When I say that tuberculosis, that disease of universal distribution that "great white plague"-which causes so much misery and so much mortality, whose mere mention has in the bygone sent the fear of God into many of us, and on the prevention of which vast funds and a vast amount of energy have been expended, is a mild disease, if not the mildest, and, what is more to the point, the most preventable, I am not premature, nor am I speaking of conditions to obtain centuries ahead of us, but of the present. That is the truth of the matter. If we analyze the disease in the perspective, disjointed from the near and dear ones afflicted, we find that the disease in the body behaves just like the bacillus outside of the body-namely, it is difficult to develop under ordinary cultural conditions, and even when cultivated is very delicate and is easily destroyed. The vitality of the tubercle bacillus is extremely low. Indeed, this germ will not infect any one unless, so to say, the body persistently forces itself into position to accept infection. And even after infection, if the body will be given but half a chance, it will of itself overcome the infection. It can safely be stated that tuberculosis is a disease which is least likely to arise by itself, without the intervention of some condition especially favorable to the growth of the tubercle bacillus, such as some other disease, personal or drug abuses. There must be some special reason or contributing factor for the tubercle bacillus to develop in the body. Let us see what they are.

Mixed Infection

We said above that under ordinary conditions the tubercle bacillus is a very weak adversary. It finds victims only in the most miserable surroundings, from among the most miserable physically, or from among those with the most abused bodies. Yet even when for some reason it finds an individua! temporarily below par and infects him the bacillus soon succumbs after this temporary weakness is remedied. A cure is the natural result. When, therefore, we endeavor to account for infections among the intelligent and the previously healthy we invariably find that they are caused frequently not alone by the unaided power of the tubercle bacillus, but by the aid of other bacteria. It may even be said that only when this tubercle bacillus sees the body engaged in a struggle perhaps with a very formidable bacterial adversary does it also stealthily steal in unawares to make ruin the more certain. It seems that when the tubercle bacillus grows in the body in company with other bacteria its growth is rapid, luxurious, and most damaging. While the body can easily overcome the tubercle bacillus alone, it cannot

always overcome two or more relentless bacterial foes.

The largest problems, then, in the prevention of tuberculosis, are those aiming to prevent the many acute infections from attacking the body, especially during the periods when it is for any reason weakened. Never should the body be left sufficiently weakened to fall a prey to this puny but treacherous bacillus. Moreover, there are certain well known diseases whose presence particularly predispose to the rapid development of tuberculous diseases. All disease contributes its mite in this direction. Perhaps the whole field of preventive medicine could well be subsidized to anticipate this especially insidious disease. But to return to the influence of the specific diseases I have in mind-namely, measles, influenza, and whooping-cough-in the increase of tuberculosis. They are diseases common enough, and little feared by most people. Let us not wonder that there is even this amount of influence, but rather let us wonder that, considering the frequency, there is not an infinitely greater influence. How much less tuberculosis would there be if the unusually large toll of measles could be eliminated! And the great waves of influenza which keep sweeping across the country! And the dreaded whoopingcough! After all of them, the statistics of tuberculosis soar to new heights.

These diseases are still such potent factors in large part through ignorance, and in greater part through neglect. They will become less common when this indirect consequence is recognized; when parents no longer will voluntarily expose their children to these commoner of the contagious diseases of childhood on the superstition that the sooner they are over with them, the better; when, for example, a case of measles will cause the greatest concern-when an exposure to measles will mean an exposure to tuberculosis. In the medical profession lies the responsibility for early diagnosis, for proper quarantine, and for the advocacy of a long period of convalescence under the best possible conditions.

Such

While these specific diseases are pre-eminently concerned in the increase of tuberculosis there may be others that play as great a part and, for all we now know, even a greater part. is the nature of the tubercle bacillus that almost every disease prepares the body for it and is a forerunner of tuberculosis. And it is the sphere of the profession-of preventive medicine --to eliminate the preventable diseases, and thus the preventable elements in this fungus-like disease, tuberculosis, called a fungus because it has a tendency to attach itself to that which is down.

The important consideration of mixed infection in respect to tuberculosis is that the tubercle bacillus is not a pyogenic or pus-forming organism, and that, therefore, the destruction of tissue, cavity formation, fever, sweats, the hectic flush, etc., are not the results of an infection with the tubercle bacillus, alone but of an infection mixed with other bacteria. The moral is to keep your tubercle bacilli unadulterated.

The strongest and practically the only safeguard against all infection is a strong, fully prepared body, one that is always on the alert to ward off disease. Here, if anywhere, is preparedness the watchword of safety. The mere presence of hosts of bacteria can never disturb the body. There must be a concomitant lessening of the vitality. It is the necessity constantly of overcoming the attacks of the bacteria that develops and hardens our bodies. In other words, we develop an immunity against them. This is the way we have become hardened against many formerly common diseases, and now almost extinct.

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Communicability of Tuberculosis

Tuberculosis is perhaps the least infectious or, better, the least communicable of diseases. Can you think of another disease with which, because of a universal distribution, you are so much in contact as with tuberculosis where the likelihood of contracting the disease is a factor only in the weak? Moreover, against most diseases there is active quarantine, but rarely against tuberculosis. The health authorities do not interfere with cases unless so requested. They want to know about the cases, of course. Many of the new cases," especially in congested sections, find their origin in ignorance. Here, it is not sufficient protection that the tubercle bacillus enjoys a low degree of infectivity, for when multiplied it presents no inconsiderable front. What a mass of new cases would be anticipated if among the crowded and the ignorant there could be maintained an adequate quarantine! It need not necessarily be an absolute isolation, but a separation from those who are susceptible; not so much an isolation of the person, but a more certain isolation of the infectious materials from the body, the sputum and the like. This is the sort of isolation or quarantine that all intelligent people maintain against one another.

It is not, however, the known tuberculous that are most dangerous. Usually they have been taught to safeguard others. The danger emanates from those who do not yet know that they are victims of this disease, or those who are so low in the scale of intelligence that they are insensible to the resultant discomfort, pain, or debility. The number of the tuberculous who never come under scrutiny is very large. They form the foci for whatever infection there is. Most of these unknowns have short, transitory, mild infections, often taken for a slight "cold," bronchitis, or influenza, and 'get well" before the true nature of their trouble is discovered. The great Virchow long ago pointed out that all of us may have had at some time an infection with the tubercle bacillus. All of us, therefore, may be the innocent causes of the spread of this disease unless we are at all times careful in our

personal habits. These mild infections, becausc of their wide distribution, spread as much infection as the more severe ones. The mild forms may be in persons of strong physical capacity and vital resistance; perhaps in those having strong natural immunities; or in those persons who because of age or for other reasons do not present good food media for the bacilli; or in persons who necessarily get well because the tubercle bacillus is the only germ with which they have to contend. But when the disease is passed to some one else it may be passed to one who is naturally sensitive or susceptible to this germ, who may be very young and unhardened— a very sweet and tender morsel-or to one who is already contending with other bacteria. To escape this disease one must never be engrossed in dissipation or in a struggle with unwarranted, because preventable, disease. Eternal vigilance is still the price of safety.

Susceptibility to Tuberculosis

Aside from the general susceptibility of all of us there are a few who have a special susceptibility to tuberculosis. No one actually inherits the disease from ancestors, although there is an inherited affinity for it. Yet children of tuberculous parents need never contract the disease if out of contact with them or with those conditions, general or special, which are likely to give rise to it. The chances of the children of tuberculous parents remaining well vary directly according to the time these children are in contact with their parents. There are a very few parents so careful that they do not infect their children, but the number is a negligible factor in this problem. It is much safer to separate young children from tuberculous parents. The biologic affinity of the susceptible for the tubercle bacillus, even when they meet at long range, or even when the former are in better condition than those not thus affianced, makes it imperative for them at all times to exercise the greatest care against exposing themselves to disease, never allowing themselves to become run down, to assume bad habits, or to engage in unsuitable occupations or live in bad surroundings. They must at all times maintain an overcorrection of the body mechanisms.

All of us, however, can afford to pay more attention to our bodies and less to the adornments. I mean this in the broader sense of luxuries. Every symptom of even the slightest disturbance of body function is Nature's warning that there is a rip somewhere in the tissues. It will enlarge rapidly, and more rapidly the larger the tear, unless repaired. To this end all of us should submit to periodic physical examinations-periodic physical inventories, so to sayand a thorough overhauling when found necessary. "Know thyself" might well be added to the decalogue. In this maxim is constituted the rational means of anticipating disease. Periodic physical examinations have long been urged by health authorities and carried out in many organizations. Many theretofore undiscovered diseases have been brought to light and remedied. Every bodily disturbance is an opening for the ever-ready bacterial vultures.

Do not consider that it is energy wasted if

after examination no disturbance is found or if you only get some fatherly advice. This advice may be the means of saving you with more certainty than perhaps an appropriate, though difficult, delicate, and serious operation for which you would be glad to pay a large fee. When one views the many physical wrecks that strew this universe and that might have been saved by a little of this fatherly advice he cannot help wishing for the Chinese method of paying physicians only while well.

Preventive Measures

If the causes for the presence of and the spread of tuberculosis could be epitomized they could easily be embraced in disease, dirt, drink and drugs, poor food, and strenuous life pressure. There is no need for any of these, and when once eliminated, tuberculosis becomes ancient history. Disease. The disease factor has already been discussed.

It

Uncleanliness. Dirt is a very broad term. includes actual filth, that which is the result of congestion and overcrowding and that which is the result of insufficient light, air, and clothing. The ill effects of dusty atmospheres are well illustrated in the proneness of workers in the dusty occupations to contract tuberculosis. This source of disease is fast being remedied by legislative enactments. Dust, no matter of what nature, irritates the mucous membranes, clogs the cilis-those fine hairs on the cells of the mucous membrane which are purposed to sweep away any foreign matter-so that they are too busy with the dust to wrestle with the bacteria. The reason, very largely, for sending patients to high altitudes is to get for them the advantages of a dust-free and smoke-free atmosphere. Without the dust and smoke nuisances of the cities there would remain very little reason for sending away incipient patients. The greatest advantage of the country is the inducement for out-ofdoor life. While outdoor dust is bad enough, it is not nearly so bad as the kind usually created indoors by improper methods of dusting. Dry dusting disturbs the dust with its bacterial inhabitants and throws them from their rest onto the air passages of the members of the household. Dust, like children, is harmless when at rest. If the dust thus disturbed happens to contain some live tubercle bacilli which have settled, perhaps, after being carelessly coughed out into the air or been ground up after the reprehensible and always disgusting habit of expectorating about the house, dry dusting stirs up the bacteria to light upon the first likely victim. Safe dusting is wet dusting. Unfortunately the modern vacuum dusting is not usually possible where most needed.

In respect to health, cleanliness is far more important than disinfection. There are few, if any, circumstances under which cleanliness cannot be carried out. Not so with disinfection. Some bacteria are so resistant that they cannot be destroyed by ordinary methods. Nothing short of incineration will do it. Except in the laboratory, we do not often have them where we can incinerate them. On the body, disinfection is out of the question, for anything that will kill bacteria will kill the tissues containing

them. We do not desire to disinfect our bodies; we do desire to remove the bacteria. When necessarily in contact with disease it is general cleanliness which is the best safeguard, and not a dependence upon disinfection. Disinfection is in itself a danger because of the unwarranted feeling of safety it instills in the minds of many. Health authorities are even now doing away with the obsolete methods of disinfection after contagious diseases and instead are enforcing simple mechanical cleanliness. Bacteria, like all parasites, grovel and revel in filth. Remove the filth and you eliminate bacteria.

The special danger of dust infection is not so much the danger of a pure tubercle infection as it is from a mixed or combined infection with a number of bacteria.

Perhaps the greatest element in reducing the range of contact with, or the danger from the tuberculous has been the evolution of modern notions of culture, social refinement, and personal etiquette. Fastidious as some of these notions may seem, they are yet the necessary and natural outgrowth of the increasing tendency to contact, to communal grouping, and close relationship into which members of modern communities are thrown. But Nature tries to protect the individual from his neighbor by erecting this barrier between them. It is quite as necessary to maintain a physical individuality and reserve as the mental. Catching disease from real ladies and gentlemen, no matter how active their diseases, is not very likely to occur. We know that the usual method, of carrying disease from person to person, is by the droplet method that is, by infection through the drops of moisture, containing the bacilli, expelled in the cough of careless persons, in improper speaking, in spitting, or in unprotected sneezing. People of culture and refinement are careful not to do these things even in health. What lady or gentleman will cough without protecting the mouth, sneeze without protecting the nose, spit at all except in proper places and receptacles, or talk carelessly or boisterously so that saliva is allowed within reach of others--and still remain a lady or gentleman? Who is it that will drink out of a common drinking-cup, use a common towel or common eating-utensils, or wash in common water? What diseases, how much filth one escapes by merely maintaining the standards of ladies and gentlemen! What a great mass of the tuberculous would never have been had they themselves maintained this standard, or had others maintained it toward them! Refinement is a matter of safety, not merely of elegance and fastidiousness.

Drugs. Although not always of our own placing, we are often the victims of disease and uncleanliness. But drugs, and notably drink, which is so common a vice, and causative of so much physical and mental degeneration and disease, both immediate and hereditary, and so much tuberculosis, are of our own making. Considering the disease factors of the drinker alone, there is little wonder that there is still so much disease in spite of the progress of preventive medicine. Indeed, the degenerative diseases have even had an enormous rise. It is strange that there has survived a superstition

that excessive drink is curative of tuberculosis. There are many who believe quite sincerely that alcohol kills the bacilli. May be so, but not sooner than it kills the drinker. Alcohol can, in an emergency, take the place of food for a short time. It has a high combustive value, is easily absorbed and rapidly diffused. Its continued use, however, produces a baneful effect upon the arteries, the heart, and the circulation, and on other tissues. There is paralysis of the blood vessels which causes stagnation of the blood current; and no new materials are brought to the tissues. Degeneration is the natural outcome. Where there is stagnation, the bacteria have a picnic. The vitality is so reduced that almost any germ can take hold easily. In chronic drinkers there is an unusual proneness to tuberculous infection of a rapid and fatal form. Ordinarily, latter-year tuberculosis is not so severe, but in drinkers it is very virulent. The tubercle bacillus, like all parasites that live on their hosts, likes young and tender tissues better, and therefore it is that the young fare more badly. Then, too, tuberculosis is a disease of early life not alone because the tissues are so tender, but also because of the unusual activity of early life, whether it is the mere activity of growth, of learning, or of abuse, and because of the many other diseases which attack the young. In older persons there is less destruction of tissues and less impairment of power. Tuberculosis must be particularly guarded against in early life. If you must dissipate wait till your tissues are tougher and harder.

Food. The importance of food, of a proper dietary, can never be overestimated in its relation to health. Poor food and irregular habits in eating are at the bottom of much human misery. And the role of the metabolism, the inner diet, is just beginning to dawn upon science. The causation of heretofore mysterious diseases is now laid at the door of disturbances in metabolism. The tendency to tuberculosis of a fulminent form is very high in that best-known of metabolic diseases, diabetes. In like manner every deviation from the straight and narrow path in food may be serious. There is a singular tendency in the large cities among the poor and the underpaid, those with the poorest home surroundings, to lavish what little money they have on outward display and superficial amusements at the sacrifice of food. Withal, it is not so much the lowest of the low of these sections, the more ignorant and unsophisticated of them, who so often contract tuberculosis in the first instance, as it is the newer generations who, while they possess the same economic and environmental standing, yet indulge in irregularities and dissipations in which their more lowly brothers fortunately do not know how to indulge. Re member that tuberculosis is a disease of the neighborhood "belle" and "sport."

It is never wise to live above one's means, to make appearances at the expense of the healthto "pinch the cheeks to make them red." How often does the red become the hectic red, that flush that wanes with death. Food is not so expensive when it is simple, good, and not too much. It is not the high cost of living so much as it is the high cost of over-eating that hurts. Food

should be taken at regular hours. Midnight is for sleep, not for food. Better that digestion end at midnight than that it begin there.

It is quite necessary that food shall be free from disease, such as animal or vegetable parasites and especially tuberculosis. Unfortunately the individual cannot well control the use of disease-free food. That is for the community at large to do. Milk from tuberculous cows causes a considerable amount of human tuberculosis. To control the menace from this source it is necessary to sterilize or pasteurize suspected milk, to supervise properly dairy organizations, and to test every herd with tuberculin.

Life pressure. And now for the much-vaunted strenuous life! Is it worth while? The strenuous life of the present is not so much the result of the desire to do things as it is a necessary means in the mad scramble for wealth and power. The disastrous effect of this life is only too often in evidence from the many wrecks left in its wake. The efficiency method advanced in the industrics, without a proper consideration of the limits of human endurance, is not real efficiency. There is also an individual tendency to work at high pressure, often under privation, even if only for a short period, with the idea of acquiring during that period sufficient means to live a life of ease in later years. But this does not pan out. When the time for rest comes it is a permanent rest-rest from which there is no rise. Whether individual or co-operative, high pressure is equally baneful. The intelligent investigation of endurance, fatigue, psychological strategy, and general industrial hygiene will go a long way to reduce this source of tuberculous disease. After all, our store of energy is limited. Even the rich break down when they live too fast.

The industrial lines, however, are not alone in this desire for high-pressure efficiency. Even the modern higher educational systems demand it. There is a considerable quantity of tuberculosis among the student body. It may be that the general student body, coming from peoples not engaged in the muscular occupations, are to begin with physically underveloped and find the grind too much for them. This cannot, of course, apply to the student body of better economic standing with whom physical and mental development run parallel, and from whom are drawn those specimens of manhood that comprise the college athlete. It does apply to that part of the student body of poor circumstances, of families where perhaps only one member of a family is chosen for higher education, probably because already such a poor specimen physically as to be unfitted for the family occupation. In this student's interest the rest of the family sacrifice themselves. He is goaded on to study, and to study at greater and greater pressures, so that his early success may the sooner be the realization of the family's economic salvation. There is no time for rest and recreation. Spare time is spent at some occupation to help "pay their way through." In the student quarters of large centers of learning this type is usually well exemplified. The speed is most cruel. If there is anything that brain workers need most it is good food, good surroundings, and adequate recreation. To be sure, in many schools of learning

there is an effort made to balance the mental grind with physical training. But before it can be remedial the training must be suited to the individual needs of each student. There is still too much competitive exercise and too little developmental.

To those who hunger for knowledge or for economic salvation it is useless to advise against undertaking the task even when they are plainly unsuited for it physically. Yet the change from a sphere of ignorance to one of higher education is too sharp an incline for the human motive power to negotiate. It is educational revolution fraught with cruelty. A slower evolutionary change would be slower but surer. A striking illustration of the ill effects of revolution in vocation can be seen in peoples who for generations have engaged in one form of occupation and who suddenly change, as, for example, the proneness of the agricultural Irish or Italians to develop tuberculosis when suddenly transformed to American city labor. It is a biological truism that the primitive or the young are at their best among their own. Wandering among the unknown leads to their destruction. He who tries suddenly and forcibly to separate himself from the stock gets lost. Separation must be gradual. The mongrel in any walk of life, while it may "set the town on fire," does not last. This is no longer the age of "the poor, but ambitious" boy. While discouraging, it is nevertheless true that the public demands not a superficial rapid training gained at high pressure, and most often swallowed unmasticated, but deep, thorough, and lengthy training, an opportunity rarely offered the student of the lower classes. Modern society desires highly trained and specialized servants-and is willing to pay the price.

Those of us who have seen hopes blasted just before realization by these physical breakdowns, tubercular in nature, cannot help feeling that these struggles of heart-breaking cruelty are not worth while. In this attempt of the poor to grind through their children an education in the shortest possible time they start them at school at very early ages, want them to skip classes only to hurry, hurry, hurry. They are already usually too precocious, too nervous, and too mature. It is a boast too often encouraged, that a child of so early an age is already head and heels over its class. Are you asked to look at the physical side of this mental Hercules, but physical Lilliput? Would you then be willing to join in the boast?

There is a ray of light in this otherwise dark ground. When this type contracts tuberculosis it reacts very rapidly and favorably to changes. Those who have poor physiques from overwork, heredity, or environment find in the countrythe out-of-doors with more air, with better food, with less grind, or, better, with no grind-such a wonderful change for them that they get well much sooner than those who have lived out-ofdoors, but who have, perhaps, a particularly severe strain of tubercle bacillus, or who have a mixed infection, or, what is more likely, in whom the disease is the end result of much dissipation. It is a common experience to find that for them there is no change. They have had the bestand have abused it. For the former, an attack

of tuberculosis which forces them away from their grind is a blessing in disguise. They return the better, stronger, and the wiser for it.

Tuberculosis Statistics

And now some skeptic will tell you that in spite of all the advance in medicine, in hygiene and sanitation, in general preventive measures, in personal refinement and in culture, the tubercular statistics are still just as large, and the dread of tuberculosis just as great as in social states much lower. Who questions that the dread of this disease has been much lessened, though not done away with, of course? That takes time; it is coming. The fight is still young. The number of cures, the number who are able to return to their occupations without recurrence, has risen. They are so large that the public is beginning to take notice. They have been the most forceful and the most useful factors in the anti-tuberculosis campaigns.

It is quite true that the number of the tuberculous is still large, say, even larger than formerly. They are not, however, the advanced hopeless cases. Formerly the number of incipient cases recognized was very small, because diagnostic methods were crude. Only such cases as demanded attention by their very severity were recognized. Now conditions are reversed. The recognized incipient cases are very large, while the advanced cases are smaller. The toll of the incipients must be large since they are found in the very earliest stages, even, so to say, before there are any symptoms, and while a cure is certain. The number of the incipient cases is even forcibly swelled by adding all suspicious cases, so as to be on the safe side in respect to preventive measures. Indeed, it is intended to raise the statistics of the tuberculous so that we can have them all together "to, up, and after 'em." Any other aim parallels the action of the ostrich who hides his head in the sand so that

he cannot be seen. Every incipient case discovered is many advanced cases prevented. We can boast of the increase of the statistics since it is a boast of successful watchfulness of having them all corralled. Those communities which boast of small statistics are those that have exercised the least care in discovering them; those who have found the least, not those who have the least.

The Outlook

At one time the diagnosis of tuberculosis was tantamount to a death sentence because the diagnosis was made so shortly before the end. Now, with early diagnosis, it means merely a modification in the mode of living, a change of occupation, no dissipation, good food, plenty of the out-of-door, plenty of sleep, and a general abstinence from such conditions, environments, or infections as might cause the disastrous mixed infections. No longer does such a diagnosis mean a wandering, exhausting exile, but rather a restful domicile. Within certain limitations and under certain conditions of care most cases do better in their own locations, because of the mental satisfaction they receive from being near their dear ones. The medical profession realizes the crime of exile and no longer