COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD ' -^ ■ T Mif^ i - I . ,. as t^liirsea.^e of the Masses and How to Combat It or TME INTERNATIONAL TÜEEStCüLOS!S CONGRESS PRIZE ESS4 msi?m^ Berlin.. IS99 ^mSM§$^^s5a mzw YORK WURTH AMERICAN EDITION >V ^ Columbia ®mtiers;itp COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by tine Internet Arcinive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/tuberculosisasdOOknop TUBERCULOSIS AS A DISEASE OF THE MASSES AND HOW TO COMBAT IT FOURTH ISSUE REVISED AND ILLUSTRATED With Supplement on Home Hygiene, School Hygiene, Installation of the Sanatorium Treatment at Home, and a Histor- - ical Review of the Anti-Tu- berculosis Movement in the United States Motto : To combat consumption as a disease of the masses successfully; requires the combined action of a wise govern- ment, well trained physicians, and an intelligent people. PRIZE ESSAY BY S. A. KNOPF, M.D., New York Director in the National Association for the Study and Prevention of Tuberculosis ; Associate Director of the Clinic for Pulmonary Diseases of the Health Department ; Visiting Physician to the Riverside Sanatorium for Con- R sumptives of the City of New York, etc. " The " International Congress to Combat Tuberculosis as a Disease of the Masses," which convened at Berlin, May 24 to 27, 1899, awarded the ]| International Prize to this work through its Committee on July 31, 1900 AMERICAN EDITIONS First Issue. 1901 ; Reprinted, 1 903 ; Reprinted, 1 905 ; Revised with Supplement, 1907 Published by FRED. P. FLORI, 514 E. 82nd St., New York Also for Sale by "CHARITIES AND THE COMMONS" 105 East 22nd Street, New York City 1907 rwwworarwsrarararMMrarararwarwarjrarararwarararwjrwdraracarxwjr 4 Copyright, 1 90 1 ByS. A. KNOPF, M.D. NEW YORK LIST OF TRANSLATIONS The American edition is translated by the Author and published by Fred. P. Flori, 514 East 82d Street, New York. The Arabic Edition is translated by Dr. Mary P. Eddy, Beirut, Syria, and published by the Board of Foreign Missions of the Presbyterian Church. The Brazilian edition is translated by Dr. Clemento Ferreira, and published by the " Revista Medica de Sao Paulo," Brazil. The Bulgarian edition is translated and published by Professor A. Bezenseck, of Philippopel. The Dutch edition is translated by Dr.. J. W. F. Donath, and published by F. Van Rossen, Amsterdam. The English edition is adapted for use in England by Dr. J. M. Barbour, and published by Rebman, Limited, 129 Shaftesbury Avenue, London. The Finnish edition is translated by Dr. Johannes Moving and L. Rosendahl, F.M., and published by Dr. Joiiannes Hoving, New York. The French edition is translated by Dr. G. Sersiron, and pub- lished at Paris by G. Masson, 120 Boulevard Saint Germain. The German edition is published by the "German Central Com- mittee for the Combat of Tuberculosis," at Berlin, 9 Eich- horn Strasse. The Hebrew edition is translated by Dr. L. W. Zwisohn, and published by E. Zunser, 158 East Broadway, New York. The Hungarian edition is translated by Dr. Wm. Roth-Schulz, and published by Mai Henrik es Fia, Budapest. The Icelandic edition is translated by Dr. G. Björnsson, and published by the Danish Government at Reykjavik. The Italian edition is translated by Prof. Dr. Roberto Massa- longo, of Verona, and published at Milan by Francesco Valardi. Another Italian edition is translated by Dr. Giovanni Galli, and published by the Societa Editrice Dante Alighieri, at Rome. The Japanese edition is translated by Dr. Goro Shibayama, Tokio. The Mexican edition is translated by Dr. D. Vergara Lope, and published by Eduardo Murguia, Mexico. The Polish edition is translated by Dr. Stanislaus Lagowsky, and publisiied by E. Wende i S-ka, Warsaw. The Russian edition is translated by Dr. F. M. Blumenthal, and published under tiie auspices of the Pirogoff Society of Russian physicians by A. A. Levenson, at Moscow. The Second Russian edition is translated by B. I. Wender, and published by P. I. Makuschin, Tomsk, Siberia. The Serbian edition is translated by Drs. V. P. Popovic and V. Vojislav Mihailovic, Graz, and published by Paher & Kicic, at Mostar. The Spanish edition is translated by Dr. Ernesto Sanchez y Rosal, and published by Ern.st Litfass' Erben, Berlin C. The Swedish edition is translated and published by Dr.Johannef Hoving, New York. The Turkish edition is translated by Dr. Mary P. Eddy, of Beirut, Syria, and published by the Translator. PREFACE" TO THE GERMAN EDITION. fBy Geh. Med. -Rath Professor B. FRÄNKEL, of Berlin, Germany, setting forth the conditions under which the prize was awarded.) At the meeting of the "International Congress for the Study of the Best Way to Combat Tuberculosis as a Disease of the Masses " which convened at Berlin, May 24-27, 1899, the sum of 4,000 marks was donated by two Berlin merchants, lay mem- bers of the Congress, as a prize to be offered for the best essay on the subject "Tuberculosis as a Disease of the Masses and How to Combat It " (" Die Tuberkulose als Volkskrankheit und deren Bekämpfung "). The Congress decided on the following regulations concerning this prize : 1. The best popular essay on the subject "Tuberculosis as a Disease of the Masses and How to Combat It," comprising not more than eighty, and not less than forty-eight, printed pages, shall receive the prize of 4,000 marks. In case the jury of the prize committee should decide that two essays deserve the prize, the best may receive 3,000 marks, and the second best 1,000 marks. Or, should the decision of the judges find two essays of equal value, each shall receive 2,000 marks. 2. The following gentlemen have consented to act as judges : Ge- heimrath Prof. Dr. B. Fränkel; Geheimrath Prof. Dr. Ger- hardt; Kapitän z. S. Harms; WirkL Geh. Ober Peg. -Path Präsident Köhler; Generalarzt Prof. Dr. von Leuthold, Excellenz; Geheimrath Prof. Dr. von Leyden; Freiherr Dr. Lucius von Ballhausen, Excellenz; Geheimrath Dr. Nau- mann ; Oberstabsarzt Dr. Pannwitz ; Dr. Graf von Posadow- sky-Wehner, Excellenz; Se. Durchlaucht der Herzog von Eatibor. 4 PREFACE TO THE GERMAN EDITION. 3. All essays must be sent by December 1, 1899, to Privy- Councillor Prof. Dr. B. PrUnkel, 4 Bellevue Strasse, Berlin, and each essay must bear a motto, selected by the writer, who shall insert his name within a sealed envelope having the motto on the cover. 4. The essay, or essays (see § 1), to which has been awarded the prize, become the property of the "German Central Com- mittee for the Erection of Sanatoria." The latter will take upon itself the printing of the essay and the least expensive method of distribution. 5. The decision of the judges is to be announced through the public press. The foregoing regulations were published in the medical and lay papers, and as a result eighty-one essays were received by December 1st. The essays were distributed among the judges with the request to select from them such as were deserving of closer examination. The judges recommended twenty-six for that purpose. The fifty-five rejected essays were once more examined by the undersigned and his assistants, Drs. Edmund Meyer, Alexander, Finder, Claus, and Elwert, but these gentleineu could not recom- mend any of the fifty-üve essays for further consideration. At the meeting of the jury on February 25, 1900, under the presidency of his Serene Highness the Duke of Eatibor, it was decided that the twenty-six selected essays should be once more carefully examined by Drs. Frankel, Gerhardt, Harms, Köhler, von Leuthold, von Ley den, Freiherr von Lucius and Pannwitz, and the result was that three were ultimately selected for closer choice. At the next meeting of the judges, on June 15th, it was decided to form a sub-committee composed of Drs.. Fränkel, Gerhardt, Harms, Köhler, and Pannwitz, to decide upon final action. After careful consideration this committee came to the conclusion that the work bearing the motto, "To combat consumption successfully requires the combined action of a wise government, well-trained physicians, and an intelligent people," SO much surpassed all the others in excellence, that it should be PREFACE TO THE GERMAN EDITION. 5 awarded the Congress prize. It was then found that Dr. S. A. Knopf, of New York, was the author of this work. A few changes, as recommended by the judges, were accepted by Dr. Knopf, and have been incorporated in the present work. At a subsequent meeting of the German Central Committee it was resolved to publish this essay and arrange for its widest dis- tribution. Pkofessor B. TeSneel. Berlin, October 1, 1900. PREFACE TO THE FIRST ISSUE OF THE AMERICAN EDITION. In presenting to the English-speaking world, and particularly to the people of the United States, a translation of the essay, originally written in German, the author desires to state that, while having endeavored to make as exact a translation as possi- ble, he found it necessary to change several passages, making some additions and omissions. His reasons for having done so will be obvious to all who have studied pulmonary tuberculosis or consumption, not only in its medical, but also in its sociological aspects, and who wül bear in mind the fact that the habits of na- tions differ, and that in a popular essay it is absolutely necessary to take these differences into account. Thus it was even necessary, before the original German essay could appear in print, that the author should consent to make certain changes bearing on the particular local conditions and situation of the consumptive poor in Germany. These changes were suggested in detail by the judges who awarded the prize. With a generosity which cannot be lauded too highly, these gentlemen did not expect to find in the essays, submitted to them for competition from all over the world, a complete knowledge of the sanitary laws and regulations which are now in vogue in the German empire, nor did they expect the essayists to be familiär with local conditions to the extent of 6 PREFACE TO THE ENGLISH TRANSLATION. knowing all that would or would not be practicable in the carry- ing out of suggestions to prevent the spread or the development of tuberculous diseases. The social conditions in Germany differ very much from those in the United States, and the author felt it his duty to speak in this American edition of all the important points bearing directly on the question of tuberculosis as a " social disease " in America. The evils of alcoholism, of the overcrowding of tenement houses and of unsanitary dwellings of the poor in general, also some of the causes of malnutrition or underfeeding of the laboring classes, are treated as fully as the nature of such an essay permits. As an example of the necessity of making certain changes in this work, intended for an American public, I may be permitted to state the following : in Germany every laboring man and wom- an must be insured against old age, accident, and disease, includ- ing tuberculosis, and the employer is held responsible for the compliance with this law. No such laws exist in the United States, where even private insurance companies will not insure a tuberculous invalid. As another illustration of the vastly different conditions here and in Germany regarding our subject, we must consider that every one of the forty-seven States of the Union has its own sanitary laws and regulations. They differ widely in rigor and completeness in regard to the prevention of tuberculosis in man as well as in beast. In Germany there is one homogeneous law for all the states and provinces ; there is a ministry for " Medic- inal Angelegenheiten " (medical affahs) with a cabinet officer at the head, who has for his advisers the highest medical authorities connected with the " Eeichs-Gesundheitsamt " (imperial office of health). I hope the time is not far distant when our own be- loved country will have similar institutions ; when all the State, coimty, and city boards of health will look to Washington, the seat of the future secretary of public health, as their supreme head and guide in medical and sanitary matters. In the mean time let us labor as best we can; let each State, county, and city board of health do its best toward an intelligent, rigorous, and yet not too oppressive public prophylaxis of bovine and human tuberculosis ; and let the people at large lend a willing hand in this combat against our common foe, the "Great White Plague." S. A. Knopf, M.D. 16 West Ninety-fifth Stbebx, New Yobk, January, 1901. PREFACE TO THE FOURTH ISSUE OF THE AMERICAN EDITION. After three issues of the American edition of this essay have been printed without any material change from the original trans- lation of the German edition, I am confronted with the problem of either writing a new edition or making a supplement which will contain what is new and of interest to the Medical Profession and the Public. I have decided to present the matter in the form of a supplement which will contain what had to be left out of the original edition because the jury of the Berlin tuberculosis congress limited the number of printed pages, and also the most important things that the experience of seven more years in tuberculosis work has taught me. Thus I have added two paragraphs, one on Home Hygiene, and one on School Hygiene. An equally valuable addition I hope will be found in the chapter added on the Instal- lation for the Sanatorium Treatment at Home.. Lastly, there will be a short historical review of the anti-tuberculosis movement in the United States from its beginning to the present day. My reason for adding these four new chapters in the form of a supplement, instead of inserting them in the text, is purely an eco- nomical one. Inserting them would increase the cost of the book materially, while by writing a supplement the book can still be sold at retail for $0.25 paperbound and $0.50 clothbound, and at wholesale correspondingly cheaper. There are enough good books on tuberculosis in the market costing $2.00, $3.00, and $5.00, in- tended to inform the layman; but for the masses, who need this information most, there are few at a price within their reach. In this connection I must explain why this essay has not been published by one of the well-known firms handling medical and popular scientific books. The low price at which I insisted the book should be put on the market seemingly did not insure sufR- 8 PEEFACE TO THE AMERICAN TRANSLATION. cient remuneration to the various firms to whom I applied. But I was fortunate enough to interest a former secretary of mine, Mr. Fred. P. Flori, who has undertaken the pubUshing and selling of the book at this low price. I desire to thank him for the interest and devotion which he has brought to the task. I must not send out this little volume without expressing my sincerest thanks and appreciation to Drs. Barbour, Bezenseck, Björnsson, Blumenthal, Donath, Eddy, Ferriera, Galli, Hoving, Lagowsky, Lope, Massalongo, Mihailovic, Popovic, Rosendahl, Roth-Schulz, Rosal, Sersiron, Shibayama, Wender, and Zwieshon, who have honored me by translating the essay into their native languages. " Tuberculosis as a Disease of the Masses and How to Combat it" is now printed in twenty-one dilTerent languages, thus reaching people in all parts of the civilized world. It is particularly gratifying to me that the much needed infor- mation which this little book is intended to give, has been so far- reaching. The original German edition has been reprinted many times and largely distributed by the German Government, for which I have now a second edition in preparation. Five thousand copies of this present issue are to be sent to the Health Officers of this State for distribution. I wish to thank Dr. Eugene H. Porter, the present Commissioner of the Department of Health of the State of New York, for his efforts in causing this to be done, thus giving his official approval to the work and furthering education in the prevention of tuberculosis throughout the Empire State. May this fourth issue, which I trust is enhanced in value by the supplement, meet with the same kind reception that has been accorded to the previous editions, and may the information which the book is intended to convey be helpful to physicians and patients, teachers and parents, statesmen, employers and employees, to rich and poor, in short to all able and willing to help in the solution of the tuberculosis problem, and thus add to the health, prosperity and happiness of all the people. S. A. KNOPF, M.D. 16 West Ninety-fifth Street, New Yobk, April 1, 1907 TABLE OF CONTENTS. CHAPTER PAGE Preface to the German Edition 1 Preface to the First Issue of the American Edition 5 Preface to the Fourth Issue of the American Edition (with Sup- plement) 7 Introduction 11 I. What Is Consumption ? 15 II. How may the Germ of Consumption (Bacillus Tuberculosis) Enter the Human System ? 16 III. How does the Inhalation of the Bacilli Take Place ? 16 IV. What must be Done to Check the Spread of Consumption Caused by the Expectoration of Pulmonary Invalids ? 17 A. Destruction of Tuberculous Expectoration. B. Disinfection of the Sick-Room. V, What can be Done to Protect Oui'selves from the Small Particles of Saliva Containing Bacilli, Thrown Out by the Consumptive Dur- ing Dry Cough, Loud Speaking, or Sneezing ? 23 VI, How may Man Give Tuberculosis to Animals ? 24 VII. How can We Guard Against Germs of Tuberculosis in Our Pood ? 25 VIII. In What Other Ways may the Bacilli or Germs of Consumption Enter the Intestinal Tract ? 26 IX. How may Tuberculosis be Contracted through Inoculation (Pene- tration of Tuberculous Substances through the Skin)? 27 X. What Other Forms of Tuberculosis Exist, and What are Their Principal Symptoms ? 28 XI. Wliat Protects the Healthy Individual from Contracting Tubercu- losis ? 30 XII. How may One Successfully Overcome a Hereditary Disposition to Consumption ? 31 XIII. How can a Predisposition to Tuberculosis, Other than Hereditary, be Created or Acquired ? 41 XIV. How may an Acquired Predisposition be Overcome, and Seemingly Unhealthy Occupations Me^de Relatively Harmless ? 42 XV. What can Weil-Meaning and Conscientious Employers in City and Country Do to Help Combat Tuberculosis ? 43 XVI. What can the Farmer and Dairyman Do to Diminish the Frequency of Tuberculosis among Animals, and Thus Indirectly Stop the Propagation of the Disease among Men ? 45 XVII, What are the Occupations in Which Tuberculous Invalids, Even in the First Stages of the Disease, Should Not be Employed ?. . 55 XVIII. What are the Main Signs and Symptoms of the Beginning of Tuber- culosis of the Lungs or Consumption ? 56 10 TABLE OP CONTENTS. CHAPTER PAGE XIX. What are the Early Symptoms of. Other Formis of Tuberculosis ? 57 XX. How can Children be Protected from Scrofula and Other Eorms of Tuberculosis ? 59 XXI. Can Tuberculosis, Especially in Its Pulmonary Form, or Con- sumption of the Lungs, be Cured? 61 XXII. Have the Former Patients Who Left Sanatoria or Special Insti- tutions for the Treatment of Consumption as Cured, Remained Lastingly So ? 62 XXIII. What are the Modern Methods to Treat and Cure Consumption ? 63 XXIV. What is a Modern Sanatorium for Consumpti ves? And can Such a Sanatorium Become a Danger to the Neighborhood ? 65 XXV. What are State Sanatoria? And What are "Volksheilanstalten" or People's Sanatoria ? 71 XXVI. What Evidence Exists That by Taking Care of Consumptives in Special Institutions and by Hygienic Measures, Tuberculosis as a Disease of the Masses can Really be Successfully Com- bated ? 72 XXVII. Can the Treatment of Consumption be Carried Out with Satis- factory Results Outside of an Institution ? 73 XXVIII. What can Philanthropists and Other Men and Women of Good Will Do to Help Combat Tuberculosis as a Disease of the Masses ? 76 XXTX. How Might the Tuberculosis Problem in the United States be Solved by Judicious Legislation and a Combination of Public and Private Philanthropy ? 80 XXX. Conclusions 85 SUPPLEMENT. A. Home Hygiene to Prevent Tuberculosis 87 B. School Hygiene as a Factor in the Prevention of Tuberculosis. . . 89 C. Installation for the Sanatorium Treatment of Consumptives at Home ^^ D. Historical Review of the Antituberculosis Movement in the United States 101 TUBERCULOSIS AS A DISEASE OF THE MASSES AND HOW TO COMBAT IT. mTEODUCTIOK Tuberculosis has been called a disease of the masses on account of its gi-eat prevalence among aR classes of people. It has been known for hmidreds of years as the most feared, most prevalent, and, alas ! also as the most fatal of all diseases. Hippocrates, the most celebrated physician of antiquity (460 to 377 B.c.), and the true father of scientific medicine, described pulmonary tuberculosis or consumption as the disease which is " the most difB.cult to treat, and which proves fatal to the greatest number." Isocrates, also a Greek physician, who lived about the fifth century before Christ, was the first to write of tuberculosis as a disease transmissible through contagion. In the middle ages (1550) the celebrated physician Montano declared consumption to be one of the most dangerously contagious and most easily contracted, of diseases. An equally strong advocate of the theory of contagion was the cele- brated anatomist Morgagni (1682-1771), who never performed an autopsy on an individual who had died from tuberculosis. Toward the end of the eighteenth century the sanitary authorities of some cities of Italy and France considered consumption a highly in- fectious and contagious disease, and a French medical author of the name of Janett de Langrois reports that the municipal au- thorities of Nancy had caused the furniture and bedding of a wom- an who had died from consumption, to be destroyed by fire. The contagion in this case had actually been demonstrated, inquiries revealing that the deceased woman had slept frequently with a consumptive girl friend until she finally succumbed to the same disease. 12 TUBERCULOSIS AS A DISEASE OF THE MASSES In Naples a royal decree, dated September 20, 1782, ordered the isolation of consumptives and the disinfection of their apart- ments, personal effects, furniture, books, etc., by means of vinegar, brandy, or lemon juice, sea-water, or fumigation. Any violation of this law was punished, if the individual was an ordinary mor- tal, with three years in the gaUeys, and if he happened to be a nobleman he was sent for the same time to the fortress and had to pay 300 ducats. The physician who faüed to notify the au- thorities of the existence of a tuberculous patient was fined 300 ducats for the first offence, and a repetition of the neglect would banish him from the country for ten years. According to Portal (1742-1832), there was a law in Spain and Portugal which obliged the parents or nearest relative of a consumptive to notify the au- thorities when the patient had arrived at the last period of the dis- ease. This was done for the purpose of making sm^e of the disin- fection of the personal effects of the patient after his death. In the first half of the nineteenth century little attention was paid to the infectious theory of tuberculosis even by medical men. The contagiousness or communicability of the disease could not be scientifically demonstrated, and although there were physicians here and there who believed in the infectiousness of the disease, nothing positive was taught in regard to it at the centres of medi- cal learning. At last, in 186.5, the French physician Villimin demonstrated beyond a shadow of doubt that tuberculosis could be transmitted from one individual to another. He inoculated animals with tu- berculous substances and reproduced tuberculosis not only in the lungs but also in other portions of the body. Since this discovery and its verification by numerous experimenters, such as Cohnheim, Welch, Prudden, Straus, and others, it has been generally ac- knowledged that tuberculosis is an infectious disease, and that for its production a specific germ is essential. The discovery of this specific organism (bacillus tuberculosis) was reserved to the gi-eat German scientist Eobert Koch (1882). Consumption is an endemic disease, that is to say, habitually prevalent, and it exists m all civilized countries. Wild tribes and less civilised people succumb to the disease, as a rule, very rapidly AND HOW TO COMBAT IT. 13 as soon as they come in contact with civilization. The proof of this we might find among the North American Indians and among the negi'oes and their descendants now livmg in the United States. According to the recent report of the Board of Health of Toronto (Canada), pulmonary tuberculosis is dangerously prevalent among the Blood Indians of the Dominion of Canada. Of every hundred deaths which occm-red among this tribe in the year 1898, twenty- three were due to consumption. Since these Indians are kept on a reservation under the supervision of the Canadian Government, these statistics should be considered reliable. The mortality from tuberculosis among the colored population of the United States is nearly twice that of the white population. However, let us state right here that the cause of this increased mortality among Indians and negroes is to be ascribed not to the blessings of civilisation, but rather to the vices, such as alcoholism and excesses of all kinds, which, alas ! too often accompany civil- izing agents. There have been so many statistics published concerning the general mortality from tuberculosis in the United States and Eu- rope, that we do not think it necessary to reproduce in detail any of the published tables, but will content ourselves with some gen- eral statements. It is now universally admitted that tuberculosis is the most frequent cause of death. According to some statistics every seventh, according to others every sixth, death is due to tu- berculosis in one form or other. According to Dr. George F. Keene, of Ehode Island, who is a very close observer, the annual tribute of the United States to this scourge is over 100,000 of its inhabitants. Each year the world yields up 1,095,000, each day 3,000, each minute 2 of its people as a sacrifice to this plague. Tuberculosis occurs most frequently in its pulmonary form, com- monly known as consumption. According to the Imperial Sani- tary Office of Berlin, thirteen per cent, of the deaths (during the years from 1888 to 1892) were due to pulmonary consumption. However, it must be stated that of late the mortality from tuber- culosis has decreased in some European and American cities (Ber- lin, London, New York, Philadelphia, etc.), thanks to better pre- ventive measures and more rational methods of treatment. In one Consump- tion an Endemic Disease. A Few Statistics. 14 TUBERCULOSIS AS A DISEASE OP THE MASSES SIS. of the succeeding chapters we shall speak more in detail of public prophylaxis and special institutions for consumptives in the combat against tuberculosis. In relation to statistics we desii'e, lastly, to mention only some interesting facts gleaned from a pamphlet pub- lished last year by the Imperial Health Office of Berlin. Accord- ing to this latest report the mortality from tuberculosis is greatest in Eussia and Austria, being more than 3,500 per million inhabi- tants. It is lowest in England, being less than 1,500 per million. Germany occupies about the middle, while France comes immedi- ately after Austria.* The researches of recent years have demonstrated that consump- tion and also many other forms of tuberculosis may not only be prevented, but can in many cases be arrested and lastingly cured. The governments and the medical profession are aware of this, and have laboriously, energetically, and most unselfishly worked in the direction of solving this important problem, which means so much to the welfare of the people. The Congresses for the Study of Tuberculosis, which have met biennially since 1888 in Paris; the International Congress, which convened at Berlin in May, 1899, under the protection of her Majesty the Empress of Germany, and the Italian Congi^ess, which was called together for the same pur- pose last year in Naples, give the best proof of the zeal of the medical profession and the governments to combat tuberculosis with all possible means. But, as the motto of this essay expresses it, the intelligent co- operation of the people ia this work is indispensable. To enable all men and women to participate intelligently in this combat against a common foe is the purpose of this essay. We shall now give a brief description of the form of tuberculosis known as tuberculosis of the lungs, pulmonary tuberculosis, or consumj)tion. * The United States was not included in this table, but would probably come close to Germany. AND HOW TO COMBAT IT. 15 CHAPTER I. What is Consumption? Pulmonary consumption, or tuberculosis of the lungs, is a chronic disease caused by the presence of the tubercle bacillus, or germ of consumption, in the lungs. The disease is locally charac- terized by countless tuber- cles, that is to say, small rounded bodies, visible to the naked eye. The bacilli can be found by the million in the affected organ. It is this little parasite, fungus, or mushroom, belonging to the lowest scale of vegetable life, which must be consid- ered as the specific cause of all tuberculous diseases. This parasite not only gradually destroys the lung substance through ulcerative processes, but gives off at the same time certain poisonous substances called toxkis which give rise to various, and often serious, symptoms. The important symptoms of pulmonary tuberculosis are cough, expectoration (spittiug phlegm), fever (increased temperature of the body, especially in the eveniug hours), difficulty in breathing, pains in the chest, night-sweats, loss of appetite, hemorrhages (spit- ting of blood), and emaciation (loss of flesh). In the matter expectorated, it is often possible to find the tubercle bacillus with the aid of the microscope and certain coloring matters. It appears in the form of smaU, slender rods. To give an idea of the minute size of these bacilli or bacteria, we reproduce here what is called a microscopic field twelve hundred times enlarged ; in other words, just what one sees after having prepared a smaU portion of expectorated tuberculous matter under the microscope. The Fig. 1.— Tubercle Bacilli in ExpectxDrated Matter. 1,200 times enlarged. 16 TUBERCULOSIS AS A DISEASE OF THE MASSES rods represent the bacilli; the round or in-egnlar bodies represent other substances which have been ejected along with the bacilli (Fig. 1). CHAPTEE II. How MAY THE GeRM OF CONSUMPTION (BACILLUS TUBERCU- LOSIS) Enter the Human System? 1. By being inhaled; that is, breathed into the lungs. 2. By being ingested ; that is, eaten with tuberculous food. 3. By inoculation ; that is, the penetration of tuberculous sub- stance through a wound in the skin. Of these three ways in which the bacilli may enter, the first one seems to be the most important. CHAPTEE III. How DOES THE INHALATION OF THE BACILLI TaKE PlACE? A consumptive individual, even at a period when he is not con- fined to his bed, may expectorate enormous quantities of bacilli. Now if this expectoration, or spittle, is carelessly deposited here and there, so that it has an opportunity to dry and become pulver- ized, the least draught or motion iu the air may cause it to mingle with the dust, and the individual breathing this dust-laden atmos- phere is certainly exposed to the danger of becoming tuberculous, if his system offers a favorable soil for the growth of the bacilli. By " favorable sou for the gi-owth of the bacilli " must be understood any condition in which the body is temporarily or permanently en- feebled. Such, a condition may be inherited from parents, or ac- quired through alcoholism or drunkenness or other intemperate habits, through privation or disease. Besides the danger arising from carelessly deposited sputum, or spittle, the inhalation or ingestion of the small particles of saliva which may be expelled by the consumptive during his so-called dry cough, or when speaking quickly or loudly, or when sneezing, must also be considered as dangerous for those who come in close AND HOW TO COMBAT IT. l7 contact with the invalid. These almost invisible drops of saliva may contain tubercle bacilli. Eecent experiments in this direc- tion have shown the possibility of infection by this means. CHAPTEE IV. What must be Done to Check the Speead of Consumption Caused by the Expectoration of Pulmonary Invalids ? A. Destruction of Tuberculous Expectoration. — Consumptives and those living with them must know that all precautionary meas- ures are instituted in the interest of the invalid as well as of his fellowmen. These measures protect the patient from reinfection and others from the danger of contracting the disease. A patient suffering from pulmonary consumption should know that, no matter in what stage of the disease he may be, his expec- toration or spittle may spread the germ of the disease if the matter expectorated is not destroyed before it has a chance to dry and be- come pulverized. The patient should, therefore, always spit in some receptacle intended for the purpose. It is best to have this vessel made of metal so as not to break. It should be half filled with water or some disinfecting fluid, the main thing being to make it impossible for the expectoration to dry. In factories, stores, railroad cars, waiting-rooms, court-rooms, restaurants, saloons, meeting-places, theatres, menageries — in short, wherever many people congregate — ^there should be a sufficient number of cuspidors well kept and regularly cleaned. They should be made of unbreakable material and have wide openings. If such measures are carried out, there will be no excuse for any one to expectorate on the floor and thus endanger the lives of his fellow-men. In the sick-room of a private home, at hospitals or sanatoria, only covered cuspidors should be used, and it is better to have them placed on stands, in niches, or in elevated boxes. We give an ex- ample of the last-named kind in Fig. 2, showing a blue enamelled iron spittoon in a box elevated on a stand. The spittoon is fast- ened by a clamp to the door of the box, and can be easuy removed 2 18 TUBERCULOSIS AS A DISEASE OP THE MASSES for cleaning. The stand is most convenient when about three feet in height. Such an arrangement, besides making it more sure that the sputum will all reach the inside of the spittoon, has the addi- tional pleasant feature of making the cuspidor visible only while it is being used by the patient. The cover of the receptacle pre- vents flies and other insects from coming in contact with the spu- tum. It has been proved that insects, especially flies, often carry the bacillus out of the sick-rooms of consumptives when sufficient care is not taken to cover the ex- pectoration. The fly which has come in contact with tuberculous matter may spread the disease in three ways. First, it may carry small particles of spittle on its feet, and leave them wherever it may alight. Secondly, if it has partaken of tuberculous matter, it deposits its excrement at the next oppor- tunity on some article of food, and thus the bacilli find their way into the digestive organs of man or beast. Thirdly, these insects may dry and trumble to dust which contains the bacilli, and the germs of the disease may thus enter tlie lungs. The cuspidor of metal elevated and covered, presents further advantages over the usual un- covered vessel of porcelain or earthenware. Ani- mals, such as dogs, cats, etc., will not be able to reach the contents of the cuspidor ; and there is less danger of its bursting when placed out- doors at freezing temperature if enclosed in a box. ^^^- ^- ~^n^"^''^ ^p**" Fig. 2.— Elevated Spittoon. AND HOW TO COMBAT IT. Id Fig. 5 a.— Knopf 's Nickel- plated Flask (Closed) . Fig. 4.— Dettweiler's Pocket Flask. For factories, workshops, etc., Predohl's enamelled iron spittoon, nine inches high, eight inches in its largest and three inches in its smallest diameter, seems to answer all prac- tical purposes. As the accompanying drawing (Fig. 3) indicates, it can be suspended atany height, and is very easily cleaned and disinfected. AVTien outdoors, the pa- tient should use a pocket flask to receive the spittle. There are numerous flasks in the market, and I repro- duce a few of them : Dett- weiler's, of blue glass and in three pieces (Fig. 4) ; Knopf s,of nickel-plated metal (Figs. 5 and 6); Liebe' s, of blue glass in two pieces (Fig. 7). The dh-ections for use usually accompany each flask. The more expensive ones (Figs. 4 and 5) can be manipulated with one hand. The cleaning of all of them is easy. The expectoration received in any receptacles, large spittoons or pocket flasks, should be so disposed of that the bacilli are killed. Wliere there is a good sewerage system the con- tents of these cuspidors may, without danger, be poured into the water- closet. Where there are no running water and perfect sewerage, it is better to boü the con- pj,.. 6._Knoprs Aiumi- tents of the spittoons before pouring them into coTCn''^'^ ^"'^ ^'^*° Fig. 5 ?j.— Funnel and Cover to Fig. 5 n. Pocket Spittoons. 20 TUBERCULOSIS AS A DISEASE OF THE MASSES the water-closet, or disposing of them otherwise. Thus, whenever possible, the tuberculous expectoration, that is to say, tlie entire contents of all classes of cuspidors, should be placed in a pot kept for that purpose which is partially filled with water. Every twenty-four hours or so this pot should be put on the fire and the contents brought to a boil. To raise the boiKng point it might be well to add to each quart of water one or two teaspoonfuls of washing soda. After the mixtm-e has boiled for about five minutes, it can be considered totally harmless, for all the ba- ' '"spittoon. cilli will have been killed. The disinfection of tuberculous expectoration by carbolic acid (5 per cent.) or mercu- Disinfec- ^^^^ solutions (1 : 2,000) is not so certain, since these substances tion and cause the albumen in the expectoration to coagulate, and thus Destruction form, in a measure, a protective cover for the bacilli and make Tiibereu- ^^^^ total destruction more difficult. lousMatter. vinegar is a better and more con- venient disinfectant and need not be diluted when used. When people are so situated as not to be able to dispose of the contents of the pocket spittoons by boiling or disinfection, we would recommend the following method : poiu* the contents of the flask on several layers of news- per, gathering up the edges and being careful not to spill any, and throw the whole at once into the fire. A handkerchief should never be used as a receptacle for sputum. Patients who are too sick to make use of light porcelain or aluminum cups (Fig. 8), Seabury & Johnson's spitting-cup of pasteboard (Fig. 9), or the Kny- Scheerer pressed-paper cup (Fig. 10) should have a number of moist rags within easy reach. Care should be taken that the rags always remain moist, and that the used ones aie burned before they have Ordinary conmiercial wood Fig. 8.— Spit-Cup of Aluminum or Porce- lain. AND HOW TO COMBAT IT. 21 a chance to dry. The paper spit-cujjs with their contents should, of course, also be destroyed by fire. There will always be some consumptives who cannot be per- suaded to use the pocket flask, for the simple reason that they do not wish to draw attention to their malady. The only thing for these people to do is to use squares of soft muslüi, cheese-cloth, cheap handker- chiefs, or Japanese paper handker- chiefs specially manufactured for that purpose, which can be burned after use.- They should also place in theii- pockets a removable lining of rubber or other impermeable substance which can be thoroughly cleaned. This ad- ditional pocket could be fastened to the inside of the ordinary pocket by clamps, and would thus be of no inconvenience to the patient. A pouch of vulcanized rubber or an Oriental tobacco-pouch may be used in place of the extra pocket of impermeable material. Fig. 9 a.— Frame of Seabury & John- son's Spitting-Cup. Fig. 9 b.— Folded Cardboard, to be Burned Alter Use. Fig. 10.— Kny-Sclieerer's Sanitary Spittoon Cup. In any case it is weU. to have more than one of these pockets or pouches, so that the patient is never without one while they are being cleaned and immersed in some disinfectant solution or boiling water. Of course, all invalids using handkerchiefs, rags, or Japanese paper as receptacles for expectoration, are in danger of 22 TUBERCULOSIS AS A DISEASE OF THE MASSES infecting their hands, and should always wash them thoroughly before touching food. B. Disinfection of the Sick-Boom. — The rooms occupied by a tuberculous patient should be thoroughly disinfected at regular in- tervals, since it is possible that even with great care the furniture, floors, walls, etc., may have been infected. Even the occasional disinfection of the personal effects of the patient is advisable. In case of decease it is, of course, self-understood that everything the consumptive might have come in contact with, particularly furni- ture, bedding, clothing, books,* etc., should be thoroughly disin- fected. In many communities such disinfection is now attended to by the board of health. Where the aid of the health board caunot be secured, the following directions will enable one to make a thorough disinfection by formaldehyde gas: 1. All cracks or formalde- openings in the plaster, in the floor, or about the doors and win- -.. 7 „ dows should be caulked tight with cotton or strips of cloth, tion of 2. The linen, quilts, blankets, carpets, etc., should be stretched Rooms, etc. out on a line in order to expose as much surface as possible to the disinfectant. They should not be thrown into a heap. Books should be suspended by theh covers, so that the pages will fall open and be freely exposed. 3. The walls and the floor of the room and the articles contained in it should be thoroughly sprayed with water. If masses of matter or sputum are dried on the floor, they should be soaked with water and loosened. No vessel of water should, however, be allowed to remain in the room. 4. One hundred and fifty cubic centimeters (five ounces) of the com- mercial forty-per-cent. solution of formalin for each one thousand culjic feet of space should be placed in the distilling apparatus and be distilled as rapidly as possible. The keyhole and spaces about the door should then be packed with cotton or cloth. 5. The room thus treated should remain closed at least ten hours. If there is much leakage of gas mto the surrounding rooms, a second or third distillation of formaldehyde should be made at intervals of two or three hours. *The possibility of transmitting tuberculosis through books has been de- monstrated, particularly if the patient has been in the habit of moistening his fingers with saliva while turning the leaves. AND HOW TO COMBAT IT. 23 To be sure that the work is well done, it is always best to have it supervised by a physician. To managers of hotels and boarding- houses in health resorts, this method of disinfection is particularly to be recommended, and the disinfection of rooms occupied by con- sumptive guests should always take place immediately after their removal. In some cities and villages tuberculosis seems to cling to certain localities and houses. The disease appears in a veritable endemic form, that is to say, it is always present there, either from the fact Permanent- that careless tuberculous patients have lived for years in these ly Infected houses, or owing to the equally important fact that the soil on -H-ouses. which they are built, or the manner in which they have been con- structed, is such as to favor the retention of the tuberculous infec- tion indefinitely. When a thorough sanitary overhauling does not suffice to stamp out these sources of infection, the destruction of such dwellings seems the only remedy. CHAPTEE V. What can be Done to Protect Ourselves from the Small Particles of Saliva Containing Bacilli, Thrown Out BY the Consumptive during Dry Cough, Loud Speaking, OR Sneezing? There is real danger from this source of infection only when one remains a considerable length of time very near the tuberculous patient while he coughs or speaks. At a distance of three or four feet the danger practically ceases. The relatively few baciUi which are expelled with the saliva during the dry cough, sneezing, or loud speaking, are probably never thrown farther than three feet, and fall rapidly to the ground. But even the lesser danger which may arise from the bacilli having fallen to the floor with the particles of saliva must be pre- vented. They must not be allowed to accumulate and so be blown up with the dust into the air. Therefore the floor of the room of a tuberculous patient should never have any fixed carpet ; and even the wooden floor should never be swept with a broom, but should be frec[uently wiped up with a wet cloth or with crude oil. Dusty fur- 24 TUBERCULOSIS AS A DISEASE OF THE MASSES Arrange- ment of the Consump- tive's Boom, Precau- tions to be taken by Nurses. Precau- tions with the Washing. niture should be cleaned in the same way. Plush, velvet, or cloth-covered fiirniture, heavy curtains or other fancy decorations, which might serve as dust-catchers, should not be allowed in the room of a tuberculous patient. Leather-covered, rattan, and plain wooden furniture are certainly the best, and the curtains should always be of washable material. Fancy curtains of cloth, velour, or silk, which accumulate dust and keep the air and sun out of the rooms, should be discarded. If at all possible, every patient should have his own room, but he should always have his own bed. For a well person to sleep in a bed very close to a tuberculous patient is almost as danger- ous as to sleep together in one bed. Friends, relatives, and nurses should not remain very near the patient longer than necessary, and the tuberculous invalid should be urged always to hold a handkerchief before his mouth and nose while coughing or sneezing. He should, furthermore, be advised to carry two handkerchiefs with him always : one to hold before his mouth and to wipe it with after having expectorated ; the other to use only to wipe his nose. By being careful with the use of his handkerchiefs, the danger of infecting his nose and bronchial tubes will be materially lessened. All soiled linen (sheets, pillow-ciases, underwear, napkins, hand- kerchiefs, etc.) used by the consumptive, should not be handled more than necessary, but should be placed in water as soon as possible after removal from bed or body. It is better to wash these articles separately, and only after having been thoroughly boiled should they be put with the common laundry. Wlierever it is not possible to carry out these precautionary measures in their entirety, one should strive to follow them as far as it is m one's power. CHAPTER VI. How MAY Man Give Tubekculosis to Animals? In one of the preceding chapters we have spoken of the im- portance of elevated spittoons to protect domestic animals, such as cats, dogs, etc., from the danger of becoming tuberculous by lick- ing up tuberculous expectoration. By the careless expectorating AND HOW TO COMBAT IT. 25 of consumptives in meadows, fields, or stables, animals may be- come infected with the disease. The following very instructive fact came to the notice of the author of this essay : In an institu- tion for the treatment of consumptives, managed by Sisters of Charity, and where, I am sorry to say, there was not enough strict medical supervision, there existed only certain rules concerning the care of the expectoration within doors; outside of the institution the patients were at liberty to do as they liked, and they expec- torated wherever they pleased in their daily walks in the near- by meadows. A neighboring farmer who, some time before, had bought five healthy cows, had them retested, with the result that two were found to be tuberculous. He had the tuberculous cows killed, the stable cleaned and disinfected, and no longer allowed the patients of the neighboring sanatorium to promenade in the meadows where his cows pastured, and no more tuberculosis ap- peared among his cattle. Now, although it is true that the sun and the ah* ultimately destroy the germs of the tuberculous sputum, it is not wise to rely upon this. Tuberculous substances may do harm by being licked up by animals before the sun and air have had time to kill the bacilli, and in dark and damp places it often takes a long time be- fore atmospheric influence renders the tuberculous matter absolute- ly inoffensive. The stools of patients suffering from tuberculosis of the intes- tines should be disinfected by a five-per-cent. solution of carbolic acid. The superficial burying of tuberculous meat or tuberculous expectorations without previous thorough disinfection must be considered as dangerous. Danger of Superficial Burial of Tubercu- lous Substances. CHAPTER VII. How CAN We Guard Against Geems of Tuberculosis in Our Food? \'\Tienever one is not reasonably certain that the meat he eats has been carefully inspected and declared, free from disease germs, it should be very thoroughly cooked. By this means one is cer- tain to kill all the dangerous micro-organisms. Against the sale 26 TUBERCULOSIS AS A DISEASE OF THE MASSES of tuberculous milk there are very excellent laws in some States of the Union, which are rigorously enforced. In some the laws are less good, and in some there are no laws at the present time. In justice to farmers and dairymen it must, however, be said that there are many who do their very best to protect themselves and theh fellow-men from the danger of tuberculosis. They have -their cows tested regularly, destroy the animals which are found to be tuberculous, and keep their stables and utensus for milk as clean as possible. Unless one can be reasonably sure that the cows from which the milk is derived are healthy and not tuberculous, the milk should Boiling or be boiled or sterilized before use, more especially when it is in- Sterilizmg tended as food for children. Milk obtained from stores and from Milk milk peddlers should invariably be submitted to boiling or steril- ization. When milk is kept slowly boiling for five minutes, all the bacilli are killed, and the same result is obtained by the steril- izing process, that is to say, to keep the milk heated for at least half an hour at a temperature of about 70° C. or 160° F. There are now in the market a number of cheap and practical apparatuses for sterilizing milk, which can be obtained at almost any drug store. CHAPTEE VIII. In What Other Ways may the Bacilli or Germs of Con- sumption Enter the Intestinal Tract? Since the tubercle bacillus may be found in the saliva of a tu- berculous patient, it is best never to kiss such a person on the Infection rn"utli. The habit of caressmg or kissing domestic animals (par- by Saliva, rots, canary-buds, dogs, cats), many of whom are tuberculous, is equally dangerous, for through such habits these animals can cer- tainly transmit tuberculosis to man. Tuberculous patients should have their own drinking glasses, spoons, forks, etc. ; or, at least, all table utensils which have served the tuberculous patient should be boiled after use. The patient should never, out of false modesty, swallow his ex- pectoration. He will thus avoid the danger of contracting intes- tinal tuberculosis. How important this warning is may become AND HOW TO COMBAT IT. 27 evident from observations of the tuberculous insane. These un- Danger of fortunate people, with whom hygienic education is impossible, Swallowing often swallow their expectoration, and as a consequence intestinal tuberculosis or consumption of the bowels is very frequent among them. Every consumptive patient should remember never to touch food before having washed his hands very thoroughly. Even with the greatest care, it is possible that he may have soiled his hands with tuberculous expectoration. Tubercu- lous Sputum. CHAPTER IX. How MAY Tuberculosis be Contracted through Inocula- tion (Penetration of Tuberculous Substances through THE Skin)? Inoculation of tuberculosis happens perhaps most frequently through injmies received while cleaning nicked or chipped glass or porcelain cuspidors which had been used by consumptives. It is also possible for the bacilli to enter the circulation if the person cleaning the spittoons happens to have a wound or open sore on his hand. Persons entrusted with the care of the spittoons in a private home or an institution for consumptives should wear rubber gloves while cleaning these vessels. At times the patient may inoculate himself by placing an acci- dentally injured finger in his mouth, or by carelessly soiling an open wound with his expectoration. Physicians, students of medicine or veterinary science, butchers, etc., are also exposed to the danger of wounding themselves with instruments which may have come in contact with tuberculous matter. Extreme care is the only remedy for all persons thus exposed. If one has been unfortmiate enough to receive an injury and tuberculous inoculation is feared, the best thing to do is to let the wound bleed freely, wash it thoroughly with water that has been boiled, with a five-per-cent. solution of carbolic acid, or with pure alcohol; dress the wound with a clean rag dipped in any of these liquids, and seek as soon as possible the advice of the physician. By tattooing tuberculosis has been transmitted in various ia- Care to be Taken in Cleaning Spittoons. 28 tubercutjOSis as a disease of the masses stances, because the operator was a consumptive. Men who follow the profession of tattooing have, as a rule, the habit of dissolving the colors, necessary for theii' work, with their own saliva, hence the infection. The best thing, therefore, is never to permit such barbaric decorations on one's body. Of less frequent causes of propagating tuberculosis, but which, in the light of modern sanitary science, can and should be pre- vented, we wül cite the ritual act of cii'cumcision, practised according to Jewish rites, when the operator happens to be con- sumptive. It is also well known that, through lack of skul in after-treatment, secondary hemorrhage and wound infection have ensued. Too many a young life has thus been needlessly sacri- ficed. The operation of circumcision, when skilfully and rapidly performed, is in itself trifling, but the sucking of the prepuce afterward makes it dangerous. Since it will be difficult to stop this practice by a simple protest on the part of physicians, and as the law cannot interfere with the free exercise of a religious rite, I should suggest as a remedy that only such persons should be allowed to perform circumcision as have shown the necessary skul before a medical board of examiners, and that every time they are called upon to perform the rite, they should submit themselves to a medical examination. Only when bearing a certificate from a regular physician, stating the absolute freedom from specific dis- eases, should they be allowed to perform ritual circumcision. As another reliable measure against the possibility of inoculating the child, when the parents insist upon the orthodox method of circumcision, is the suction by the aid of a glass tube, as practised in France and Germany. CHAPTEE X. What Othek Forms of Tuberculosis Exist, and What are Their Principal Symptoms ? In the foregoing chapters we have treated of the bacillus of tuberculosis, its mode of entrance into the system, and of the symptoms of the most frequent form of the disease — that is to say, consumption or pulmonary tuberculosis. Now we will consider some of its other forms or manifestations. AND HOW TO COMBAT IT. 29 More closely related to consumption than any other form of tuberculosis is laryngeal tuberculosis, also called tuberculosis of the larynx, or tuberculosis of the throat. This disease is not nearly so frequent as pulmonary tuberculosis, but sometimes oc- curs with it. Besides all the symptoms which tuberculosis of the throat has in common with tuberculosis of the lungs, such as fever, nightsweats, emaciation or loss of flesh, difficulty in breath- ing, cough, etc., there are in this disease additional symptoms, such as more or less pronounced hoarseness and frequent and intense pain during the act of swallowing, which makes eating bread, meat, and other solid food exceedingly difficult. The inter- nal appearance of the throat shows little tuberculous growths and ulcers in the region of the vocal cords and neighboring tissue. • Tuberculosis of the bones, which not infrequently leads to a total necrosis — ^that is, a softening and final decay of the bones — is not a rare disease. If the seat of the disease is the spinal column, the decay of one or more vertebrae may result in the deformity commonly known as hunchback. If through this breaking down there should result a compression of the spinal marrow, paralysis of arms or legs, and other distiubances, such as difficulty in retain- ing the uime and the stools, may be observed. While tuberculosis of the bones and joints is almost painless at the beginning, it may gradually lead to loss of the use of the joints, to maturation and destruction, which may become extensive enough to make even amputation necessary. In younger children tuberculous spinal meningitis is not rare, and, alas ! very often proves fatal. The essential symptoms of this disease are digestive disturbances (vomiting or constipation), uneasiness and depression, later on paralysis of the extremities, delirium, and sometimes coma (profound insensibility). More frequent and almost as dangerous as tuberculous menin- gitis in children, is tuberculosis of the intestines and the perito- neum (the lining of the abdominal cavity). This affection is sometimes also called consumption of the bowels. The most pro- nounced symptom in such cases is very often a protracted diarrhoea, which cannot be easily controlled by dieting or medica- tion. Tuberculo- sis of the Throat. Tuberculo- sis of the Bones. Tubercu- lous Meningitis. Consump- tion of the Bowels. 30 TUBERCULOSIS AS A DISEASE OF THE MASSES At times the whole body is invaded by the tuberculous disease, and countless little tubercles are distributed in all the organs. This disease is then called " miliary tuberculosis " because the tu- bercles are like millet seeds. The orighi of this disease is probably always due to the sudden outbreak of a localized tuberculous lesion, which had been at a standstill before. The first symptoms of mil- iary tuberculosis resemble those of typhoid fever. They are gen- erally depression, lassitude, and fever. This is also one of the forms of tuberculosis which often prove fatal. Of the so-called localized tuberculous diseases, we must mention the form which manifests itself as a skin disease and is known as lupus, showing itself as ulcerous patches mainly on the face. So-caUed scrofulosis, or scrofula, is now considered also as a form of tuberculosis. It appears almost exclusively during child- hood. It is a milder disease than the other forms of tuberculosis, and manifests itself mainly in swelling of the glands, eruption of the skin, and inflammation of eyes and ears. CHAPTER XL What Pkotects the Healthy Individual feom Contracting Tuberculosis ? After all that we have said of the contagiousness, or rather the communicability, of tuberculosis, and consumption in particular, one must not think that a l^reath in an atmosphere accidentally laden with bacilli would certainly render a healthy individual consumptive, or that by a swallow of tuberculous milk or a lit- tle injury from a broken cuspidor one must necessarily become tuberculous. The secretions of our nasal cavities, doul)tlessly also the blood, and the secretions of the stomach