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so firmly in the embrace of this loose and ignorant manner of dealing with this disease that it is only with a great effort that we can free ourselves from old prejudices and apply in a practical way the knowledge we have gained by bacteriological research. However, if we can take ourselves aloof and look at the subject from a scientific standpoint, we can see what an immense loss of life there is simply from ignorance and neglect on the part of individuals and the community. The mortality from war is nothing in comparison, and all calamities such as the wreck of the Maine and the Chilcoot avalanche sink into insignificance when we think of the suffering and death caused by tuberculosis.

In consideration of the subject of prevention of this disease, two features in regard to causation are to be kept in mind. The first is the necessity for proper soil and the second for seed which in this case are the germs of the disease. It is probable that almost any individual will furnish the soil and consequently contract tuberculosis when the infection is sufficiently violent and continued, while the opposite also is true that without infection from the bacillus no one will contract the disease. In a full discussion of the prevention of tuberculosis all means should be considered which make the individual more resistant as well as methods to prevent the dissemination of the bacilli; but to bring out the latter more prominently the former will be omitted in this paper.

On this subject the bacteriologist has done his full duty, but the clinician is far behind him. With such an appalling death rate staring us in the face and the cause of the disease clearly pointed out, is it not strange that we sit idly by doing nothing? Let a case of smallpox be found in a hotel and how soon he is hustled off to the pest house and the hotel quarantined, while the patient in the last stages of phthisis is depositing enough tuberculous sputum about the rooms and corridors of that same hotel to infect the whole citv. Not only this, but the tuberculous individual goes into public conveyances and on the streets and in fact everywhere, learing an infectious trail behind him. The medical profession, however, is awakening to its duty and in some cities it is made obligatory to report cases. Our own state society has made a good start with an active committee during the past year. But there is so much to accomplish that we should work without ceasing until we are in a position to attain good practical results. This subject is all the more important to Western Washington because everything is favorable

for the multiplication and dissemination of the

of the tubercle bacillus. More especially in its favor is the long, damp, rainy season, with almost no sunshine. During the past year in Seattle one death in nine has been caused by tuberculosis, and this proportion would be much higher were it not for the fact that so many leave here to go to a better climate during the later stages of the disease. The unsettled floating population of these western cities tends to increase the spread of the disease. For instance, a tuberculous patient occupies a furnished room in a hotel or lodging house for a week or a month, and passes on to infect another room, while a healthy person occupies the former room and contracts the disease. People with tuberculosis in the family move to another house, and the house they leave, without disinfection or even cleaning, is immediately rented and occupied by another family. Thus they go, and the bacillus is still thriving and multiplying

Now, what can we do to better this condition? By united and persistent effort we can accomplish a great deal. This society can bring its influence to bear on the state and local boards of health to secure the passage of laws in all cities and towns of the state to regulate this disease: also to secure the passage of state laws for the same purpose. We should first strive for the enactment of laws in the more important cities, first to prohibit expectoration on sidewalks and in public conveyances; second, to compel reports by physicians of all cases of tuberculosis; third, to give the health officer supervision over these cases, i. e., when reported he should visit them and caution them in regard to care of sputum to prevent infection of others and reinfection of themselves. The patient should be required to notify the health officer of change of residence. Then that residence should be thoroughly cleaned and disinfected before any one else is allowed to occupy it.

If these ordinances were passed the public would soon learn to obey them, and take it all as a matter of fact just as they do the regulations in regard to any other infectious disease. These ideas could probably be best carried into effect by giving entire charge to our committee on tuberculosis, with instructions for this committee to appoint a sub-committee of three in each of our larger cities, and of one in every village and hamlet in the state, and thus prosecute this matter by personal work so vigorously that the committee can report at our next meeting progress in this line everywhere throughout the state.

Tuberculosis is principally transmitted from one human being to another, but there is another source of infection which is of importance to deserve attention here, and that is tuberculosis of cattle transmitting the disease to the human subject by meats and dairy products. To give some idea of the extent to which this exists, I will give the following extract, taken from Wood & Fitz practice:

"Of 4093 cattle in Massachusetts tested for tuberculosis by means of tuberculin, 1081 reacted positively, and were killed, and anatomical evidence of tuberculosis was found in all but two. Of 132,294 cattle slaughtered in Copenhagen, 17.7 per cent., and of 142,872 killed in Berlin, 15.1 per cent. were tuberculous."

With this percentage of disease among beef cattle, we cannot expect anything better among the herds of Washington, and we would rather expect a higher percentage of the tuberculous among our dairy cows. Certainly there is every reason for the state to look into this. I thoroughly competent man should be secured to examine at least all dairy cattle in the state and all that are found to have tuberculosis should be killed.

Gentlemen, we have here a disease which takes from among us many a life full of promise, which affects young people particularly, which when it once attacks is usually fatal, and when recovery is brought about it is only by the greatest sacrifice the part of the patient and

and the patient's family. All told it causes more distress of mind, suffering and death than any other disease. We know the cause of tuberculosis and know that by proper methods the percentage of people with the disease can be lessened, yet in the state of Washington, until within the last year, absolutely nothing has been done to check the spread of the disease. Is it not time to be up and doing? Let us all work, both as a society and as individuals, and do all in our power to stay the progress of tubercuolsis in the state of Washington.

on

Ohio proposes to compel candidates for matrimony to undergo a suitable medical examination as to their physical and mental condition. Those guilty of insanity, consumption or dipsomania are especially barred out.

By C. W'. Sharpless, 11. D., Seattle, Washington.

[Read before the Washington State Medical Society; May

10th, 1898.]

Exophthalmic goitre is one of the diseases that is known, unfortunately, by two or three other names, according to a pernicious habit of attaching the name of some writer who has early in the knowledge of tlie disease, written a good description of it. This habit has gone so far that oftentimes one familiar with a disease in all its "ologies" will fail to realize what group of symptoms is meant when he lears such names as Basedow's disease, Grave's disease, Duchenne's palsy, etc. It is only recently that I read of Mitchell's disease, and would never have known what the writer was writing of hail I not a few days before seen his own account of erthromelalgia.

In this short paper on exophthalmic goitre I only want to call attention to the recent facts that may have decided the origin of the disease, or rather the organ in which the primary changes occur and to illustrate the treatment of two cases that have been ratlier more benefited than the usual run of cases.

To serum therapy and its associated innovation of ductless gland therapy we owe, among other good things, a better knowledge and a theory of the pathology and etiology of a more substantial basis than any before promulgated. I hope that these facts that I have here collected will convince vou that the seat of the disease is in the thyroid gland and that the cause of the peculiar train of symptoms is the outpouring of an overabundance of secretion from this gland into the blood which in turn acts on the nervous system. Some writers held that it was a purely vascular disease; others that it was of the sympathetic ganglia and nerves; others that it

was in the medulla, others that it was a matter of pressure and others that it was an over secretion of the thyroid, though the present knowledge was then wanting. We read of three cardinal symptoms, viz: Exophthalmos, an enlarged thyroid gland, and tachycardia stated in the reverse order of frequency and precedence. As more cases were studied these three symptoms by no means represented the complete symptomatology of the disease. Throbbing of the head, ringing in the ears, pulsations in the neck and in the thyroid itself, vertigo, tremors, excessive sweating, flushing, tingling in the limbs, diarrhea and vomiting, help to make up a complete picture of the disease as it manifests itself in different cases.

In the study of the thyroid gland two most markedly contrasted states, myxædema and exophthalmic goitre, attract attention. In the former every one admits the atrophy of the gland, and in the latter its enlargement. In the former, the expression of the face is as markedly changed by the halfopened eyes as it is in the latter by the very prominent eyeballs. In the former there is a slow pulse, regular, small and with an apparently small sized vessel, while in the latter there is a pulse, rapid, irregular, with a large wave and an actual increase in the size of the vessel. In the former there is ú thick dry skin and in the latter the skin is soft and thin. In the former a dull, lethargic mental state, in the latter it is marked as active, quick and easily excited.

On the introduction of gland therapy the natural thing to do was to administer it to those cases of diseases associatel with pathological alterations of that particular gland. So in myxædema, and especially in that state known as sporadic cretinism, the thyroid gland produced a diminution in the swelling and increase in the length of the bones (more particularly in cases that were treated during the first few years of life) a thinning of the skin, a complete change in the general appearance of the individual, an apparent increase of the size of the palpebral fissure and an increase in the intellectual activity of the patient. On the other hand we find many statements to the effect that thyroid extract administered to cases of exophthalmic goitre caused an exaggeration of the clisease. One case has been reported in which, after a subsidence of all symptoms, the extract was administered, causing their return. Many cases are recorded of exaggeration of the existing symptoms. One death is recorded as de

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