuberculous lesion, active or obsolete, is as high as seventy-five. Large as these figures appear, they are probably very incorrect if, as has been done in Ribbert's laboratory, a systematic inspection is made for the purpose, tuberculous lesions are found in practically one hundred per cent. of adult bodies."-Osler. Fortunately for the perpetuation of the human race, all persons are not equally susceptible to infection with the tubercle bacillus. There is a difference in what may be called the tissue soil of the body to infection. When the fertility of the tissue soil is plus, the invading tubercle bacilli develop rapidly and grow luxuriantly.

On