lives, and tended, perhaps, more than any one thing to lengthen the life of a generation. Great strides have been made in improving the manner of disposing of sewage filth of large cities; in the water-supply, in the construction of public buildings, in plumbing and guttering, in the introduction of traps to prevent the escape of sewer-gas into the houses, and in proper ventilation. All these sanitary measures and improvements have been effected by the genius of medical men. This is not all; by observation and research, the habitats of malaria and other disease-producing causes, have been ascertained, and their evil effects in a great measure combated. These are some of the means effected by the profession to greatly protract the longevity of man over what it was a century or so back; and all humanity should, with loud acclaim, award the honor to its proper source.

The

Notwithstanding the vast results thus obtained in a sanitary point of view, we are, it might be said, only in the midst of the great work. It is believed by many that in the near future means will be discovered to prevent the occurrence of destructive epidemics as well as to remove other preventable causes of disease, so that the life of man will be greatly protracted beyond its present limit. minds of a few enthusiasts are imbued with the idea that the utopian age of three score and ten, allotted to man, will yet he attained. The question, right here, may be asked how are these great desiderati to be accomplished? At present we can only hint at the means to be employed. Hygiene must be taught in the public schools, epidemics must be prevented, more attention must be given to the hygiene of childhood. The management of children and the prevention of epidemics are the great means to be used in the preservation of human life, as nearly fifty per cent of the children born die before the age of ten years. But, before much can be effected in the curtailment of the mortality of childhood, it will be necessary not only to instruct parents in sanitary matters, but a system of inspection of premises will have to be inaugurated. This can, of course, only be done by legal enactment and at public expense.

When it was learned that some diseases were due to bacteria, and by some believed that all diseases were of microbian origin, it was hoped by some, and almost believed by a few enthusiasts, that we were on the eve of a grand discovery; that a germicide would soon be found by which the cause of all diseases could be removed and thereby all diseases avoided. But this utopian idea is becoming somewhat diminished. There is another thing in the way of public hygiene that but few of our profession have undertaken to combat; I allude to alcoholism. I regard this as being in the line of great obstacles to good health, to say nothing of morals; and whatever is detrimental to morals, as a rule, is injurious to health.

In my estimation, as a hygienic measure, the profession will soon be compelled, if not by the force of public opinion, by a sense of duty on their own part as well as justice to the public welfare, to grapple with this hydraheaded, pathogenic monster. The attention of all philanthropists is turned in this direc tion. The evil effects of the use of alcoholic liquors on the general health, and in the development of disease are so palpable to the observation, not only of the medical man, but to all thinking minds, that it is hardly necessary to recite the fact. This being true, why have the profession ignored the matter so long? We know that it is a bull with dangerous horns (popularly speaking) and will have to be handled with care; but nevertheless it must be handled, and it is nearly time our profession had inaugurated the movement. Dispensing with the use of this beverage would prolong life in the aggregate more perhaps than any one other measure of a hygienic character. Some doctors may tell you that they could not practice medicine without its use. This has been the view of a great many for centuries, as it has been regarded as a stimulant-one which, in their estimation, could not be substituted. It is at the present time regarded as a stimulant by a large majority of the profession. But it has of late been satisfactorily demonstrated (see Dr. Richardson's work, "Diseases of Modern Life") that it is not properly a stimulus, but a sedative, and in small doses

tends rather to lower the temperature than to increase it. It therefore can not be termed a heat-producer. He regards it more as a narcotic or sedative than a stimulus, and compares it in its physiological action to chloroform. In speaking of its use in a moderate way, Dr. Richardson says: "As a rule, the effect of the continued use of alcohol carried to the degree under consideration, is to create a series of functional, and afterward of organic changes which end in the establishment of distinct and irrevocable phenomena of disease." And further remarks: "To have to speak of diseases originating from the use of a fluid which, next to water, forms a part of the daily beverage of immense populations of civilized people seems a satire on civilization. It is nevertheless the duty of every physician to speak plainly on this subject, because it is his painful task, day by day, to treat the most terrible and fatal diseases, for the origin of which he can assign no other cause than the use of alcohol. It adds to the pain of the physician, while he makes these observations, to feel that when he calls to his aid the study of physical laws he can find no place for alcohol as a necessity of life. He contemplates its action. on living function to discover that it supplies no force to living matter, and no new matter that is of natural character for the construction of organized tissue. In whatever direction he turns his attention to determine the value of alcohol to man, beyond the sphere of its value as a drug which he may at times prescribe, he sees nothing but a void; in what ever way he turns his attention to determine the persistent effects of alcohol he sees nothing but disease and death; mental disease, mental death; physical disease, physical death."

Our government establishes quarantines and creates health boards at public expense to prevent the ingress and spread of epidemics, when the loss of life from alcoholism is equal to, if not greater, than that from all the epidemics this country is subject to. From the best sources of information it is estimated that about sixty-five thousand people die annually in the United States, directly or indirectly, from the effects of alcohol. A large majority of this number consists of men in the prime of

life. This is not all; the evil effects of alcoholism are inflicted upon untold millions through heredity. And yet our governments, both State and National, license its sale, and thereby encourage its use.

Then it is readily seen what a vast field is open for work, both for the physician and philanthropist, not only as to the health-destroying effects of alcohol, but also as to its destruction of morals. It is estimated by some jurists that nine tenths of the crimes committed are done under the influence of alcohol.

As a sample of the salutary results of excluding alcohol from a community, I would cite the city of Pullman, near Chicago. It does not contain a saloon or any place where liquor is sold. In consequence the city has no jail, no police force, no sheriff or constable, nor does it need any. Peace and quietude reign supreme.

There are other narcotics which are taken at first to allay pain or by way of amusement, but by frequent use a habit is established by which the system calls for increasing doses; by persistent and long-continued use these may, and frequently do, develop various diseases, and occasionally by overdoses kill directly. I allude more particularly to opium, tobacco, chloral, chloroform, hashish, etc. The habit of using all these drugs, as well as alcohol to excess, is a legacy entailed by civilization. Here also is a wide field open for work on the part of the profession, first using their influence to have the evil effects of all these things, as before remarked, taught in our public schools; and, secondly, to directly exert their influence among the people to prevent the acquirement of such habits.

There is one other cause of destruction of human life which demands the serious consideration, not only of our profession, but of all philanthropists. I allude to syphilis. This terrible disease scatters in its march a vast amount of human misery, and registers its victims by thousands. This is not all; it lays its deadly grasp on their posterity. Some idea may be had of its blighting effect on offspring by examining reports of children's hospitals, clinics, etc. Prof. Larrabee, of Louisville, reports over fifty per cent of diseases at his clinic

for children as due to the effects of syphilis. Reports from similar institutions in New York give about the same statistics. Perhaps, if it could be ascertained, the destruction of the embryo, resulting in abortion from syphilitic influence, would about equal the number of children born at full time who are affected with this scourge. It is only from hospitals and clinics of the poor that we can obtain any thing like definite statistics of mortality resulting from syphilis and alcoholism. From other sources we fail on account of deference to family feeling.

The question arises, can any thing be done by which this terrible scourge can be arrested, or even modified? Some suggestions and even efforts have been made in this direction, but so far of but little avail. Some ten or more years ago the plan of inspection was tried in St. Louis, but as it was connected with the license system the churches took such a stand ' against licensing houses of ill-fame the whole plan was soon abandoned. Possibly a wellregulated system of inspection, universally observed, might be promotive of a great deal of good in the suppression of this ungodly disease. I presume, however, that this means would not be sufficient to entirely stamp out the disease as it frequently exists in private houses. The short time the license and inspection plan was tried in St. Louis promised favorable results. In one year the disease was curtailed thirty-five per cent.

In enumerating diseases and their causes, I have omitted to mention consumption, as there is at present but few if any known means at our command which can be used to ward off the disease, unless we could educate the people to the danger of intermarrying with those predisposed. This, however, would be a hard matter to accomplish, as the judgment of the young is frequently eclipsed by the passions. As a general thing that portion of the human family predisposed to tuberculosis is possessed of traits of delicacy and beauty of features calculated to captivate the strong and robust of the opposite sex; hence any argument on the subject, as a rule, would prove nugatory. Enactment of laws to prevent such intermarriage would be regarded as arbitrary and

unjust. Some microbe enthusiasts have of late gone so far as to assert that no case of consumption ever existed that had not for its origin the bacillus tuberculosis, and that heredity has nothing to do with it. Were this theory true, we might be induced to hope that by isolation, if not by germicides, the spread of the disease might be arrested and finally exterminated. But this theory in contradistinction to heredity will hardly ever become prevalent. This disease carries off about one seventh of the people of civilized nations, and no greater boon could be granted the race than a means to prevent its existence.

Judging from what has been accomplished by the science of our profession in the way of public hygiene, we are led to hope that in the near future the most of the obstacles to health and life herein named will be removed, when we shall expect that man's life will be extended on the average to the Divine allotment.

Why should this be an unreasonable hope, when we have on record men living in modern times twice that long? By way of illustration we cite the names and ages of a few who died within the last two centuries: Michael Dougherty, 135 years; Margaret Patton, 137; Countess Desmond, 145; Thomas Parr, 152; Thomas Damme, 154; John Rovin, 172, and Peter Torton, 185. It is quite common to see an account of persons living to be one hundred years old, and it is reasonable to suppose that if all preventable causes of disease were removed, and the laws of nature preservative of health were strictly observed, the human family might be preserved to the age of seventy years. Too much praise can not be awarded to the genius and philanthropy of our profession for the great advances made in the prevention and cure of disease within the past century. We are commanded in Holy Writ to earn our bread by the sweat of the brow, but our medical philanthropists work to destroy the means of their livelihood. In other words, they work to prevent the occurrence of disease for which they would get pay for treating. We see this exemplified every day in the working of our health boards. We have over one hundred county boards of health in Kentucky, all of which work for nothing and bear their own

expenses. Is there any other class of men who do as much charity work as physicians? In many localities about one third of the work is among the poor who are unable to pay. But as a rule we do not complain. If we all could regard such work in the same light as did the celebrated Boerhaave, who on one occasion, being asked how he could afford to do so much charity work, replied that "God was the paymaster of the poor," we perhaps might do our work more cheerfully. It is fortunate that, as a general thing, the right kind of men get into the profession; and it should be a rule with all preceptors to ascertain the true character of applicants who wish to study medicine. No young man should think of studying medicine who is not possessed with kindness of heart, and is willing to do charity work. Any man who studies medicine with the sole purpose in view of making it pay is not one of us. He that can not sympathize with the unfortunate poor and render them help in time of sickness and distress does not belong to our guild.

ETIOLOGY OF PHTHISIS.

BY R. W. TAYLOR, M. D.

My attention has been directed to the etiology of phthisis pulmonalis by a paper on this subject from Dr. Didama, of Syracuse, N. Y. The doctrine advanced by him is so radically different from that which has heretofore been considered orthodox, that I have been led to look up some of the recent literature on the subject. I must confess that the result of researches my has not been very encouraging to such as expect the profession to settle the question at an early day.

There has never been a time when opinions touching this question were more unsettled than at present; notwithstanding the fact that phthisis is more or less prevalent all over the globe, and in most civilized countries is responsible for nearly twenty per cent of adult mortality, we to-day know but little of its etiology.

The discoveries of Koch and others have done much to unsettle the mind of the profession. And as his discoveries are still in an incomplete state, we may expect to have to

wait a good while before we know how to estimate them. Some of his more sanguine followers are claiming that his doctrines are already established. This claim I think premature; yet I am inclined to think favorably of his views, and his experiments seem almost conclusive.

Phthisis pulmonalis is a constitutional, specific disease, produced by a specific germ. It may be congenital, it may be hereditary, or it may be acquired. The victim may have been born with that condition of the system or that diathesis that afterward developed into phthisis. He may have been born with this diathesis because a parent or parents were the subject of tubercular phthisis. It that case it would be hereditary. Again, consumption may be acquired where the diathesis does not exist. There are authorities who deny that the disease itself can be inherited, and say that at most only a certain aptitude may be inherited. It may be asked what is the difference between inheriting phthisis and inheriting the diathesis of phthisis? I admit that it is somewhat difficult to explain the difference, yet I think there is a material difference, and the distinction is just this: In case the diathesis only is inherited we can not have the disease unless we have extraneous agencies brought to bear. In the event the disease is inherited, it will be developed without the agency of extraneous causes. That the disease is inherited, I think has been pretty well established in the minds of a majority of physicians who have had. much acquaintance with it. I have on my mind now the case of a gentleman who died thirtyfive years ago, a victim of phthisis. Since his death as many as five or six of his children have died of the disease. The last one died less than two years ago.

I have seen too many instances in which it would be difficult to explain or account for the disease upon any other assumption than heredity. How often have we known of large families. of children, reared it may have been under favorable hygenic conditions until they had reached manhood and womanhood, perhaps married and settled in localities at a distance from the parental home, but still under favorable but dissimilar sanitary surroundings, one

after another became victims of this disease! These instances are of such frequent occurrence that we can not attribute them to mere chance. The most rational explanation of these cases is that they have the germ of the disease in them, and when the time has arrived it is developed. That phthisis may be acquired is, so far as I know, not denied; all agree that we may have the disease where it is neither congenital nor hereditary. There is, however, a difference of opinion as to how and under what circumstance it may be acquired. Some authorities hold that it may be due to antecedent diseases of the lungs, traumatism, a "bad cold," or to noxious dust, as in the case of miners, marble cutters, grinders, etc. This, however, is denied by Flint, whose opinion I am inclined to adopt. These at most can only favor the development of the germ already planted, and if the germ is not there it can not be produced by any of these agencies. Probably a majority of our patients in giving a history will say that their trouble began with a "bad cold." This, I think, is due to the fact that the symptoms of incipient phthisis are very much those of a "bad cold." Age seems to have much to do in the develop ment of the disease, and we find great uniformity in all countries. A very large percentage is found between twenty and thirty; after that we find it decreasing with each decennial period until sixty is reached, after which it is rare. Climate seems to have much to do in its production; and, while no country or climate is exempt, it seems to prefer the temperate zones to either the frigid or torrid. This may be due to the fact that we have a greater range or variation in temperature in the temperate zones.

It is more apt to occur in moist than in dry atmospheres Hence high altitudes with dry soil are to be recommended to those who desire to avoid it. Sedentary habits, confinement to ill-ventilated apartments, insufficient food, or food of poor quality, as well as great and prolonged mental depression, all tend to promote its development. Pregnancy seems to hasten its development; so does prolonged lactation.

Certain diseases, as measles and pertussis, seem to favor its development, while others, as chlorosis, emphysema, mitral regurgitant lesion, chronic alcoholism, according to Flint, hinder it.

It has long been a mooted question whether or not it can be communicated from one person to another; and while there is no very conclusive evidence on this question, I am inclined to the opinion that it may be so communicated under favorable circumstances. This is rendered more probable if we accept the "baccilli theory" of Koch and his school. In fact the strongest argument that can be urged against this theory is, that if the disease is infectious it should be more prevalent than it is. I am inclined to the opinion that the germs are often expectorated, and, becoming dry, are taken up as particles of dust, and in this manner find their way into the larynx of the attendants. The disease has been experimentally communicated to animals, and I see no reason why this may not occur in man. When the germs have in this way reached the lungs, after a period of latency or incubation, tubercle will be developed. We know nothing of the length of this period of latency or incubation; and it may be so long that the circumstances of exposure have been forgotten, or at least as to lead us to discredit any connection between the exposure and the result. I think it is pretty generally conceded that eating tuberculous meat may produce the disease. Dr. Bang, of Copenhagen, has recently found baccilli in milk from a cow with tuberculous udder.

Drs. Dugent and Harricont "have made the discovery that the fungus of pityriasis is very nearly allied to baccilli tuberculosis, and may be cultivated in the same way, and, when so cultivated and injected into guinea-pigs and rabbits, produces tubercle just as the tubercle baccilli. If this is true, it is a matter of very great importance, as this fungus may be found in several other skin diseases that have heretofore been considered trivial, and may we not in this way be able to account for a large number of cases that have heretofore seemed inexplicable."

In order that infection may be accomplished we must not only have the germ, but the system must be in a favorable condition to receive the germ. Now this is not only true of phthisis, but it is also true of all other contagious disBy this favorable condition I do not mean diathesis. I am now speaking of acquired

eases.