TUBERCULOSIS. 515 TUBERCULOSIS. Consumption prevails in all latitudes. To- ward tlie poles and in very high altitudes the mortality is somewhat lower. No race is ex- empt, hut negroes and Indians, and other races to whom the disease is comparatively new, are espe- cially susceptible. In rare instances the disease is congenital, derived from the mother; there has been found no proof of paternal transmission either in man or animals. The great frequency in young infants of tuberculosis, whether of the lungs, meninges, or bones, is taken by many ob- servers to prove that the virus can be trans- mitted. Ileredit.v plays an important role in de- termining the disease in individuals. Children of tubercular parents are more liable than others to contract consumption, and hereditary pre- disposition can often be traced in a family for several generations. Two classes of individuals naturally predisposed toward consumption have long been recognized: the one tall, with straight limbs, regular and even beautiful features, dark hair, long eyelashes, thin and delicate skin; the other stunted, with coarse features, thick lips, light hair, sluggish action, and a tendency to en- largement of tile lymph glands. A predisposition to tuberculosis is acquired under conditions that seriously lower vital resistance. Among those are overcrowding, deficient ventilation, poor food, prolonged and exhausting disease, preg- nancy and lactation, i d unhealthful occupa- tions, such as glass-blowing, coal-mining, street- sweeping, exposure to cold and damp, and the excessive use of alcohol. The disease is most frequently- acquired in early adult life ( from twenty to thirty-five). The pulmonary compli- cations following measles and whooping-cough in children are often forerunners of a tubercu- lous deposit in the lungs. The direct medium of contagion is the sputum of the tuberculous pa- tient. The number of bacilli throAvn otT in this manner is enormous. By a patient moderately advanced in the disease Nutt.all estimated there were expectorated in the twenty-four hours be- tween two and four billions of bacilli. The sputum becomes dry and desiccated, the bacilli are distributed by the dust and obtain entrance to the body again through the respiratory tract. The flesh or milk of tuberculous cattle is capable of transmitting the disease both to man and to other animals. Many cases of intestinal and mesenteric tuberculosis in children are attribut- able to this source. Finally, infection can be brought about by direct inoculation. Demonstra- tors of morbid anatomy, butchers, and handlers of hides are subject to a local tuberculosis of the skin. Infection has taken place from circum- cision, washing the clothes of phthisical patients, and through a cut from a broken sputum cup. When the tubercle bacilli have once definitely invaded the lungs the disease runs its course with different degrees of rapidity. It may be fatal in three or four months, or ten to fifteen years may elapse between infection and death. During this time it may be quiescent for months or a year or more. Two types are usually recognized. The rapid form (galloping consumption) begins after a cold or exposure, with rapidly rising tempera- ture, pain in the side, difficult breathing, rust- colored sputum, and consolidation of one or more lobes of a lung: in other words, like an attack of pneumonia. Instead, however, of improving at the end of the tenth day, the symptoms become graver, the fever continues high, the lung is rapidly softened and destroyed, and the patient dies in from three weeks to as many months. This form is always fatal. The second type, sometimes called chronic ulcerative phthisis, comes on more slowly and runs a longer course and includes the majority of cases of pulmonary tuberculosis. The disease begins with a slight but annoying and unproductive cough, chilly sen- sations, indigestion, loss of appetite, and "grad- ually increasing weakness. As the trouble pro- gresses, the cough becomes severe and constant, with 3-ellow or whitish expectoration, contain- ing usually multitudes of bacilli, and sometimes tinged with blood. Fever is higher in the after- noon and evening and the temperature rarely drops to normal. Night sweats, pains in the chest, steadily progressing weakness, dyspna?a, and wasting are now present. Occasionally quan- tities of blood are brought up (hemopt.ysis) dur- ing a paroxysm of coughing. It is bright red, frothy, and due to the ulceration of an artery of some size. The course is not always fatal; {he disease may be arrested at any stage, and partial or complete healing take place, leaving scars or cavities in the lung. Improvement may be only temporary and the process start up again under favor.able conditions. In fatal cases the last stage is marked b.y an exhausting diarrho?a, and swell- ing of the lower extremities. Death may take place suddenly from hemorrhage or gradually from exhaustion. Examination of the chest shows a deficient expansion of the ribs, rapid heart ac- tion, exaggerated voice sounds, irregular and high-pitched respiration, and different varieties of rales, depending on the stage of the morbid proc- ess. The prevention of tuberculosis is one of the most difficult problems with which the sanitarian has to grapple, the disease being so widely dis- seminated, and so insidious in its approaches. Efforts in this direction are mainly directed to destroying tuberculous cattle, segregation of phthisical individuals, and destruction of their sputum. Municipal ordinances against spitting in public places have been passed in many cities. In sanatoria patients use special receptacles for their sputum, which is thoroughly disinfected and burned. Boards of health in the larger cities are taking note of cases in private life and urging them to dispose of expectorated matters in a sanitary way. Individuals predisposed to consumption should lead an exceptionally careful life in an equable climate and out of doors. Particular attention should be given to keeping the upper respiratory passages in a healthy condition and guarding against colds. Tuberculosis is a curable disease in its earlier stages. Spontaneous cure is an everyday phenomenon, and a large proportion of individuals dying of other diseases are found on autopsy to possess healed tubercular lesions in the lungs. There is no successful specific treatment. Koch's tuberculin and its various modifications and the different antitoxins and antitubercle serums are being used, but are still in the ex- perimental stage, and have to be administered with great circiunspection. The treatment of consumption is in most eases best carried out in well-regulated sanatoria, where the patient's life and habits are under expert surveillance. Tlie main objects in view are to place the sufferer in
