Dr. Ella E.Huntington \StLM t2-l*'1 VUtA*' OF . r c ( r- 1 ' r. i R r, HISTOKICAL AND GEOGRAPHICAL PHTHISIOLOGY 1 H7777 SPECIAL REFERENCE TO THE DISTRIBUTION OF CONSUMPTION IN THE UNITED STATES COMPILED AND /ARRANGED BY GEORGE A. EVANS, M.*D. MEMBER or THE MEDICAL SOCIETY OF THE COUNTY OF KIKO8, NEW YORK MEMBER OP THE AMERICAN MEDICAL ASSOCIATION FORMERLY PHYSICIAN TO THE ATLANTIC AVENUE, AND BUBHW1CK AND EAST BROOKLYN DISPENSARIES, ETC. NEW YORK D. APPLETON AND COMPANY 1888 i ' /"-*\_ iMQlS'Y-KM COPYRIGHT, 1888, BY D. APPLETON AND COMPANY. PREFACE. Ix the following volume I have attempted to present a sketch of the development of our knowledge of pul- monary consumption from the time of Hippocrates up to the present day, together with the ascertained facts re- garding the geographical distribution of that affection. It has also been my effort so to arrange the statistics in regard to the geographical distribution of consumption in the United States as to make them available for con- venient reference in selecting localities of resort or resi- dence for invalids, and also for those who are in health. Dr. Bell says : " It is an almost universal practice to measure the influence of climate by the relation which dillcrent regions and localities hold to pulmonary con- sumption ; a disease which, probably more than any other, depends upon preventable conditions, intimately associated with foul soil, or density of population." * This treatise is made up, to a great extent, of the observations of others, and for the most part in their own * " Climatology," etc., by A. N. Bell, A. M., M. D., New York, 1886. 4 PREFACE. words ; however, I have endeavored to give full credit in all cases. The historical portion of this work, from Hippocrates up to and including Empis, was translated almost entirely from Waldenburg's " Die Tuberculose, etc.," " Nach his- torischen und experimentellen Studien," Berlin, 1869. Some assistance was obtained, however, from Euehle's "Historical Sketch" of pulmonary consumption.* Hirsch's " Handbook of Historical and Geographical Pathology " has supplied most of the data pertaining to the geographical distribution of consumption in countries other than the United States, and his observations and opinions concerning the influence of the various factors of climate, etc., have been utilized and adopted so far as they have seemed to agree with well-established facts. The statistical data, under the head of "Summary for States, Groups, Cities, and for Counties of Ten Thousand Population, etc., showing the Number of Deaths from Consumption per One Thousand Inhabit- ants," as well as other data relative to the geographical distribution of consumption in the United States, were compiled, after much labor, from the " Tenth U. S. Census Reports." In reference to these reports, Dr. J. S. Billings says : " The term ' consumption,' as used in the enumerators' (census) returns, is, no doubt, a vague one, and includes many cases which are not due to true tubercular phthisis, especially in infants ; yet it is probable that a very large * " Ziemssen's Cyclopaedia," etc., American edition. PREFACE. 5 majority of the cases thus reported are rightfully named, and that some conclusions may be drawn from the figures as to the relative prevalence of tubercular lung-disease which will be reliable to a great extent."* At all events, they represent the most reliable data attainable at the present day. G. A. EVANS. 909 BEDFORD AVENUE, BROOKLYN, N. 7., May, 1888. * " Tenth U. S. Census Report," vol. lii. CONTENTS. P10 I. HISTORICAL SKETCH 9 1. Study of pulmonary phthisis in ancient times and during the middle ages. Hippocrates to Benedictus, pp. 9-17. 2. Dis- covery of pulmonary nodes and nodules. Befonnation of the doctrine of consumption, identification of phthisis with scrofula, and uncertain recognition of tubercle. Sylvius to Morton, pp. 17-20. 8. Period of standstill in the study of consumption. Sydenham to Anenbrugger, p. 20. 4. First positive knowledge of tubercle, and first attempt to discriminate between pulmonary phthisis and scrofula. Stark to Reid, pp. 20, 21. 5. Period of transition from old to new doctrines. Cullen, p. 21. 6. Rapid development of the new doctrine. Baillie to Vetter, pp. 21-28. 7. Emancipation of tuberculosis from scrofula. Pulmonary con- sumption synonymous with pulmonary tuberculosis. Bayle to Laennec, pp. 23-25. 8. Contention for and against the doctrine of tuberculosis in France. Bichat to Andral, pp. 25, 26. 9. De- velopment of the new doctrine in Germany. Meckel to Rokitan- aky, pp. 26, 27. 10. Development of the same in England. Ali- son to Stokes, pp. 27, 23. 11. First microscopic investigations of tubercle. Gluge Lebert and Reinhardt, p. 28. 12. The new reformation in Germany. Virchow to Niemeyer, pp. 28, 29. 18. Various doctrines. Ruehle to Empis, pp. 29, 80. 14. First arti- ficial production of tuberculosis by means of tuberculous matter. Klencke to Villemin, pp. 80, 81. 15. Artificial production of tu- berculosis by means of non-tuberculous materials, auto-inocula- tion, etc., pp. 82, 88. 16. Artificial production of tuberculosis in man, p. 33. 17. Tubercle-bacillus. Koch, pp. 84-88. 18. Mod- ern doctrines, pp. 88-40. II. GEOGRAPHICAL DISTRIBUTION OF CONSUMPTION IN COUNTRIES OTHER THAN TIIE UNITED STATES . . 41 8 CONTENTS. III. GEOGRAPHICAL DISTRIBUTION OF CONSUMPTION IN UNITED STATES IV. TOPOGRAPHY AND CLIMATE OF STATES AND TERRITORIES, AND SUMMARY FOR STATES, GROUPS, CITIES, AND FOR COUN- TIES OF TEN THOUSAND POPULATION AND UPWARD, SHOW- ING THE NUMBER OF DEATHS FROM CONSUMPTION PER ONE THOUSAND INHABITANTS 105 Maine, p. 105. New Hampshire, p. 107. Vermont, p. 108. Massachusetts, p. 110. Ehode Island, p. 112. Connecticut, p. 113. New York, p. 114. New Jersey, p. 116. Pennsylvania, p. 118. Delaware, p. 120. Maryland, p. 122. District of Co- lumbia, p. 123. Virginia, p. 124. West Virginia, p. 125. North Carolina, p. 127. South Carolina, p. 129. Georgia, p. 131. Florida, p. 134. Ohio, p. 135. Tennessee, p. 138. Kentucky, p. 140. Indiana, p. 142. Illinois, p. 144. Michigan, p. 146. Wisconsin, p. 148. Iowa, p. 151. Missouri, p. 153. Arkansas, p. 156. Louisiana, p. 157. Mississippi, p. 159, Alabama, p. 161. Texas, p. 163. Kansas, p. 166. Nebraska, p. 168. Min- nesota, p. 170. Dakota, p. 172. Montana, p. 174. Idaho, p. 175. Colorado, p. 178. Wyoming, p. 180. Arizona, p. 182. New Mexico, p. 184. California, p. 186. Nevada, p. 188. Washington Territory, p. 190. Oregon, p. 192. Utah, p. 194. V. METEOROLOGY 198 United States Signal Service Reports : Barometer, p. 200. Tem- perature, p. 206. Eelative humidity, p. 210. Precipitation, p. 215. VI. ETIOLOGY .224 Temperature, p. 224. Humidity, p. 226. Dampness of soil, pp. 227-231. Elevation, pp. 231-243. Differences in the social, hygienic, commercial, and industrial conditions, p. 243. Phthi- sis in prisons, p. 258. Heredity, p. 261. Contagious transmis- sion, p. 263. Individual predisposition, congenital or acquired, p. 280. VII. CONCLUSIONS 284 The value of statistics, pp. 284-286. Curability of pulmonary consumption, p. 287. Treatment of consumption by residence at great altitudes, pp. 289-293. Antiseptic (local) compressed- air treatment of consumption, with table of results, pp. 294, 295. I. HISTORICAL SKETCH.* So far as our information goes, pulmonary consump- tion has always existed. "It is," as Prof. Hirsch re- marks, " emphatically a disease of all times, all countries, and all races. No climate, no latitude, no occupation, no combination of favoring circumstances, forms an in- fallible safeguard against the onset of tuberculosis, how- ever such conditions may mitigate its ravages or retard its progress. Like typhoid fever, phthisis dogs the steps of man wherever he may be found, and claims its vic- tims among every age, class, and race." f Hippocrates (460-377 B. c.) seems to have been the first to describe phthisis with any degree of clearness; he considered the affection to consist of a suppuration of the lungs due to various causes, and that it may as- sume an acute or chronic character. It may occur as a result of inflammation. It may proceed from a chronic pneumonia, which is complicated by a defluxion of mucus from the brain into the lungs. * With the special assistance of " Waldenburg'a "Die Tuberculose," etc., Berlin, 1869. f " British Medical Journal." 10 PHTHISIOLOGY. It may arise from an extravasation of blood into the lungs, which, through its failure of absorption, is con- verted into pus, or it may occur whenever a collection of mucus, blood, or any morbid products in the lungs or pleural cavities, fail to be expectorated or absorbed within a specified time. Hippocrates believed phthisis to be curable when due to either of the above causes. He considered the affection to be non-specific, and that it always occurred as a natural result wlien mucus, blood, or morbid products in the lungs or pleural cavities, were converted into pus through their failure of ab- sorption. He recognized, however, another form of phthisis, the result of " phymata." * " Phyma " being generally translated " tuberculum " in Latin, this circumstance constitutes the only evidence that Hippocrates recog- nized the existence of tubercle. "Phymata" referred, according to Yirchow, f to points of cheesy matter or small collections of pus. Hippocrates wrote concerning " phymata " not only of the lung, but also of the pleura, tonsil, bladder, urethra, and as a cause of fistula, so there can be scarcely any doubt that he referred to simple abscesses. In short, throughout all his writings we find that " phyma " signifies a collection of pus the result of inflammatory action, which has depended for its origin upon a failure of mucus, blood, or bile to be absorbed. In none of his works, however, does there * Waldenburg. f Ibid., loc. cit. HISTORICAL SKETCH. H exist the least evidence for supposing that tubercle of these times was known to him. It is quite evident that the only distinction Hippocrates made between "phy- ma" and simple suppuration was, that the former rep- resents a circumscribed condition, while the ktter is more diffused in character; however, he considered phthisis to exist when either form appears in the lungs. Hippocrates undoubtedly found tuberculous nodules, not only in the lungs of man, but also in those of the lower animals; but he seems to have attached no importance to their existence, except to consider them as centers of simple inflammation or suppura- tion. His book of "Epidemics" treats of phthisis as an epidemic disease supervening upon attacks of semi-ter- tian.* In Adams's translation of Hippocrates's works, the following history of phthisis is given : " Early in the .ning of spring, and through the summer, and toward winter, many of those who had been long grad- ually declining, took to bed with symptoms of phthisis ; in many cases, formerly of a doubtful character, the disease then became confirmed, in these the constitu- tion inclined to the phthisical. Many, and in fact most, of them died. . . . The greatest and most dangerous disease, and the one that proved fatal to the greatest * Francis Adams's " Genuine Works of Hippocrates," London, England. William Wood & Co., New York, 1886. 12 PHTHISIOLOGY. number, was consumption. "With many persons it com- menced during the winter, and of these some were con- fined to bed, and others bore up on foot; the most of those died early in spring who were confined to bed; of the others, the cough left not a single person, but it became milder through the summer ; during the autumn, all these were confined to bed, and many of them died ; but in the greater number of cases the disease was long protracted. Most of these were suddenly attacked with these diseases, having frequent rigors, often continual and acute fevers ; unseasonable, copious, and cold sweats throughout; great coldness from which they had great difficulty in being restored to heat ; the bowels variously constipated, and again immediately in a loose state, but toward the termination in all cases with violent loose- ness of the bowels; a determination downward of all matters collected about the lungs; urine excessive, and not good; troublesome melting. The coughs through- out were frequent, and sputa copious, digested, and liquid, but not brought up with much pain; and even when they had some slight pain, in all cases the purg- ing of the matters about the lungs went on mildly. The fauces were not very irritable, nor were they troubled with any saltish humors; but they were viscid, white, liquid, frothy, and copious defluxions from the head. But by far the greatest mischief attending these and the other complaints was the aversion to food, as has been described. . . . The form of body peculiarly sub- ject to phthisical complaints was the smooth, the whitish, that resembling the lentil; the reddish, the blue-eyed, HISTORICAL SKETCH. 13 the leucophlegmatic, and that with the scapulfflL_haiing the appearance of wings." (" Aphorisms." *) Phthisis most commonly occurs between the ages of eighteen and thirty-five years. "In pleuritic affections, when the disease is not purged off in fourteen days, it usually terminates in ein- pyema. " Persons who escape an attack of quinsy, and when the disease is turned upon the lungs, die in seven days ; or if they pass these they become affected with em- pyeina. " In persons affected with phthisis, if the sputa which they cough up have a heavy smell when poured upon coals, and if the hairs of the head fall off, the case will prove fatal. " Phthisical persons, the hairs of whose head fall off, die if diarrhoea set in. " In persons who cough frothy blood, the discharge of it comes from the lungs. " Diarrhoea attacking a person affected with phthisis is a mortal symptom. ** Persons who become affected with empyema after pleurisy, if they get clear of it in forty days from the breaking of it, escape the disease ; but, if not, it passes into phthisis." Adams, in a note to the above aphorisms, states that Hippocrates applied the term empyema to the purulent expectoration that follows inflammation of the lungs and * Adams's trans., " Genuine Works of Hippocrates." 2 14 PHTHISIOLOGY. pleurisy, and also to that which proceeds from a cavity of the lungs in tubercular phthisis. Isocrates, a contemporary of Hippocrates, considered pulmonary phthisis to be a contagious disease ; this opin- ion, he claimed, was based on clinical observation. Celsus (about 30 B. c. to 50 A. D.) recognized three forms of consumption: an atrophy of lung, the re- sult of its imperfect nourishment; cachexia, i. e., consti- tutional weakness, the result of protracted sickness, de- pressing therapeutics, imperfect nutritive processes, etc. ; and ulceration of lung, which is characterized by fre- quent cough, putrid expectoration, and high fever. Celsus recognized neither phyma nor tubercle in the lungs, although in the fifth volume of his work he speaks of phyma of the skin ; phyma he, however, translated as tubercle, and used the term tubercle to designate tumors which occur in various pathological processes ("Furun- culus vero est tuberculum acutum, etc."). Aretseus Cappadox (50 A. D.) was the first clearly to describe pulmonary phthisis as a special pathologi- cal process, although he admitted that the pus of empy- ema frequently infiltrates the lungs, and gives rise to a pathological condition the symptoms of which resemble those of phthisis. Nevertheless, he drew a sharp distinc- tion between the two affections. He considered phthisis to be due to abscess of lung, chronic bronchitis, or pul- monary haemorrhage, and that either of these might give rise to an accumulation of pus in the lungs. The term phyma was not used by Aretseus. In the second book of his work ("De causis et signis acutorum morborum"), HISTORICAL SKETCH. 15 Chapter I, he states that peri-pneumonia may, in its course, develop abscesses and tumors in the lungs, and that when these ulcerate they give rise to phthisis. The development of phthisis from pulmonary haemorrhage, pleurisy, and empyema, was considered to occur only when their morbid products failed to be absorbed, were converted into pus, and finally established purulent in- filtration of lung-substance. Suppuration of lung and phthisis were synonymous; however, Aretseus believed that phthisis frequently occurred as a result of chronic catarrhal bronchitis. IL-II (131-201 A. D.) ("De Methodo Mendi") de- scrips phthisis as consisting of simple ulceration or sup- puration of the lungs, by which portions of the organ are slouched off, become putrid, and are discharged in the expectoration ; he considered ulceration of the lungs in connection with ulcerations of other organs, viz., stom- ach, bladder, uterus, mouth, etc., and we find nowhere in his writings any recognition of phthisis as a specific disease. He believed the affection to be due chiefly to mechanical irritation of lung-tissue, frequently induced by violent respiratory action, catarrh, etc., followed by pulmonary haemorrhage and finally ulceration. Injury to lung-tissue was considered by Galen to run the same course as injury to the tissue of other organs of the body, and tli at ulceration would occur if the reparative process failed to be completed in a few days. He also recognized that tilceratiou of the lungs might occur independent of pulmonary haemorrhage, as a result of corrupt secretions ; this form of phthisis, however, he regarded as incurable. 16 PHTHISIOLOGY. In order to cure pulmonary consumption Galen con- sidered it necessary to make use of the same method of treatment which had been found to be most successful in healing ulcers in other organs of the body, the skin, stom- ach, bladder, uterus, etc. This treatment, he explains, consists of measures for drying up the secretions or dis- charges, thereby inducing cicatrization. In deference to this opinion, Galen was in the habit of sending his phthisi- cal patients to dry-air localities. He considered the phymata of Hippocrates to be latent abscesses, which in the beginning produced no symptoms other than dysp- no3a; he seems to have attached no special importance to simple abscess of the lungs, and did not consider that it constituted in itself pulmonary phthisis, although he undoubtedly believed that it might lead to the develop- ment of that affection through its irritation of lung- tissue, extensive suppuration, haemorrhage, or blood- poisoning. It is quite evident that Galen not only had no knowl- edge of tubercle of later times, but we may feel certain that he failed to recognize nodes or nodules in the lungs. Very little advance was made in the knowledge of pulmonary phthisis from the time of Galen until the be- ginning of the seventeenth century ; the principal writ- ers during that interval were, according to Waldenburg, Rhazes, Maimonides, and Benedictus. Rhazes (A.1 Razi), of the Arabian school (923 or 932 A. D.), adopted the opinions of Hippocrates and Galen concerning phthisis, and copied extensively from their works. In his writings on the subject he states HISTORICAL SKETCH. 17 that suppuration of the lungs may result from peri-pneu- monia, pleuritis, haemoptysis, or an injury, and that pa- tients die from it because the lungs can not be treated like external parts by the knife or cautery. Maimonides (1135-1204) devoted his attention chiefly to the pathological anatomy of those animals which the Jews of his time slaughtered and used as food; and, although his studies in this direction were actuated by a sense of religious duty (being a Jew), nevertheless he utilized the information thus gained in his consideration of the morbid changes which occur in the tissues of man. Maimonides made, however, no addition to the knowl- edge of phthisis of his time. He adopted almost en- tirely the opinions of Hippocrates and Galen; and, al- though he undoubtedly found nodules in the lungs of beef-cattle, he nevertheless failed to consider them in connection with phthisis (pearl-disease), or to attach to the i n any special importance. Alexander Benedictus (1525) considered Hippocrates as the highest authority on pulmonary phthisis, and adopted his opinions concerning its etiology and pathol- ogy almost without reservation. He makes no mention of "phyma" or tubercle in his writings. Franciscus Delevoe Sylvius (1614-1672) seems to have been the first to recognize the existence of nodes in connection with ulcerations and suppurations of the lungs. He believed in inherited or acquired predispo- sition to the development of phthisis, and speaks of en- hirged pulmonary glands in connection with nodes, from the softening of which tubercles, both large and small, 18 PHTHISIOLOGY. as well as cavities, are formed. He recognized two forms of pulmonary phthisis : the first, due to purulent infiltra- tion of the lungs, resulting from haemoptysis, peri pneu- monia, or empyema, and characterized by ulceration, sup- puration, and loss of lung-substance ; the second variety he considered as occurring in scrofulous subjects, and due to nodes in the lungs which suppurate to form cavities, in association with enlarged pulmonary glands which soften and are converted into tubercles. Sylvius declared (" Tractus de Phthisi ") his observa- tions and teachings concerning pulmonary phthisis to be entirely new, and we are compelled to believe him when we consider that he was the first, so far as we can learn, to describe ulceration of the lungs as due to a suppu- ration of tubercles. He recognized hard, tuberculous masses in the lungs which first soften in the center, be- come abscesses, and finally disintegrate for the produc- tion of cavities and putrid expectoration ; he believed in the existence of two kinds of tubercle, large ("tuber- cular majora ") and small (" tubercular minora "), and it is not improbable that he recognized as "tubercular minora" the miliary tubercle of to-day. He described nodes in the lungs as " glandulosa tu- bercula," and' believed that invisible glands exist in the lungs as well as in other organs of the body, which, in scrofulous subjects, enlarge to form small tubercles ; that these in turn develop into a larger variety, which, when they have finally attained a certain size, suppurate to form cavities, etc. scrofula of the lungs. Willis (1622-1675) endeavored in his writings to dis- HISTORICAL SKETCH. 19 prove the identity of phthisis with ulceration of the lungs. lie claimed that extensive post-mortem investi- gations showed the affection to consist of an infiltration or hardening of lung-substance, due to imperfect or vica- rious nutritive processes, characterized by the presence of tubercle, and resulting in destruction of lung-tissue, and demonstrated at the same time that ulceration of the lungs did not occur in coexistence with pulmonary phthisis. Willis undoubtedly recognized miliary tu- bercle. After Willis, the writings of Bonnet (1620-1689) at- tract attention. The first volume of his work on pathological anat- omy gives his observations concerning over one hundred and fifty cases of pulmonary phthisis. He considered the affection due to various pathological changes in the lungs, such as ulceration, abscess, suppuration, empyema, induration, scirrhus, tubercle, etc. In certain cases he identifies tubercle with the phyma of Hippocrates, and speaks of tubercle or abscess of the pleura as "tubercula glandulosa," which shows, according to Waldenburg, that tubercle was regarded by him with the same significance as it was by Sylvius and Willis. Bonnet made no distinction between scirrhus and tu- bercle. Vomit- he considered as slowly developing abscesses, generally due to the softening or breaking down of tubercles. Mauget (1700), in a revised edition of Bonnet's works, recorded his own observations in forty-nine cases of general miliary tuberculosis. In one case (a young 20 PHTHISIOLOGY. man who died from phthisis) he made a post-mortem ex- amination, and found miliary tubercles (" grandines ") in the lungs, liver, spleen, kidneys, mesenteric glands, and intestines. He likened these bodies to millet-seed, and considered them to be scrofulous in their nature. He states that they are found not only in the tissues of man, but also in those of the lower animals, and when they occur in the lungs they soften at first in the center, for the production of "vomicae," which finally suppurate and develop phthisis. Morton (1689), in his work on " Phthisiology," dis- tinguishes different forms of pulmonary phthisis from one another those which are due to syphilis, pneumonia, haemoptysis, and scrofula. He believed that a general febrile condition of the system, due to impaired vitality, gives rise to the formation of nodes in the lungs in every variety of phthisis, and that their suppuration leads to a general destruction of lung-tissue. He identified nodes with tubercles, and believed that no form of pulmonary phthisis could develop without them. Morton's writings do not show that he recognized miliary tubercle. Sydenham (1624-1689), Leigh (1694), Hoffmann (1660-1742), Boerhaave (1668-1738), Mead (1673-1754), Morgagni (1682-1771), Yan Swieten (1700-1772), Sau- vages (1706-1767), Anenbrugger (1722-1809), and many other prominent observers wrote concerning pulmonary phthisis. However, none of them seem to have advanced the knowledge of the subject. Stark, whose observations and writings on phthisis pulmonalis were first published in 1785 (fifteen years HISTORICAL SKETCH. 21 after his death), gave a more accurate description of tu- bercles than had ever been given before, and showed how cavities were formed from them. Reid (1785), who published the researches of Stark, together with his own, considered that tubercles were derived from coagulated lymph, and strongly opposed the old doctrine of their glandular or scrofulous nature. Cullen (1709-1790) believed phthisis may arise from an expectoration of blood ; from a suppuration of lung- tissue, the result of inflammatory action ; from catarrh occurring in flat-chested subjects; and, finally, when nodes are developed in the lungs. He described small bodies (tubercles) in the lungs, resembling hardened glands, which, when they become inflamed, ulcerate and develop phthisis. Kortum (1786) occupied in his opin- ions concerning pulmonary phthisis a position midway between the old and new doctrines. Baume (1795) failed to consider the teachings of Stark and Reid. Either they were unknown to him, or else he regarded them as of no importance. However, Baume failed to advance the knowledge of phthisis. He believed that tubercles are developed from pulmonary glands in scrofulous subjects, and that their suppuration gives rise to phthisis. Matthew Baillie published (in 1793) a small work en- tit lel "The Morbid Anatomy of some of the most Im- portant Parts of the Human Body." It made an era in medical science. In this work Baillie describes, as the most frequent lesion in the diseased (phthisical) lungs, the presence of nodes, which are at first about the size of the head of a pin, but afterward, by the coalescence of 22 PHTHISIOLOGY. several, increase to larger nodes. The breaking down of these nodes into pus he regards as the cause of consump- tion. He also distinguishes them from glands. At the same time, however, he speaks of the more diffuse de- posits as composed of scrofulous matter, although he thinks that they consist of the same substance as the nodes. In the lymphatic glands he speaks of this matter as " caseous." In many other organs, such as the kid- neys, bladder, testicles, etc., this scrofulous matter may be present as well as the tubercles, and everywhere they both possess the common property of being converted into a soft, caseous mass. Portal (1780) followed quite closely in the footsteps of Baillie in his opinions concerning the morbid changes which occur in the lungs in consumption. In his writ- ings, he designates caseous matter as tuberculous, and says that this is the term in general use. Portal described bronchial and lymphatic glands, and believed that tubercles were frequently derived from the latter. He states, however, that tubercles may develop in the connective tissue of the lungs, independent of these glands, through extravasation of lymph from the lymphatic vessels. He recognized not only tuberculosis of the lungs, but also of the pleura, liver, spleen, mesen- tery, etc., and considered tuberculosis of all these organs as hereditary scrofulous affections. Yetter, whose "Aphorisms on Pathological Anato- my" were published in Vienna in 1803, distinguished the "phthisis pulmonalis" ("ulcus pulmonum "), which is characterized by suppuration (" vomica "), the result HISTORICAL SKETCH. 23 of an inflammation of lung-tissue, from that form of the affection whose primary lesion consists in a formation of tubercles in the lungs. He considered tubercles to be non-scrofulous in their nature, although he believed that a predisposition to their development in the lungs might be acquired as a result of external debilitating influences. He denied the glandular origin of tubercles, and con- sidered that they develop primarily either in the open- ings of the small bronchial tubes or in their contiguous connective tissue. Vetter also described tuberculosis of the peritonaeum, bowels, liver, spleen, and even the uterus ; however, he failed to consider tuberculosis of these organs in connec- tion with tuberculosis of the lungs. Bayle (1774-1816), who, according to Waldenburg, is the real founder of our knowledge of the tubercle, used the term miliary tubercle, and described a granular as well as a tubercular phthisis. He considered the former variety as not at all infrequent, although other writers do not mention it. He described six varieties of phthisis : (1), " phthisic tuberculeuse " ; (2), " phthisic granuleuse " ; (3), " phthisie avec melanose " ; (4), " phthisie ulcereuse " ; (5), " phthisie calculeuse " ; (6), " phthisie cancereuse." Out of 900 cases of phthisis reported by him, 624 be- longed to the first, 183 to the second, 70 to the third, 14 to the fourth, 4 to the fifth, and 3 to the sixth vari- ety. He declared tubercular phthisis to be a distinctly ^urific disease, which may or may not be complicated with inflammations, catarrh, hoemoptyses, etc., but does not originate in them. 24 PHTHISIOLOGY. Bayle found miliary tubercles in various organs of the body, and was the first to recognize them in the larynx and trachea. He considered tubercular phthisis to be a constitutional rather than a local disease, the result of cachexia. Hufeland (1819), who made so many important con- tributions to the medical literature of his day, failed to contribute anything of value to the study of phthisis. Laennec (1781-1826). Kindfleisch says: *"It is well known that there was a time when pathological anatomy pointed with pride to its knowledge of phthisis tuber- culosa. Laennec's theses concerning the gray granula- tion and its change into yellow tubercle spread, after long controversy, a welcome light over the nature of the entire process. The manifest resemblance of the le- sions in different organs, especially in the lungs, kid- neys, and mucous membranes, were explained by the axiom that there was only one phthisis a phthisis tu- berculosa." Laennec amplified and perfected the doctrine of phthisis tuberculosa which Bayle was the first to pro- mulgate. f " He begins his anatomical description of phthisis with the statement that the tuberculous matter is devel- oped under two principal forms, that of isolated bodies and that of infiltration. Both of these forms present several varieties, according to the stages of development. * Zicmssen's " Cyclopaedia of the Practice of Medicine," vol. v, American edition, William Wood & Co., New York, 1875. f Ruehle, in Ziemssen's " Cyclopaedia," etc. HISTORICAL SKETCH. 25 The isolated tubercles have four principal varieties, the miliary, the crude, the granular, and the encysted tu- bercle ; while the infiltrated has three, the irregular, the gray, and the yellow. In both forms the tuberculous matter is at first gray and hyaline, gradually becoming opaque and very dense; afterward it softens, becomes more and more fluid like pus, and is finally discharged through the bronchi, thus giving rise to tuberculous cavities. Judging from the only signs of inflammation which were then attainable, Laennec denied the inflam- matory nature of tuberculous matter, and particularly that pneumonia could pass into tuberculosis. He was, moreover, just as skeptical in regard to the causation of tuberculosis by bronchial catarrh, for the reason that he was unable to satisfy himself from anatomical evidence that the latter was ever directly converted into the former." Bichat (1771-1802) and Beclard (1821) adopted La- ennec's views almost completely. Broussais (1772-1838), Gendrin (1826), Lobstein (1829), and Lombard (1834), strongly opposed the teach- ings of Laennec. Broussais considered pulmonary phthisis as chronic pneumonia, the result of irritation and inflammation of the connective tissue of the lungs. Inflammation of the pleura and bronchial catarrh also frequently give rise to phthisis. Tubercle and tuberculous matter are simply products of inflammation. Louis (1823) adopted Laennec's views completely, and his monograph, " Recherches anatomiques, pntho- 26 PHTIIISIOLOGY. logiques et therapeutiques sur la Phthisie," was for a long time the standard text-book on the subject. Audral (1842) considered tubercle to consist of a yellowish-white substance, a product of secretion, which, originally liquid, becomes friable or cheesy, and maintains this consistency because liquid between its molecules prevents their complete cohesion the scrofulous, tuber- culous, steatomatous, or cheesy matter of other writers. He speaks of " tuberculization of pus," and its conversion into cheesy matter. Although Andral opposed Laennec's views on many points, he subsequently adopted the opin- ion that tubercles were produced independently of any irritative or inflammatory process, but their presence ex- cited a secondary inflammation, which ultimately expelled the tubercles. "Walclenburg speaks of Andral as the predecessor of Keinhardt and Yirchow. Meckel (1818) and Neumann (1822) identified tuber- cle with scrofula. Schonlein (1839) considered phthisis a secondary dis- ease, a result either of inflammatory or non-inflammatory changes in the lungs, independent of tuberculosis and scrofula, although it frequently occurs as a sequel to them. Engel (1845) separated the miliary tubercle from the infiltrating tubercle ; he considered the latter to be an in- flammatory exudation. Vogel (1845) derived tubercle from liquid exudation, which he considered to be a result of qualitative changes in the constituents of the blood, and of hyperinosis. Yo- gel made no distinction between isolated and infiltrating HISTORICAL SKETCH. 27 tubercles; lie, however, distinguished tuberculosis from scrofula. liokitansky * (1842-1861), " whose pathological anat- omy made its first appearance in 1842, declared that tubercles are neoplasms, and adopted them for both of Laennec's two forms. As late as 18G1 he speaks of the miliury tubercle and the tuberculous infiltration as the two forms of tubercle. The latter, he says, consists in the impaction of the texture of the lungs with a reddish, gnivi>h-red, grayish, finely granular, stiff, tuberculous mass, BoiiK'times involving a whole lobe, as a lobar tuberculous infiltration, but very often lobular that is, affecting single lobules or small aggregations of the same. The tubercu- lous infiltration differs from the tuberculous granulation in the fact that in the former the tuberculous substance is produced uniformly, and in so solid a form that the pul- monary structure over a large extent becVmes unrecogniz- able and impermeable." Alison (1824). In England, the doctrine of tubercu- losis slowly developed; at first Baillie's views were generally adopted, and scrofula occupied a position in the foreground. Phthisis was regarded as a local expression of scrofula and tubercle, one of its products. Alison and many other prominent observers of his time adopted these views. Baron (1828) identified tubercle with hydatid cysts, while Addison considered tubercle as abnormal epithelial cells which he derived from white blood corpuscles. * Ruchlc, in Zicmssen'a " Cyclopaedia," etc. 28 PHTHISIOLOGY. Carswell regarded miliary tubercle as a neoplasm, readily disposed to caseation, in consequence of which change the tubercle becomes opaque, white, and finally yellow. He defined the tuberculous infiltration as an inflammation which becomes modified in various direc- tions, and considered caseous pneumonia to be a scrofu- lous affection. Clark adopted the views of Laennec almost com- pletely, while Stokes occupied a position, in his opinions regarding pulmonary phthisis, about midway between those which were held by Laennec and Broussais. Gluge (184:1) seems to have been the first to utilize the microscope for the investigation of tubercle. Lebert * (1844). " The views of the French writers in regard to the specific nature of phthisis were con- firmed, microscopically, by Lebert, who demonstrated small, irregularly oval, granular corpuscles, to which he gave the name tubercle corpuscles, and which he regard- ed as characteristic of all tuberculous matter, including both the miliary tubercle and the tuberculous infiltra- tion." " Reinhardt f (184:7) demonstrated that tubercle cor- puscles may originate from pus-cells, and thereby de- prive them of their importance. By 1850 he had established the fact that many substances hitherto re- garded as tubercle were identical with the products of inflammation." Virchow (1850) founded, according to "Rind- * Ruehle, in Ziemssen's " Cyclopaedia," etc. f HISTORICAL SKETCH. 29 fleisch," * " the new doctrine to supplant Laennec's teach- ings. He taught that only the miliary tubercles were to be called tubercles, and that no process was to be called tubercular unless the gray miliary granulations were found. Cheesy conditions could be formed from thick- ened pus and other cellular new growths just as well as from miliary tubercles. It should be the office of patho- logical anatomy to separate the cheesy products of inflam- mation from cheesy degeneration of miliary tubercles. . . . Virchow had called attention to the fact that, in almost all cases of acute, disseminated miliary tubercu- losis, cheesy forms could be found somewhere in the body, usually a cheesy lymphatic gland. Practical medi- cine, however, for a long time regarded Virchow's teachings with distrust. Felix Niemeyer was the only clinical teacher who boldly adopted the new doctrine." Ruehle f says : " All the recent numerous investiga- tions have been based upon this histological distinction between the miliary tubercle and the infiltration ; but it is not too much to say that as yet they have failed to establish conclusions which have met with general accept- ance." "Bayle's miliary tubercle plays, however, only a sub- ordinate rdle in pulmonary consumption ; it is an acci- dental secondary product. When it forms the only ana- tomical lesion, we have to deal with an acute infectious disease, the acute miliary tuberculosis, which does not belong to phthisis. There is probably no chronic miliary * Rindflcisch, ibid. f Ruehle, in Zicrasscn's " Cyclopaedia," etc. 30 PHTHISIOLOGY. tuberculosis in the old sense of the term. Phthisis is also anatomically a chronic inflammatory disease, with inter- current simple forms of inflammation which heal by cicatrization. But the pernicious form of phthisis is a specific variety of inflammation with characteristic caseous metamorphosis ; this inflammation is localized in different parts of the tissues, is characterized by the fact that it begins with and also produces the true histological miliary tubercle of the smallest kind, and in itself undergoes no other metamorphosis except necrosis." Lorain, Robin, and Empis denied the identity of miliary granulations with tubercle. Empis, who made extensive microscopic investigations of tubercle, con- sidered the granulations, which Laennec derived from miliary tubercle, as a result of inflammatory action. He admitted, however, that they may occur in combination. He, as well as Lorain and Robin, strenuously opposed the doctrine which Yirchow had promulgated. Klencke * (1843) : " Isolated, imperfect attempts at the artificial production of tuberculosis, made at the end of the last century, gave only negative results. The credit of the first successful experiments belongs to Klencke, who in the year 1843 succeeded in inducing an extensive tuberculosis of the lungs and liver in rabbits, by inocu- lation with portions of miliary and infiltrating tubercles from man, and he did this by the introduction of these masses into the veins of the neck. He did not continue * " Investigation of Pathogenic Organisms," vol. i, by Dr. Robert Koch, 1881, translated by Victor Horslcy, B. S., F. R. C. S., New Sydenharu So- ciety, London, England, 1886. HISTORICAL SKETCH. 31 his researches, and they were consequently soon forgot- ten." In 1857 Buhl pointed out that an outbreak of tuberculosis was almost always attributable to the pre- vious existence of caseous matter somewhere in the body." Villemin presented to the French Academy of Medi- cine, December 4, 1865, his first memoir on the origin and nature of tubercle, and its transmission to rabbits fn>m man. It contained a detailed record of methodical and thorough experimental investigations into the nature of tuberculosis. " Villemin * inoculated not only with tubercular mate- rial from human beings, but also from cases of bovine tu- berculosis, and proved experimentally the identity of the latter disease with tuberculosis." Villemin's researches, from the number of his experi- ments, the careful manner in which they were carried out, and the employment of suitable control experiments, appeared to have decided the question in favor of the infective theory. The numerous workers, however, who repeated Villemin's experiments after the same or a modified method, arrived at very contradictory results." Villemin's conclusions were : 1. Tuberculosis is a spe- cific affection. 2. It is produced by an infective agent. 3. Rabbits may be successfully inoculated from man. 4. Tuberculosis should be classed with virulent diseases, such as variola, scarlatina, syphilis, and glanders. * Koch, ibid. 32 PHTHISIOLOGY. " Yillemin's * conclusions were soon confirmed by a series of experiments carried on by Simon, Marcel, Clark, and Lebert. In 1868 Sanderson and Fox succeeded in producing tuberculosis in Guinea-pigs, not only by the in- sertion of tuberculous material, but also by that of non- tuberculous. Fox used the following non-tuberculous materials : Putrid muscles, pus of various kinds, pneu- monia products, lardaceous liver, cirrhosed kidney, vac- cine matter, pysemic abscess of the spleen ; and in a large proportion of the cases produced tuberculosis of the various organs. Sanderson and Fox also produced tuber- culosis by inserting setons of cotton-thread under the skin of these animals without inoculating them with any morbid material. Waldenburg, Cohnheim, and Fraenkel found that in the Pathological Institute at Berlin all the Guinea-pigs into whose abdominial cavities they intro- duced pieces of cork, paper, and cotton-thread, etc., be- came tuberculous, and concluded that the formation of a suppurative inflammatory focus is sufficient to ren- der certain animals tuberculous, and therefore the non- specific character of tubercle. But a repetition of these experiments, with antiseptic precautions, at a later date, led Cohnheim and Fraenkel to modify their opinions. Schottelins, of "Wiirzburg, produced granular pulmonary tuberculosis in dogs, by making them re- spire air charged with pulverized phthisical sputum. But he produced similar .results with air charged with the * Williams, " Pulmonary Consumption," etc., London, England. P. Blakiston, Son & Co., Philadelphia, 1887. HISTORICAL SKETCH. 33 expectoration of bronchitis, Liraburg cheese, and with vermilion. Rindfleisch * calls attention to the remarkable simi- larity between the predisposition of "certain animals" for tuberculosis, and the occurrence of tuberculosis in a cer- tain group of persons the scrofulous. He declared that any large-celled infiltration of a tissue is to be regarded as tuberculous or scrofulous in character. Zieglerf demonstrated in 1875 that neither giant-cells nor epitheloid cells are exclusively confined to tubercle, but are to be found in all granulations. " In 1874 Demet and Paraskova Zablonus, of Syra, in Greece, succeeded in inoculating a man of fifty-five with tuberculosis. The patient was dying of gangrene of the left foot through obliteration of the femoral artery. Phthisical sputum was inserted into the upper part of the right leg, the lungs having been previously examined and pronounced perfectly healthy. Three weeks after the inoculation, signs of commencing induration of the ri<_ r ht apex were detected, and seventeen days later (i. e., thirty-eight days after inoculation) the patient died of gangrene. The autopsy showed seventeen tubercles, vary- ing in size from a mustard-seed upward, at the right apex, and a smaller number at the left apex, all evidently of recent formation. . . . Klebs, firmly convinced of the specific nature of the tubercle, had described an actively * Rindfleisch, in Ziemssen's " Cyclopaedia," etc. f Ernst Zicglcr, " Ucber die Hcrkunft dcr Tuberkelelemcnte," etc., Wur/.bure, 1875. | Williams, "Pulmonary Consumption," etc., Philadelphia, 1887. 34 PHTHISIOLOGY. moving organism as its cause. . . . Schiiller and Tons- saint had pictured a spherical micrococcus in connection with the disease. . . . Aufrecht had found more than one form of organism, and thus paved the way for the next step, which was the discovery of Robert Koch." Koch,* in 1882, judging from the results which had been recently attained concerning the etiology of many infective diseases, considered it not unlikely that the cause of tuberculosis might also be found in some micro-organ- ism. In his investigations into the etiology of tubercle he followed the method by which the parasitic nature of splenic fever was so effectually established. He first turned his attention toward proving the presence of a pathogenic organism, thence passing on to isolation and inoculation experiments. " Koch,f having by means of certain aniline dyes de- tected the bacillus tuberculosis, succeeded through a series of ingenious cultivations in procuring it pure and simple. He first took tubercle, and, after washing it with a solu- tion of corrosive sublimate, removed the outer layers and separated a portion, into which he might fairly expect that no bacteria of putrefaction had penetrated. This he spread over a nutrient soil, consisting of the blood-plasma of the ox, which had been previously sterilized by boil- ing in a test-tube. The coagulum of this, with the tuber- cle added, was introduced into a test-tube with a cotton- * " The Etiology of Tuberculosis," by Dr. Robert Koch, vol. ii, Berlin, 1884, translated by Stanley Boyd, F. R. C. S., New Sydenham Society, Lon- .don, England, 1886. f Williams, " Pulmonary Consumption," etc. HISTORICAL SKETCH. 35 wool plug, and kept in an oven at a temperature of 98-6 to 100'4 Fahr. Nothing appeared daring the period of incubation of the ordinary bacteria of putrefaction, but at the end of ten days there were seen on the dry surface of the coagulum a number of very small points or dry- looking scales surrounding the pieces of tubercle, spread out in circuits more or less wide, according to the distri- bution of the tubercle-fragments. After a few weeks' more exposure these crusts ceased to enlarge, and were then transferred to a fresh test-tube containing blood- plasma similarly prepared. After another interval of ten days the scales appeared, became confluent, covering more or less of the surface of the coagulum, as the seed was scattered, and so from test-tube to test-tube the experiment was carried out, under the most vig- orous antiseptic conditions, as many as a dozen times, and for a period extending over one hundred and fifty days. With the results of these culture experi- ments two hundred rabbits and Guinea-pigs were in- oculated, the places selected being under the skin, the peritoneal cavity, or the anterior chamber of the eye. With one exception all these animals acquired tuber- culosis of the lungs, liver, spleen, and other organs, the tubercles having the structure of true tubercle, and in- cluding giant-cells, which latter were found to contain bacilli." According to Powell,* " the main facts with regard to * " Diseases of the Lungs and Pleura," by R. Douglas Powell, M. D., London, England. William Wood & Co., New York, 1886. 36 PHTHISIOLOGY. the life-history and potentialities of the tubercle-bacillus may be stated as follows : " " 1. The tubercle-bacillus is a minute rod-shaped fun- gus, measuring from 0*003 to 0*0035 millimetre in length, and about one third that measurement in thickness. The rods are straight and slightly curved, with rounded ends, and often inclose bright, spherical, spore-like granules of uniform size, arranged in linear series, and separated from one another by hyaline intervals. After having been stained with methyl blue, f uchsin, or magenta, and then washed in nitric acid, ten per cent, they retain the origi- nal dye, and are thus distinguished from putrefactive or other bacilli. " 2. This organism is only capable of growth and mul- tiplication under culture in blood-serum or animal broth, at a constant temperature of 30 centigrade. It is of comparatively (to other bacteria) slow growth, and is un- able to continue its development in decomposing fluids in the presence of more rapidly growing bacteria (Koch). " 3. All the conditions essential for the development of the bacillus are, so far as its life-history is known, alone to be found naturally in the animal body. " 4. The bacillus is, however, of very tenacious vitality, and will preserve its virulence and capacity for develop- ment for six weeks or longer in decomposing sputum, for six months or longer in the dry state. "5. If a minute portion of bacillus containing matter be placed upon a neutral culture surface, and allowed to germinate, and if a fragment of the product of germina- tion be similarly cultivated on a fresh surface, and so on HISTORICAL SKETCH. 37 for many generations, all foreign germs being excluded, the last product, if inoculated into an animal, will be as potent in producing tuberculosis as the first. " 6. The bacilli, whether derived from free cultivation or from tubercle, if intimately diffused in water, and scattered in the form of spray through an atmosphere in which animals are placed so that they inhale it, will pro- duce tuberculosis in them. "7. In the sputa of all cases of well-marked phthisis the bacilli are to be found. " 8. In cavities in the lungs of tubercular or caseous pneumonia i. e., of phthisical origin whether large or minute, bacilli are invariably to be found. " 9. In caseous and catarrhal pneumonic consolidations of the lung, excepting in the immediate neighborhood of cavities, large or minute, bacilli are sparse and rather difficult to find ; large fields of sections may be traversed without discovering them; yet this material is virulent in producing tubercle when inoculated. " 10. In the granulations of miliary tuberculosis bacilli are very generally but not invariably to be found, and often only in small numbers. In their most recent re- searches upon the artificial inoculation of Guinea-pigs with tuberculosis (bacilli-containing) sputum, Drs. Klein and Gibbes found that the tubercular legions contained but few and in many instances no bacilli. " 11. The result of inoculations made with dry bacillus- c-ulture by Koch and many others, with the most minute precautions, have with much reason been accepted as proving the organism to be per se the virus of tubercle." 38 PIITHISIOLOGY. Jaccoud * (1880) admits two distinct varieties of pul- monary phthisis : one the inflammatory, or pneumonic form ; the other the chronic, or ordinary form of the com- plaint. He states that . "1. Caseation is at all ages the result of debility. " 2. The origin of true tubercle is the result of de- bility. "3. The common forms of accidental irritation of every kind, affecting the larynx, bronchial tubes, or lungs, have a deleterious effect upon tuberculosis and phthisical lesions. This may happen in three ways : " Firstly, in those who are healthy, but in whom pre- disposition exists, such irritation favors the development of tubercles, or of the inflammatory changes which pro- duce phthisis. "Secondly, in those already affected it gives rise to a fresh development of tubercles. " Thirdly, it aggravates and hastens the course of pre- existing disorders. "4. Fever is a process of consumption." Loomis f (1884) states that " the essential pathologi- cal change of chronic phthisis is consolidation and in- duration of lung-substance. Tubercles may or may not be its primary lesion, and when present they may con- stitute but a small part of the morbid processes." Re- * " Curability and Treatment of Pulmonary Phthisis," by S. Jaccoud, translated by Montague Lubbock, London, England. D. Appleton & Co., New York, 1885. f Loomis, " Practical Medicine," etc. William Wood & Co., New York, 1884. HISTORICAL SKETCH. 39 ferring to the part played by the tubercle-bacillus, lie says: "The case at present may be stated as follows: The presence of a distinct bacillus in connection with tubercle, and its absence in all other morbid conditions, are generally confirmed by the most competent observers. The etiological relation of tliis bacillus to phthisis still rests solely upon Koch's demonstration." Flint * (1885) defines two forms of chronic phthisis tubercular and fibroid. He states that " heretofore pul- monary phthisis and pulmonary tuberculosis were con- sidered as convertible terms, but, adopting Virchow's theory, in a certain proportion of cases pulmonary phthi- sis is not a tuberculous disease. Hence arose a variety of names denoting non-tuberculous phthisis, such as chronic broncho-pneumonia, chronic lobular pneumonia, catarrhal pneumonia, cheesy pneumonia, etc. These names have shared the fate of the theory from which they originated, the latter, at the present time, having but few supporters in any country. It is convenient to distinguish the morbid product which is characteristic of pulmonary phthisis as a tuberculous product, and it will be so distinguished in this article." Flint states that " clinical experience fails to furnish positive proof of the communicability of phthisis." Powell f (1886), referring to the etiological relation of the tubercle-bacillus to phthisis, says : " Notwithstanding the apparently insurmountable antagonism between those * Flint on Pulmonary Phthisis, in Pepper's " System of Medicine," vol. iii. Lea Bros. & Co., Philadelphia, 1885. f Powell, " Diseases of the Lungs," etc. 40 PHTHISIOLOGY. who adhere to the essentially bacillus nature of phthisis, and those who do not, there is a neutral ground where the two views meet, and where they may perhaps ulti- mately agree. Even Koch himself believes that certain pathological changes are, if not necessary, at least highly favorable to the reception of the germ." II. GEOGRAPHICAL DISTRIBUTION. ACCORDING to Hirsch,* " Corresponding to the preva- lence of consumption at all times is the universality of its geographical distribution at present. It extends over every part of the habitable globe. It may be designated an ubiquitous disease in the strictest meaning of the term. . . . Taking the mean death-rate of the whole of a population to be 22 per 1,000, and the average of deaths from phthisis of the lungs to be 3 per 1,000, we find that the deaths from consumption are nearly one seventh of the whole mortality (or in the ratio of 3 to 22)." Estimating the total yearly mortality of the world to be 35,000,000, we find that about 5,000,000 deaths are due to consumption, being the greatest number report- ed by reliable observers as due to any single cause of death. The following tables of death-rates from pulmonary phthisis, and other data regarding its geographical distri- bution in countries other than the United States; have been taken from Hirsch's great work : f * Ilirsch's " Hand-book of Geographical and Historical Pathology." New Sydcnham Society's translation, London, England, 1886. f Ibid. PHTIIISIOLOGY. Table of Death-Kates from Pulmonary Consumption. LOCALITY. Period. Deaths per 1,000 inhabitants. Norway 1871-'75 Christiania 1866-'75 Sweden 1861-'76 Stockholm Falun 1861-'65 Denmark. Copenhagen 1876-'83 Five largest towns Twenty-four medium towns Twenty-five smallest towns Germany. Northeast coast and German plain. Konigsberg 1877-'80 Dantsic Stettin Liibeck Kiel Posen Breslau 1869-"78 Frankfort-on-Oder 1877-'80 Berlin 1869-'82 Magdeburg 1 8 77-' 80 Halle Leipsic Northwest coast and German plain. Hamburg 1871-' Altona 1877-80 Bremen Brunswick .' 1864-'73 j 1877-'80 Hanover i Central and southern hill-country. Dresden Chemnitz 1870-'80 Erfurt 1877-'80 Gotha Cassel Wiirzburg 187l-'79 Nuremberg 1877-'80 Augsburg Munich Stuttgart 1873-'82 Plain of upper Rhine. Frankfort 1863-'83 Wiesbaden 1877-'80 Mainz Darmstadt 2-5 3-4 3-5 4-1 3-0 3-0 2-6 2-2 2-1 2-8 2-5 2-6 2-6 2-9 3-0 3-7 3-5 8-8 3-8 2-7 3-5 34 3-8 3-2 4-0 4-3 3-8 3-8 2-9 2-3 2'5 3-7 5-2 4-7 3-9 4-0 2-8 3-5 4-0 8-9 3-7 GEOGRAPHICAL DISTRIBUTION. Table of Death- Hates from Pulmonary Consumption (continued). LOCALITY. IVr-l. Deaths per 1,000 :ii..ii>.' all' .-. Mannheim 1877-'80 Carlsruhe Strassburg , M.'tz Plain of lower Rhine. Dortmuud Bochum Ilagen Ore fold Diisseldorff Elbcrfeld Barmen ,-clieid Gladbach Cologne Bonn 1867-'72 Coblenz 1877-'80 Aix-la-Cbapclle Treves Austria. Prague 1865-'74 Briinn 1873-'74 Linz V ienna 1865-'74 Tru-ste 1870-'74 Pesth 1872-'75 England 1872-'73 London 1859-'69 Southeastern counties . . . Southern inland counties Eastern counties Southwestern counties . . :n inland counties. Northern inland counties Northwestern counties . . lire Northern counties W:ik-d Scotlniiil. E.linbunrh 1857-'61 Lcith Glasgow . . Dum! Bclffium 1866-'69 Brussels 1864-'78 Antwerp 1868-'74 Liege 1865-'74 4-0 8-8 8-5 8-5 4-7 5-7 6-3 5-8 8'5 4-0 4-5 8-8 7-3 4-4 8-5 43 8-8 4-7 8-5 (?) 9-9 (?) 8-9 (?) 7-7 4-5 6-9 2-2 8-2 2'6 2-3 2-4 2-2 2-2 2-4 8-2 2-8 2-7 S'l 8-0 2-0 4-0 8-4 4-1 6-6 8-3 4-0 44 PHTHISIOLOGY. Table of Death- Sates from Pulmonary Consumption (continued). LOCALITY. Period. Deaths per 1,000 inhabitants. Holland 1869-'74 North Brabant Herzogenbusch Breda Gelders , Arnhem Nymwegeu South Holland , Gravenhaag Delft Lcyden Rotterdam Gonda Dordrecht North Holland Amsterdam Alkmaar Haarlem Seeland Middleburg Utrecht Utrecht Fricsland Leeuwarden Overyssel Zwolle Deventer Groningen Groningen Drenthe Limburg Maestricht Switzerland 1865-'69 Zurich Winterthur Chur Bern Geneva France Paris 1872-'77 Italy Venice 1862-'85 Padua 1872-'77 Milan 1875-'78 Turin 1869-'76 Genoa 1875-'78 Verona 1874-'78 2-4 24 2-8 3-3 2-4 2-8 2-4 2-2 2-4 2-7 2-6 2-7 2-2 2-2 2-3 2-5 2-9 30 1-8 2-4 2-6 3-2 2-5 2-7 3'2 3-3 3-6 2-3 2-7 3-0 2-3 2-9 1-8 2-4 2-5 3-0 3-9 2-2 4-2 4-0 28 3-8 2-7 20 2-0 GEOGRAPHICAL DISTRIBUTION. Tabk of Death- Bates from Pulmonary Consumption (continued). LOCALITY. \\r.A. ;.. r 1.' .<> inhabitants. Rome 1874-'78 Bologna 1875-'78 Naples Palermo 1873-'78 Messina 1876-'78 Catania 1877-'78 Malta 1822-'34 East India. Native troops 1850-'60 Autt ratio. Melbourne 1865-'70 St. Helena 6 years. Algiers 1852-'B9 . Pernambuco Rio de Janeiro 1855-'58 Detterro. 8. Catarina 1862 Uruguay. Montevideo . . . 1871-'74-'75 3-4 3-8 2-7 2-6 3-0 1-4 3-3 30 2-2 2-2 2-9 6-2 5-0 3-9 4-0 Although these statistical data should not be credited, as we have seen, with more than limited value, yet they supply incontrovertible evidence that there are differ- ences in the frequency of consumption, sometimes even very considerable differences, in the various- divisions of a country, and even at various points within a small area ; and that is the conclusion which is fully borne out by information come by in other ways as to the amount of the disease in different parts of the world. A very remarkable fact in the geographical distribu- tion of consumption on European soil is its rarity in many of the islands and coast districts within the more northern latitudes, such as Iceland, the Faroe Islands, the Hebrides, the Shetland Islands, and places in Norway. 46 PHTHISIOLOGY. Schleisner, writing of Iceland, says: "According to the unanimous testimony of practitioners in the island, consumption does indeed occur there, although remark- ably seldom. In my own practice I have most care- fully examined every patient who complained of even the slightest trouble in the chest, and, out of 327 persons suffering from chronic diseases of the organs of respiration, I found only three with phthisis, one of these being a person of Danish extraction." That statement is borne out in the more recent writings on the state of health in Iceland by Leared, Hjaltelin, and Finsen. It would appear that it is not with any national peculiarity that we have here to do, from the fact that Icelanders who migrate to Denmark fall into consumption not unfrequently. To the same effect is the information given by Manicus and Panum for the Faroe Islands / among 100 patients examined by the latter, there were only two with phthisis. In the Hebrides this disease is almost unknown, in the Shetland Islands it is said to have been not at all common until recent years. Consumption appears to be more common in Sweden than in Norway. As a general rule, con- sumption is more prevalent in the southern than in the northern regions of Sweden, although the difference is not so great as in Norway. In the islands and mainland of Denmark the disease stands at about the mean average of frequency, accord- ing to the results of Lehmann's inquiries. The same appears to hold good for the northern governments of Russia in Europe, although the very meager and some- GEOGRAPHICAL DISTRIBUTION. what vagne information from that country does not enable us to come to any conclusion with certainty. In St. Petersburg the disease is not more frequent, at all events, than in the average of large European cities ; in Finland and the Baltic provinces there is little of .cept in the large towns; from the central and southern parts of the country we hear of it as frequent in Novgorod, Viatka, Kasan, Kursk, Kischniew, Odessa, Sebastopol, and Astrakhan ; in Orenburg, also, it is not altogether rare. But among the Kirghiz of the steppes it is quite un- known ; so much so, that Neftel did not see a single case of phthisis among them during a period of several years. In the Caucasus, consumption is prevalent mostly in the higher parts of the interior ; it is but rarely seen along the course of the Bion or on the Black Sea oout The following table shows the distribution of phthisis in North Germany: Mortality from Phthisis in Prussia from 1875 to 1879. DEPARTMENT. Inhabit- ants per i ; : ' ii kilometre. Deaths from phthisis per 1,000 In- habitants. Ratio in the urban popula- tion. Ratio in the country popula- tion. Bailie. 47 1'96 2-77 1-84 Kuiii |T sbcrg .... . . 62 1'74 2-49 1-48 I):i!17i" 68 1-74 2-39 1-41 Muriemveriler 45 1-61 2-64 1-35 Stettin 67 2-39 2-90 2-08 in 89 1-86 2-68 1-60 Str:il.-simerature is from 40 to 45 Fahr. The mean annual nun full is from 35 to 40 inches. The density of the 72 PHTHISIOLOGY. population is below 45 persons per square mile. The proportion of the colored population is below 7 per cent. The proportion of the foreign population is be- tween 10 and 20 per cent. The causes of death in this region, to which are at- tributed more than an average proportion of the deaths reported, are as follows : Scarlet fever, diphtheria, old age, cancer, diseases of the nervous system, more especially apoplexy, paralysis and convulsions, diseases of the heart, and railroad accidents. The causes of death in this region, to which are at- tributed less than the average proportion of the deaths reported, are as follows: Measles, whooping-cough, en- teric fever, diarrhoea, dysentery, malarial fever, erysipelas, puerperal septicaemia, premature birth, still-birth, scrofula and tabes, dentition, and childbirth and abortion. 7. REGION OF THE GREAT NOETHEEN LAKES. This comprises those parts of New York, Ohio, Indiana, Illinois, Michigan, and Wisconsin, which border on the Great Lakes, and it partakes to a certain extent of the characteristics of the Atlantic coast region. These large bodies of fresh water undoubtedly exert a very considerable influence upon the climate in moderating its extremes. The mean annual temperature in the southern part of this region is from 45 to 50 Fahr., and in the north- ern portion from 40 to 45 Fahr. The mean annual rainfall is from 30 to 40 inches, except in northern Michigan, where it is only from 20 to 25 inches. The CONSUMPTION' IN THE UNITED STATES. 73 elevation is nowhere above 500 feet. The colored popu- lation is below 7 per cent, and the foreign population is over 30 per cent, of the whole. The causes of death in this region, to which are at- tributed, more than an average proportion of the deaths reported, are as follows: Measles, scarlet fever, diph- theria, still-births, old age, cancer, convulsions, diseases of the heart, croup, peritonitis, and railroad accidents. The causes of death in this region, to which are attributed less than the average proportion of the deaths reported, are as follows : "Whooping-cough, enteric fever, dysentery, malarial fever, scrofula and tabes, consump- tion, dropsy, pneumonia and diseases of the respiratory system generally, dentition, diseases of the liver, urinary calculus, childbirth, and diseases of the bones and joints. The proportion of deaths reported as due to con- sumption is low on the western shore of Lake Michigan in Wisconsin, and increases as we pass eastward. 8. THE INTERIOR PLATEAU. This comprises that portion of the plain stretching from the base of the Appalachians eastward which in- cludes part of Pennsylvania, Virginia, and North Caro- lina, and also, on the west side of the Appalachians, the plateau country of central New York and western Pennsylvania. It consists of three regions, which are not contiguous, viz., (1) the western parts of New York and Pennsylvania, (2) the southeastern comer of Pennsylva- nia, and (3) central portions of Virginia and North Caro- lina. The characteristics of the second of these regions, 7 74 PHTHISIOLOGY. so far as returns of deaths are concerned, are largely due to the fact that it contains the cities of Philadelphia and Reading. These regions have little that is characteristic in climate or surface. Lying as they do between the Appalachians and the Atlantic coast region on the one hand, and the lake region on the other, they partake to a certain extent of the climate of both. The sur- face is broken and hilly, but nowhere rises into mount- ains. The group is an upland country originally covered with forests, which have been in great part cut away. It contains comparatively little water surface or swamp- land. The mean annual temperature is from 45 to 50 Fahr. The annual rainfall is from 40 to 45 inches in that part east of the Appalachians, from 30 to 35 inches in the northern portion. The density of population varies from 45 to 90 per square mile. The proportion of the colored population is below 7 per cent in Pennsylvania, and about 35 per cent in Yirginia and North Carolina. The foreign population is about 10 per cent of the whole in Pennsylvania, and is below 1 per cent in Virginia and North Carolina. The causes of death in this region, to which are at- tributed more than an average proportion of the deaths reported, are as follows: Diphtheria, debility, old age, consumption, cancer, tumor, dropsy, apoplexy, paralysis, convulsions, diseases of the heart, Bright's disease, and diseases of the kidney. The causes of death in this region, to which are attributed less than an average proportion of the deaths IN THE UNITED STATES. 75 reported, are as follows : Measles, whooping-cough, dysen- tery, malarial fever, croup, pneumonia and diseases of the respiratory system generally, and childbirth and abortion. The proportion of deaths from consumption is high in New York, somewhat lower in Pennsylvania and jinia, and lowest in North Carolina. 9. SOUTHERN CENTRAL APPALACHIAN REGION. This region is a continuation of Grand Groups V and VI, passing to the southwest. It includes portions of Virginia, West Virginia, the Carolinas, Kentucky, Ten- o, Georgia, and Alabama. In Virginia and West Virginia the character of the country is very similar to that, of Grand Group VI, but as we proceed southward there is a gradual rise .in the ridges, and a tendency to break up into peaks, which in North Carolina develops to the highest degree, presenting in the western part of that State a complex of mountains, rising without much apparent system to heights of from 6,000 to 6,700 feet. In Virginia and farther southward the feature which was outlined in Pennsylvania becomes very characteristic, viz., the great valley occupied in northern Virginia by the Shenandoah, farther south by the branches of the Nc\v River and the heads of the Tennessee, and in Ten- nessee by the river of that name. This forms a great de- ion which, throughout the whole region, is traversed by numberless minor ranges and ridges, while it is lim- ited on either side by higher ranges, represented in North Carolina by the mountains of the western part of that 76 PHTHISIOLOGY. State, while the western boundary of the belt is the Cumberland range or plateau. In Georgia and Alabama these ranges gradually fade out and disappear. The mountains of this region rise from 1,000 to 6,700 feet above the sea, and the valleys are at elevations varying from 500 to 2,000 feet. The temperature of the habit- able portions of this region varies with the altitude and the latitude, but nowhere is the mean annual temperature much higher than 55 Fahr., and it falls below 40 in the higher country. This region is covered with heavy for- ests of pine and hard-wood. The mean annual rainfall is ffom 35 to 45 inches in the northern half, and from 50 to 60 inches in the southern half. The density of population is below 45 persons to the square mile. The colored population is below 17 per cent of the whole. The foreign population is below 1 per cent, except in a few localities, and is nowhere above 5 per cent. The causes of death in this region, to which are at- tributed more than an average proportion of the deaths reported, are as follows, viz. : Measles, whooping-cough, enteric fever, diarrhoea, dysentery, still-births, ' rheuma- tism, scrofula and tabes, dropsy, croup, pleurisy, urinary calculus, diseases of the bones and joints, and gunshot- wounds. The causes of death in this region, to which are at- tributed less than an average proportion of the deaths reported, are as follows : Scarlet fever, diphtheria, cholera infantum, malarial fever, erysipelas, debility, old age, consumption, hydrocephalus, cancer, diseases of the nerv- ous system, especially convulsions, diseases of the heart, CONSUMPTION IN THE UNITED STATES. 77 pneumonia, bronchitis, Bright's disease and diseases of the kidney, and childbirth. 10. THE OHIO RIVER BELT. This group includes those parts of Ohio, Indiana, Kentucky, and West Virginia which border on the Ohio River. It is an area of broken country, becoming more and more diversified in the upper part of the river. For the most part the rivers flow in deep, narrow valleys, bordered by high bluffs and broken hills. The area of bottom-land is limited. The mean annual temperature is from 45 to 55 Fahr. The annual rainfall is from 45 to 50 inches. The density of population is from 45 to 90 per square mile. The elevation is less than 500 feet from the mouth of the Ohio River to Cincinnati, and above this point it is from 500 to 1,000 feet. The colored popula- tion is below 7 per cent north of the Ohio River, and from 17 to 35 per cent south of that stream. The for- eign population is from 5 to 20 per cent north of the Ohio River, and from 1 to 5 per cent south of it. The causes of death in this region, to which are at- tributed more than an average proportion of the deaths reported, are as follows : Scarlet fever, enteric fever, cholera infantum, inanition, still-births, scrofula and tabes, consumption, diseases of the nervous system, and diseases of the bones and joints. The proportion of deaths from consumption is com- paratively hi SUMPTION IN THE UNITED STATES. 93 cent of the whole. The foreign population in California forms 20 per cent and over of the whole ; in Washing- ton and Oregon it is from 5 to 10 per cent. The causes of death in this region, to which are at- tributed more than an average proportion of the deaths reported, are as follows: Puerperal septicaemia, old age, hydrocephalus, cancer, tumor, diseases of the nervous system, especially apoplexy and paralysis, diseases of the heart, diseases of the digestive organs, especially diseases of the liver, Bright's disease, and accidents and injuries, especially gunshot-wounds, homicide, and suicide. The proportion of deaths from consumption is high in California, and slightly lower in Oregon and Wash- ington Territory. The causes of death in this region, to which are at- tributed less than an average proportion of the deaths reported, are as follows: Measles, scarlet fever, diph- theria, whooping-cough, enteric fever, diarrhoeal diseases, malarial fever, erysipelas, old age, rheumatism, scrofula and tabes, dropsy, tetanus, trismus nascentium, croup, pneumonia, pleurisy, diseases of the kidney, and diseases of the bones and joints. In concluding this subject of the relation of special causes of death to topographical features of the country, the general result of the study may be summed up in Raying that the conditions of climate, the amount of an- nual rainfall, the amount of low-lying and swamp land, age and sex, the distribution of the people, and the pro- portion of the colored and foreign population, appear to PHTHISIOLOGY. be the chief causes of the differences between the several grand groups, or between different portions of the same grand group. Except in so far as it influences climate or drainage, the geological formation of different regions does not appear to have a marked influence upon the proportion of deaths from various causes, with the excep- tion of diseases due to impurities in the water-supply. The following table shows the principal reported causes of death in the order of their frequency, each, ex- cept apoplexy, having caused over 1 per cent of all the deaths from known causes: Principal Causes of Death, in Order of their Frequency. DEATHS FKOM Deaths. Per 1,000 of known causes. Total deaths. 756,893 Unknown cause 37,133 Consumption 91,270 Pneumonia 63,053 Diphtheria 38,143 Heart-disease 26,068 Cholera infantum 24,983 Still-born 24,876 Enteric fever 22,854 Malarial fever 20,231 Croup 17,966 Convulsions 17,844 Scarlet fever 16,388 Dropsy 14,788 Debility 14,619 Old age 14,168 Paralysis 13,907 Dysentery 13,427 Cancer 13,068 Enteritis 12,640 Diseases of the brain 12,280 Whooping-cough 11,054 Bronchitis 10,984 Inflammation of the brain 10,903 Diarrhoea , 10,825 Apoplexy 9,658 126-80 87-60 52-99 36-21 34-71 34-56 31-75 28-10 24-96 24-79 22-76 20-54 20-31 19-68 19-32 18-65 18-15 17-56 17-06 15-37 15-26 15-14 15-03 13-41 CONSUMPTION IN THE UNITED STATES. 95 The total number of deaths reported as due to con- sumption during the census year (1880) was 91,270, being the greatest number reported as due to any single cause of death. Of this number, 40,512 were of males, and 50,758 were of females. It is reported as causing 12,059 in every 100,000 deaths from all causes as against 14.11)1) in 1870, 12,453 in 1860, and 10,376 in 1850. The census figures indicate that it is more frequent in females. In the fifty large cities, out of each 1,000 deaths from known causes, it caused 131'9 in males, and 144-3 in females; and in the rural districts it caused 101-9 deaths in males and 146*6 in females. A greater mor- tality from this disease in the female might be expected, because women are, as a rule, more confined to the house and more exposed to air contaminated by the products of respiration. The mean age at death of those reported as dying from consumption during the census year was thirty- seven years. The following table shows the proportion of deaths reported as due to this cause at various ages: Showing the Number of Deaths from Consumption at Each Group of Ages in each 1,000 Deaths reported as caused by this Dis- AGES. \Uk -. Females. Under 1 year 2986 19-28 1 year 14-76 11-23 2 years 8'73 6*96 4-C9 4-11 4 vi-ars 2-98 2-87 Total under 5 years 61-00 44-46 96 PHTHISIOLOGY. Showing the Number of Deaths from Consumption at Each Group of Ages in each 1,000 Deaths reported as caused by this Dis- ease (continued). AGES. Males. Females. 5-10 years 1 1-08 10-15 years 14-46 15-20years 59'74 20-25years 131-73 25-30 years 1 18'74 30-35 years 97'01 35-40 years 93'47 40-45 years 76'26 45-50 years 68'72 50-55 years 61-53 55-60 years 6M6 60-65 years 49'08 65-70 years 40-40 70-75 years 31-54 75-80 years 20-81 80-85 years 9'05 85-90 years 3'08 90-95 years 0'87 95 and over 0'30 Unknown 4'64 12-66 26-18 107-03 167-92 142-15 107-21 90-18 67-85 51-87 41-91 30-28 32-26 27-67 22-31 16-04 8-03 2-79 0-87 0-34 3-82 In considering this table it must be borne in mind that it does not represent the relative liability to the disease at different ages, because the decrease of the living population at the higher ages is not taken into account. It will be seen that the great majority of the deaths from consumption occur between the ages of fifteen and sixty-five the greatest proportion in any decennium occur- ring between the ages of twenty and thirty. The proportion of deaths between the ages of fifteen and thirty-five is greater in the female than in the male. If we take the group of ages from fifteen to sixty-five and compare the number of deaths reported as due to consumption with the total number of deaths from speci- SUMPTION IN THE UNITED STATES. 97 fied causes at the same group of ages, we find that the proportion is greatest in the large cities, being, per 1,000,000 deaths, for males, 307,154, and for females, 338,571, while in the rural districts it is, for males, 218,455, and for females, 298,583. At the same group of ages in those regions where distinctions of color and parentage are made, the proportions are, for whites, in each 1,000,000 deaths, males, 242,842, females, 302,046 ; for colored, males, 248,179, females, 326,973 ; for those of Irish parentage, males, 309,507, females, 375,636 ; and for those of German parentage, males, 249,498, females, 254,958. From these figures it would seem that the pro- portion of deaths from this cause in the colored race is but slightly greater than in the white, and that it is greatest of all in the Irish. Showing for Certain Group* of Ages the Number of Deaths from Consumption, and the Proportion of Death* from thit Cause per 1,000,000 Deaths at the Corresponding Age- Groups, with Distinction of Sex, of Rural and Cities, and, for Certain Re- gions, of Color and Parentage. DEATHS. PEOPOBTIOS IN 1,000,000 DEATHS AT CERTAIN AGES. DEATHS FROM C< gf SUMPTION IH OM> ti and U tad i. >v> is. IS lo M. orr. DM**. SlolJ. 15 to M. OTV. M UM 1,090 82,559 4.278 HJHi :,.'.:--, I <.:; 81.345 "' ' ' ' * r MM I ' I 42,407 I ;; K m 1*1 ' 1 806,699 - "ii Rural M IJBK 815 tt,' : i 1,688 tr,ou n MI ,'!- IBB K2.314 1 i .;:.; 1,573 - .' " i ) . - * ' i - -.1 .> 67,887 M ' < ' 86,660 Cities H. 673 215 0,788 687 ii m ttjsn 807,154 ;:,: H r 615 1 ; '. ' " " ' J 603 16,056 : : . ' -.' ''r*'* . ' . '. , , ,; , Whit.-, in 10 JM. 927 271 i-' a 1,971 II -.;: S0,967 MMtt n . i ; grand groups ! 756 544 (,{ M ;.>-,-; mjsu ;,'' ii;- - 1 " ' !. in ID M. 419 ' ' ' - i 801 86,808 98,906 MS,170 :: - ' . Irish parent- , ,. in 14 VST k'rand groups \ ' 103 89 761 68 116 I M I - I.:... M M 1 r,.:;i 151,957 ujut MI n . :..-.-. ; ,;: Ml < ... . i JM -..: ; in j>i\r- t ,. entage, in 14 -. grand groups \ M 79 46 60 ;.;'-r M 175 10.771 ,744 :.'..-..' ;..- - MJM 74,691 98 PHTHISIOLOGY. These figures indicate a great excess of deaths from consumption at ages under fifteen in the colored race. The greatest proportion of the deaths reported as due to consumption appears in New England and the Mid- dle States, the middle Atlantic coast, the Ohio Valley, the western part of Kentucky, the central part of Ten- nessee, and on the coast of California. The special prevalence in those counties of Mississippi bordering on the Gulf coast is, in part at least, due to the peculiar distribution of the population of this region as regards age. The proportions indicated in Florida, northern Min- nesota, California, and eastern Colorado are much too great, because of the number of deaths occurring in these localities of persons who had contracted the disease else- where, and who went to these places because of their supposed freedom from influences producing or aggravat- ing the disease. The proportion of deaths is greater in the interior of Michigan and Ohio than on the lake coast, and on the Gulf coast of Texas than in the interior of that State. The regions showing the least proportion of deaths are in southern and western Georgia, central Alabama, Arkansas, Kansas, and the Western Territories ; the Appalachian region also shows a low proportion as compared with the country lying on either side. The following table indicates the relative proportion of deaths from this cause in each of the 21 grand groups, with distinction of rural and cities, and, for certain regions, of white and colored, and Irish and German parentage : SUMPTION IN TIIE UNITED STATES. 99 > 101-6 100-9 186-1 136-9 156-8 l>,; r, 171-0 196 .; 116-5 1157 125-3 84-4 li 1 1 .-,'< > !-.M 1 139-1 IM-I l.'il n 144-3 126-2 189-1 198-4 123-6 nh Atlantic coast region 2. Middle Atlantic coast region :j. South Atlantic coast region 4. (Julf coast regiuii 1487 ::;,' n :< 96-0 131-0 99T 109-8 116-0 101-5 137-1 WO BM :>\ :, n:, i ;! i -.-! :i m i 118-2 >- n i aw m-g tan 151-2 147-1 I-.J37 947 1423 162-8 14H-0 145-4 153-2 1 \-i-J 140-7 101-0 160-4 231-0 212-6 .,.,,,, 1837 201-4 171-0 179-6 145-5 140'-2 1407 61-9 175-2 107-9 146-0 140-2 147-3 113-4 1432 116-1 165-0 137-9 ibb'-a 81-5 80-1 1-.' -,' 101-8 1449 113-4 140-9 175-1 S-M! 105-8 115-8 120-0 rtheustrrn hills and plateaus, atral Appalachian region 7 i:-gion of the Great Northern lakes. 8. The interior plateau 138-4 124-3 1507 s:; :t 81-1 1707 179-3 M81 100-4 108-8 9. Southern Central Appalachian 11 10. The Ohio River belt 125-0 151-0 11. S< mt hern interior plateau. it h Mississippi River belt . ... I-'!. North Mississippi River belt 1 1. Southwest central region iTal region, plains and prairies 1'i. The prairie region . ... 116-9 isi'-b 118-8 155-3 70-3 HH 77-0 XI I -i.uri Kivcr lielt 847 145-8 121-3 110-5 ,'ion of the Western plains t imbered region of the i west .... SO. Oordilleran region . illc coast region 170-4 139-8 The States and Territories presented together for Comparison, showing the Proportion of Deaths from Consumption to Deaths from all Causes. STATES AND TEEBI- . Total number of deaths from all causer Deaths from con- sumption. Percentage from con- sumption. T'nitcd States 756 893 91 551 12-09 Alabama 17,929 1 729 9-00 291 18 t,"i A! k iMSa.S 14 812 MH 6-3 California 11 530 1 v , 16-5 Colorado 2,547 110 82 Connecticut 8 179 1 369 16'0 Ii.iknu 1 :."! 116 8-8 * ire " " 1 1! 857 16-1 t of Columbia 4,192 :; I.YI 7'.':: Ml 18-9 83 1 21.549 L8M 8-7 100 PHTHISIOLOGY. The States and Territories presented together for Comparison, showing the Proportion of Deaths from Consumption to Deaths from all Causes (continued). STATES AND TEEEI- TOKIE3. Total number of deaths from all causes. Deaths from con- sumption. Percentage from con- sumption. Idaho 323 22 6'8 Illinois 45,017 4,653 10-3 Indiana 31,213 3,943 12'3 Iowa 19,377 1,925 9'9 Kansas 16,160 1,117 7'3 Kentucky 33,718 3,733 11-5 Louisiana 14,514 1,514 10-4 Maine 9,523 1,829 19'2 Maryland 16,919 2,381 12'0 Massachusetts 33,149 5,207 15-7 Michigan 19,743 2,613 13'2 Minnesota 9,037 848 9'3 Mississippi 14,683 1,287 8-7 Missouri 36,615 3,604 9-8 Montana 336 18 5'3 Nebraska 5,930 416 7-0 Nevada 728 61 8-3 5,584 866 15-5 New Jersey 18,474 2,630 14-2 New Mexico 2,436 50 2-1 New York 88,332 12,858 14-5 North Carolina 21,547 2,130 9-9 Ohio 42,610 5,912 18-8 Oregon 1,864 226 12-1 63,881 8,073 12-6 4,702 691 14-8 South Carolina 15,728 1.543 9'8 Tennessee 25,919 3,767 14-5 Texas 24,735 1,622 6-5 Utah 2,314 69 3-0 Vermont 4,024 813 20-2 Virginia 24,681 3,025 12-3 Washington Territory West Virginia 755 7,518 100 969 13-2 12-9 15,011 1,681 11-2 WVoming Territory 189 5 2-6 As has been stated, the proportions of deaths from consumption indicated in Florida, Minnesota, Colorado, and California are much too great, because of deaths in these localities of persons who had contracted it elsewhere. CONSUMPTION IN TUB UNITED STATES. 101 The State and Territories presented together for Comparison, thow- iny the Relation of Population per Square Mile to the Death* from Consumption per 1,000 Inhabitant*. STATES AND TEBRITOBIES. Inhabitants per square mile. Deaths from phthisis per 1,000 Maine 19'0 New Hampshire 87 Vermont 84-0 Massachusetts 214'0 Rhode Island 221-0 Connecticut 124-0 i .rk 113-0 New Jersey 144-0 Pennsylvania 94'0 Delaware 71'0 Maryland 77'0 District of Columbia 2,537'0 Virginia 85'0 Virginia 24'0 North Carolina 26'0 South Carolina 82'0 i.i 26 - Florida 4-7 Ohio 77-0 -ce 86'0 Kentucky 40'0 Indiana 64 '0 Illinois 64 - Michigan 27'0 :isin 23*0 Iowa 28 :i 31-0 Arkansas 14'0 Louisiana 19'0 ;>pi 24'0 Alabama 24 '0 Texas 6'9 Kansas 12'0 Nebraska 6'8 Minnesota 9'0 Kakota 0'9 Montana 0*2 Idaho 0'3 Colorado 1'8 W\ oinin^ 0'2 Arizona 0'8 ' \ico 0'9 California... 6'4 in 0'5 2-8 2-4 2-4 2-9 2-3 2-2 2-5 2-3 1-8 2-4 2-4 4-4 1-9 1-5 1-5 1-5 1-1 0-9 1-8 2-4 2-2 1-9 1-4 1-6 1-2 1-1 1-6 1-1 1-6 10 13 1-0 M 0-9 1-0 0-8 0-4 0-6 M 0-2 0-4 0-4 2-0 0-9 102 PHTHISIOLOGY. The States and Territories presented together for Comparison, show- ing the Relation of Population per Square Mile to the Deaths from Consumption per 1,000 Inhabitants (continued). STATES AND TERRITORIES. Inhabitants per square mile. Deaths from phthisis per 1,000 inhabitants. Washington Oregon Utah ., 1-0 1-8 1-6 1-3 1-2 0-4 Showing for Fifty Cities in the United States the Number of Deaths from Consumption for each 10,000 of Population. CITIES. Population. Deaths per 10,000 inhabitants. New York, N. Y 1,206,299 Philadelphia, Pa 847,170 Brooklyn, N. Y 666,663 Chicago, 111 603,185 Boston, Mass 362,839 St. Louis, Mo 350,518 Baltimore, Md 332,313 Cincinnati, Ohio 255,139 San Francisco, Cal 233,959 New Orleans, La 216,090 Cleveland, Ohio 160,146 Pittsburg, Pa 156,389 Buffalo, N. Y 155,134 Washington, D. C 147,293 Newark, N. J 136,508 Louisyille, Ky 123,758 Jersey City, N. J 120,722 Detroit, Mich 116,340 Milwaukee, Wis 115,587 Providence, R. 1 104,867 Albany, N. Y 90,758 Rochester, N. Y 89,366 Allegheny, Pa 78,682 Indianapolis, Ind 75,056 Richmond, Va 63,600 New Haven, Conn 62,882 Lowell, Mass 59,475 Worcester, Mass 58,291 Troy, N. Y 66,747 Kansas City, Mo 55,785 Cambridge, Mass 52,669 Syracuse, N. Y 51,792 Columbus, Ohio 51,647 35-56 31-59 29-84 16-75 33-37 22-93 34-93 27-71 30-64 39-42 17-04 18-79 18-16 41-95 28-42 32-48 27-58 18-48 17-30 29-37 25-89 23-27 11-18 24-91 41-66 19-24 35-30 25-04 35-77 11-29 26-77 26-83 19-55 CONSUMPTION IN THE UNITED STATES. 103 Showing for Fifty Cities in the United States the Number of Deaths from Consumption for each 10,000 of Population (continued). CITIES. Population. Deaths per 10,000 Inhabitants. <>n, N. J 61,031 29-98 Toledo, Ohio 60,137 9'57 Charleston, S. C 49,984 49-21 liver. Mass 48,961 27-67 Minneapolis' Minn 46,887 17-27 Scraiiton Pa 45,850 12-21 Nashville, Tenn 43,360 31-37 43,278 25-64 Wilmington, Del 42,478 36-96 Hartford, Conn 42,016 28-08 (.'ami leu, NJ . 41,659 26-40 Si I'aul, Minn 41,473 11-57 Lawrence, Mass 39,151 38*56 Dayton, Ohio 38,678 21-97 88,274 29-00 35,629 17-40 Oakland, Cal 84,555 17-36 Attention is here called to the relatively greater degree of immunity from consumption, as shown by the above table, in the cities of the upper lakes. NOTE. In this country, as elsewhere, the death-rate in the cities is larger than in the rural districts. As compared with the rural districts, the cities have been for the last twenty years gaining most in healthiness, owing to the fact that systematic sanitary work has been carried on in them to a much greater extent than in the smaller towns and villages. The following table shows the relations of deaths reported as due to consumption in the thirty-one regis- tration cities with relation to the month of death. It \vill be seen that in the aggregate the distribution of -li-HOJOOJ>(JJr-ci-cKli-IT)arrus Caawell Catawba Chatham Clcaveland Davidson Davie Kdgecombe Forsyth Franklin Gaston Granvillc 1,000 Inhabitants. Guilford 1'9 Halifax.. 1'7 1-8 ._,.,, 0-t 11 1-8 M 1-6 -I ,,-s Harnett M Iredell 1-6 Johnston 2'0 Lincoln 1'9 Mecklenburg 2-4 Moore I'O Nash 0-9 Northampton 1*8 Orange 1'7 Person 2 - 5 Randolph l' Richmond 0'7 Rockingham 1'G Rowan 2'4 Stanley 1-1 Stokes 1-2 Union 0'7 Warren 1'9 Wake 2-5 Wilson I'l Yadkin 1-4 Remainder of group 2'7 Group 3 I'O Ashe 0-2 Buncombe I'l Burke 1-4 Caldwell 1'4 Haywood 0'8 Henderson 0'8 Madison 0'5 Rutherford 1'3 Surry I'l Wilkes 0'9 Remainder of group TO STATE OF SOUTH CAROLINA. Topography. South Carolina forms an irregular tri- angle, Laving the coast-line for its base, and North Caro- 130 PHTHISIOLOGY. lina and Georgia for its other sides. Its extreme length east and west is about 275 miles, its greatest breadth 210 miles, and its area about 30,570 square miles, or 19,564,800 acres. The only mountains are those of the extreme northwest, the Blue Ridge. The highest peak is called Table Mountain, and has an elevation of about 4,000 feet. The coast is low; the country stretching inward for 100 miles is flat, and beyond the sand-hills which traverse what is known as the "middle coun- try " the land rises abruptly, continuing to ascend until Table Mountain is reached. There are about 200 miles of coast-line and several good harbors, the most nota- ble being those of Charleston and Port Royal. Along the coast are many small islands on which the " sea- island" or long-staple cotton is grown. The Savan- nah River forms the southwestern boundary. Other important streams are the Great Peedee, the Santee, and the Edisto; the first named being navigable for a distance of about 150 miles from the sea. There are also many small rivers, and the State is well supplied with water. Climate. The temperature ranges from 15 to 95 Fahr., and the mean of the different seasons is spring, 65 ; summer, 80 ; autumn, 68 ; winter, 51 ; the whole year, 67. The average rainfall is from 46 to 50 inches, but on the Georgian border it is somewhat less. The climate is generally healthful and equable, and, aside from epidemics of yellow fever (usually confined to the seaports), the health of the State is good. Frosts seldom occur, and Aiken and some other towns have become TOPOGRAPHY AND CLIMATE OF STATES. 131 favorite winter resorts for consumptives and other in- valids, who find relief in the dry and mild climate of that region. Population, 995,577. Inhabitants to the square mile, 32. Deaths per 1,000 Inhabitant*. uc 1-5 Group i re Beaufort M Charleston 1'4 Charleston (city) 4 '9 Clarendon 16 Colleton 1-2 Georgetown 0'7 Hampton 0'3 Ilorry 0'5 Marion 0*7 Williamsburg 0'7 GroupS 0'8 Oconee 0'8 Pickens 0*7 GroupS 1'5 Abbeville 2-3 Aiken 1'6 Barnwell 0'7 Chester 2'8 Chesterfield 0'8 Darlington. 1'4 Edgefield 1-6 Fairfield 1-8 Greenville 1*4 Kershaw 0'8 Lancaster 1*3 Laurens 1*5 Lexington I'O Marlboroug 0*7 Newberry 2-0 Orangeburg 1-1 Richland 1-9 Spartanburg 1-6 Sumter 1-3 Union. 1-6 York.. . 2-0 STATE OF GEORGIA. Topography. The extreme length of the State north and south is 320 miles; extreme width, 254 miles; area, 59,475 square miles, or 38,064,000 acres. The sur- face is quite diversified. In the north are the Blue Ridge and Etowah Mountains, with other spurs of the Appalachian range. The center consists of an elevated table-land, which gradually diminishes in height until the low and swampy country near the coast and along 132 PHTHISIOLOGY. the Florida border is reached. In the southeast corner is the Okefinokee Swamp, a series of marshes having a circuit of over 150 miles. The coast extends from Tybee Sound southwest to Cumberland Sound, a dis- tance of about 100 miles, but owing to the irregularities and indentations the shore-line is nearly five times that length. The most important rivers falling into the Atlantic are the Savannah and Altamaha. The other principal rivers are the Ogeechee, Ocmulgee, Oco- nee, Satilla, Allapaha, Chattahoochee, and Flint. Many of the rivers of the mountain country are rapid, and con- tain picturesque cataracts. Of these, the chief are the Falls of Tallulah, in Habersham County, and Toccoa Falls, in the Tugaloo, 180 feet high ; Towaliga Falls, in Monroe County; and the Amicolah Falls, which have a descent, including the rapids and the cataracts, of 400 feet in less than a quarter of a mile. Climate. In the north the summers are compara- tively cool and the climate is healthy, but in the south- ern lowlands the heat is often oppressive, the thermome- ter sometimes reaching 110 Fahr. The winters are very mild, the temperature seldom falling below 30 Fahr. The annual mean temperature at Augusta is about 63, and at Savannah 66, and the rainfall is over 60 inches per annum. The swamp-lands of the southeast are un- healthy, and malarious fevers prevail at certain seasons. NOTE. Speaking of the presence of extensive pine-woods extending along the eastern and middle portions of this State from one end to the other, Tyndall says : " That consumptives derive benefit from air charged with the odors of pine-trees is not to be denied. . . . Continuous respiration in an antiseptic atmosphere may yet lead to results hitherto unattained." TOPOGRAPHY AND CLIMATE OF STATES. 133 Population, 1,542,180. Inhabitants to the square mile, 25. Deaths per 1,000 Inhabitant*. The State M Group 1 1'5 Chatham 3'6 Liberty 0'4 Lowndes 0'2 Screven 0'5 Remainder of group 0'7 Gr-xi/, .' !-_ Bartow., 1-3 Chattooga 3'2 Cherokee 0'5 Cobb 1-4 DeKalb 0'8 Floyd 1-6 Foreyth M Franklin 0'6 Fulton 2-0 Gordon ri Gwinnctt I'l Hall 0-5 Jackson 0'9 Paulding 0'5 Polk 0'9 Walker 3-1 Whitfield 2-3 Remainder of group 0'9 Group 3 0-9 Baldwin V2 Bibb 1-9 Brooks 1-0 Burke 0'7 Carroll...- 0'5 Clarke 0'9 Columbia 0'7 Coweta. 1 -2 Decatur 0'2 Dooly 0-7 Dougherty l : n Elbert 1-0 Greene 1*1 Hancock 1-1 Harris 0'8 Henry 10 Houston 0'4 Jasper 1'3 Jefferson 0'5 Jones 1 -0 Laurens 0'7 Lee 0'6 Milt-on 0'7 Meriwether ri Monroe. 1 -2 Morgan IK) Muscogec 1-0 Newton 1-7 Oglethorpe I'l Fike 0-9 Pulaski 0'7 Putnam 0'8 Randolph 04 Richmond 2'5 Spalding I'l Stewart 07 Sumter 0'3 Talbot 0-8 Terrell 0'8 Thomas 0'7 Troup 1-8 Upson 1'4 Walton 1'2 Warren 1'9 Washington I'l Wilkes O'l Wilkinson 0.4 Remainder of group 0*6 134 PHTHISIOLOGY. STATE OF FLORIDA. Topography. Florida consists of a peninsula stretch- ing south, for 350 miles, between the Atlantic and the Gulf of Mexico, and of a long, narrow strip of land running along the Gulf, to a distance of 340 miles from the Atlantic coast-line. The peninsula is about 100 miles in width, and contains nearly four fifths of the total area, which is 58,680 square miles, or 37,555,200 acres. On all sides but the north, the sea forms the boundary, and the State has 1,146 miles of coast-line, but few good harbors. The Keys and Tortugas are a chain of small coral islands south and southwest of the point of the peninsula. The most important of these is Key West, where a naval station has been established, and where there is a good harbor. The northern division of the State is generally flat and uninteresting ; in the center are many patches of higher ground, which are extremely fertile ; and south of latitude 28 the Ever- glades begin. Florida is well watered and has a number of navigable rivers, the principal ones being the St. John's, Appalachicola, Perdido, Charlotte, and Suwanee. The northern division is of limestone formation, and what is known as the "Backbone Bidge," an elevation of 150 to 1Y5 feet, runs down the center of the peninsula, as far south as Charlotte Harbor. The southern part is of a recent coral formation, similar to that of the Keys, and the process of growth is still going on. Climate. The climate of this State is excellent. Frosts are rare in the north and unknown in the south, TOPOGRAPHY AND CLIMATE OF STATES. 135 and snow never falls. The average temperature is about 72 Fahr., the thermometer rarely falling below 30 or rising above 90, while at Key West the difference be- tween summer and winter temperature does not exceed 15. The atmosphere is generally dry and clear, and most of the rainfall, which is about 54 inches per annum, is in the summer months. Population, 269,493. Inhabitants to the square mile, 4'7. Deaths per 1,000 Inhabitants. The State (forms one group) ... 0'9 Alachua 0'2 Duval* 3-2 Escambia 1'8 Gadsden 0'7 Jackson.. 0*2 Jefferson 0'6 Leon. 0'6 Madison 0'4 Marion 0'4 Monroe I'O Remainder of group 0*8 STATE OF OHIO. Topography. The greatest length of Ohio east and west is 225 miles ; greatest breadth, 200 miles ; area, 41,060 square miles, or 26,278,400 acres. Kelley's Isl- and and the Bass Islands in Lake Erie, north of San- dusky, belong to Ohio. The great divide which forms the water-shed passes diagonally across the State from Trumlmll County in the northeast to Mercer and Darke ('unities in the west, and has a general elevation of about 1,200 feet above the sea-level, rising to 1,500 feet in Logan County. The surface slopes gradually from * The proportion of deaths from consumption indicated for this county i.- much too prcat, because of the large number of deaths occurring in Jack- sonville of persons who had contracted the disease elsewhere. 136 PHTHISIOLOGY. the divide north and west to Lake Erie, which is 565 feet above the sea, and southwest to the Ohio River, which at Cincinnati is about 430 feet above sea-level. The Ohio is the principal river, and has a course of 430 miles on the southern and eastern border. It flows through a valley, with wooded hills rising from it to a height of 500 to 600 feet. The Muskingum, Scioto, Hockhocking, Mahoning, and Great and Little Miami are the next in importance, and all flow south into the Ohio. On the north there are smaller streams, such as the Cuyahoga, Yermillion, Huron, Chagrin, Rocky, Black, Portage, Sandusky, and Maumee, which drain into Lake Erie. Climate. The mean annual temperature is from 50 to 54 Fahr., the warmest section being the southwest, along the Ohio River. The climate is, as a rule, mild, but the changes of temperature are often sudden. Con- siderable snow sometimes falls in the north, but not in quantities to interfere with communication, or to do any damage to the crops. The mean annual precipitation of rain and melted snow varies from 36 inches on the Lake Erie shore to 47 inches in the extreme south. Population, 3,198,062. Inhabitants to the square mile, 77. Deaths per 1,000 Inhabitants. The State ................... 1'8 Group 1 .................... 1'6 Ashtabula ................. 1'8 Cuyahoga .................. 1'7 Cleveland (city) ............ 1'7 Erie ........ . ............. 13 Geau 1-5 1-4 1-5 2-1 1-9 1-7 1-6 1-2 1-3 1-2 1-1 2-7 1-4 1-6 1-6 Inhabitants. Brown 1-8 Bureau 1-5 Cass 1-8 Champaign T2 Christian TO Clark 1-9 Clay 2-0 Clinton. 1-6 Coles 2-4 Crawford M Cumberland. 1-2 DeKalb. 1-3 De Witt 0-9 Douglas 1-0 DuPage 0-8 Edgar 2'0 Effingham 1-4 Fayette 1-5 Ford 0-8 Franklin 1-6 Fulton 1-8 Greene 1-2 Grundy 0'8 Hamilton 1'2 Henry 10 Iroquois 1*8 Jasper 1'8 Jefferson I'l Kane 1'6 Kankakee 1'2 Kt-ndall.. . 1-4 146 PHTHISIOLOGY. Knox Deaths per 1,000 Inhabitants. 1-3 Piatt 1-5 La Salle 1-3 Richland . ... 1-9 Lawrence 2-4 Saline . ... 1'6 Lee 1-7 1'2 Livingston.. . . 1-1 Schuyler .... 2'2 1-8 Scott ro McDonougli.. . 1-5 Shelby 1'6 McHenry 2-0 Stark ... 0'6 McLean 1-3 Stephenson ... . . 1-3 Macon 1-5 Tazewell . 0'8 Macoupin 1-1 Vermilion 1'4 Marion 1-5 Warren 1'5 Marshall 1-4 Washington . 1 Mason 0'9 Wayne ... 1-0 Menard 1-4 White . . rs Montgomery . . 1-2 Will 1'2 Morgan 1-9 Williamson ... ro Moultrie ... . . 2'0 Wlnneba^o 1'3 Ogle 1-1 Woodford I'O Peoria 1-3 Remainder of group., . . . . . 4'8 Perry.. . . 1-2 STATE or MICHIGAN. Topography. Michigan consists of two peninsulas, known as the Upper and the Lower, and of a number of islands in Lake Michigan and Lake Superior. The total area is 58,915 square miles, or 37,705,600 acres. The two divisions of the State are dissimilar in character and configuration. The Lower Peninsula consists of plains and table-land, with occasional prairie and much timber, while the Upper is rugged and rocky, broken up by hills, which in the western portion rise to the height of 2,000 feet. The length of the Lower Peninsula from north to south is 277 miles ; its greatest breadth east and west, 259 miles. Saginaw and Thunder Bays on Lake TOPOGRAPHY AND CLIMATE OF STATES. 147 Huron, and Grand and Little Traverse Bays on Lake Michigan, form natural harbors of great size. The sur- face is generally level, but there are some irregular hills in the south, and the bluffs and sand-hills bordering on Lake Michigan are from 100 to 300 feet high. The Upper Peninsula is 318 miles in length from east to west, and from 30 to 164 miles in width. The western portion of the peninsula is largely given up to mining, but in the east farming is attended with the most favor- able results. The total length of the lake-shore is 1,620 milis, exclusive of the frequent bays and inlets, and the State contains numerous rivers and small lakes. The principal islands are Isle Royale and Grand Island, in Lake Superior; Marquette, Mackinaw, and Bois Blanc, in Lake Huron ; and the Beaver, Fox, and Manitou groups in the northern part of Lake Michigan. Climate. Michigan is a State of great climatic differ- ences. The climate of the southern portion is compara- tively mild, but that of the northern is cold and rigorous in winter. The mean annual temperature at Detroit for nine-teen years was 47'25 Fahr., and at the Sault Ste. Marie 40-37 a difference of 7. The peach-orchards and vineyards along the entire fruit-belt, from St. Joseph to Grand Traverse Bay, prove that the climate is not so e as to interfere with fruit-raising. The average annual rainfall at Detroit is 30-07 inches, and at Sault Marie 31'35 inches. The mean summer tempera- ture at the two points named was 67'60 and 62 re- spectively. At Marquette, in the L T pper Peninsula, the annual mean was 38'3, and the average rainfall 23-46 148 PHTHISIOLOGY. inches. The climate is healthy, and the death-rate low. Population, 1,636,937. Inhabitants to the square mile, 27. Deaths per 1,000 The State 1'5 Group i 1*4 Allegan 1'4 Bay , 1-3 Berrien 1*8 Houghton 0'5 Huron 0*4 Macomb 1*9 Manistce I'l Marquette 0'7 Mason 1'8 Menominee - 5 Monroe 1*4 Muskegon 1'3 Oceana 2'0 Ottawa 1-5 Saginaw 1'4 Saint Clair 1'4 Sanilac 1'3 Tuscola 1-1 Van Buren 1'8 Wayne 1'6 Detroit (city) 1-8 Remainder of group 1'4 Group 2 1-6 Barry 1'7 Inhabitants. Branch T4 Calhoun 1-4 Cass 1-6 Clinton 1-3 Eaton 1-9 Genesee 1'6 Gratiot I'O Hillsdale T8 Ingham 1'3 Ionia 1*3 Isabella 2'2 Jackson 1'3 Kalamazoo 1'8 Kent 1-9 Lapeer ]-3 Lenawee T6 Livingston 1'8 Mecosta 1-2 Montcalm 0'7 Newaygo 1'3 Oakland 1-6 Osceola 1-3 Saint Joseph l - 2 Shiawassee l - 4 Washtenaw 1-6 Remainder of group 4' 9 STATE OF WISCONSIN. Topography. The scenery of Wisconsin is more di- versified than that of the States contiguous to it, although its general character is that of a large plain. The plain is from 600 to 1,500 feet above the level of the sea, the TOPOGRAPHY AND CLIMATE OF STATES. 149 highest lands being those at the sonrces of the rivers tributary to Lake Superior, which, near the Montreal River, are 1,700 feet above the ocean. The Mississippi, Fox, and "Wisconsin Rivers have a considerable descent while passing through or along the boundary of the State, thus furnishing valuable water-power for mechani- cal purposes. In the southwest part of the State there are a number of elevations known as " mounds," ranging from 1,200 to 1,700 feet above the sea-level, and the cliffs on the east shores of Green Bay and Lake Winne- bago form a bold and commanding ridge, from which there is a gradual slope to Lake Michigan, 589 feet above the sea. Besides the Great Lakes Superior on the north and Michigan on the east there are numerous bodies of water in the central and northern parts of the State. These lakes are from 5 to 30 miles in extent, with high, picturesque banks, and, as a rule, deep water. From these, many rivers take their rise, a number having beautiful cascades or rapids, and flowing through narrow, rocky gorges, or " dells," the scenery of which has be- come famous. "Wisconsin has an endless variety of beau- tiful scenery. The four lakes which surround Madison ; the Dells, near Kilbourn City ; the weird beauty of Devil's Lake, which in the mystery of its origin rivals Like Tahoe; and the calm peace which reigns at Geneva Like, all possess attractions for summer tourists. The -st length of Wisconsin north and south is 300 mile-;; greatest breadth cast and west, 260 miles; area, !' square miles, or 35,865,600 acres. ' -- LTivatly. The mean temperature at Santa .vith an elevation of 6,862 feet, is: spring, 49'70 186 PHTHISIOLOGY. Fahr. ; summer, 70-4 ; autumn, 50-6 ; winter, 31-6 ; year, 50'6. The thermometer rarely rises above 88, or sinks below 5. Pulmonary complaints are infre- quent, but, owing to the rarity of the atmosphere, pneu- monia and similar complaints are frequent. The rainfall is very slight, sometimes not exceeding ten inches per year. Population, 119,565. Inhabitants to the square mile, 0*9. Deaths per 1,000 Inhabitants. The Territory 0'4 Group 1 0-1 San Miguel 0'2 Remainder of group O'O Group 2 0-5 Beraalillo . . . . 0'2 Rio Arriba. 0'5 Santa Fe O'Y Taos 0-9 Valencia 0'2 Remainder of group 0'4 STATE OF CALIFORNIA. Topography. California, the largest State in the Union with the exception of Texas, has an extreme length of 770 miles, an extreme breadth of 330 miles, and an estimated area of 158,360 square miles, or 101,- 350,400 acres. The Sierra Nevadas and the Coast Kange of mountains run northwest and southeast, generally par- allel, and are connected in the north and south by trans- verse ranges. Between the two ranges lie the San Joa- quin and Sacramento Yalleys. The Yosemite Yalley, situated in the midst of the Sierras, forms one of the chief attractions of the State. The Sierra Nevadas have a general elevation of from 8,000 to 15,000 feet. In the southern part of the main range is Mount Whitney, TOPOGRAPHY AND CLIMATE OF STATES. 187 15,000 feet high. In the north Mount Shasta, a bare volcanic peak of 14,400 feet in height, is the best known. The Coast Range is inferior in grandeur to the Sierras, having an average elevation of 2,500 to 4,000 feet. The Sacramento River rises near Mount Shasta, and flows south until in latitude 38 it unites with the San Joa- quin. The latter has its origin in Tulare Lake, and its course is northerly until it joins the Sacramento. After receiving the San Joaquin the Sacramento flows west to the sea. The Klamath has its origin in Oregon and flows through the northwest part of California, and the Colorado forms in part the southeast boundary and emp- ties into the Gulf of California. The principal lakes are Tulare and Mono. Lake Tahoe forms part of the bound- ary between California and Nevada. The principal bay is that of San Francisco, which is forty miles long and nine wide, and forms the best harbor on the western coast of North America. ( llmate. The variation in climate, owing to the dif- ference in elevation and latitude, is great. On the coast the winters are mild and the summers extremely pleas- ant. At San Francisco the summer mean is 60 Fahr., that of winter 51, and of the year 56. In the interior the summers are much warmer, and in the Sacramento Valley the mercury often reaches 100. In the twenty- three years, 1850-1872 inclusive, the rainfall at the same city varied from 7 to 50 inches per annum, and ex- treme variability from year to year is shown in other parts of the State. In the south the average is not over 10 inches, and at Fort Yuma even less. The heavy 188 PHTHISIOLOGY. snows which rest on the Sierras partially correct the ir- regularity of the rainfall. Population, 864,694 Inhabitants to the square mile, 5 '4. Deaths per 1,000 Inhabitants. The State* 2'0 Group 1 1-6 Amador 1*4 Butte 1-0 Colusa 1-7 El Dorado 1-0 Napa 2-6 Nevada 0'6 Placer 1-3 Sacramento 2'1 San Joaquin 3 - 2 Tulare 1'7 Tolo 1-4 Tuba 3'5 Kemainder of group 1/2 Group 2 2-3 Alameda 1'4 Oakland (city) !? Contra Costa 2'0 Humboldt 1-6 Los Angeles 27 Marin 1'5 Mendocino 1-2 Monterey - 9 San Francisco (city) 3'0 Santa Clara 2'0 Santa Cruz 1'8 Solano 0'6 Sonoma 1'7 Remainder of group 1'8 STATE OF NEVADA. Topography. Nevada has an extreme length north and south of 485 miles ; its greatest breadth through the center is about 320 miles; area, 110,700 square miles, or 70,848,000 acres, with 58,436,498 still unsurveyed. The surface is an elevated table-land, with an average altitude of 4,500 feet above the ocean, and broken by parallel ranges of mountains running from north to south, which attain a height of from 1,000 to 8,000 feet. The Sierra Nevadas, which reach an elevation varying from 7,000 to 13,000 feet, form a part of the western * Many of the deaths from consumption indicated for this State were of persons who had contracted the disease elsewhere. TOPOGRAPHY AND CLIMATE OF STATES. 189 boundary. It would be difficult to say what part of the State is the water-shed, for the rivers, which are not navigable, run in all directions, and with few exceptions fail to reach the sea. Some empty into lakes or sloughs and others sink into the earth. The Colorado River forms a part of the eastern and southeastern border, and the longest stream is the Humboldt, which rises in the northeastern part of the State and has a course of 300 miles within it, terminating in Humboldt Lake. Lake Tahoe, among the mountains on the California border, is twenty-one miles long and ten miles wide, and has a depth of 1,500 feet. It is more than 6,000 feet above the ocean, but keeps a temperature of about 57 Fahr. the year round. Pyramid and Walker Lakes are also extensive bodies of water and of great depth. The other lakes are little else than marshes formed by the overflow of the streams, and in many cases their waters are alkaline or brackish. Among the most noticeable natural features are the " mud-lakes " and warm springs. Some of the former cover 100 square miles, and are com- posed of thick alkaline deposits in the dry season, or of a foot or two of very muddy water during the rains. Most of the springs contain sulphur or other mineral ingredients and possess medicinal qualities. Climate. The winters are mild, with little snow ex- cept upon the mountains, but in the north the ther- mometer sometimes falls as low as 15 below zero. In the south and east the weather is much more moderate and frosts are rare, but the summer temperature ranges up to 95 and even 105 Fahr., May and June being 190 PHTHISIOLOGY. the hottest months. The rainfall is light, and occurs principally in the spring, or from January to the end of April. The air is invigorating and bracing, and the climate is considered very healthy. Population, 62,266. Inhabitants to the square mile, 0'5. Deaths per 1,000 Inhabitants. The State (forms one group) 0'9 Storey 1-0 Remainder of group - 9 TERRITORY OF "WASHINGTON. Topography. The greatest length of the Territory east and west is 340 miles ; greatest breadth, 240 miles ; area 69,180 square miles, or 44,275,200 acres, of which 28,836,985 acres are still unsurveyed. The Cascade Mountains traverse it north and south from British Columbia to Oregon, and divide it into two unequal por- tions, the eastern section containing about 50,000 and the western nearly 20,000 square miles. The highest peak is Mount Rainier, 14,500 feet, and there are several others little inferior. Between Puget Sound and the Pacific the Coast Range attains considerable prominence and culminates in Mount Olympus, 8,100 feet high. There are also the Blue Mountains in the southeast, which extend into the Territory from Oregon. Eastern Washington is an irregular, broken country, and the chief divisions of the western section are the Columbia and Puget Sound basins and the valley of the Chehalis. The Columbia River enters the Territory from the north, traverses its whole breadth, constitutes almost the entire TOPOGRAPHY AND CLIMATE OF STATES. 191 southern boundary, and with its tributaries drains nearly its whole area. The Snake, Walla Walla, Spokane, Col- ville, and Clarke's Fork are its principal affluents. It is navigable throughout the Territory, and the Snake is navigable from the Idaho border to its junction with the Columbia. The Territory has a coast-line on the Pacific of about 180 miles, and the deep indentation of Puget Sound, with Admiralty Inlet and Hood's Canal, fur- nishes many excellent harbors. The scenery of the Columbia River is in many places picturesque and even grand, flowing as it does through rocky mountain-gorges and containing a number of cataracts and rapids. Of these, the chief are the Cascades, where the river breaks through the Cascade Mountain range ; the Dalles, 40 miles above ; Priest rapids, 179 miles above the Dalles ; Buckland rapids, 66 miles farther ; and Kettle Falls, 27-i miles above ; the last having a perpendicular fall of fifteen feet. At Vancouver the river is a mile wide, and so great is the force of the current that it overcomes the effect of the tide, and the water on the bar is rendered drinkable. Climate. On the western slope there are but two seasons, the dry and the rainy, the latter commencing late in October and lasting until April. The rainfall is from 70 to 125 inches. The winters are mild, with but little snow or ice, and the summers cool and pleasant, the thermometer in July and August seldom reaching 90 Fahr., while the nights are cool, and there is usually a breeze from the sea. At Steilacoom, Puget Sound, the mean temperature of the year is about 50 Fahr. ; sum- 192 PHTHISIOLOGY. mer, 63 ; winter, 39. The rainfall averages about 50 inches per annum. The section east of the mountains possesses a drier climate, and the seasons of spring and autumn are more definitely marked. Washington Ter- ritory is extremely healthy, and, from the absence of marshes and the elevation of most of the land, is entirely free from miasma. Population, 75,116. Inhabitants to the square mile, 1-0. DeatTis per 1,000 Inhabitants. The Territory 1 .3 STATE OF OREGON. Topography. The Cascade Mountains, which cross the State from north to south, dividing Oregon into two unequal parts, known as Eastern and Western Oregon, range from 4,000 to 10,000 feet in height, reaching the region of perpetual snow. The principal peaks are Mount Hood, 11,225 feet ; Mount Jefferson, 10,200 feet ; the Three Sisters and Diamond Peak, each 9,420 feet ; and Mount McLoughlin, 11,000 feet. The Coast Range runs parallel with the ocean, at a distance from it of about 25 miles, the general altitude varying from 1,000 to 4,000 feet. Each of the great ranges throws out spurs, and the eastern division is broken by the Blue Mountains, which run northeast and southwest, and have an average altitude of from 5,000 to 7,000 feet. The valleys are deep and irregular, and in many places the rivers cut their way through romantic canons of great depth. The principal accessible harbors are the mouths of the Colum- TOPOGRAPHY AND CLIMATE OF STATES. 193 bia and Rogue Rivers, and Tillaraook Bay and Port Or- ford. The State has an average length east and west of about 360 miles, a breadth of 260 miles, and an area of 96,030 square miles, or 61,459,200 acres. The State has many streams, especially in the western half, but few of them are navigable. The Columbia rises in the Rocky Mountains, in latitude 50 20', and is navigable for ships 115 miles from the sea, and for steamers 165 miles. It is a rapid stream, and receives nearly all the rivers of Oregon. The Columbia is 1,300 miles in length, and forms the State boundary for about 300 miles. Its numerous cascades, caftans, narrows, and rapids enhance the beauty of the scenery along this stream. The Rogue River, in southern Oregon, and the Umpqua, which flows through the valley of the same name, both take their rise in the Cascade Mountains and empty into the Pacific. Most of the lakes, of which there are a large number, are situated in Grant and Jackson Counties. Climate. The climates of the two divisions differ widely, that of the western half being moist and equable, while the eastern never has an excess of rain, and, though somewhat subject to extremes of temperature, the climate is usually pleasant. The summers of the eastern half are dry, there being little rain and less dew, but the crops do not suffer from drought. The mean tempera- ture at the Dalles is, in spring, 53 ; in summer, 70*5 ; in autumn, 52 ; and in winter, 35*5 Fahr. ; and the rainfall does not exceed 18 or 20 inches annually. It is very different in Western Oregon, the annual rainfall at Astoria being 60 inches. Snow and ice are here 17 194 PHTHISIOLOGY. unknown, but on the mountains and elevated table-lands frosts are frequent, and the higher peaks wear their snowy crowns the year through. The mean annual temperature at Astoria is 52 ; that of spring, 51 ; sum- mer, 61-5; autumn, 54; winter, 42-5 Fahr. Population, 174,768. Inhabitants to the square mile, 1*8. Deaths per 1,000 Inhabitants. The State 1'2 Group 1 1-0 Wasco 2-0 Remainder of group 0'7 Group 2 1-3 Linn O8 Marion 1'9 Multnomah l - 7 Remainder of group 1'2 TERRITORY OF UTAH. Topography. The average length of Utah north and south is about 350 miles; average breadth, about 260 miles ; area, 84,970 square miles, or 54,380,800 acres. The country is rugged and broken, and is separated into two unequal sections by the "Wahsatch Mountains, which cross it from northeast to southwest. Extending east from the Wahsatch, along the southern border of Wyo- ming, are the Uintah Mountains. Other prominent ranges are the Roan, Little Sierra, Lasal, Sierra Abago, San Juan, and Sierra Panoches. In the southeast are exten- sive elevated plateaus, and in the west a series of discon- nected ridges and mountain-ranges, generally extending from north to south. East of the Wahsatch the drainage is mostly by the streams which form the Colorado. Of these the chief are Grand and Green Rivers. White, Uintah, and San Rafael are tributary to Green River. TOPOGRAPHY AND CLIMATE OF STATES. 195 The Rio Virgin, in the southwest, joins the Colorado in .NVvada. Among the lakes, the largest is the Great Salt Lake in the northwest, which is 75 miles long and about 30 broad. Utah Lake is a beautiful sheet of fresh water, having an area of about 130 square miles, and closely hemmed in by mountains. It is connected with the Great Salt Lake by the Jordan River. Bear Lake is on the Idaho border, and partly in that Territory. The IScviur River, rising in the southern part of Utah, flows north for 150 miles, receiving the San Pete and other smaller streams, then bends southwest and forms Sevier Lake, about 100 miles southwest of the Great Salt Lake. Climate. The climate for the most part is mild and healthful. The mean annual temperature east of the Wahsatch Mountains is from 38 to 44, and west of that range from 45 to 52 Fahr., while in the valley of the Rio Virgin and in the southwest generally the sum- mers are dry and hot. The rainfall averages 15 to 16 inches per annum, and sometimes reaches 20 inches in the north. Most of the rain falls between October and April ; spring opens in the latter month, and cold weather seldom sets in before the end of November. In the mountainous districts the winters are severe, and the snowfall is heavy. Population, 143,963. Inhabitants to the square mile, 1*6. Deaths per 1,000 Inhabitants. The Territory (forms one group). 0'4 Cache 0'4 Salt Lake 0'5 Sanpete 0'2 Utah 0-2 Weber I'D Remainder of group 0*4 196 PHTHISIOLOGY. Table showing Relative Healthfulness of States and Territories. STATES AND TERRITORIES. Deaths from all causes per 1,000 inhabit- ants. Deaths from consumption per 1.000 in- habitants. Arizona * 7'19 Montana 8'58 Wyoming 9'09 Dakota 9-64 Idaho Qr90 Washington 10*05 Oregon 10-66 Minnesota 11-57 Nevada 1 1'69 Florida 11-72 Iowa 11-92 West Virginia 11-99 Michigan 1 2'06 Wisconsin 12'17 Mississippi 12'88 Nebraska 13'10 Colorado 13'10 Ohio 13-32 California 13'32 Georgia 13-97 Alabama 14'20 Kentucky 14'38 Illinois 14-62 Connecticut 14-74 Maine 14-87 Pennsylvania 14'91 Delaware 15-08 Vermont 15-11 Kansas 15-21 North Carolina 15-36 Louisiana 15-44 Texas 15 53 Indiana 15*77 South Carolina 15'79 New Hampshire 16-09 Virginia 16'13 New Jersey 16-33 Utah 16-76 Tennessee 16'80 Missouri 16-88 Rhode Island 17-00 New York 17-37 Maryland 18'09 Arkansas 1 8*45 Massachusetts 18-59 New Mexico 20*37 District of Columbia 23'60 0-4 0-4 0-2 0-8 0-6 1-3 1-2 1-0 0-9 0-9 1-1 1-5 1-5 1-2 1-0 0-9 1-1 1-8 2-0 1-1 1-3 2-2 1-4 2-2 2-8 1-8 2-4 2-4 1-1 1-5 1-6 1-0 1-9 1-5 2-4 1-9 2-3 0-4 2-4 1-6 2-3 2-5 2-4 1-1 29 0-4 4-4 TOPOGRAPHY AND CLIMATE OF STATES. 197 Although the United States possesses almost every variety of climate, it is very difficult accurately to classify its types. This is due in most part to the fact that definite climatic conditions do not prevail to an equal degree, throughout the year, for any given locality. While vari- ous combinations of atmospheric tension, temperature, humidity, and precipitation (which always occur in defer- ence to natural laws) distinguish one type of climate from another, they also give rise to the changes which occur from time to time in the climate of any given locality. The following classification, which comprises most of the climates of this country to which consumptives resort for relief or recovery, commends itself to the writer as sufficiently accurate for general consideration : 1. Climate cool and moderattJy moitl. General elevation, 2,000 feet. Western slope of the Appalachian chain. Adirondack, Catskill, Alleghany, and Cumberland Mountains. g. Climate moderately warm and moderately moixt. Western North Caro- lina: Asheville elevation, 2,250 feet Western South Carolina: Aikcn. Georgia : Marietta, Thomasville. 3. Climate warm and moist. Florida (equable). Southern California, coast-region (equable). 4. Climate warm and moderately dry. Elevation about 2,000 feet Southwestern Texas, southern California, inland. 5. Climate cool and moderately dry. Elevation about 1,000 feet Min- nesota, Nebraska, Dakota. 6. Climate cool and dry. Elevation from 4,000 to 7,000 feet. Mon- tana, Wyoming, Colorado, northern New Mexico, and western Kansas. 7. Climate warm and dry. Elevation, 8,000 to 6,000 feet Southern New Mexico and southern Arizona. V. CONSUMPTION IN THE U. S. AKMY, AND METEOKOLOGICAL EEPORTS. Ratio of Deaths from Pulmonary Diseases per Mean Strength U. S. Army* _ Mean Strength. DISCHARGES PER 1,000 FOB DEATHS PER 1,000 FROM Loss PER 1,000 FROM Consump- tion. Diseases of the respira- tory organs. Consump- tion. Diseases of the respira- tory organs. Consump- tion. Disrases of the respira- tory organs. U.S. Army, white troops, 1870-T4. U. S. Army, colored troops, 1870-V4 25,989 2,530 564,646 5,804,616 3-828 2-962 1-395 296 1-462 2-47 1735 2-486 1-462 3-162 953 788 5-29 5-432 1-735 2-486 2-867 3-458 953 788 Arizona California Dakota Kansas Minnesota Montana Nebraska New Mexico Oregon Texas Utah Washington Wyoming United States * Bell's "Climatology," etc., loc. cit. Notes to Table on page 199. a. Temperature and rainfall estimated for October, 1873. 6. Temperature and rainfall not given. c. Rainfall estimated for February, 1871, and June, 1872. d. Rainfall estimated for January, 1874. e. Temperature and rainfall estimated for the year ending June 30, 1874. /. Temperature and rainfall for last two years only. g. Rainfall estimated for January, 1871. h. Rainfall estimated for January, February, March, 1871. f. Temperature and rainfall for first two years only. j. Temperature and rainfall imperfect and incomplete. CONSUMPTION IN THE UNITED STATES ARMY. 199 Ratio of Diseases and Death* from Consumption to Total Num- ber of Diseases and Death* from all Causes at Military Potts of the United States Army, 1870-1874. Abstract of Cireu- lar No. 8. MILITARY FOOTS. , i I 1 i 1 8 1 I I J i "S 11 1 - Ftr cnt of caammp- Uon to all other dlUMH. j 1 !| ; i Pr cent ofdubi fr'm eonninipt'n to dlh from all cauMt. Northern Coast. imbus, NY 51T& i; go 46-46 46-10 In. ;.-.. ;; -^i mm MB 2,184 uwo 170 4,618 IJU4 537 72 17 8 7 2 0036 0019 0130 0279 - B : 1 6 1 0882 1111 0000 0000 1 i ma, R, I Kt IiiilriM-inlfin'1'. Mass lile. Me. a AVT:I.C" . ... 50-51 i-, ,,i t,m 6,741 29 0043 -i 7 0864 Southern and Ovlf <*ts. Ft. Monroe, Va 58-18 42-16 1,861 601 ni 606 LflBfl BOB 875 LJtB 16 5 4 4 0097 0055 0045 0030 u B - B 8 2 1 3 2307 BM 1250 3333 Charleston, 8. C. fe Key West Barracks, Fla. c Ft Brown, Tex 78-09 72-41 4487 BrM Average ............ Sea-level. 69-50 &94 2,940 4,846 29 0056 9' 1 2500 Northern Interior. West Point, N Y d Ft. above -M |."..-1 157 186 840 9GO "1 -Jl !.,. : !-J M 39-91 m MSI 31-58 1,210 KB 434 1,573 1,637 MB }.:' 2,307 13 4 3 3 0080 oon DOB 0018 i I B ;-j OflOO 0000 QOOO .-.,'! 0528 Ft. Snelling, Minn . ... Omaha Barracks, Neb. e. Average 47-25 30-46 3,500 5,688 23 0040 tB 1 -n Interior. >>ia, 8. C. /. 800 10 521 f 64-06 51-88 53-01 14-75 57-04 886 975 448 1,492 1,722 |,BM 711 -.'.>'! 8 6 7 6 0046 me I.-:.' ; BOO 1,700 6260 54-tt i;-"! n ; i 70-07 61-08 I-', H 1 wag ta-M n-i?< 1,167 -:i 876 450 BH 1,986 1,719 1.CH1 1,302 BB4 on ;,'> 8 9 8 1 2 8 0046 0063 0011 DM tBH i- ;,' 7 in -'! 8 8 i 166 250 *BOO <-"-. -.. D 1667 Ft. Hays, Kan h I v, Dakota iied, Kan 11. Ariz Ft Sill li:'l T- r Average 57-95 78 5,941 9,584 31 1MB 99 15 1764 or, above 2,500 ft. Camp Douglas, Utah ;;, c'.il 4,004 ; 0B i 1 . -., BJBOO 4.C80 -.' "1' M .'. H 8 16-47 1249 W 1MB 1,200 no BBO 460 !.>; 241 :.'"'' OH -:. 81 n 802 8 5 5 2 2 0008 D07I een oon 0066 I'- ll 1 1 : 1 1 1 1 1 4 n i : - ' . '. 001)0 ,.-.! 1666 48-07 15-05 Average, 51-34 18-81 MM LJ01 17 ooio it 0900 200 PHTHISIOLOGY. Cq 1 i ^ ? II = r. If sa II i co x ~ X o & if) Cl -JS O -J! 5J .- / s 2 '". ~ - *-*f<*OOTt>-t~OI>O T-< 1.0 TO i- x o ^r o 5> - 10 ^ :? ? - * ~. -- i:: c; : XT ojino; So x t- in TC c oc oiiSi^s :cf{ mn oc 7} oc - ^^ ?C - O l Ci :SSH O O Cl O C CO CC CJ SC CC isiS8- T- Tfi ci 5i ?J ?i cl VI : in g? 1-1 TO m o o -* cc t- --o M -r x t~ t- -r^x ts o t- x T> i.* O CC l-H X TJ< Ci O tT ~ -~ ^~ "^ ~ i - T? ^. - I"" W t^ ?< T-T r4oi" T-T of METEOROLOGY. 201 iiiiiii; aaaaaaaai i -, 1 :: -", :"-:;-: iaaaiaiai Pi$ii$P s * ^* 5 O7.~~- - *-'7(-~-v*T> ; . . - . . _ - , --> - - So3"~- : ; i- ~ . ; : >~ c5|SJi ; lies: 202 PHTHISIOLOGY. Is S X t- o X ,- x : x 5J 53 o H ^- X i~ o? o is c: t- -i* i- r? c. :r: ~ ~ ?* ~ i- i~ i - -,c ?* ' ;- o x ?< -r x TT -. - - :: c. i -^ ^ P- > - 5) ~. t- x i-i ~. t- c; c; c: c-. T-> o -f 5 o o o r: ~> - i OS t^- O TH C5 I-H tC X *f C* O CC O t CJ! t- t- S } >^qDfcQeo M* x co o o c* --H t - o o o op ooao T^Q : CO O -r 1-1 O C~- X -^ -f ?? O O 5* -* r: X t- ^ < t- T ?* X " i ; t- X cc t- 1- x o cs T-I i- i- c: o c: x c: ?< o i x *- o *2 o c^ ^ ?* x c; -r x i- ^ o i cc M u~ o ^ -r o r< c-- . x o . 7f > -- --r i-c^ x ti t- p SU i- TH 71 OJ p jc r-i t- p c p X T c 55 co 55 i S ij 55 5< S i ? 5( 55 aj : i- -; i- .-i o >-< t -c-. i>--i rM- t-: 7; T( i - ; - .- J5 5j 5} 5i 5< 5; 5i o *- ?o ? co in x c? ?* 2?x??o* ^ Sj: 1; 15 oxci'^?"*^ : i- t- -r *~ 5? '^ '-.' J - ~-~ A 2J ' -~ ; '- "-^ ^' :A ^ i r ;r ' * ZT P "Z ^ i? ! . . . 55 5 iJ 55 55 K si n 55 r: ?: 55 55 :< 55 55 55 55 55 55 55 55 5j *> <1 ^ So^ 5SBSSS x c; a ?!r3IJ 5 55 S 55 55 55 S S 55 55 51 5ici 55 55 55 55 55 55 5* o? CD x c '.: -r < *-i x c-. i ^i TJ u- -.c r? r : -r. 7> : TI ri ?< - :> ;r i - -; '-. '. ^JCCtT ( T *'^*''W?7'CCC t ?O'"- ' l 7(~ftCOCCTCO 7? ir. ir. ~ cc ci o ^ "5 ^ *r5 " ^i t- v* T* ? ?* ssssassaasssaaassaa 55 5 5 55 55 55 S 55 55 55 55 55 55 55 55 5J 55 5i 5? 555 5J s5 i 55 55 ?i 55 55 55 55 5i 55 5 5 5 5? 1*>J '[A8I-M n,m 8Aoq i}a -raortq jo o -p ;o noiaiaia &g Isaaas O^) T)- '-'.t^ !>. ; O 7> 2 " = 5 ti c; 5s METEOROLOGY. n "- g a i < ixaaaaaa liSiSSfcSSSSSfcfeSSSSS RiSSfcBS gs| - - - v" ' ' kaasaaaaaaalM iaaaa i i" _ t v v ; I '. iiiiifSiii igip taaaa liaiiaii 204 PHTHISIOLOGY. ; c: 5* c; X ?* O so ac TT 7-" ci c: cc p i"- c 30 STH Ifl >O CO $- CO O ICiiOOOTCjJ*-^ M Xi-tCr??* .T ~i-J- X. C5 S X ?* <- 5 . *~ Ci ~* ~ X r? "' i - i~ -r . ~ X X SJ X p 55 at {- w c : c5 1^ 5: rt p 5 X ot 7^ -7 Ju-: ci t- . ^r x X *r: x o SlIllflllSllslslsg^iH 55 OT i} 55 5i s> S ;5 55 5* J O O O 5 T- ; Q LO l^ ?> X t- is O C: O . sS t-Ci- 2 ~ ^1 ~. L- C-. X i . X - i- . .- : i- ; 7> o x TO H- -^ =5 . c- . ~. i- x x : so o ^ i-i t^ i- >-; ^ !: -" K ~ ? .;- -c ; -i- r. ,-_-.-. : rr .- - "< 55 st 5t si ; f { ?. $ f; S O ^^-(-r- CO CC X O C: ~ -* <- ' a ^ . - . - -< -j; x cr. i- x : i o cc -- -.:-?; -- i- -. - : ! cc ?> o -r 13 i^ i* ^; r7 c; I- . ^ ;; o i- -c i- :> i-. re . ~. . r: -^ = x r? x c-. -^ U,m 9A(M^V J9J9 -raojuq jo uaaj -p jo oonAl3 t-O' - -. ~- r Sit- METEOROLOGY. 205 Notes to Table on Page* 200-20 4. * Boll's "Climatology," etc., toe. eit. letermmed. u>n closed November 30, 1880. 6 29 days only. c 26 days only. d 28 days only. 30 days only. / 24 days only. a 21 days only. A Observations discontinued Dec. 81, MBA i' ,*? (lays only. 1 2H days only, i- 25 days only. I Station closed June 27, 1881. m Office and records burned Dec. 23, 1880 ; no observations taken Dec. z'.. M, and SB. n Ob8ervation8commencedOct.l8,lfl80. o Barometer readings commenced .Ian. 1. ML p Observationscommenced Dec. 8,1880. q No mail reports received prior to AUK. 1. 1HHO. r Record incomplete ; observer sick. rvatiuus commenced Sept. 27, t Data incomplete owing to sickness of observer. u From 20th to 81st only. v Barometer unserviceable. to 17 days only. x 18 days only. y Observations commenced Jan. 8, 1881 A Observations commenced Dec. 1, 1880. B Prior records incomplete. O 9 days only ; office and records de- stroyed by fire Nov. 17, 1880. D Observations commenced Jan. 1, 1881. K Observations commenced Sept. 1, 1880. r Station closed Sept. 3, 1880. Station closed Apr. 1, 1881. H Observations commenced Apr. 10, 1881. 1 August 16 to 81, j Station closed May 23, 1881. K Observations commenced Feb.l, 1881. L Station removed to Eagle Rock, Idaho, on Nov. 19, 1880. M 8 days only ; office and records de- stroyed by fire, Dec. 4, 1880. Note* to Table on Pages 206-209. a Local observations discontinued Oct. 6 For 15 days only. c Local observations discontinued Dec. 21, 1880. d For 9 days only. e Observations discontinued Nov. 90, |S>il / Observations discontinued Dec. 81, i-^> a Observations commenced Oct. 13, h For 30 days only. i Office burned Dec. 88, 1880 ; no ob- servations taken Dec. 28, 24, and 25. j Observations commenced Dec. 8, HBO fc Local observations commenced Jan. i. IXM. 1 Local observations discontinued March 31, 1881. m i fenrTattaMoomn oedJao.84ttL rm commenced Dec. 1,1880, --> days only. }> For -.".I days onlv. q Local obHervatious discontinued July 81. 1C r For 9 day* only ; office destroyed by fln- on Nuv. 17, 1880. Observations commenced Jan. 1, 1881. t For 80 days only. u Observations commenced Sept 1, i-.-'. v For 29 days only. to Station closed Sept 3, 1880. x For 25 days only. y For 26 days only. t For 24 days only. A For 18 days only. B For 21 days only. c For 23 days only. D August loth to 31st only. x Observations commenced April 1, lxl. K Local otanvfttai IMIII.-H.-I-.I .I.KI. 1,1881. Local observations discontinued March 19, 1881. H Station removed to Eagle Rock, Idaho, on Nov. 19,1880. 1 For 8 days only ; office and records destroyed by fire ; observations J Local olwervatious commenced Feb. 1,1881. K Observations commenced Sept 4, 1880. 18 206 PHTHISIOLOGY. ^ 'S H, N a; Oi "e s 8 7 A Observa 80, to Ju 8 f n Temperature, fro July, 1 ations by four ; S. Signal Servic d twice the 9 p. M. f days in the month. . M. mb 7 A. M., by the m th ly mean Me and Annua Mo aily means are obtained by means by dividing the panco9-9Aoq o T cfc fc TT co S TJI ejooot-ioaot-OTO-f 05* iT. I- SISS? :2%%i53 oo o t~ t- e 1-1 gx jc p - 53 t>- t'- I i X. t- O 5O C5 O t- OOCST-i5Sl~-*C:'!>O 00 tO 1- OS i-l t- METEOROLOGY. 207 r t- ?*> i t- O> ip X O Macao-" 9*?" 9* 9*7" 9* 9 7* I? 5 ? 1 op ao p *5 i p eo w ' 9 s l^m ji-wt-w ;p ;pp t ----- ; 9a> ?? 9. .H -2 e 208 PHTHISIOLOGY. *-i oc T- o c* i- ?* c~. ^ T i? =>. ? Kpg>oo3gpt-ipooapceieOTCC>pcs3 c o t- o >o oo >* co ri OOCO*t-ppCpl~pp7fpr-Np^fJ OO^OpOt-OOOOi-iC^OJlQiO QO to -^ aj T)> i-i oo i-i I-H e t- I-H 10 in co os TH oo oct-t~o-*}9jcsi-f'j'aooe* i-l O CC SO t- t- OS rl O C5 JO i-l O -i co t- OD to so i- oo o et Oi^cocoi >O O 00 K2 K5 00 00 r-c 1O O5 i- X 5 T)< -^ O TH t~ OC i g ^ ^ Hfi r iapc39p9pt-t-cftojp9p'jj> i-iooccsaco CO CO SS TO !S 0* o3t-Tiooaoaot-7J'C|OO>TH ^^ac^otCT-i^cii^i 1C Oi S3 Cl Jj K -9 C 1-1 c* c* o 5 -^ i-i 1-1 o o t- o ^ OD o 10 ic o ca os x w^ 1 co e* oo Tioxi- co co cS co t-O OSO (NO 1O O WOOD C OO:OJ'?>XW-*-*Ot-CJ M O >C 5 O IS 16 ft O T)> TT WJr-iOOp^Oilp^-CCOOi-llO 00 1-1 CO {- ^ 7J VZ -> i- -' M5tf3iNcoeapco^-qoeooipo o i- o 1-1 oo * oc o ** -tt-csocfti-"C5rH t- TP & t- S CO S > i-ii>acoQTH!-'!- csp wososp t- e> o ee o H ; e ^- 05 1- * e * o> ^ / r. .*. / ~ r . 210 PHTHISIOLOGY. J5- fa II and 9 P. M. observations by th f days in the month. (U. 8. Si the 7 A. M. the numb he sum means are obtained by divi iding the sum of the SQO^OOOOQCCCOk^O SOlOt-SOOi.-1-lOiO t t- L* J> t- 1>- oa t'- s - t- 00 tO t> - 50 1- 00 I- o T- e: 5? -r c; ao O t- 1C CS 1C O X O S^-tCO^^-l^t- o 5 -~ ic. i- '-iCOt-'NMt-X S5 00 =0 t~ t- I- X to OOt-*pW3flDHpgDCpt^CipaOO3ppCOp W5 t- CS 3 Ci 3 THC003O>'J'eOOJOO<0'*COt-O^INMO g^cciji-iOi-i -J>o6t-l-OO fOQO&pCOy^QOCRt'-CpCO^i'CpCiCOCOOCQGt"- 00 Tji -* O CO t- t- s cc^c2.i!S<:c-T : -r^-=c^3--;3 :: ^' ? - :: >,-;;-- 5*3 ~S - "^ ^ i "^ - 2 c '- - '2 ~ ~ ~"? S2S5=~^2 - METEOROLOGY. 211 r*"!"?w BEfe88fe8Cfi xp -iXxe>swoeippoio- r. so * SeSSJofeSSg cISSfclSSIiSsiHec eo p c o as * p ~ eo j-^ ~ ip eo ft ? 09 o tp ^-w eo o> ~ *- w^^ eo t- .1 o i o i 0003 Ei r / w 9*7* :9>ppe r ir' ooaoo?o :< BIGC yy^BS^iyF Li!!?:lito5li4i4llMfJ! bOSUU 212 PHTHISIOLOGY. 1 g- got- jej^oi-jfiogot- | o> >-c 1-1 o oo H o ^ o t- 1- m o TH * a es co o 05 >o 1-1 e os as et so oo 00 to *r w o o co 10 TJ< o o i~ 05 >o 10 ^ieppiaepb-Oi' t- I- t- i- I- t-p Si ICO gg woiososoujoooot-oopiaoiip cppt-pppgopt-pwwp O 00 t O O i-- O O t-- O X CD t H 9OOT-ilNC7HT}iWrHO50Cpep i^ o o i~ c~. o T rt ^* c: cc 'f ^ W t- t- i- X TC t- TT t- 05 peppopoe*t-ow^ft-o3t- ppjpoir-i5poDooot-oDap w w^ 1 QD i-i o ao i- as o f- - 1- - oppopoospSJ ooooiowwsOi-ieOi-iowiot-oto Ol W CC ^ O O O O O CC 77 O i" '-^ X ^^ i.* 7? 1^ ^-< i>t-ioi-ot-t-t-t-i-5ii-i-t=oxTrt-;?;5o -i oo o oo i< oo to ^c st * ao -^ t- oo w w ** si oo ia METEOROLOGY. 213 >ipet-i ia^f>aia'Kf ?es??8?:J!!!e5*s2ee?e '--s il?Hfc2|| ESS ESI >r \rnet? iJJ :Sri?{-n! H J ~ .-.,./ : : e ISilllnill^iliis |8 ills ; * ~ T" "^ ' Sfi?r:g{:S9SnS2?S838 I : 97ripW7f3t-w -^-i Ujllillliyilll ^j M -^r^ . 1 9 '. /. /. 214 PHTHISIOLOGY. Notes to Table on Pages 210-213. a Local observations discontinued Oct. 13, 1880. 6 For 15 days only, c Local observations discontinued Dec. 21, 1880. d For 9 days only. e Station closed November 30, 1880. / Observations discontinued Dec. 31. 1880. g Observations commenced Oct. 13, 1880. h For 30 days only, f Office burned Dec. 23, 1880 ; no ob- servations taken Dec. 23, 24, and 25. j Observations commenced Dec. 3, 1880. k Local observations commenced Jan. 1, 1881. I Local observations discontinued March 31, 1881. m Observations commenced Jan. 3,1881. n Observations commenced Dec. 1, 1880. o For 28 days only. p For 29 days only, g Local observations discontinued July 31, 1880. r For 8 days only ; office destroyed by fire on Nov. 17, 1880. s Observations commenced Jan. 1,1881. t For 30 days only. u Observations commenced Sept. 1, 1880. v For 29 days only. w Station closed Sept. 3, 1880. x For 25 days only. y For 26 days only, z For 24 days only. A For 18 days only. B For 21 days only, c For 23 days only. D August 16 to 31 only. E Observations commenced April 1. 1881. F Local observations discontinued March 19, 1881. G Office removed to Eagle Rock, Idaho, on Nov. 19, 1880. H For 3 days only ; office and records destroyed by fire, Dec. 28, 1880. i Local observations commenced Feb. 1, 1881. j Observations commenced Sept. 4, 1880. Notes to Table on Pages 215-219. a Too small to measure. 6 Station closed Nov. 30, 1880. c Station closed Dec. 4, 1880. d Observations discontinued Dec. 31, 1881. e ObservationscommencedOct.13,1880. / Station closed July 27, 1881. g Observations commenced Dec. 3,1880. h For 14 days only. i For 20 days only, j Station closed Feb. 12, 1881. k No mail reports received prior to Aug. 1, 1881. I Data incomplete ; observer sick. m Observations commenced Sept. 27, 1880. n May 20 to 31 only, o Observations commenced Jan. 3, 1881 p No ram-gauge at this station during prior months. q Observations commenced Dec.l, 1880. r Record for October incomplete. s For 24 days only. t For 25 days only. u Office destroyed by fire Nov. 17, 1880, no record of rainfall during mouth. v Observations commenced Jan. 1, 1881. w Observations commenced Sept. 1, 1880. x Station closed Sept. 3, 1880. y Station closed. z Observations commenced April 10, 1881. A August 16 to 31 only. B Observations commenced March 30, 1881. c Record of rainfall for August incom- plete. D Station closed May 23, 1881. E Observations commenced Feb. 1, 1881. F Observations commenced Sept. 4, 1880. G Office moved to Eagle Rock, Idaho, on Nov. 19, 1880. I * IT ^ I I - I METEOROLOGY. $$ 215 oo eo w 6 t- is t- ** <0-OJ- *"*" 00 7 7?.-- -:/ -7 ' CO 00 O * t- t- t- G6 OOOOiOCOOO 'O^ in act- oo VCD eat- fli =3 ~6 :- r: r-. :: -> r OOtOCiX^^OWt-^' r: - . : ,. r. > .-.:/. -. i-' at' Saio^' ' * o et ao * o o * >i coco 6w co ^cov^ eo i- o - o w r-i eoos M 99 t- OD OS re .- .- c .- -i r? - ~- : / :V^ ;- IO I0 11 00 &tf8% ^tjrfi? iisiii 216 PHTHISIOLOGY. ^> -^ B * 3 a 'a S g t-co^-v t-i-ioa 00 latoi-tt-ot j-i-w oo " ~~ooooeoi ^ 'ii-ido oo J 5 co TIT-I o ri so T-I cb at at ri 60 " oo oj a* T-I TH ~ obi 06 11 et T-I " iicb^-i 1 ~"~ ^f if o X Q .< g'' 2 i-i oj i- rt i- 1- Ti" " " cV-io" JOTC" Oi-it- Tfoj "OiN I , Vj & vm^ioet' jor-ioo 10 st TH co o 10 1- j' o rttsco-vco T-KN i-cjuo 5 e *g ^ O TT CO Tf p CO * T-I 1-1 CO ia 1O I-H CO 1O <* CO i-l O 00 TH to 00 METEOROLOGY. 217 tj so - et ' oj v.-i as - oo o* oo *!> e* .1 ' ot>-i6i^-i < '-^^- - : r9^5jS3S ' '''' ' 9888988S ri .-. /. -i ri e< o 11 oa o s <-ie-i oo - ~ i i ~ .-. - : - -I : :-. 11 ^eo eo -Jr 6 e is TI co ^-i do oo o oo oo is oo M 1-1 -. o coco CO O TH 00 i t go 00 O O C5 CD CO C5 T-I AO i~ O 10 co o c 1-1 ^ a I e 8 N " e e CO t CO CO * CD * Tf ^ O 5 -^< TO CO OJ rl TH S TH os ib oj 6j cb Tt T)I oj "b oo eb -THlO 00 T-l H^-C ' COt- ' COOJ s at ao o T? t- Tfosco 51 T S O IK Q CO CC K O X O O TI jifi 3aSafc^}z;lz;|Zi!2;!z;KO<5O(S(5SSsSSS((S(2(2lftiKS METEOROLOGY. 219 :S iusi*iiMia88 is -: i-> s* ii 6 ' eg 6 ^ * ' ~ii-> 6* 03rl040( 2S88S9R- ire* i t- -^SasSSSfcSS :83 32 '.9SSS N OOrl'fll IO -V r-HH ^1 CO eo' ~6" 6 - moot o ' VO' ' CO ' i ' i-t ' 10 00 SS $2S82f:fea8SSe iHi ^ :gj! :_ : W - :::!' :^'6 ^ -..i > = Sl -l"" 'it 5^-^ = = = =^^ r == -5 ==.= = = ?-"3 :ims'? 2 >illiplllilllll - ^ = s S ' i. S. S..J ._ ^- ' ;: .= ~ 5 = > - - - - s :-:-:-.- - = s i. . ..J ._ ^- ' ;: "Z X X X X X cZ 00 a5 Cfi ODOD X X X X X :/. J. J. 7. 220 PHTHISIOLOGY. Elevations of Signal- Service Barometers above Mean Sea-Level on June 30, 1881, and of Thermometers and Sain- Gauges above- ground (United States Signal Service). STATION. AB'VE SEA-LEVEL ABOVE-GROUND. Barometer. Thermom- eter. Rain-gauge. Albany, N. Y Feet. 75-3 609-4 1,131-3 12-9 182-8 45-2 20-0 Feet 50-9 54-4 77-7 9-7 18-1 33-1 5-5 50-5 16-4 6-5 19-3 155-9 6-4 20-2 72-0 54-6 44-4 5-0 7-0 16-5 18-0 18-6 16-0 20-3 405 34-6 42-6 15-3 69-2 28-9 67-8 78-5 4-1 52-0 5-6 18-6 46-1 5-8 15-7 17-0 12-8 16-8 45-3- 35-0 Feet. 69-7 52-0 92-2 37-2 39-8 69-1 7'6 58-0 5 4-5 32-1 161-6 3-5 40-4 67-2 72-0 77-6 2-1 1-0 14-3 1-0 6-1 8-0 34-7 56-6 47-0 59-2 24-0 92-0 29-7 76-3 74-0 Alpena, Mich Atlanta, Ga Atlantic City, N. J Augusta, Ga Baltimore, Md Barnegat, N. J Benton, Mont. . Bismarck, Dak 1,704-3 1,508-0 B. 2,768-0 B. 142-2 1,137-0 B. 43-4? 664-5 268-0 377-3 2,527-0 8-4 16-0 15-0 27-0 778-0 B. 22-5 52-5 837-8? 783-2 6,089-0 660-9 18-5 620-4 689-7 1,735-0 B. 804-6 1,888-0 B. 447-5 614-7 1,700-0 B. 4,630-0 B. 1,160-0? 20-0 767-4 5,293-6 849-0 Boerne, Tex Boise City, Idaho Boston, Mass Brackettsvillc, Tex Brownsville, Tex Buffalo, N. Y Burlington, Vt Cairo, 111 Campo, Cal Cape Hatteras, N. C Cape Henry, Va Cape Lookout, N. C Cape May, N. J Castroville, Tex Cedar Keys, Fla Charleston, S. C Charlotte, N. C Chattanooga, Term. Cheyenne, Wyo Chicago, 111 Chincoteague, Va Cincinnati, Ohio Cleveland, Ohio Coleman City, Tex Columbus, Ohio 70-0 On ground. . 30-0 77-0 1-7 . 23-9 5-0 26-6 28-2 56-1 45-3 Concho, Tex Corsicana, Tex Davenport, Iowa Dayton, Wash Dcadwood, Dak Decatur, Tex Delaware Breakwater, Del Denison, Tex Denver, Col Des Moines, Iowa . . METEOROLOGY. Elevation of Signal Barometer* above Mean Sea-Letel, etc. (Con- tinued.) STATION AB'VE SKA-LEVEL ABOVl t-OBOUHD. Barometer. Thermom- eter. Rain-gauge. Detroit Mich Feet 661.4 Feet 61*4 Feet 71-1 Dodge Citv, Kan 2,512-5 16*3 29-9 Dubuiiue Iowa 665*1 81-9 48*1 Ihiluth Minn 644*1 18*9 27*7 K:i"lf Pass, Tex. 800*0 B 6*8 1 i iock, Idaho 4,780-6 12*2 1*0 ' t Me 61*2 82*5 65*5 El Paso, Tex 3,956*0 B. 16*8 14*1 i 681*1 81*6 60-6 Escanaba, Mich 611-6 24-9 88*2 Florence, Ariz 1 553*0 B 4*9 8 9 Fort Apache, Ariz 6004*0 7*0 1 Fort Assiniboinc, Mont 4-9 Not up. Fort Bennett, Dak 12*0 17*0 Fort Buford, Dak '1,876*0 B 7*8 Fort Custer, Mont 8,100*0 B. Fort Davis, Tex 4 918*0 B 3*2 2*0 Fort Elliott, Tex 6*4 On ground Fort Gibson, Ind. T 510*1 19*1 36*4 Kort Grant, Ariz 4,737*0 B 6*6 10*0 Fort Griffin, Tex 1,243*0 B. 7*0 8*0 Fort Keogh, Mont 13*8 37*0 Fort Mat-on, N. 11*0 8*1 4*8 F'.rt MrKuvett, Tex 4-1 21*1 Fort Missoula, Mont 6*9 Fort Sliaw, -Mont Fort Sill, Ind. T 1 190'0 B 6'5 2*0 Fort Stevenson, Mont 1 734*0 B 7-5 4*5 Fort Vi-rtle, Ariz 8 106*0 B 5*5 8*6 Fredcricksburg, Tex 1,742*0 B. 15*8 24-0 n, Tex 39'5 ::'.] 61*5 (iniiiil Haven, Mich ,-.,,,.-> 22*6 76*8 HiitUTas, N. 19*5 6*3 1*0 Helena, Mont 4,315*6 B. Henrietta, Tex 915*0 B 4*0 3*5 Huron, Dak 1,800-0? :nilis, Inil 753*3 62*2 73*5 IiKiiannla, Tex J.Y'.t 29*2 39*9 Jacksboro, Tex 1,133-0 B. 5*8 17-6 ; ... ... I:;-. > 87*4 67*0 Ki-okuk, Iowa .... 617*6 46*9 .vi-.-, Fla 'i',- i 42*9 62'1 Kittvha-vk, N. (' .,.,.,, 8*9 1*0 Knotvillc, Trim il-n 72*4 77*4 La Crosse, Wis. . fte-0 WO 222 PHTHISIOLOGY. Elevation of Signal Barometers alone Mean Sea-Level, etc. (Con- tinued.) STATION. AB'VE SEA-LEVEL ABOVE-GBOUND. Barometer. Thermom- eter. Bain-gauge. La Mesilla, N. Mex Feet. 4,124-0 B. 401-0 B. 841-9 619-0? 298-2 350-1 530-0 651-5 949-2 672-9 1,620-0 B. 320-8 697-1 68-9 219-0 923-0 962-6 6,2590? 507-0 106-4 46-6 52-4 44-4 Feet. 178 4-2 34-5 22-5 25-6 36-6 89-3 30-5 32-6 36-4 16-3 52-8 105-4 64-5 33-6 23-3 10-2 6-0 34-1 112-4 28-6 45-3 19-1 58-0 8-2 147-8 20-0 18-8 22-9 59-2 34-7 20-0 99-0 3-6 5-1 17-2 5-0 87-7 7-0 80-0 27-7 44-9 8-1 10-1 138 Feet. 16-0 5-2 48-0 37-6 57'2 50-0 102-5 50-0 56-8 56-7 1-7 51-0 134-8 84-6 58-2 41-4 ro 2-0 49-0 108-3 57-2 77-1 43-0 Leavenworth, Kan Lewiston, Idaho Little Rock Ark Los Angeles Cal Louisville, Ky Lynchburg, Va Marquette, Mich Mason, Tex Memphis Tenn Milwaukee, Wis Mobile, Ala Montgomery, Ala Moorhead Minn Morgantown \V. Va Mount Washington, N. H Nashville Tenn New London Conn New Orleans, La Newport, R. I New River Inlet, N. C New Shoreham, R. I 27-4 164-3 30-1 2,841-0 36-0 1,113-3 304-2 29-8 52-4 1,068-0 B. 14,134-2 800-0 6,220 B. 762-2 7-1 632-9 45-4 67-0 No bar. 5,339-0 B. 13-1 22-8 144-9 52-5 7-5 38-2 74-6 62-2 36-2 95-0 18-7 1-0 35-6 22-6 85-6 2-0 63-0 76-7 59-8 29-4 4-6 35-4 New York, N. Y Norfolk Va North Platte, Neb Omaha Neb Oswego, N. Y Pensacola, Fla Philadelphia Pa Pike's Peak, Col Pilot Point Tex Pioche Nev , Pittsburg Pa Port Eads La Port Huron, Mich Portland Me Portland Ore Portsmouth NC Prescott Ariz Punta Rassa. Fla METEOROLOGY. 223 Elevation of Signal Baromctert above Mean Sea-Level, etc. (Con- tinned.) STATION AB'VB MA-LBVKL ABO VI I-OBOCXD. Barometer. Thermom- eter. Rain-gauge. Red Bluff, Cal Feet 328'9 Feet 20*8 Feet SI -9 Rio Grande City, Tex. 4*9 *0 Rochester N Y 188*9 10O-O Qft'1 Roschurg, Ore 537-0 20*0 QO'B 69'6 K4-4. 667*8 104*4 100*0 80-0 13*0 "8 St. ran!, Minn 610-9 32*0 68*0 St. Vincent, Minn 804-0 8*8 14*0 Salt Lake City, Utah 4 848-0 62'6 74*6 675-7 17*2 82'8 San Diego, Cal 67-1 19-0 80'6 Sandusky, Ohio 638-6 64'0 66"! Satulv Hook, N. J 27-9 14*9 ro San Francisco, Cal 604 48-0 78*0 Santa Fe, N. M 7,046-0 20*8 18*8 Savannah, Ga. 86-9 41*0 67'7 226-8 33-3 43*8 Silver Citv N M 6,796-0 B. 4-8 1*0 Sitka, Alaska 63-0 64*4 95-6 SrnithvilU- N. C 83-7 17-6 36*4 Socorro, N. M 4,664-8 6*2 18-4 644*0 88*8 60*9 120-6 64-2 63-6 Spokane Falls, Wash. 1,910-0 18-6 Stockton, Tex 3,063-0 B. 6-8 1-5 Thatcher's Island, Mass 48-1 7-0 4-0 Toledo, Ohio 661-2 63-8 104*7 Tucson, Ariz. '. . 2,404-0 6-3 16*7 I'matillii, Oro 884-0 B. 7-8 8*0 13-4 15-8 1*1 Tex 891-0 B. 8-6 On ground. Vicksburp, Miss 242-6 82'6 62*6 6,810-0 B. 24-2 29-0 Visalia, Cal 848*1 22-4 44*6 'ton, D. C 104*6 44*1 60*8 Wu'ki-nhurjr, Ariz 1,400-0 B. 4-6 2*1 Wilmington, N. C 82-0 28*0 44-8 WilllU-Hllirc:i N'rV 4,827-8 7*0 8*0 Hull, Mass 35-0 6-1 84-0 1,228-4 19*8 28-4 Yuma, Ari/ X. ... 140-8 6*1 26-0 VI. ETIOLOGY. "A GLANCE at .the sketch of the distribution of phthisis over the globe does not permit us to doubt that circumstances of climate are on the whole of merely subordinate importance for the lines of that distribution ; that the disease occurs, cceteris paribus, in all geographi- cal zones with uniform frequency; that equatorial and subtropical regions are visited with consumption not less than countries with a temperate or an arctic climate; that the differences which come out on comparing the amount of the malady in several parts of a given zone are of the same kind as in all other zones ; that in many regions the number of cases has gone up considerably without any corresponding changes in the climate, but under circumstances of another kind " (i. e., crowded population, in-door occupation, etc.), " and, accordingly, that the notion, which is still prevalent, of a preponder- ance of the disease in cold or temperate latitudes, is just as erroneous as the other opinion which has lately come to the front, that consumption is found with especial frequency in those very regions that have a warm or hot climate." * * Hirech's " Hand-book of Geographical and Historical Pathology," vol. iii. ETIOLOGY. 225 Cold does not produce consumption, and warmth gives no protection against it. The mean level of tem- perature, therefore, has no significance for the frequency or rarity of phthisis in any locality. " But it exer- cises a very decided influence on the course of the dis- ease, for, according to nearly all the authorities in tropical countries, including India, Cochin-China, China, the Pa- citic Islands, Panama, Guiana, Brazil, and Peru, it runs usually a much more rapid and pernicious course in these countries than in higher latitudes, the removal of the patient from such a climate as speedily as may be being in fact the only sure protection against a rapidly fatal issue." * Hirsch not only shows that the absolute height of the temperature has no determining influence upon the frequency of phthisis in a locality, but also tliat se- vere and sudden changes of temperature from day to day have just as little on their own account. Evidence of this is found on a large scale in a number of places on the eastern slope of the Rocky Mountains and from the elevated prairies in the western United States. We must, however, take into account the important fact that these regions have an absolutely dry climate, for the cir- cumstances are entirely different in the case of a damp climate subject to great variations of temperature. It is an established fact that, where we have a moist climate, along witli a great range of temperature, catarrhal affec- tions of the bronchial mucous membrane are very fre- quent. Hirsch states that this climatic influence is in * Hirsch. 226 PHTHISIOLOGY. all probability a real predisposing factor in the develop- ment of phthisis. Dryness and variability of tempera- ture i. e., elevation are, according to Dennison,* "the most important elements in the climatic treatment of phthisis." According to Hirsch, " There are few countries of the world so characterized by uniformity of temperature and comparative dryness of the air as the inland districts of Lower Egypt and the valley of the Nile in central and Upper Egypt, regions in which phthisis, accord- ing to all observers, is very uncommon. On the other hand, localities on the coast, such as Alexandria, Dami- etta, and Port Said, with a moist climate and a great range of temperature, are much subject to the dis- ease." Hunter says, " The localities specially distinguished by dryness of climate and uniform temperature, be they on the plain or among the hills, are least affected by phthisis." Humidity per se is not a factor for the production of consumption. The Hebrides, Shetlands, Iceland, and the Faroe Islands, are continually bathed in moist sea-air, and they all enjoy a remarkable immunity from con- sumption. Lindsay f says, "The remarkable rarity of consump- tion in the navy (British) as compared with the army is a fact quite incompatible witli the prevalent notion that breathing moist air predisposes to the malady." * "New York Medical Journal," September 13 and 20, 1884. f " Climatic Treatment of Consumption," by Dr. J. A. Lindsay. ETIOLOGY. 227 Bowditch* seems to have been the first to institute inquiries in reference to the proportion of phthisis to the e of saturation of the soil : " They were instigated by the discovery that the residents in certain localities or quarters, or even in certain houses, suffered from phthisis in a peculiar degree, while places around, even those in most immediate proximity, were less affected by the disease or unaffected by it altogether. These inquiries, carried out as they were at various places, served to show that the number of cases was in direct ratio to the degree of dampness of the soil, that the disease was found to be least prevalent upon dry soil, the drainage of the ground having been followed by a decrease in the num- ber of cases, and that it is a matter of absolute indiffer- ence whether the saturation of the ground proceeds from one source or another." The conclusions of Bowditch have been corroborated by Milroy, Buchanan, Pepper, and other prominent observers. " Elliott f believed that the cause of the enormous prevalence of consumption in New Orleans is to be looked for in the influence exercised by a soil saturated with moisture ( 4 the water-level of the soil is coincident with the surface of the soil')." In this connection it is interesting to note the influence of drainage in lowering the mortality from consumption in the District of Co- lumbia. The tenth census (1880) of the United States sli>\vs a mortality from phthisis for the city of "Wash- * " Transactions of the Massachusetts Medical Society," 1862, vol. vi, page 2. f Hirach, loc. tit. 228 PHTHISIOLOGY. ington of 41 for every 10,000 inhabitants, and for the rural (unsewered) portion of the District of Columbia is shown a mortality of 57 for every 10,000 inhabit- ants. The bad effects of aggregation are here more than balanced by the benefits of drainage. "In a like sense Hermann* accounts for the some- what heavy mortality from phthisis in St. Petersburg. Reeves thinks that the remarkable increase of consump- tion in Melbourne can be explained by the extensive irri- gation lately introduced in the vicinity of the town. Devertil holds that the high death-rate from phthisis in Sodermanland, particularly in the basin of Lake Malar, while it is in part due to the great poverty of the dis- trict, is partly to be attributed to the wetness of the whole valley, the subsoil being for the most part glacial clay, which induces a high level of the ground-water, slow subsidence of the rain-water, fogs, and dampness of dwellings; and he certainly finds support for that opinion in the fact that in all the provinces south of the Dai-elf, in which the deaths from consumption reach the average or exceed it, the subsoil is glacial clay with strati- fied marl or stratified clay, whereas the parts of the country that have a small phthisis mortality rest upon rock or pervious gravel. "Noteworthy as these facts must always be, it can not be overlooked, at the same time, that the rule de- duced from them admits of considerable exceptions. Buchanan himself had to admit exceptional cases for * Hirsch, loc. cit. ETIOLOGY. 229 example, that of Ashby-de-la-Zouch, where the mortality from phthisis rose 19 per cent after the ground was drained. It was subsequently pointed out by Pearse that, in several districts of Devonshire, where the rain- fall was very considerable, the deaths from consumption were comparatively few, and that, if it were contended that these districts were on a pervious soil, and that other districts on wet clay showed a far more unfavor- able death-rate, it was still a very remarkable thing that the mortality from phthisis was less at Wisbeach, in the fen district, than at Axminster, on the red sandstone, in which part of Devonshire, as well as in others equally fortunate in their geological foundations, but with lace- making as the industry, consumption was more common among the women (who followed that occupation amid bad ventilation) than among the men ; while under hy- gienic circumstances that are as good as these are bad, as, for instance, on Dartmoor, the mortality from phthisis is very much less. Further, it is pointed out by Droeze, for Holland, that phthisis is far from taking a prominent place in the mortality, despite the extreme wetness of the soil everywhere ; that no definite relationship can be made out with the more or less considerable wetness of the ground on comparing the mortality in the various Dutch provinces; that, in fact, the more elevated prov- inces with diluvial soil suffer more than the deep de- pressions with an alluvial soil, such as Zealand, which has the smallest phthisical death-rate (1/87 per 1,000 in- habitants). According to Reck, the mortality from con- sumption in Brunswick has not been greater in the wet 20 230 PHTHISIOLOGY. parts of the town than in the quarters on a dry soil. In Dantzic, where a system of main drainage was carried out fully in 1871, the death-rate from phthisis, which had been (according to Lievin) 2*12 per 1,000 in the eight years preceding (1863-'70), rose in the nine years following (1871-'79) to 2-48 per 1,000. That the ground was drained by the system of sewers is beyond all ques- tion, and yet the amount of phthisis not only did not fall thereupon, but went up 17 per cent ; so that Lievin concludes : " ' According to Dantzic experience, any connection between the prevalence of consumption and main drain- age, as affecting the subsoil water, is certainly not made out.' At Berlin, in like manner, no notable effect on the prevalence of phthisis can be traced to drainage of the ground following the canalization of the city. Pre- vious to 1875, in which year the canalization began, the mortality from phthisis per 1,000 inhabitants was 3'6, 3*7, 4-3, 3 '8, 3*4, 3'3, and 3*5 in the successive years from 1869 to 1875. Subsequent to the latter year the annual averages were 3 - 3, 3'3, 3'5, 3'5, 3'5, 3'3, 3'3, 3 - 5, and 3-5, successively from 1876 to 1884. It is Bu- chanan's opinion that the exceptions to the rule worked out by him are not to be explained by errors in the observations, but that they indicate the presence of other influences in the subsoil, which have hitherto escaped detection. " The most striking fact in connection with the geo- graphical distribution of consumption is the rarity of the disease at great altitudes. The observations published ETIOLOGY. 231 by Archibald Smith and Tschudi as to the extreme rarity of phthisis on the high plateaus of the Andes in Peru, and as to the good effects upon the phthisical of a resi- dence thereon, were the first statements to direct general attention to the comparative immunity from consump- tion of regions at a great elevation. Further inquiries in the same direction have confirmed the general fact ; but they have in part also given color to an opposite conclusion, so that the question may be said to be still a lis sub judice for those who would decide it absolutely and without regard to accessory circumstances. " It is not to be denied that phthisis does occur at the highest inhabited spots on the globe, and that it is rare in many places situated on low plains. None the less is it an incontestable fact that consumption is, CCB- teris paribus, much less frequently met with at high- lying places than in those at a lower elevation or on the sea-level. Not only so, but the number of cases stands in some kind of definite proportion to the degree of elevation, while the exceptions to the general rule find Kiti> factory explanation in other etiological factors com- ing into play at the same time. " The rarity of phthisis at high elevations comes out on a great scale in the returns of sickness from that most extensive of the earth's mountain-chains which runs along the whole Pacific coast of the "Western Hemi- sphere. For the Eocky Mountains of North America wu have evidence of the fact from a number of places in the Territories situated toward the southern end of the range, such as New Mexico, Arizona, Colorado, and 232 PHTHISIOLOGY. also Utah. In like manner all the authorities speak of the rarity of the disease on the plateaus and mountain- slopes of Mexico, Guatemala, Salvador, Costa Eica, and Panama (for example, on the Cordilleras of Yeragua and Chiriqui). From Bogota, in New Granada, Holten writes that he did not see one consumptive person in the hos- pitals of the town during a prolonged residence there. "For the Peruvian Andes we have the statements of Smith and Tschudi, already mentioned. During a year's stay on the Cerro Pasco the former saw only one case of consumption, and that was in a woman who had come from Europe. In those parts of the Argentine Republic that are within the limits of the Andes, the influence of high elevations upon the rarity of phthisis is observable as far down as Salta. It is still more obvi- ous in the elevated valleys on the western side as well as on the Bolivian plateau, at Chuquisaca, Cochabamba, Potosi, and other places. In the mountainous parts of Guiana, also, consumption is almost unknown. "In the Eastern Hemisphere this immunity from phthisis comes out most decidedly on the plateau of Armenia, where the disease is found almost solely among those who have come from less elevated places ; also, on the table-land of Persia, where it is extremely rare, and among the natives of the country almost unknown; on the northern and southern slopes of the Himalayas, at the elevated points of the Western Ghats, on the Nil- ghiri Hills, on Mount Abu (4,000 feet) in the Arawalli range, and in Nearer India ; on the plateaus of Abys- sinia, and those of Southern Africa. ETIOLOGY. 233 " In Europe a certain rarity of phthisis begins to be noticeable even at comparatively small elevations, as in the Iser range and on the northern spurs of the Car- pathians in upper Silesia, on the elevated plain of Thu- riniria, in the upper Harz, and in the Spessart. Writing of upper Silesia, Virchow says : " Although I have seen an exceptionally large number of sick persons of the poorer class, both in town and country, at their homes and in hospital, yet there has not come under my notice a single case of phthisis, and the statements of the medi- cal men bear out the notion that the disease is rare." In the upper Harz consumption is so unusual that Brock- mann, during a practice of many years and extending to 80,000 sick persons, found only 23 phthisical patients, of whom only 14 had been born in the upper Harz. In the lower valleys the malady is more common, but the hiirli plateau is almost exempt. In the Spessart, accord- ing to Virchow, phthisis is at all events rare. In the larger villages he met with only an occasional case, while the registers of deaths rarely contained the entry of con- sumption or decline. I shall add here the interesting note by Gross, that consumption is almost unknown in l!ri:mcon (Hautes-Alpes), the most elevated town in Eu- rope (1,306 metres or 4,285 feet), although the place is a small fortress, with a good deal of filth and a number of industries. " Statistical inquiries, such as have been carried out in Saxony, Baden, and Switzerland, on the amount of phthisis at elevated places as compared with low-lying places close at hand (due regard being had to any differ- 234 PHTHISIOLOGY. ences in the mode of life), have confirmed that law of immunity of the more elevated places from phthisis which had been deduced from the study of the higher elevations by themselves. The following is Merbach's table for Saxony, based on a period of three years, from 1873 to 1875, and including only those towns with up- ward of 5,000 inhabitants and only the ages between fourteen and sixty: Altitude in metres Deaths from phthisis per 1,000 (8J feet). within the limit of age. 100 to 200 4-9 200 to 300 3-3 300 to 400 3'2 400 to 500 3-5 550 to 650 '. 3-3 "Merbach concludes as follows: 'There is certainly nothing shown here of any marked influence due to the elevation of the various localities or of such an influence as would cause the number of deaths from phthisis to decrease pari passu with the increase in elevation. A result of that sort was indeed not to be looked for, inas- much as the several towns are subject to other influ- ences and some of them noxious ones, such as the oc- cupation of the inhabitants, the density of the population, and the like, which are capable of neutralizing the good effect of an elevated location. At the same time, even in the instances before us, the good effects (otherwise sufficiently proved) of a high situation upon the preva- lence of consumption can hardly be overlooked whenever we begin to compare the villages in the lowest situation with those in the highest. . . . The contrast comes out ETIOLOGY. 233 with special clearness when the averages calculated for towns situated at one and the same level are compared together.' "Corval has worked out this relationship from the Baden bills of mortality over a period of four years (18C9-'72), including in his total, as he was bound to do, all those cases where the cause of death was given as 4 tuberculosis,' 'chronic pneumonia,' or * phthisis.' He distinguishes six groups of localities according to ele- vation : Table of Mortality from Phthisis in Baden, according to Elevation. Elevation in fat Number of towns or villages Population (av- erage of 4 yra.). Deaths from phthisis per 1,000. 1 830-1,000 760 933,773 8-36 2 1,000-1,600 837 224,210 2'75 y 1 600-2,000 160 81,066 2'60 4 2 000-2,600 190 104,289 2'76 r> 2,600-3,000 97 69,166 2-33 6 Above 8,000 47 20,367 2-17 " In order to ascertain what effect is produced upon the death-rate from phthisis by density of population, industrial pursuits, and other things peculiar to towns, wo may make a calculation of the mortality according to the size of every town or village in Baden, using Corval's figures. We shall find, accordingly, that it is 3-12 per 1,000 inhabitants for the whole of Baden, 3 for villages of 3,000 and under, 3'49 for towns from 3,000 to 10,000, and 4-56 for towns with more than 10,000 inhabitants; " If, no\v, we arrange the places that are respectively over and under 3,000 population in two columns, classi- 236 PHTHISIOLOGY. fying them in the six groups according to elevation, we shall get the following table of the death-rate from phthisis : Altitude groups. Under 3,000 population. Over 3,000 population. 1 3-11 4-06 2 2-73 3-08 3 2-49 4'99 4 2'71 4-72 5 2-29 3-06 6 2-17 "In the series with less than 3,000 inhabitants the favorable influence of increasing elevation is quite ob- vious; but in the second column of death-rates it will be seen that the benefit is in some circumstances more or less neutralized by detrimental factors belonging to the social and industrial life of the larger centers or the towns. Still, from the facts such as they are we may adopt Corval's conclusion that ' cases of phthisis de- crease with increasing elevation, or, in other words, in mere increase of altitude we may discover one of the most important factors in checking the development of consumption.' " Miiller's inquiries into the effect of elevation upon the prevalence of phthisis in Switzerland have led him to the same conclusion ; although the results, as he is careful to explain, can be said to be only approximately correct, for the reason that the data at his service were not free from a good many omissions and errors. He distinguishes three groups of places : (1) Those in which 43 to 63 per cent of the inhabitants follow some indus- ETIOLOGY. 237 trial occupation (cantons of Outer Appenzell, Glarus, Neuchatel, town and country divisions of Basel, and Geneva) ; (2) where the industrial part of the population reaches from 31 to 43 per cent (cantons of Zurich, St. Gall, Thurgau, Zug, Inner Appenzell, Aargau, Schaff- hauscn, Solothurn, Bern, Ticino) ; and (3) the agricultu- ral cantons where the industrial population is only 13 to 26 per cent (Lucerne, Schwyz, Unterwalden, Vaud, Frei- burg, Grisons, Uri, Vallais). Grouping the places in each of these divisions according to their elevation, within a limit of 200 to 1,800 metres (650 to 6,000 feet), we get the following table of death-rates: Table of Death-Kates from Phthisis in Swiss Towns and Villages. Elevation (in mctrt-s). Industrial cantons. Mixed cantons. Aprtcultural cantons. Average. 200-500 2-7 1-85 1-4 2-15 600-700 8-0 1-55 1-2 1-9 700-900 1-35 1'7 0'7 1-0 900-1,100 1-5 1-9 1'9 1-2 1,100-1,300 2-3 2'3 0-7 19 1,800-1,500 1-4 0-6 0-8 1,500-1,800 1-8 0-7 1-1 2*55 1-7 1-1 1-86 " Miiller concludes from these facts that in Switzer- land consumption can be shown to decrease as we as- cend ; that the malady does occur, although rarely, at the highest inhabited spots ; that the lowest locali- ties have, on the average, about twice as many con- sir, nptives as the highest, and very much more than that if cases where the phthisis had been acquired elsewhere be subtracted ; that the decrease of phthisis 238 PHTHISIOLOGY. with ascending elevation is, however, neither constant nor proportionate; and that the irregularities and fluc- tuations which are noticeable are owing mostly to the position in the social scale, inasmuch as the industrial groups of places show the irregularities most, and the mixed groups on the whole a regular decrease with height, while the agricultural groups touch their lowest death-rate at a comparatively small elevation. " What the minimum of elevation is that a locality must have before it feels the good effects of altitude on the prevalence of consumption is a question that can not be answered with certainty from the facts before us. Gustaldi puts it at 600 to 1,000 metres (2,000 to 3,300 feet). It seems to me, however, that a notable decrease in the disease can be shown to occur at as small an elevation as 400 or 500 metres (1,500 feet), provided other circumstances are favorable. " Opinions differ as to the nature of the influence of altitude. Some trace it to the air being free from de- composition-products dust and the like others to the dryness of the air and of the soil. " The only explanation that I can offer, and one to which I shall hold until something more satisfactory pre- sents itself, is that people who have been born and brought up at great elevations have been always nnder the necessity of making frequent (or perhaps deep) in- spirations, as a consequence of breathing a rarefied at- mosphere; that they are continually practicing a kind of pulmonary gymnastics, from which there proceeds a vigorous development of the breathing-organs, and a ETIOLOGY. 239 greater power of resistance on their part to noxious in- fluences from without. ' After looking at the bustle of traffic in towns like Bogota, Micuipampa, Potosi, and such like, at elevations of 8,000 to 12,000 feet,' says Boussaingault ; ' after witnessing the strength and mar- velous skill of the toreadors in the bull-fights at Quito, 9,000 feet above the sea-level; after seeing young and delicate girls dancing a whole night at places almost as high as Mont Blanc, on which the celebrated Saussure had hardly strength enough to use his instruments of observation, and his hardy guides fell down in a swoon as they proceeded to dig a hole in the snow ; when we remember, finally, that a famous battle, that of Pichincha, was won almost in the altitude of Monte Rosa I think that you will agree with me that man can become adapted to breathing the rarefied air of the very highest mount- ains.' I will readily grant that many of the accounts of embarrassed breathing experienced by natives of the plains on ascending very high mountains are exagger- ated; and I must confess that, in my own case, after resting for a short time at elevations of 10,000 feet and upward, I was conscious of no considerable want of breath, or did not become aware, at least, of any need for quicker or deeper inspirations. At the same time, it is not to be denied that the atmosphere at elevations of 10,000 feet, especially in a warm climate, is rarefied to the extent of more than one third of its volume at the sea-level. The quantity of oxygen contained in it is, therefore, considerably diminished, and a man must take in a larger quantity of air in a given time, or must 240 PHTHISIOLOGY. inspire oftener than on the plains, so as to cover his requirements for oxygen. To that assumption no well- grounded objection can be raised, whether from the side of physics or of physiology, and there is equally little reason why we should not assume that those who have been born and have lived all their lives under such cir- cumstances will have had their breathing-organs power- fully developed. I do not hesitate, therefore, to discover the reason of the immunity from phthisis enjoyed by the residents of elevated places, in the influence which a con- tinuous residence in a rarefied atmosphere exercises over them." Bell * savs, " The special effects of rarefaction of air t/ 7 -i. upon the animal economy has been illustrated and most satisfactorily studied during and since the construction of the Oroya Railroad, by Mr. Henry Meiggs, the only one in the world reaching the altitude of 15,640 feet." He gives the following particulars regarding the effects of rarefied air from his own experience on this road, and from the written and oral statements of Dr. G. A. Ward, who has been employed professionally on the road since its beginning : " The labor employed in building this road was prin- cipally the native Peruvians of the mountains, who are a short, thick-set race, called serranos, and have immense lung-capacity. Mr. S. "W. North, civil engineer, made some measurements of these serranos at Yauliyacu, an altitude of 16,000 feet, as follows: * " Climatology," etc. ETIOLOGY. 241 BKIOBT. AGE. Chest measure- ment. Proper height in Inches, of twice the chest measurement, European standard. Actual height in feet and inches, and in inches alone. Difference in inches. 14 years Inches. 36 Inches. 72 Ft in. in. 4 10 68 14 24 years 36 72 5 6J 66} H 21 years 85 70 5 4 64 3 341 69 5 60 9 80 years 3 69 5 41 641 41 Average difference in height between European and serrano, 7J inches. " This enormous increase in size of the chest is owing to the rarefaction of the air in which these natives live, enabling them to undergo an active and even laborious existence at these great altitudes. American engineers employed in building the road increased their lung-ca- pacity during their labors. One of these, Mr. John Mal- loy, informed me that the measurement of his chest had been increased four inches in two years by exposure to rarefied air in these Andes. "This peculiarity of adaptation to the demands of Nature enables these people to overcome the pains and inconveniences which are experienced by persons who ascend the Andes for the first time toward their sum- mits, and which are known under the names of soroche, veto, puna, etc. These symptoms indicate a diminished supply of oxygen, but more particularly a diminished pressure of air on the surface of the body and on the interior of the lungs. " The pressure at the sea-level, constantly diminishing as you ascend, is found to be reduced to about one half 21 242 PHTHISIOLOGY. at an elevation of 16,000 feet, or the summit tunnel of the Oroya Railroad. This withdrawal of pressure often occasions the most severe symptoms of vertigo, headache, nausea, and vomiting, all more or less alarming, and at- tended with profound prostration. The whole are at- tended with increased respiration and rapid action of the heart. Dr. Ward says some are affected with fear- ful nausea and vomiting, comparing it to the worst form of sea-sickness. Others suffer from severe frontal head- ache, palpitation of the heart, etc. From the violence of the heart's action it really seems at times as if it would burst the walls of the chest. Occasionally severe haemor- rhage occurs from all the avenues of the body. " The respirations are increased from three to five times a minute. Dr. Ward says he has counted 43 res- pirations and 148 pulse-beats in a minute at an elevation of only 9,000 feet, and that the pulse is always increased in frequency but not in volume. A person who at the sea-level has a pulse of 75 per minute would find it in- creased about ten beats at an altitude of 10,000 feet, and would experience ten additional beats for each 1,000 feet of added altitude. The rule is that no one passes for the first time an altitude of 16,000 feet whose pulse does not mount to from 130 to 150 beats in a minute. " These increased numbers of pulsations are abso- lutely necessary to avert a fatal result. The attending increased respiratory action is not accompanied with in- crease of secretions, but an increased amount of air of inferior quality, from actual reduction of the amount of oxygen, fails to aerate or properly preserve the fluidity ETIOLOGY. 243 of the blood. . . . Mountain-air of an altitude of 2,500 feet and upward, with rare exceptions, possesses the one chief attribute of salubrity common to sea-air freedom from organic impurities. Pasteur, Tyndall, and others have shown that the air of great altitudes is entirely free from organic impurities. "Miguel, as recently quoted by Weber, gives the following interesting table of the number of bacteria found in ten cubic metres of air taken as nearly as pos- sible at the same tune in July, 1883 : 1. At an elevation of from 2,000 to 4,000 metres 2. On the lake of Than (560 metres) 8 8. Near the II6tel Bellevue, Thun (560 metres) 25 4. In a room of the H6tel Bellevue 600 6. In the Park of Montsouris, near Paris 7,600 6. In Paris itself (Rue de Rivoli) 65,000 " This table is doubtless equally indicative of the difference in the amount of floating organic matter in the air at different altitudes." * " Differences in the social, hygienic, commercial, and indiist/rial conditions of various parts of the world have a real import for the more or less frequent occurrence of phthisis therein. This is shown in the first instance by the distribution of the malady respectively in town and country, in large populous towns and in those that are small or thinly populated, and among a stationary or a nomadic population. As a general rule, phthisis is commoner in towns than in the open country, and rarer in small towns than in large, or, in other words, it * Hirech. 244 PHTHISIOLOGY. is found in greater diffusion the more crowded the popu- lation. " In England, according to the statistics of mortality from 1859 to 1869, the lowest death-rates from phthisis (1*8 to 2*2 per 1,000) are found in the counties most given up to agriculture and pasture, and with few large towns, such as Kutland, Worcester, Wilts, Dorset, Som- erset, Herts, Bucks, Hereford, Gloucester, Shropshire, and Lincoln; while the highest death-rates (2'7 to 3-3 per 1,000) occur in the counties with many places of manufacture and trade, the centers of industry and com- merce, such as Notts, Derby, West and East Hidings, Durham, Northumberland, Cheshire, Lancashire, and the metropolis. For Denmark the following ratios of death from phthisis have been calculated by Lehmann from the statistics of 1876-'83 : In Copenhagen, 3 per 1,000; in the five largest provincial towns, mostly engaged in trade, shipping, and manufacture, and with populations from 12,700 to 25,000, 2-63 per 1,000; in twenty-four towns, with from 3,100 to 9,000 inhabitants, agricultural in the first place but also concerned in trade, manufact- ure, and handicrafts, 2*27 per 1,000 ; in the thirty-five smallest towns, with from 700 to 2,900 inhabitants, most- ly agricultural, but also occupied with fishing and ship- ping, 2-12 per 1,000. In Holland, according to Fokker, the death-rate from phthisis in the towns is to that in the open country as 21 to 16. Summing up his statistical inquiries on the mortality for the years 1866-'75, Droeze says, " In nearly every group of places in the most di- verse provinces of Holland the death-rate from phthisis ETIOLOGY. 24.") was greater in the towns than in the country par- ishes. " The following table, which has been compiled from Schlockow's figures, showing the mortality from phthisis in town and country in the several administrative divis- ions of Prussia, is of value in thic connection : Mortality from Phthwis in Town and Country, per 1,000 Inhabit- antt (Pruuia). Town. Country. 2'49 ( i uinhinneo 2'77 Dantsic 2'39 Maricnwerdcr 2'64 Potsdam 2*88 Frankfort 8'08 St-ttin 2'90 Kii.-lin 2-58 Stralsund 3'2l Posen 2-96 Bromberg 8'13 i 8'73 Liejmitz 2-98 8'99 2'98 :rur 2-63 Erfurt 2-60 Schleswi;,' 8-31 Hanover 8'38 Hildesheim 2'66 Liincburg 8'85 Static 8-18 Osnabriick 4'87 Aurich 8-81 Miinster 6'50 Mindcn 4'78 Arnabcrg 6'46 8-48 Wiesbaden 8'82 ('..l.lrlitZ 4-JM i-irf 6'22 Cologne 4-76 Tiwcs :,: | Aix :: . t 8'1 1 1-45 1-84 1-41 1-35 2-33 2-25 2-08 1-60 2-12 2-04 1-85 275 2-35 2-45 2-65 2-16 2-70 8-18 4-44 8-21 3-39 4-UO 6-22 8-79 4-70 4-90 4-51 8-08 4-08 4-85 fi-29 5-34 :;;..-, 4-59 8-68 246 PHTHISIOLOGY. "In Baden, from 1852-'71, the death -rates from phthisis group themselves as follows : Tillages or towns. Population. Deaths from phthisis per 1,000. 95 100- 500 2'3 92 500- 1,000 2'6 53 1,000- 2,000 3-0 17 2,000- 4,000 8-4 3 4,000- 8,000 S-5 3 17,000-31,000 3-9 "In the Bavarian administrative section of middle Franconia, Majer estimates the proportion of deaths from phthisis between town and country at 100 to 61. In the arrondissement of Dax (departement Landes) consumption is hardly known among the rural population, but it is far from rare in the towns, and the same fact is recorded of the arrondissement of Nerac (departement Lot-Ga- ronne). In the course of inquiries upon the antagonism between phthisis and malarial diseases in Ferrara and vicinity, Bosi and Gambari came to the conclusion that phthisis was rare among the rural population at those places where malarial fevers were endemic, that it was more common in the villages with a rather crowded population, and that it was very prevalent in the large towns. They found the same proportions also in those parts of the country where malarial fever was merely sporadic ; in other words, the density of the population was, cceteris paribus, decisive for consumption. It is very significant for the question before us, as already indicated more than once, that nomad peoples enjoy an almost complete freedom from phthisis ; this holds good ETIOLOGY. 217 for the Kirghiz hordes of the Russian steppes, for the Arab tribes in Kabylia and other parts of Northern Africa, and for those of nearer Asia. The disease is met with oftenest, says Pruner, 'among those Bedouin families who have exchanged the tent for the dwelling built of stone.' " Another interesting proof of the influence exercised upon the amount of phthisis by the social factors is afforded us in the disease increasing as a result of ex- tensive immigration and the consequent founding of new town*, or enlargement and crowding of old ones. Writing in the last century, Rush * says : " Phthisis is scarcely known by those citizens of the United States who live in the first stage, of civilized life, and who have lately obtained the title of the first settlers ; it is less common in country places than in cities, and in- creases in both with intemperance and sedentary modes of life." Since that was written, the disease has in- creased considerably, not only in the Eastern States but also in the Western, along with the founding of cities and the rise of traffic and industry. Writing in 1828, of the western counties of Pennsylvania, Callaghan says that "phthisis is increasing among the sedentary popu- lation of our towns with fearful strides " ; and for a more recent period there are accounts from that State, as well as from California, of the disease increasing hand in hand with progressive immigration and additions to the * " Medical Inquiries and Observations," Philadelphia, 1789, p. 159. Hirsch, loc. cit. 248 PHTHISIOLOGY. population of the towns. Still more recently Davis has written of the "Western States as follows : " Close build- ings and increased aggregation of population are increas- ing the prevalence of pulmonary tuberculosis in our country at an alarming rate. ... In still earlier days, dating back to the early settlements of this country, New England and the Northeastern States were as free from consumption as are now the much-vaunted far- Western States and Territories. It was immediately consequent upon the change from an agricultural to a manufacturing population that the rapid increase in the death-rate from consumption is apparent in these States. Fifteen or twenty years ago Indiana, Illinois, and the lake region were the favorite resorts for consumptive patients. . . . Now we have a constantly increasing pro- portion of cases originating in this same region, not evidently from any change that has taken place in the climatic conditions, but, as before stated, from the change in the occupation and hygienic surroundings of the people." Flick* discovers in the Americanizing influences to which our inhabitants of foreign parentage, particularly the Irish, are usually subjected, a potent factor in the etiology of consumption. Although his views on the subject, which I give in his own words, may be incorrect, they nevertheless possess the merit of being novel: * " The Hygiene of Phthisis," a paper read before the Philadelphia County Medical Society, January 11, 1888, by Lawrence F. Flick, M. D., loc. cit. The " Journal of the American Medical Association," February 4, 1888. ETIOLOGY. 249 "According to the United States census reports for 1880, . . . among people of Irish parentage, 309,507 males and 375,636 females die of consumption to every million deaths ; and among people of German parentage the victims of the disease number 249,498 males and 254,958 females to every million deaths. It will be seen that the largest percentage of deaths from the disease is among Irish immigrants and their children. This is usually ascribed to the change in climate. Ireland has a much damper climate than America, and therefore one better suited to the development of phthisis. The real cause for the larger mortality from consumption among foreigners, and especially among the Irish, is the change in diet. At home they have been accustomed to a plain, healthy diet, and when they come to this country they at once take to the varied heavy diet of Americans. Where they have eaten little meat at home, they eat it in profusion here ; where they have drunk good milk and eaten vegetables at home, they drink teas and cof- fees and eat spiced foods here. They soon become thor- ough Americans in their stomachs, and even outdo the natives. The consequences are indigestion, malnutrition, tuberculosis, etc. The German, though frequently pur- suing a similar course, is often spared by his character- istic thrift and economy. lie partakes more sparingly of the y the assumption that coal-dust 254 PHTHISIOLOGY. actually possesses the power of inhibiting the develop- ment of consumption. This theory is so opposed to all our knowledge of the disease that we are inclined to look elsewhere for an explanation. Two facts may perhaps give us the clew to a more acceptable hypothesis : The work in coal-mines is excessively laborious, hence it is not at all likely to be chosen by those whom hereditary tendency or acquired debility of any kind predisposes to \^- consumption ; in the second place, we know how often a sudden and marked impairment of physical vigor is the first premonition of threatening consumption hence it is probable that many coal-miners, on becoming sensible of this diminished vitality, relinquish their laborious work, and, seeking a livelihood by some lighter occupation, fail to be tabulated as miners in the mortality returns." Returning to Hirsch, we find the following valuable data on this subject : " Summing up Greenhow's inquiries, which were based in part on official statistics of the mor- tality, and in part on independent local researches into the death-rate from consumption in the manufacturing districts of England, Simon concludes as follows: " ' In proportion as the male and female populations are severally attracted to indoor branches of industry, in such proportion, other things being equal, their re- spective death-rates by lung-disease increased, . . . and this further conclusive proof was given as to the influ- ence of an accused occupation, viz., that the high death- rate from lung-disease belonged, according to the occu- pation, to men or to women of the district, that it some- times was nearly twice as high for the employed sex as ETIOLOGY. 255 for the unemployed sex, and that it only extended to both sexes where both were engaged in the occupation.' " Smith has ascertained, for one thousand persons treat- ed for consumption at the Brompton Hospital, that 70 per cent of them had been in the habit of spending their time in over-crowded, hot, and dusty places indoors. Finkelnbnrg's summary of his inquiries into the causes of mortality in Rhenish Prussia is as follows : "'The victims of pulmonary phthisis are the more numerous the more generally are indoor occupations followed by the one sex or the other, especially when the materials of their work are such as to create dust wool-carding and spinning, knife-grinding, and metal- polishing are the most pernicious. Wherever these oc- cupations are found among the rural population as well, there also the mortality from phthisis reaches a high figure, although never so high as in towns with the same industries.' " From the paper of Schweig on the distribution of phthisis in Baden, it appears that the mortality from it is in proportion to the density of the population, as well as to the more or less industrial character of each locality, the smallest communities being mostly engaged in agri- cultuiv, while the larger villages and largo towns are occupied with industrial pursuits. Kolb shows, from the statistics of Bavarian hospitals for 1877 and 187*, that 'consumption in Bavaria is com- monest in the highly industrial region of central Fran- conia, where the influence of manufactures has born at work for generations.' In Miiller's inquiries into the 256 PHTHISIOLOGY. state of health in Switzerland, he divides the country into agricultural, industrial, and mixed sections (the last being partly devoted to farming and partly to manu- facture), and he finds that the phthisical death-rate of the industrial group stands to that of the agricultural in the ratio of 69 '8 to 30'2 ; of the industrial to that of the mixed, in the ratio of 53'8 to 46'2 ; and of the mixed to that of the agricultural, in the ratio of 66'5 to 33*5. The general law deduced from his research is, that the mortality from phthisis in the industrial circles is, on the average, more than double that in the agricultural. The actual figures are 2*55 per 1,000 in the industrial localities, 1'7 in the mixed, and I'l in the agricultural, giving a proportion of 47'7 to 31/8 to 20*8. In Belgium, according to Meynne (loc. cit.\ the highest proportion of deaths from phthisis falls to the industrial divisions of the country. From a paper by Chatin, it appears that the amount of phthisis among the factory-hands in Lyons is altogether enormous ; it is greater than in any other part of France or in any other country, the mortality from it having amounted in 1866 to 33 per cent of the deaths from all causes at the Hopital de la Croix-Rousse. This fact is confirmed by Fonteret, who says that the female part of the working-class suffers more than the male, for the reason that the women are more subject than the men to the noxious influences (sedentary indoor life in factories). "Poulet calls attention to the fact that, in the vil- lage of Plancher-les-Mines (arrondissement Lure, departe- mente Haute-Saone), where the people until about thirty ETIOLOGY. 257 years ago were occupied with agriculture almost exclu- sively, but have been devoted since that time mostly to industrial pursuits, phthisis now causes 12'5 per cent of the total mortality, whereas formerly it was very seldom seen. The malady is exceedingly common among the Kashmiri weavers in and around Amritsur (Punjaub), who live, as Hinder tells us, crowded together in con- fined, dark, and filthy rooms. "The same circumstances serve to account for the strikingly common occurrence of phthisis in nunneries, SL'ininark-s, and such-like institutions, in evidence whereof a number of observations have been brought forward by Fourcault ; also in the Oriental harems, not only among the women, but among the children also ; again, among badly lodged troops, of which we have evidence from England, France, Turkey, and India; and, above all, in prisons. " Among army- surgeons there is complete agreement that cases of phthisis are least common in soldiers when they arc leading an active life in the open air, on the march, or in manoeuvres and campaigns, and that the cases mount up as soon as the troops enter on their gar- rison-life, as, for example, in winter, and spend their time in ill-constructed, crowded, filthy, and badly venti- lated barracks. "Welch, who treats of this matter with reference to the British army, says that * nearly half of army consumption is connected with vitiated barrack atmosphere,' a similar opinion having been expressed by earlier writers, such as Tulloch and Maclean, the latter including in his btau-mcnt the- British au.l native troops 258 PHTHISIOLOGY. in India. With respect to its frequency in the French army, we find a similar reading of the facts in the papers by Champonillon, Tholozan, Viry, Lausies, and others." Phthisis in Prisons.* "Consumption prevails in prisons to a truly disastrous extent. In United States prisons from 1829 to 1845 the mortality from phthisis was 12-82 per 1,000 prisoners at Philadelphia, and at Auburn and Boston 9'89 and 10-78 respectively ; in Bal- timore prison it was 61 per cent of the mortality from all causes. In the French prisons, particularly those in which long terms of penal servitude are worked out, the death-rate from phthisis amounts to between 30 and 50 per cent of the mortality from all causes. In the Dutch prisons it reaches the same height; in the Danish con- vict-prisons it amounted in 1863-' 69 to 39 per cent of all the deaths; over the whole of the prisons of the Austrian Empire in 1877-'80 it was 61'3 per cent ; and in the nine large convict-prisons of Bavaria from 1868 to 1875 it was* 38-2 per cent. In the penal establish- ments of "Wurtemberg, according to Cless, the yearly average of deaths from phthisis from 1850 to 1859 was 24 per 1,000 ; while from 1859 to 1876, in consequence of an improved diet, it fell, as we have seen, to 8 per 1,000, although it still remained two or three times greater than among the people at large. During a pe- riod of eleven years (1869-'79) the mortality in the prisons of Prussia was 4-2'87 per cent of the deaths from all causes, and 12'32 per 1,000 prisoners. * Hirsch. ETIOLOGY. 259 " For England we have Baly's report on the preva- lence of phthisis from 1825 to 1 842 among the convicts at Millbank Penitentiary, where 31 out of 205 deaths were due to cholera, and 75 of the remaining 174, or 43 per cent, due to phthisis ; while of 355 prisoners discharged during the same period on account of ill health, 90 were phthisical, and of these quite three fifths, according to precedent, would have died of that disease if they had been left to complete their term. In that way we bring the annual mortality from phthisis at Millbank up to 13 per 1,000, or more than three times that of the London population at large. Pietra Santa gives the following facts for the prisons of Algiers : Of 23 natives who died in the public prison of Alger, 17 succumbed to phthisis ; in the central prison of 1'Harrach there were 57 deaths from phthisis in a total of 153, or 37*2 per cent The important influence of imprisonment on the occurrence of this disease is very clearly brought out by its preva- lence in those regions where phthisis is in general a rare thing, as, for example, in Lower Bengal. Webb quotes the following remarks by Green with reference to the commonness of the disease among the natives in the prison of Midnapore: " * After a careful examination into the early history and origin of the cases of this disease as they have oc- curred, I have been led to the conclusion that many of the men thus affected were previously hale, and capable of (.'urnintT their livelihood, and were not subject to cough before imprisonment. I find that, after they have been working a few weeks or months on the roads here, and 260 PHTHISIOLOGY. inhabiting the jail, they have become the subjects of attacks of inflammation of the lungs, and from time to time of frequent repetition of these attacks, which have ended, in some cases, ... in death in the acute stage, in others in a prostrate sinking state, with a gradual wasting away of the body, and all the symptoms and ultimately all the post-mortem morbid appearances of tubercular disease of the lungs.' Next to the hard labor, Green lays most stress on the bad ventilation of the cells, and on the highly defective construction of the prison in other respects " The great frequency of consumption in convict-pris- ons may seem to be due to many of the prisoners bring- ing the disease with them ; but that such is not the case follows from the well-authenticated fact that most of the deaths from phthisis among prisoners do not occur until the later years of their term of confinement. At Millbank Penitentiary signs of a pulmonary affection on admission could be made out, as Baly tells us, in only 12 prisoners among 1,502 who entered in 1842, and in only 15 among 3,249 who were received in 1844. Among the convicts of 1842 there were 510 women sentenced to transporta- tion, who remained at Millbank not longer than three months, and of these 2 fell ill with phthisis or scrofula during that time, whereas of the remaining prisoners ad- mitted no fewer than 47 became consumptive before the completion of their terms of two or two and a half years. It is further to be kept in mind that most of the convicts sent to Millbank had already served longer or shorter terms in smaller prisons elsewhere, and not a few of ETIOLOGY. 261 them more than one term, so that, in a certain proportion of those who were found phthisical on admission to the central prison, the seeds of the disease might have been implanted while they were undergoing sentence previ- ously." * Heredity. Of real importance for the frequent occur- rence of phthisis is the transmission of the disease by way of heredity. "That phthisis propagates itself in many families from generation to generation is so much a matter of daily experience that the severest skeptic can hard- ly venture to deny an hereditary element in the case, even if we be unable for the present to decide whether it consists in the transmission of a specific poison, some- thing like that of syphilis ; or, in other words, whether it be heredity in the narrower sense ; or whether it does not rather depend upon a congenital disposition toward the disease, a disposition that has to be looked for naturally in the organization of the respiratory system. " In Switzerland, according to Midler, the number of cases in which heredity was made out for certain ex- ceeded by a little (5 or 6 per cent) those in which the malady had been acquired. "Walshe found phthisis to be hereditary in 162 out of 446 families, or in one third * In closing this subject I wish to call attention to the fact that there exists in this great country, populated as it is by sixty million people, one seventh of whom will succumb to pulmonary consumption, but one institu- tion for the rational (pure air) treatment of the disease under considera- tion. An able appeal for the general establishment of such institutions in the United States was made in a paper which was read before the New York Academy of Medicine, February 18, 1888, by Paul IL M. D., but it has met with little suoeeM. 262 PHTHISIOLOGY. of them. In a thousand cases of consumption, Smith ascertained that the parents had been phthisical in 21*1 per cent, and the brothers or sisters in 23 per cent. Briinicke reckons the number of hereditary cases in Copenhagen at 46 per cent of the whole. Gjor was able to prove heredity in 197 out of 357 patients treated for phthisis in the hospital of Christiania, or 55'1 per cent." * Eeferring to hereditary tuberculosis, Koch f says : " There are no facts to prove the view that tubercle- bacilli may be present in the immature organism, either in the intra-uterine or extra-uterine state, without leading in a relatively short time to visible changes. Now, tuber- culosis is very rarely found in the foetus and the newly- born, hence we must conclude that the infective material comes into operation only exceptionally during intra- uterine life. This view corresponds with the fact that those of the animals experimented on, particularly Guinea- pigs, which were either pregnant before or became so after inoculation, in no case gave birth to young which already showed signs of tuberculosis. The young of highly tubercular mothers were free from tuberculosis and remained healthy for months. In my opinion, he- reditary tuberculosis is explained most naturally by sup- posing that the infective germ itself is not inherited, but rather certain peculiarities favorable to the development of germs which may later on come into contact with the * Hirsch. f " Investigation of Pathogenic Organisms." New Sydenham Society's Translations, 1886, p. 200. ETIOLOGY. 263 body ; in fact, it is the predisposition to tuberculosis which is inherited." Contagious Transmission. Hirsch, speaking of the contagious transmission of tuberculosis, says that " those who start convinced that the terms * pulmonary consump- tion J and * pulmonary tuberculosis ' cover each other ex- actly, or that the anatomical changes proper to phthisis in -sues of the lung depend absolutely and always upon the penetration of tubercle-bacilli into that organ, and who know or seek to know nothing else than the positive results of experiments to inoculate animals with tubercle-bacilli such persons have no object in discussing the question of the spread of phthisis by contagious transmission ; it is answered for them absolutely and unconditionally in the affirmative. But the case is different with those who proceed to solve the question from the side of actual ex- perience (and in such matters these men have an impor- tant voice), who look at those experiences on all sides, and test their value as proofs that may be adduced in favor of the contagiousness of consumption. " It will have been observed that there have lately been instituted in England ' collective investigations' or etio- logical inquiries upon a number of the more ordinary dis- eases, conducted in common according to a definite plan. One of these has had reference to phthisis, and has yielded the following conclusions with respect to the transmission of that disease: Of 1,078 answers to the question, 673 were simply neutral that is to say, so many of those who returned the card had no information to give one way or another; in 105 of the answers, the 264 PHTHISIOLOGY. question was decidedly negatived ; in 39, the answer was doubtful ; and in 261 cases, transmission was absolutely affirmed. Among these 261 cases, phthisis had passed from husband to wife in 119, from wife to husband in 69, from parents to children or between the children of one family in 81, to more distant relatives in 13, and to those who stood in no relationship in 8 cases. Prof. Humphry, of Cambridge, and Dr. Mahomed, of London, who edited the report of the committee on these collect- ive investigations, do not admit any further inference from them than that, "if phthisis is a communicable dis- ease, it is only under circumstances and conditions of ex- tremely close personal intimacy, such as persons sharing the same bed or the same room, or shut up together in numbers in close, ill-ventilated apartments." C. T. "Williams gives the following facts relating to the Brompton Hospital for Consumption, the largest in- stitution in the world devoted to the treatment of the phthisical : * "The hospital has been in existence since 1846, in which year it was opened with 90 beds. In 1856 the number of beds was increased to 200, and in 1873 to 240. Three fourths of the patients suffer from phthisis in its various stages, the remainder being admitted for bronchitis, pleurisy, empyema, chronic pneumonia, and the like. Previous to 1877 the left wing was ventilated most imperfectly ; since that year, however, the extrac- tion of foul air has been well performed. The spittoons * "British Medical Journal," September, 1882, page 618. ETIOLOGY. 265 of the patients are changed two or three times a day; but until lately no attempt was made to disinfect them unless the odor was unpleasant. " The out-patient department was until the winter of 1881-'82 situated in the old hospital, and was much too small for the number of patients, who averaged 200 to 300 daily, mostly phthisical. This large concourse must, on the theory of infection, have proved a considerable source of danger to the assistant physicians, to the clerk who enters their names, and to the porters who marshal them and keep order. "The deficiency in the ventilation," says "Williams, " must have led to a large accumulation in the wards of the products of respiration and also of our friends the bacilli. We consequently ought to have seen an extension of the disease to non-consumptive cases or to the nurses; but nothing of the sort occurred, only the usual results of hospitalism, i. e., erysipelas and sore throat. Among the physicians, assistant physicians, clinical clerks, nurses, and others, to the number of several hundred, who had served in the hospital (not a few of them having lived in it for a number of years continuously), phthisis had not been more common than it may be expected to be on the average among the civil population of a town ; and only in three or four cases could the outbreak of it be brought in any way into connection with the individual's resi- dence in trie hospital. " The evidence of large institutions for the treatment of consumption, such as the Brompton Hospital, directly negatives," Williams concludes, "any idea of consump- 23 236 PHTHISIOLOGY. tion being a distinctly infective disease, like a zymotic fever." He admits that in his private practice a few cases had occurred of phthisis ensuing in those who had been in very close intimacy with consumptives; "but, when we bear in mind the far greater number of exam- ples of consumptives living in close intimacy with healthy people, in such relationships as husband and wife, mother and daughter, or sisters sleeping together, where no spread of tubercular disease has taken place, we must admit that the negative evidence against infection great- ly preponderates over that of the very few positive in- stances." " During a practice of twenty-three years in an exten- sive district (Tynedale), Fraser had not seen a single case of consumption which told in favor of transmission from husband to wife, or vice versa. In twenty-six fatal cases, in which either the husband was affected or the wife, the married couple had shared the same bed and lived in the closest intercourse with each other without any trans- mission of the disease taking place. Over a half of these twenty-six persons had near relatives similarly affected ; phthisis had already proved fatal to children of nine of these marriages, and, judging from appearances, many more were likely to suffer. Reginald Thompson has had under observation fifteen well-marked examples of wives infected by husbands out of something like 15,000 cases of phthisis, so that the proportion may be reckoned as not less than one per thousand. "Bennet gives it as his opinion, based on twenty-five years' experience, that, if there has been any spread of ETIOLOGY. 267 phthisis at all by means of contagion, it has occurred extremely seldom, and only in quite peculiar circum- stances." * " If we inquire," according to Koch,f " how far phthi- sis may occasion the transference of tubercle-bacilli from diseased to healthy subjects, it is very evident that all the conditions for the distribution of the infective material in very large quantities are here present. It is necessary only to remember that on an average one seventh of mankind die of phthisis, and that most phthisical patients eject for at least some weeks, often for whole months, large quantities of sputa, containing immense numbers of spore-bearing tubercle-bacilli. Most of these countless infective germs, which are scattered everywhere, on the floor, on articles of clothing, etc., perish without finding an opportunity of settling again in a living host ; but if we further bear in mind the results of Fischer and Schill's experiments, from which it is seen that tubercle- bacilli may retain their virulence for 43 days in putrefy- ing sputum, and for 186 days in sputum dried at the ordinary temperature of the air i. e., if we remember the immense number of tubercle-bacilli derived from phthisi- cal patients, and, as we have just seen, their tenacity of life both in a moist and in a dry condition a sufficient explanation is afforded of the very wide distribution of the tubercular virus. " There can likewise be no doubt as to the manner in which the tubercular virus is carried from phthisical to * Ilirech. f Koch, " Investigation of Pathogenic Organisms," etc. 268 PHTHISIOLOGY. healthy subjects. By the force of the patient's cough, particles of tenacious sputum are dislodged, discharged into the air, and so scattered to some extent. Now, nu- merous experiments have shown that the inhalation of scattered particles of phthisical sputum causes tuberculo- sis with absolute certainty, not only in animals easily sus- ceptible to the disease, but in those also which have much more power of resisting it. It is not to be supposed that man would be an exception to this rule, but, on the con- trary, we may surmise that any healthy person brought into immediate contact with a phthisical patient and in- haling the fragments of fresh sputum discharged into the air, may be thereby infected. But probably infection will not often take place in this way, because the particles of sputum are not small enough to remain suspended in the air for any length of time. Dried sputum, on the con- trary, is much more likely to cause infection, as, ow- ing to the negligence with which the expectoration of phthisical patients is treated, it must evidently enter the atmosphere in considerable quantity. The sputum is not only ejected directly on to the floor, there to dry up, to be pulverized and to rise again in the form of dust, but a good deal of it dries on bed-linen, articles of cloth- ing, and especially pocket-handkerchiefs, which even the cleanliest of patients can not help soiling with the dan- gerous infective material when wiping the mouth after expectoration, and also is subsequently scattered as dust. " Examination of the air for bacteria capable of devel- opment has shown that they are not suspended separately in the air, but that they dry on the surface of objects ETIOLOGY. 269 arid do not enter the air until the dried mass breaks up, or unless the object on which the dried fluid rests is it- self so light as to be carried away by the slightest breath of air. Such readily distributed carriers are particles of dust, consisting of bits of vegetable fiber, animal hair, epidermis scales, and such like. Hence we have to fear chiefly the soiling with phthisical sputum of materials consisting of vegetable products or animal hair, such as lerwf for the purpose of ascertaining the actual * " A Contribution to the Climatological Study of Consumption in Penn- sylvania." By William Pepper, M. D., LL. D., Philadelphia. Published in the " New York Medical Journal " for December 4, 11, and 18, 1886. f The italics are mine. G. A. E. 286 PHTHISIOLOGY. movement of population, the improved method em- ployed in this tenth census, and the ability shown by Dr. Billings in the arrangement and analysis of the re- sults, render the two volumes which have just appeared highly valuable to the profession, and highly creditable to the genius and energy of their distinguished author." Billings states : " While the original schedules of deaths contain data from which it would be possible to make, in part at least, the necessary deductions to express the true tendency to this disease (consumption) in these (certain) localities, such calculations have been made impossible from the want of clerical force" * As Flick truly observes : " Medical science has grown beyond the mere art of prescribing remedies; it has become a science of protecting man against disease, and enabling him to attain his threescore and ten. As government exists for the good of society, it ought to avail itself more extensively of so powerful a means to its end." Concerning the conclusions which may be deduced from the evidence which has been submitted in regard to the geographical distribution of phthisis, I can not do better than give the following brief summary of Hirsch's conclusions : f "Phthisis is everywhere prevalent, but it is rare in polar regions, and rarer still at great altitudes. The main factor in its production is over-crowding and bad hygiene. Heat and cold, per se, have no influence. * The italics are mine. G. A. E. f " British Medical Journal." CONCLUSIONS. 287 Damp, when conjoined with frequent oscillations of temperature, predisposes to the disease; but humidity of the air is less important than dampness of soil. Oc- cupation is extremely important, but mainly indirectly, as tending to good or bad hygienic conditions." "With reference to the part played by the tubercle ba- cillus, it is reasonable to believe that it holds the same etiological relation to pulmonary phthisis that certain other micro-organisms hold to external surgical affections, to septic diseases of the (post-partum) uterus or its con- tiguous tissues, etc. That pulmonary phthisis occasionally terminates in recovery there can be no doubt. Cases are frequently reported by competent observers in which recoveries have taken place. The following recent report of a case of spontaneous recovery from pulmonary consump- tion is of so much interest in this connection that I give it unabridged:* "The subject of this communication, a young woman aged twenty-three, first came under my observation in the latter part of 1884. Her family history was bad ; her father and a brother had succumbed to lung-disease ; a sister was lying ill of phthisis, of which she shortly died; and she herself was weak, anaemic, and very dyspeptic. " Notwithstanding these hindrances, she managed, with the aid of arsenic and iron, to fulfill her arduous duties as a teacher, with but slight intermissions, until August, 1886, when increasing weak- ness, anorexia, and scrofulous inflammation of the right cervical glands Iniil II.T nsirlc. An examination of the lungs at this time revealed nothing very definite. In due time a largo quantity of * " Recovery from Subacute Phthisis." By A. G. Auld, M. D., London "Lancet," February 11, 1888. 288 PHTHISIOLOGY. characteristic pus was twice abstracted from the neck. Shortly afterward, about Christmas, an intense inflammation attacked the great joint of the thumb of the right hand, leading to sinuses, dis- charging evidently tubercular pus. After two months this discharge, with its attendant phenomena, began to disappear, while simultane- ously were developed the signs and symptoms of phthisis pulmo- nalis. The disease at first threatened a somewhat severe course. The left lung became extensively involved ; temperature ranged from 102 to 104; cough and expectoration considerable; night-sweats profuse ; circulation very weak ; appetite gone. ' Those are the gloomiest cases of phthisis,' says Dr. Button, ' where there are anaemia and weakness of the pulse.' " In the middle of May, Bergeon's treatment, then attracting at- tention, was contemplated, but the patient was considered too weak, and the idea was abandoned. About this time, however, the stom- ach, which hitherto had resisted all treatment, began to show signs of improvement, and as much suitable food as could be borne was administered. Occasional attacks of sickness were best relieved by a few drops of solution of cocaine, with ice, and the bowels were kept well open. No antiseptics were employed, as I have been invariably disappointed in their use. This improvement steadily increased, accompanied by a very pronounced amelioration of the general symptoms and a very remarkable gain of flesh, till by the middle of July the pyrexia and night-sweats had almost entirely ceased. The expectoration nevertheless continued, and there were the physical signs of a vomica in the left apex, while in the right moist rales were audible. Considering the case unusual, I communi- cated with Prof. Hamilton, of Aberdeen, in the month of August, who kindly examined the sputum, and reported that, after a very careful examination, he found that ' it contained the tubercle bacillus in considerable abundance.' From this period onward the patient was rapidly recovering, and by the end of September the cough and expectoration had nearly ceased, the moist sounds had almost van- ished, and vesicular breathing was partially restored over the dam- aged areas. Early in October menstruation took place for the first time for several years, the discharge being normal as to duration and amount. By the beginning of November the cough had entirely disappeared, no moist rales were audible, menstruation had reap- peared, and hitherto this favorable condition is maintained. " REMARKS. I think it may be fairly asserted that this is a very striking case of cured phthisis, considering that the patient was CONCLUSIONS. 289 boosed on a damp soil, in comparatively unfavorable surroundings, and recovered without tbe use of any of the ' special ' means of The generally recognized fact that pulmonary phthi- sis depends upon impure air more than upon any other etiological factor for its origin, has led to the aseptic (climatic) air treatment for its relief. That the best results have been secured at great altitudes admits of no doubt. The influences supposed to be productive of the beneficial results reported are, aseptic air, attenuated air, dry air, cold (tonic) air, and ozone. It has been shown, in a previous chapter of this work, that respiration in attenuated air demands greater respira- tory energy than it does in an atmosphere of sea-level tension in order to get the same (a sufficient) quantity of air into the lungs. Respiration of attenuated air pro- duces positive mechanical effects of undoubted benefit, not only upon the pulmonary organs per se> but also upon the circulation, by diminishing the atmospheric re- sistance to the passage of blood tlirough the lungs and tissues generally, or, in other words, by lowering the ar- terial pressure. The following reports and discussions on the " Treat- ment of Consumption by Residence at Great Altitudes " are of much interest in this connection : * " Dr. C. Theodore Williams read a paper on the ' Results of tbe Treatim-'it of Pulmonary Consumption by Residence at High Alti- tudes,' as exemplified by an analysis of 141 cases, of which the fol- * " Royal Medical and Chirurgical Society," May 8, 1888. Published in the London " Lancet " for May 12, 1888. 25 290 PIITHISIOLOGY. lowing is an abstract : The author offers a contribution from his own practice of 141 cases of phthisis treated in sanitaria varying in alti- tude from 5,000 to 9,000 feet, in the Alps, the Eocky Mountains, and the South African Highlands, during the last nine years, in or- der to deduce certain practical rules therefrom. The 141 cases have been tabulated for statistical purposes under the following headings : Sex, age, length of illness before the commencement of mountain residence, haemoptysis, history and nature of cases, state of the lungs, medicine and diet, length of residence at high alti- tudes. The Alpine climate is then compared with that of Colorado and the South African Highlands. The results of this treatment have been tabulated under the heads of general, referring to the general health, vigor, and weight, and local, including the conclu- sions arrived at from the examination of the lungs. The general results are divided into (1) cured, 41-13 per cent, where the restora- tion to health was complete ; (2) greatly improved, 29*78 per cent; (3) improved, 11*34 per cent; (4) deteriorated, 17'02 per cent; thus giving a total of 82-25 per cent improved and ]1*34 per cent deteriorated, including 13-47 per cent of deaths. The local results of the 141 cases yield improvement greater or less in 74-82 per cent (including arrest in nearly 44 per cent), deterioration in 21 per cent, and a stationary condition in 3-59 per cent. Among the first- stage cases there was improvement in 91 per cent, and arrest of disease in 63 per cent, with deterioration in nearly 7 per cent. Cases of unilateral first stage give 92 per cent improved and 70| per cent of arrests, and cases of bilateral affection yield 87*09 per cent of improved and 48'38 per cent of arrests. In the second- and third- stage cases there was improvement to a greater or less extent in 46 per cent, arrest in 10 per cent, and deterioration in 46 per cent. Single-cavity cases gave better results than cavity cases with the opposite lung involved, and left-lung cavities showed a less tendency to change, either for better or worse, than the right-lung ones. The following ^conclusions are arrived at: 1. That prolonged resi- dence at high altitudes produces great improvement in the majority of consumptive patients and complete arrest of the disease in a con- siderable proportion, such arrest being in a more or less degree per- manent. 2. That in order to secure these advantages patients must be free from pyrexia and all acute symptoms, and must possess suffi- cient lung-surface to adequately carry on the process of respiration in the rarefied atmosphere. 3. That the influence of the climate seems to promote a change in the lungs, either of a curative or de- CONCLUSIONS. structive character, and to oppose quiescence. 4. That residence at high altitudes causes enlargement of the thorax, hypertrophy of the healthy lung-tissue, and the development of pulmonary emphysema around the tubercular lesions, and that this expansion of the chest is accompanied by diminution of the pulse and respiration rate. 5. That it is probable that the arrest of consumptive disease is partly owing to the pressure exercised on the tubercular masses by the in- creasing bulk of the surrounding tissue. 6. That the above local changes are accompanied by general improvement shown in the cessation of all symptoms, and the gain of weight, color, and of mus- cular, respiratory, and circulatory power. 7. That consumptives of both sexes benefit equally by mountain residence, but that the age of the patient exercises considerable influence on the result 8. That the high-altitude treatment seems to be specially adapted in OMOn where heredity and family predisposition are present. 9. The climate is useful in cases of haemorrhagic phthisis, and that haemop- tysis is of rare occurrence at the mountain stations. 10. That mountain climates are most effective in arresting phthisis where the disease is of recent date ; but they are also beneficial in cases of longer standing. 11. That the special effects of high-altitude resi- dence on the healthy and sick are common to all mountain-ranges of elevations of 5,000 feet and upward. 12. That to insure the full advantages of high-altitude residence, a period of at least six months is necessary in the majority of consumptives. In cases of long standing and extensive lesions, one or two years are often requisite to produce arrest of the disease. 13. That, in addition to the above examples, mountain climates are beneficial in (1) cases of imperfect thoracic and pulmonary development ; (2) chronic pneumonia with- out bronchiectasis ; (3) chronic pleurisy, where the lung does not expand after removal of the fluid ; (4) spasmodic asthma, without much emphysema ; and (5) anfemia. 14. That they are contra-in- dicated in the following conditions : (1) Phthisis with double cavi- ties, with or without pyreria ; (2) cases of phthisis where the pul- monary area at low levels hardly suffices for respiratory purposes ; (3) catarrhal phthisis; (4) erethitic phthisis, or phthisis where there is great irritability of the nervous system; (5) emphysema; (6) chronic bronchitis and bronchiectasis ; (7) diseases of the heart and greater vessels ; (8) affections of the brain and spinal cord, and con- ditiunsof hypersensibility of the nervous system; and (9) where the patients are of advanced age and where they are too feeble to take exercise. 292 PHTHISIOLOGY. " Dr. Bowles discussed the pathology of sunburning, and thought that the causes of it had some share in the improvement of phthisi- cal patients. He argued that the reflected light from snow was a potent cause of sunburning, far more important than heat-rays or the atmosphere. The ultra-violet rays with most chemical action probably were chiefly causative of it. He found that painting the face with a brown pigment prevented sunburning. 44 Dr. Hermann Weber gave a few of the results of his own statis- tics of 106 cases treated at high altitudes. Of these, 38 were cured, 42 improved, 16 remained stationary, and 10 deteriorated. Of 70 in the first stage, 36 were cured, 28 improved, 11 remained station- ary, and 6 grew worse. Of 32 in the second stage, 2 were cured, 13 improved, 11 remained stationary, and 6 deteriorated. Of 4 in the third stage, 1 was improved, 1 remained stationary, and 2 de- teriorated. While granting that high altitudes did thus effect great good, Dr. Weber pointed out that equally good results might be obtained at lower levels if systematic medical and dietetic treat- ment were carried out, as at Falkenstein, near Frankfort. From this place, which is only about 2,000 feet above the sea-level, Dettweiler's statistics (which are perfectly reliable) prove this con- tention. In Dr. Weber's cases the gain in weight was observed in 58 cases, weight remained stationary in 40, and 8 lost flesh. It was remarked, however, that patients could be well nourished be- fore being sent to high altitudes, so that a gain in weight might thus be anticipated by previous treatment. " Dr. De Haviland Hall asked for experience in cases of laryn- geal phthisis treated at high altitudes. In his experience such cases did badly. "Dr. Pollock criticised Dr. Williams's paper, and maintained that equally good results could be, and in fact were, obtained by medical and hygienic treatment in London. He passed each stage of phthi- sis in review, and pointed out that it was precisely those cases which were benefited at high altitudes that did well at home. Cases of congestion and fever were always the worst, and it was well known that high altitudes did not suit such. " Dr. Tucker Wise maintained that high altitudes were most beneficial in phthisis, and that the improvement was far greater than could be obtained elsewhere. The mode of action of high altitudes was discussed and a high place given to the ascepticity of the at- mosphere. "Dr. Ewart supported the conclusion of Dr. Williams's paper, CONCLUSIONS. 293 and laid special stress on the immense benefit that accrued from the sadden change to a place of hopefulness, cheerfulness, and rest. He contrasted the cheerfulness and bitn-etre of the patients at high altitudes with those at lower levels. " Dr. Hupgard contended that high altitudes, on the whole, gave the most satisfactory results. He attributed the beneficial effects largely to the rarity of the atmosphere and its effects on the human organism. " Paul Bert's experiments on the influence of low tension on the escape of gases were applied to illustrate the effects of the treat- ment at Davos and elsewhere. " Arterial tension was lowered, and this might explain the free- dom from haemoptysis. When hremoptysis did occur, it was owing generally to too sudden arrival at great heights. The haemorrhage was then of the order known to balloonists. u Dr. Quain believed most firmly that as much good could be ob- tained at home or at low levels. The constitutional state was the most important factor in bringing about recovery. " Dr. Williams in reply argued that, though good results could be obtained at home or on sea-voyages or in warm places, high alti- tudes yielded far better results. This was shown in the actual ar- rest of the disease, which did not happen, or very rarely, when cases were treated elsewhere. By arrest lie meant total disappear- ance of all physical signs of lung-mischief as well as restoration of the constitutional state. In his experience, laryngeal phthisis was also a contra indication for the high-altitude treatment." Rhazes wrote, nearly one thousand years ago, that patients die from consumption I>ecau8e the lungs can not be treated like external parts. Loomis,* speaking of the climatic treatment of con- sumption, has said : " The air must be pure, aseptic if you choose, which could be taken in the lungs on the same principle that antiseptics were used externally in the treatment of surgical affections. Cavities in the * "New York Academy of Medicine," October 20, 1887. Published in id. - New York Medical Journal " for October 20, 1887. 294 PHTHISIOLOGY. lungs could not be washed out with antiseptic solutions, and he doubted whether such solutions could be applied by inhalations, so as to destroy the cause of the morbid processes going on in the lungs ; but, if the lungs could be bathed constantly with aseptic air, all was done that could be in the way of local treatment of pulmonary phthisis." Tyndale* says: "It is my earnest desire to draw attention to what seems to me the future path to be pursued in therapeutics, namely, to endeavor to bring nutrition to the highest point attainable, and retain it there long enough to enable us to pursue a systematic course of antiseptic treatment of the general condition, laboring under chronic septicaemia, as well as of the local lesion" The writer believes that the respiration of antiseptic air by phthisical subjects will be found, in the future, to be as successful in the treatment of consumption as topical antiseptic influences have been in the treatment of external surgical affections. Although antiseptic air does not exist in nature, medical science is able, by means of appliances now at command, to produce it, by com- bining aseptic air with appropriate antiseptic agents, in sufficient quantities, at least, for respiration by phthisical subjects during their sleeping hours. It is the hope of the writer, and doubtless of many others, that some such method of treatment for consumption, as well as for * " Treatment of Consumption." By J. Hilgard Tyndale, M. D., New York, 1882. The italics are mine. G. A. E. CONCLUSIONS. 205 other pulmonary diseases, may soon develop from what at present may seem to be only a Utopian idea. NOTE. In the "New York Medical Journal" for March 6, 1886, the writer describes a new instrument for the local antiseptic treatment of pul- monary phthisis. This apparatus has been improved since that time, so as to permit of the simultaneous operation of compressed and artificially purified air, in conjunction with the topical application of stimulating and antiseptic medi- cament. The results which have been obtained up to the present time by the writer, by means of this apparatus, are given hi the following table : STAGES. CUM. Improved Not Improved. Recovered. Died. Consolidation 67 9 8 44 1 Softening 83 20 4 8 1 Excavation 64 23 6 3 32 Total.. 154 52 13 65 34 It will be observed that these results are not so good as those reported in the article referred to. This is due in most part to the fact that a larger percentage of advanced cases have been treated since the first report was made, as a comparison of the tables will show. The writer expects to make use of this instrument, in the near future, for the production of antiseptic atmospheres for continuous respiration by consumptives during their sleeping hours. THE END. REASONS WHY PHYSICIANS SHOULD SUBSCRIBE FOR THE ]S T EW YORK MEDICAL JOURNAL, EDITED BT FRANK P. FOSTER, M. D., PUBLISHED BT D. APPLETON & CO., 1, 3, & 5 BOND STREET. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medical men of this country. 4. BECAUSE: Its "Original Articles" are the results of scientific ob- servation and research, and are of infinite practical value to the gen- eral practitioner. 5. gECAUSE: The "Reports on the Progress of Medicine," which are published from time to time, contain the most recent discoveries in the various departments of medicine, and are written by practitioners especially qualified for the purpose. 6. gECAUSE: The column devoted in each number to " Therapeutical Notes" contains a resume of the practical application of the most recent therapeutic novelties. 7. gECAUSE : The Society Proceeding*, of which each number contains one or more, are reports of the practical experience of prominent phy- sicians who thus give to the profession the results of certain modes of treatment in given cases. 8. gECAUSE : The Editorial Columns are controlled only by the desire to promote the welfare, honor, and advancement of the science of medicine, as viewed from a standpoint looking to the best interests of the profession. 9. gECAUSE: Nothing is admitted to its columns that hos not some bearing on medicine, or is not possessed of some practical value. 10. gr.i'A !'