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phthisis.' The post-mortem investigations of many observers, both in this country and on the Continent, prove that spontaneous cure of consumption occurs in from one-third to one-fourth of all adults dying after the age of forty years. When the body of the late Emperor of Russia, who died of another quite different disease, was examined, a scar was found at the apex of the right lung indicating a former seat of tubercular disease, that had run its course unrecognised from the first stage to the last. What with Mr. Gibson's ' watching for three years the blind gropings after the truth of the most learned scientists in this country,' and his 'watching the half-truths they have not discovered-but been driven by Continental scientists to acknowledge, and the wrong positions they have taken up, while all the time thousands were dying who might have been saved, and’ he could keep silence no longer,' it is difficult to take him altogether seriously, nor would it have been considered necessary to do so but for the fact that if such inaccurate and irresponsible statements are allowed under the ægis of this Review to pass uncontradicted they are certain to do infinite harm at a time when public interest has been so strongly excited and people are everywhere seeking information.
Two important questions now present themselves for consideration: 1st, What medical knowledge is necessary on the part of the laity? and 2nd, What are the means to be employed for the prevention of consumption and other forms of tuberculosis?
Previous to 1882, when Koch first announced his famous discovery of the tubercle bacillus, the treatment of pulmonary tuberculosis had been to a large extent modified by anticipation, for the theory of a bacterial origin of tuberculosis had for some years been maintained, but actual knowledge of the disease was still largely theoretical, and its treatment correspondingly speculative pirical. The immediate result of Koch's investigations was the proof of two points in what scientists call the natural history of consumption : 1st, and by far the most important in all its bearings, that pulmonary tuberculosis (the correct name) is an infectious disease; and 2nd, that it is not an hereditary malady, or at least that heredity plays only a secondary or more correctly an indirect rôle in its dissemination. We are now in a position to maintain the opinion that persons who inherit a certain type of constitution or diathesis—the strumous—are more predisposed to become infected. They do not inherit the disease, but only a constitution involving greater liability. Individuals of this type are usually large-jointed, with clear transparent veined skin, blue eyes, and fair hair shading to red, auburn, and chestnut. Their tissues generally are lacking in firmness, and the lymphatic glands and absorbent ducts are largely developed, and probably facilitate from their size and activity the absorption of the infective material from without, particularly those of the neck, the bacilli entering through the follicles of the tonsils, then passing down through the cervical chain of glands and the lymphatic vessels into the chest. In young children especially, the lymphatics of the abdominal cavity convey the bacilli through the walls of the intestines to the peritoneum or lining membrane, the glands themselves become enormously involved in the general condition which was popularly called consumption of the bowels, or medically tabes mesenterica, now known as abdominal tubercle. This form of tuberculosis is almost always caused by infected milk,” and adults apparently are nearly immune to this form of the disease. From the abdomen the lymphatic vessels may convey the infective material to the membranes of the brain, causing tubular meningitis, popularly known as 'water on the brain.' In the adult there is occasionally seen a secondary infection of this form, by bacilli carried by the lymphatics from the primary seat of tuberculosis in the lungs.
It is strange that the belief in the infectious nature of consumption should have always widely prevailed, especially among the lower orders in Southern Italy. This is probably a long-descended tradition of classic times when the vast crowded city populations of the peninsula must have been terribly scourged by this dread disease.
The determination of the infective nature of consumption and the conditions of its activity constitute by far the most important results of Koch's investigations, more especially in relation to public health, since it is from a knowledge of the conditions under which the infective properties of the bacilli become effective, that indications are furnished as to the means and measures by which the tubercular disease thus produced, is to be effectively prevented. The principal facts to be remembered are : 1st. That consumption is a conditionally infectious disease,
due to a specific micro-organism. 2nd. That the tubercle bacillus is the essential infective
element. 3rd. That this microbe is contained in the sputum of
affected persons. 4th. That therefore the sputum must be regarded and
treated as the vehicle of infection. 5th. That the bacillus retains its vitality when dried, for
unascertained periods, and at low temperatures, but its activity is destroyed above 42°C. by free exposure to fresh air, by bright sunlight in a few minutes,
and by the usual antiseptics. 6th. That the bacilli do not seem to be exhaled with the
breath. • Tuberculous cows can most probably convey infection through milk only if the adder or teats are affected by tubercular ulcerations,
The tubercle bacillus and other micro-organisms are recognised under the microscope by the difference in their power of taking up colouring matter as compared with the other minute histological elements present in the same medium. Although consumption is a communicable disease, it differs materially from other contagious diseases, such as small-pox, scarlatina, or even enteric fever, in that it is only conditionally infective-certain conditions must be present before the infective element, the bacillus, can initiate the morbid process. These conditions are : 1st. The existence of a predisposed type of constitution,
or an acquired state of lowered vitality. 2nd. Access to the lungs with their narrow, well-guarded
portal. 3rd. The pulmonary tissue must be degraded to a lowered
vitality, either by mal-nutrition, or previous catarrhal
or other inflammatory attacks. 4th. The tubercle bacilli must have access to this favourable
soil by inhalation or otherwise, but almost invariably the former.
It is these ascertained conditions that furnish the indications for prevention (prophylaxis). We recognise that tuberculosis is essentially parasitic in nature and form, and that it obeys the wellknown laws of parasitism. This classification was formulated by the present writer in 1887 at the Washington Meeting of the International Medical Congress. It was pointed out by way of illustration that in a garden, a parterre of rosebushes, planted apparently under precisely the same conditions of soil, locality, &c., would perhaps sooner or later show here and there one or more bushes evidently not thriving like their fellows, feeble in growth, thin and pale in foliage, and poor in flower. On examination they are found infested with the green fly or some form of parasite; remove the latter as often as you may, they will always return to the sickly ones, but not to their more robust companions. The latter do not furnish the degraded devitalised tissues on which alone the parasites can batten. The delicate trees need more air and sunshine, their roots require opening out into looser and richer soil, and when this is done the plant takes on a healthier life, and no vermin will now assail its luxuriant growth. This parallel illustrates in outline the essential elements of infection, cure, and prevention in tubercular disease.
Pulmonary consumption being then a recognised infectious disease, what steps for its prevention should be taken : (1) by the individual; (2) by the community? This resolves itself into a joint question of bygiene, personal and public.
* Transactions, vol. iv. p. 26.
I. Personal precautions. These refer to the individual as well as his immediate environment. The disposal of the sputum is the first and most essential of all the precautions. The patient should always expectorate into a covered vessel, or in a spittoon flask carried about the person, both containing some efficient antiseptic solution. The receptacle should be emptied twice a day, well washed in boiling water, and the contents incinerated. Open spittoons or cups are objectionable on many accounts. Handkerchiefs or other such materials should not be used to receive sputum. Strict personal cleanliness in every detail is imperative. Neither respirators nor so-called chest-protectors should be worn. The whole body should be bathed every morning and sponged every evening with tepid or cold water, salt if possible. The hands should be washed and nails brushed in hot water before meals. The hair and nails should be cut close, and the face should be clean shaven. The body and bed-linen should be frequently changed, the blankets, quilts, and body clothes should be exposed to sunlight and fresh air as frequently and for as long a time as possible. All clothing should be disinfected before washing. The patient should not be kissed on the mouth. Separate table and service requisites should be kept for the patient and separately washed.
As regards his immediate environment, the patient should invariably occupy a separate bed and room, the windows of the latter should never be closed, the bodily heat being maintained rather by sufficient bed-clothes, especially ventilated eider-down quilts, than by artificial heat. When the rooms are unoccupied, both doors and windows should be kept open. No bed-curtains, valances, windowcurtains, or any draperies that can be dispensed with, should be permitted. The floors should be sparingly covered by one or more rugs -preferably Japanese mats, so as to be easily removed, and they should be thoroughly beaten and exposed as much and frequently as possible to air and sunlight. The walls of the rooms should be distempered, or oil-painted preferably, to permit of their being frequently washed down. The absence of cornices and other ledges on which dust may collect is desirable, and all dusting should be done with damp cloths. The floor should be varnished and similarly treated.
II. Public precautions. These open up a subject far too extensive to be referred to here except in the merest outline. It includes the consideration of the following questions :
1. Whether and what special legislation is desirable or necessary. 2. Notification—as in the case of the infectious diseases already scheduled. 3. Inspection by the local authority of houses occupied by consumptives. 4. Disinfection of such houses. 5. The systematic dissemination, by circular or otherwise, of simple rules of health, especially with reference to diet and cleanliness of house and person. 6. The systematic teaching in schools of cleanly habits and the elementary rules of health. 7. Expectorating in public places, railway carriages, and other public conveyances, should be forbidden under penalty. The same rule ought also to be strictly enforced in all government premises, banks, mercantile and other offices, shops, mills, manufactories, workshops, &c. 8. The appointment of qualified medical men in every populous centre, to whom suspected consumptives—that is, persons having cough and expectoration-should be sent by their relatives or employers for examination, and, if pronounced infected, advised as to subsequent treatment. 9. The isolation of consumptives from other patients in all hospitals, and the provision of special sanatoria by the authorities in suitable localities for their separate treatment. This might involve the erection of different hospitals for the reception of hopeful cases, or advanced and hopeless respectively. 10. Further stringency as to measures directed to maintaining purity of milk supply, involving the possible necessity of permitting only the sale of sterilised milk, except where the supply can be ascertained to come from an uncontaminated source, such as dairies where the cows are put periodically to the tuberculin test.
It will be seen from the considerations here submitted what a great work the National Association for the Prevention of Tuberculosis has undertaken, and what grave responsibilities such a task involves. The combined efforts, with or without Parliamentary legislation, of the people of all classes, with all the resources of medical science will be necessary for success, and it is satisfactory to know that, if the movement should fail to accomplish all that it contemplates, yet so far as it succeeds it will have, to that extent at least, reduced the widespread and fatal ravages of pulmonary tuberculosis.
J. G. SINCLAIR COGHILL, M.D.