the other hand, when the fertility of the tissue soil is minus, the invading tubercle bacilli do not develop, or they grow slowly and the lesions produced are strictly localized. Now, while the condition of the tissues of the body, which have been spoken of as tissue soil, but is generally designated as vital tissue resistance, is, I believe, inherent and determines natural susceptibility and immunity in contradistinction to acquired or artificial susceptibility and immunity. It should not be forgotten that the condition is relative and not absolute, and that it may be greatly influenced by environment. For example, bad environmental conditions weaken vital. resistance and thereby favor infection. While favorable conditions. of environment strengthen the vital resistance and in equal degree retard, check or suppress infection. This is an important fact that should never be lost sight of in the treatment of phthisis.

INDIVIDUAL PROPHYLAXIS.

To stop the spread of tuberculosis by the careless or ignorant consumptive we must begin by convincing him of the wrong he is doing to himself and to others by the manner in which he disposes of his infectious expectoration. Such a patient should never expectorate except into a proper receptacle. He should never expectorate into a handkerchief, since the dried sputum in the handkerchief becomes disseminated when it is unfolded; besides, there is danger of the patient reinfecting himself at this time by drawing into the lungs infectious material during the deep inspiration that precedes the coughing spell.

In all places where consumptives who are able to be about are likely to be, there should be placed at suitable distances a sufficient number of properly constructed spit-boxes. They should be easily accessible, placed at a convenient height, supplied with lids that will screen the contents from flies, and so constructed that they can be easily and safely cleaned.

A suitable spitting-box for use at home is made by Seaburry & Johnson. It is made of impermeable pasteboard, with turned-in top edges, and fits into a metallic frame with handle and cover. When the cup is filled, the pasteboard is taken out and burned,

with its contents. There is also a sanitary sputum cup manufactured by the Kny-Scherer Company, of heavy compressed paper, with handle and a close-fitting cover. Its cheapness and easy destruction by fire-cup and contents together-make this a very useful cup. Among other forms of spit-boxes are those to be carried about by the patient, in his pocket, and should always be used by him when the stationary cuspidors are not at hand. A patient should always have two pocket cuspidors, so that he may never be without while one is being cleaned. The most thorough method of cleaning any cuspidor filled with tuberculous sputum is to place the spittoon and contents in boiling water, to remain there for five or ten minutes, thorough mixing of the contents with five per cent., or, better, ten per cent. carbolic acid, or 1-1000 acid sublimate solution can be safely relied upon to disinfect.

When consumptive patients can not be persuaded to use the sputum pocket flask, squares of parafined paper should be provided, each square to receive the sputum of one coughing spell. The ends of the paper should then be brought together, twisted, and the little packets carried in a bag or reticule until an opportunity to burn them is offered.

The status of a consumptive, especially one able to be about, should be clearly defined in the community. A consumptive becomes a menace to the public health only through the practice, filthy and unnecessary, of expectorating promiscuously. There is practically no danger to be feared except through this habit. Control the habit and you destroy the danger. If the habit can not be controlled by reason, then it should be done by law. No man has the right to needlessly expose others to danger and no community, through mock sentimentality, should hesitate to enforce necessary sanitary measures in such cases.

THE PUBLIC CONTROL OF TUBERCULOSIS.

LAWRENCE FLICK, M. D.,

PHILADELPHIA, PA.

A public danger demands a public remedy. This is a maxim of law which holds under every form of government. So long as tuberculosis was looked upon as a visitation of Providence or a legacy from a degenerate ancestry, governments had no concern with it, because they can not interfere with the doings of Providence nor the private rights of man. Once that it came to be established, however, that tuberculosis is a contagious disease, and consequently a preventable one, governments became responsible for its prevention. This responsibility is predicated upon the contagiousness of the disease.

In order that the public may be aroused to its responsibility in the prevention of tuberculosis, the contagiousness of the disease constantly should be kept to the forefront. There must be no obscuration of the truth nor softening down of terms which express the fact. Tuberculosis is contagious and it should be called so on all occasions. The word "infectious" is not applicable and the word "communicable" is misleading; neither should be applied to tuberculosis. Recently, in addressing the different branches of the government of a State in behalf of a State sanatorium for consumptives, the mischievous effect of the use of the term "communicable" by medical men was made manifest. A discussion just had taken place in a medical society in which preference was given to the word "communicable," and resolutions had been adopted by the society, opposing the position of Surgeon-General Wyman in declaring tuberculosis contagious. My argument for an appropriation on the score of prevention was promptly met by the statement that my premise was wrong, as the disease had just been declared non-contagious by a large body of medical men. Thus it became necessary to again prove what long since has been demonstrated and

what now should be common belief of all. The logic of laymen is often very keen. If tuberculosis is not contagious, it is not preventable, and if it is not preventable there can be no reason why governments should interfere. This is what may be called a shortcut conclusion, but it is good logic. A communicable disease practically may not be a preventable disease, and the word "communicable" does not carry with it the idea of public danger. In order that governments may interfere for the prevention of disease there must be something which the government can do. In a contagious disease the government can prevent or regulate contact, and the duty of the government becomes quite obvious, because the individual can not prevent or regulate contact himself. The word "contagious," moreover, carries with it the idea of public danger and suggests the remedy, public prevention.

Can the word "contagious" properly be applied to tuberculosis? It can, and, in truth, it is the only word which scientifically fits the case. Tuberculosis is essentially a contact disease. For implantation of the tubercle bacillus in a new host prolonged intimate exposure is necessary. This exposure, moreover, must be to a tubercular subject or to a place or thing which has been contaminated by a tubercular subject. Momentary exposure is not sufficient and even repeated casual exposure does not amount to much. In practice new implantations most frequently take place through family, employment, and business relationships, and through occupation of houses which have been occupied by consumptives.

For the public control of tuberculosis, it is necessary for governments, through boards of health,

First. To establish registration of tuberculosis.

Second. To distribute literature on the prevention of tuberculosis.

Third. To establish sanatoria and hospitals for the treatment of tubercular subjects.

Fourth. To disinfect houses and places which have been contaminated by tubercular subjects.

Fifth. To sterilize clothing, implements and belongings of tubercular subjects before these can pass into the hands of others.

Without registration of tuberculosis it is impossible to control the spread of the disease. The government must first know where a case is before it can deal with it. There has been a great deal of opposition to registration by members of the medical profession, due, no doubt, to a misconception of what it means and of what is to follow in its wake. The unnecessary hardships which often go with the registration of other diseases have raised a prejudice and antagonism against the registration of tuberculosis in the minds of medical men which is a credit to their hearts, if not to their heads. This prejudice and antagonism is unfounded in fact, however. There can be no hardship in the registration of tuberculosis or in what follows it unless it be willfully and maliciously introduced. Tuberculosis differs so from other diseases in its mode of contagion that it requires measures of prevention peculiar to itself, and these measures are all in line with humanity and benevolence. Compulsory isolation of the consumptive is out of the question, and is unnecessary. The consumptive poor are only too glad to go to a sanatorium or hospital where they can be made absolutely harmless and the consumptive middle class and well-to-do can, in nearly all cases, be taught to make themselves harmless. Even these latter are glad to go to sanatoria if the opportunity be given them. Compulsory disinfection of houses which have been occupied by consumptives and the sterilization of clothing, furniture and implements which have been used by them throw a protection around the poor and weak against the avarice of the rich and strong. The registration of one's name as a person suffering from tuberculosis can be no more objectionable before death than after it, especially as in either case the registration is a secret one. In a proper scheme for the prevention of tuberculosis registration before death would have the compensation of bringing protection to those who are near and dear, and who would not sacrifice a little sentiment to save his loved ones from so horrible a disease as tuberculosis!

Boards of health should systematically distribute literature to all persons having tuberculosis, telling them how to avoid giving the disease to others, and to all persons exposed to tuberculosis,