Aside from infection through the inhalation of dust which contains tubercle bacilli, we may have sometimes the disease produced by the ingestion of food containing these germs. It is well known that many domestic animals, and especially cows, are particularly susceptible to tuberculosis, and that the meat and milk of such an infected animal may contain tubercle bacilli. This mode of infection was formerly regarded as a very important one, but the feeling has been growing stronger and stronger among scientific men that this is a less serious source of danger than was formerly believed. Considerable doubt has been thrown upon its occurrence by the observations of Koch.

These observations seem to show that tuberculosis is not readily transmitted from cattle to human beings, although this has not been definitely proven. The explanation of this fact, if true, is that the tubercle bacilli, which cause the disease in cattle, have been somewhat modified in character by long residence in the bovine species, and as a result have lost a portion of their diseaseproducing power in the human being. This, no doubt, can be readily acquired again under special conditions. We have in other forms of disease illustrations of this same thing. Smallpox and cowpox, or vaccinia, the disease from which vaccine virus is obtained, are undoubtedly both the result of the same kind of an infection. Still, it is difficult to produce cowpox by the direct inoculation of the bovine species with smallpox virus, but if monkeys are first inoculated with smallpox virus, and then the cows inoculated from monkeys, cowpox results, the virus being modified sufficiently in its passage through monkeys to render the cow then susceptible. While, therefore, holding in abeyance a final decision in regard to the danger to human beings from the prevalence of tuberculosis in cattle, it seems quite certain that the seriousness of the danger of infection from this source has been somewhat overestimated. From what has been said, it follows: (1) That tuberculosis is a distinctly preventable disease; (2) that it is not directly inherited, and (3) that it is acquired by direct transmission of the tubercle bacillus from the sick to the well, usually by means of the dried and pulverized sputum floating as dust in the air.

It may be worth while now to estimate briefly the annual cost to the community of tuberculosis.

During the last twenty years there has been a reduction in the death rate from tubercular diseases in New York City of nearly 40 per cent. The total number of deaths in 1901 ascribed to this.

disease in New York City was 9,412. For the Boroughs of Manhattan and the Bronx alone, concerning which we have more accurate data for a series of years, we find that during the past twenty years there has been an actual decrease in the total number of deaths, notwithstanding an increase of population; that is, in 1881, the deaths from the tuberculous diseases in the Boroughs of Manhattan and the Bronx numbered 6,123; in 1901, twenty years later, they numbered 6,051. During this time the population of these Boroughs had increased nearly 70 per cent., viz.: from a little over 1,200,000 to more than 2,100,000. Taking now the deaths for the whole of New York City, annually, at 10,000-as we may safely assume that several hundred deaths each year, which should be ascribed to the tubercular diseases, are ascribed to some other cause-we may estimate the economic loss to the municipality. It may be conservatively estimated that each human life, at the average age at which the tubercular deaths occur, is worth to the municipality $1,500. The cost of each life at this age is usually more than this. This gives a total value to the lives lost annually of $15,000,000.

We may further assume that for an average period of at least nine months these persons are unable to work and must be cared for. The loss of their service, during this period, may be estimated at $1 a day, and the cost of food, nursing, medicines, attendance, etc., at $1.50 more per day, making a further loss of $2.50 per day for each person dying for a period of 270 days. This gives us a further loss to the municipality of $8,000,000, making a total annual loss to the city from tubercular diseases of at least $23,000,000. It has been estimated that in the United States annually not less than 150,000 deaths are caused by the tubercular diseases, and estimating the value of these on the basis just given, we have an annual loss to the country of more than $330,000,000.

This method of estimating the importance of the work in the prevention of tuberculosis may seem unfeeling, but it is an economic view, and one which should appeal to the various State and city officials. I have not the slightest doubt, personally, after a very large experience in the sanitary supervision of infectious diseases in New York City, covering many years, that the expenditure of a small part, annually, of this sum, would result in a very rapid decrease in the prevalence of the tuberculous diseases in this country.

A system of registration of all tuberculous cases has been in

force in New York for many years. Last year there were reported to the Department of Health more than 13,000 new cases. It may be safely estimated that this represents less than one-half of the cases actually existing in New York City, for many cases live for several years after they are brought to the attention of the Department, and are only included when originally reported, and many are not reported at all. For example, nearly 5,000 other cases were reported in 1901, which had been previously reported. I think we may safely estimate that 30,000 cases of tuberculosis in a stage of the disease in which it could be easily recognized by a competent physician are present in New York City.

I have had a census of the cases actually under treatment in the hospitals in New York City made annually for a series of years, and the total number never much exceeded 1,000, or less than 4 per cent. of the cases actually present in the city. The vast proportion of the remainder are in tenement houses. I have estimated that the total expenditure in the city of New York in its public institutions for the care and treatment of tuberculous patients is not over $500,000 a year, or not more than 2 per cent. of the actual loss to the city annually. If this annual expenditure were doubled or trebled it would mean a saving of several thousand lives annually, to say nothing of the enormous saving in suffering.

It is now fifteen years since the New York City Health Department first began, in a very small way, its efforts for the prevention of tuberculosis, and these have been rewarded by a reduction in the mortality all out of proportion to the expenditure in money and time which has been made. Still, more has been done in New York than in almost any city in the world. The measures, however, now in force are quite inadequate, as compared with the importance and magnitude of the problem. The sanitary authorities, however enthusiastic and efficient, and the medical profession, however influential and numerous, cannot grapple with this problem unless they have the hearty support of the people and the administration of the city. They must have generous appropriations for carrying on the work-for the provision of medical inspectors and disinfectors, for educational measures, for the establishment of dispensaries and sanatoria for the care of incipient cases, and of homes to which advanced cases may be removed, and where they may be made comfortable until the inevitable fatal termination comes. We must remember, in this connection, that every incipient case and every advanced case

of tuberculosis which is removed from its home and surroundings and placed in a properly equipped and conducted institution is, in this way, not only given a fair chance for recovery of health, but is educated as to the means to be taken to prevent further extension of infection, and, at the same time, one focus of infection is removed from the city. On the average, every case of tuberculosis infects at least one other case, and if removed to a hospital early enough, the infection of this second case would be, in each instance, prevented, and thus the total number of cases would be reduced.

It is in an educational way that lay organizations for the prevention of tuberculosis may be of the greatest service. They serve to arouse interest in and to disseminate knowledge of the nature of tuberculosis; they form compact bodies of public-spirited citizens, whose influence is of the greatest value in so moulding public sentiment that funds shall be forthcoming to erect and maintain dispensaries, sanatoria and homes for the consumptive poor. Through their assistance, and that of the public press, we may hope eventually to obtain State and municipal appropriations for the suitable care of the consumptive poor. New York State has made a small beginning in this way, and it is hoped that the State sanatorium, now in course of erection in the Adirondacks, may lead to very much larger appropriations for this purpose. The State is spending many millions of dollars annually for the care of the insane, and while this is absolutely necessary, for humanitarian reasons, I have no hesitation in saying that far greater returns would be obtained from the expenditure of one-quarter the amount in the prevention and cure of tubercular disease.

I believe that tuberculosis may be practically stamped out. The reduction in the mortality from it in New York City, since 1886, has been about 40 per cent., which means if applied to the Greater City, a decrease of more than 6,000 in the number of deaths annually caused by it. The vast significance of this is still more enhanced when we remember that to a very large extent these deaths take place in the working period, between fifteen and fiftyfive years of age. I have no doubt that the measures, first begun in a very small way in New York City fifteen years ago, inadequate as they have been, have resulted in saving the lives of at least twenty thousand persons. The annual deaths in the Greater City still number between nine and ten thousand, and we know that these are, to a very large extent, unnecessary.

THE INFLUENCE OF THE DISCOVERY OF THE RELA-
TION OF BACTERIA TO DISEASE ON THE
PRACTICE OF MEDICINE EXCLU-
SIVE OF SURGERY.

AWARDED THE SCHUYLER ALUMNI PRIZE FOR 1901.

By H. JUDSON LIPES, M.D., Lecturer on Obstetrics, Albany Medical College; Obstetrician to the Albany Guild for the Care of the Sick Poor.

(Continued from page 234-Preceding Number.)

From Albany "Medical Annals."

SYMPTOMATOLOGY AND COURSE OF DISEASE IN GENERAL.

We will now endeavor to consider the great changes brought about in our knowledge of the symptomatology and course of the various diseases. Assuredly the discovery of the causal relation of bacteria to disease has not influenced the symptomatology and course of disease per se, but the study of bacteriology has done much to bring, and is constantly bringing about, a regrouping and rearrangement of those clusters of signs and symptoms by means of which we have been accustomed to recognize the entities called "diseases."

There are three separate classes of diseases which should be reclassified according to the knowledge we now have of the etiology, diagnosis and symptomatology of disease.

Complex Discases. First, there are a number of diseases which we formerly supposed to be single well-defined diseases, which we now know to be complex, that is, may be of several different varieties, each variety produced by a distinct micro-organism. For example, previous to the development of bacteriology, we thought of acute pneumonia as a single well-defined disease. Now we recognize several kinds of pneumonia, and it is possible, to a certain degree, to differentiate the pneumonias according to their causative agents. In order to elucidate this subject, let us consider pneumonia in detail.

1. "Pneumococcus-pneumonia corresponds with the character