Dr. Ella E.Huntington

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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

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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

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

2-4

8-2

2-8

2-7

S'l

8-0
2-0
4-0
8-4
4-1
6-6
8-3
4-0

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

Fricsland

Leeuwarden

Overyssel

Zwolle

Deventer

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

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.

1'96

2-77

1-84

Kuiii |T sbcrg .... . .

1'74

2-49

1-48

I):i!17i"

1-74

2-39

1-41

Muriemveriler

1-61

2-64

1-35

Stettin

2-39

2-90

2-08

1-86

2-68

1-60

Str:il.-sim<l

267

8-21

2-12

Schleswie . .

822

8-31

8-18

PHTHISIOLOGY.

Mortality from Phthisis in Prussia from 1875 to 1879
(continued).

DEPARTMENT.

Inhabit-
ants per
square
kilometre.

Deaths from
phthisis per
1,000 in-
habitants.

Ratio in
the urban
popula-
tion.

Ratio in
the country
popula-
tion.

Warthe and Oder.
Posen

2'30

2'96

2'04

Bromberg

2-20

3-13

1-85

Breslau

109

3'07

3'73

2-75

2'52

2-98

2'35

Oppeln . .

104

2'55

2'99

2'45

Frankfurt

2'54

3 '08

2-25

Prussian Saxony, the Mark, etc.
Potsdam

2'53

2'88

2'33

2'79

2'98

2'65

Merscburg ..

2'29

2'63

2'16

Erfurt

109

2'70

2'69

2'70

North Sen.
Hanover

3-99

3-38

4-44

3-02

2-66

3-21

Luneburg

3'47

3'85

3-39

Stade

4 - 01

3-18

4-20

Osnabriick

5'14

4'87

5-22

Aurich

3 - 67

3-31

3-79

Lower Rhine.
Colo fr ne

164

5'11

4'76

5 '34

Treves

3-55

3-53

3-56

Aix

121

4'02

3-64

4'59

Coblenz

4'33

4'26

4'35

Dusseldorf

267

5'29

5-22

5'29

6-17

6-50

4-70

4-71

4-73

4-90

Arnsberg

127

4'86

5-46

4-51

Upper Rhine.
Cassel

3-17

3-48

3-03

Wiesbaden

122

3-98

3-82

4-08

It follows from this table, which is compiled from
the painstaking work of Schlockow, that the disease is
much less common in the territory of the Yistula, Oder,
and Elbe, where the mortality is from 1-61 to 3'22 per
1,000, than in the territory of the Weser and Rhine,
where the mortality is from 2*66 to 6'50 per 1,000. In
the kingdom of Saxony, the yearly mortality, according

GEOGRAPHICAL DISTRIBUTION. 49

to the figures for the years 1873-'80, is 2-40 per 1,000, or
nearly as much as in the Prussian department of Erfurt,
the maximum of 2*81 to 2'77 falling in the circles of
Dresden and Leipsic, with a minimum of 1'75 in the
circle of Bautzen, and one of 0-90 per 1,000 in the
circle of Zwickau.

In the kingdom of Bavaria, according to the statistical
returns of 1867-'75, the annual mortality from phthisis
has a mean of 3*14 per 1,000 ; but the results can not
be compared with those obtained from other parts of
Germany, inasmuch as they relate to all deaths from
pulmonary consumption, from general tuberculosis, and
from wasting in persons over fifteen, which should bo
compared separately to be correct. The Bavarian de-
partments with the largest death-rates are Lower Fran-
conia, with 3*61 ; Middle Franconia, with 3'49 ; and
Upper Franconia, with 3 '24. Next comes the Palatinate,
with 3-20 ; the Upper Palatinate, with 3'12 ; Swabia and
Bavaria, each with 3'06 ; while the minimum of 2'40
is reached in Lower Bavaria.

In the grand duchy of Baden, according to the
figures for the years 1874-'81, the mean annual death-
rate from consumption is 2 - 78 per 1,000 inhabitants,
being distributed in the various circles as follows:

Mannheim . . . 8'87 ! Constance . . . 2'65

Carl.xrube 8'41

Baden 8'28

Freiberg 8'05

Lorrach 2'54

Mosbach 2'37

Villinjien 2'86

Heidelberg 8-04 Waldshut 2-24

Offcnburg 2'89 1

50 PHTHISIOLOGY.

In the grand duchy of Hesse the mean annual
death-rate from phthisis was 2'73 per 1.000 (according
to the figures of 1877-'81), Starkenburg having 2-83,
Upper Hesse 2*42, and Ehenish Hesse 2'82. "We are
obliged to notice the very remarkable comparative im-
munity of the elevated regions of Germany from con-
sumption as contrasted with the low plains. The same
relative infrequency of the disease is met with in the
mountainous parts of Austria ; whereas in the level coun-
try and among the lower valleys of Galicia, Upper
Austria, Styria, and Carinthia, consumption is very
prevalent.

In England, as will be seen from the table, the
heaviest mortality (2*8 to 3-5 per 1,000) falls in London
and in certain of the northern and northwestern coun-
ties (Notts, Derby, Cheshire, Lancashire, West Biding,
Durham, Northumberland, Cumberland, South Wales,
and North Wales). The smallest mortality (1-8 to 2'2
per 1,000) is found in the southwestern and inland
southern counties of Wilts, Dorset, Somerset, Herts, and
Bucks ; in the western inland counties of Gloucester,
Hereford, Shropshire, Staffordshire, and Worcester; in
the counties of Rutland and Lincoln, the North Riding,
and the mountainous district of Westmoreland.

From Scotland we have accounts of the very rare
occurrence of the disease in the western Highlands.

Of Ireland^ Wylde says that phthisis is " by far the
most fatal affection to which the inhabitants of this
country are subject."

In Holland^ as the figures in the table show, the

GEOGRAPHICAL DISTRIBUTION.

chief centers of phthisis are in the northeastern prov-
inces of Overyssel and Drenthe, next in order being
Utrecht, Friesland, and North Brabant ; it is rarest in
Zealand and next rarest in South Holland and Limburg.
Among the larger towns, those most afflicted with con-
sumption are Deventer, Zwolle, Breda, Utrecht, Haarlem,
and Maestricht.

In Belgium^ as we learn from Meynne, there is
most of it in the industrial centers, such as Brussels,
Ghent, Bruges, liege, St. Nicolas, Venders, and Ypres;
while we have more special details of its extensive
prevalence in Antwerp, Boom, Contich, Mechlin, Haeght
(Brabant), Ecloo (West Flanders), Courtray, Furnes and
Dikmude (both in East Flanders), and in Beauraing
(Namur).

Few countries of Europe enjoy on the whole so
favorable conditions as Switzerland in respect of the in-
frequency of consumption. According to Mutter's in-
quiries, the total mortality from phthisis is 1*86 per
1,000 inhabitants. It was distributed as follows in the
several cantons:

CANTON.

TWH

rtnefied.

Deaths per 1,000

inhabitants.

Baselstadt

357

Griaons

2 to 5

250

Geneva

3 to 5

2'40

2 to 5

2'40

8 to 5

2-30

SchafThauscn

2-10

\.\\ M'l

4 to 5

2-00

4 to 5

2'00

1-96

Bern

8 to 5

1-90

Ticino . .

3 to5

1-90

PHTHISIOLOGY.

CANTON.

Tears
observed.

Deaths per 1,000
inhabitants.

Vaud

2 to 5

1'fO

Zu" ..

1-60

1-50

Thur^au

1-45

Uri

1-40

3 to 4

1-40

1-35

Vallais

1-20

0-81

The comparatively high mortality of Baselstadt,
Geneva, and Neuchatel, is explained by the industrial
character of the respective towns; that of the Grisons
by the common occurrence of the disease in Chur (3 per
1,000) ; that of Canton Schwyz, as well as the small
figure for Canton Freiburg, most probably by errors
in the returns.

The information as to the extent of phthisis in
France comes in fragments from the various parts of
the country ; and we are unable to form a general esti-
mate of it. As in other countries, it is the great cen-
ters of commerce, trade, and manufacture that form
the chief seats of the malady. "Whether, as Lambard
alleges, " it is more common in the northern and western
departments than in the southern, eastern, and central,"
it is difficult to decide.

According to Drysdale,* "out of 1,000 deaths oc-
curring in Paris weekly, 200 were from phthisis, and
25 were from external tuberculosis. Dr. Thouvenin has

* " Climatic Treatment of Consumption," by Dr. C. R. Drysdale, Lon-
don, England. British Medical Society, August, 1887.

GEOGRAPHICAL DISTRIBUTION.

shown that 65 per 1,000 of the deaths among the rich
were caused by it, while 230 per 1,000 among the poor
succumbed to the disease."

For Spain and Portugal, also, there are only frag-
mentary notices of the distribution of consumption. It
is prevalent to a very great extent on the central plateau
of Spain (in New Castile and Estremadura) as well as in
certain of the larger ports on the western and southern
coasts, such as Barcelona, Valencia, Cadiz, and Gibraltar,
Ilennen's statement that phthisis is "truly endemic" in
these having been subsequently confirmed by Chervin.
To the same effect is the opinion of Wallace, of Trogher,
and of Brant, on the frequency of the malady in Lisbon,
the last-named remarking that it takes a foremost place
among the diseases of the people in the plains of Port-
ugal and in the densely populated towns.

The following are the official figures of the mortality
from consumption in Italy, for the years 1881-'83, ac-
cording to provinces :

Table of the Death-Rate from Phthisit in Italy per 1,000 Inhab-
itant*.
Italy (general average) 2 - 45

Lombardy 3'34

Latium (Rome) 3'18

Toscana 3'16

Piedmont 2'86

./Emilia 2'75

Lipuria 2'71

Campania 2'43

Venetia 2'28

Assuming that tin se figures are trustworthy, or that
the same unavoidable sources of error have recurred in

Marches 2'06

Umbria 1'87

Sardinia 1'78

Apulia 1'63

Sicily 148

Abruzzi (Molise) 1'42

Calabria 1'36

. 0-89

54: PHTHISIOLOGY.

all the localities, it follows that there is a considerable
preponderance of the disease in the northern provinces,
and that its frequency diminishes very decidedly as we
go southward.

In Roumania consumption is unusually common, ac-
cording to the testimony of all authorities. In Turkey,
also, and particularly in Constantinople, the disease is far
from rare, being met with very extensively among the
Turkish troops. In the island of Cyprus it is said to
be almost unknown. In like manner, Greece would
seem to be comparatively well off in respect to the
rarity of consumption; thus, it is spoken of as being
seldom met with in Laconia. According to casual notices
from the countries of nearer Asia, such as the plateau
of Armenia, the coast-plains of Syria, and the table-
land of Persia, phthisis would seem to be a compara-
tively rare trouble.

As regards Armenia, Wagner says that the disease is
seen only in persons who have migrated from Arabia,
Mesopotamia, or the countries of the negro. Polack says
the same of the Persian plateau, where the indigenous
inhabitants enjoy an almost absolute immunity. The
rarity of the disease on the plains of Syria is attested by
Yates, Robertson, Tobler (for Jerusalem), and Barret (for
Beyrout). It is more frequently seen in the Lebanon,
in the neighborhood of Baalbec and of Aleppo, where
Guys tells us that it is truly endemic ; also on the Ara-
bian shore of the Red Sea, especially among those Bed-
ouins "who have exchanged the tent," as Pruner says,
"for the stone-built house."

GEOGRAPHICAL DISTRIBUTION. 55

As in the countries just spoken of, so also in India,
the prevalence of phthisis can not be given in figures.
It is, on the whole, rarer in that part of the world than
in the temperate zone of the Eastern Hemisphere, but
by no means so rare as the earlier observers supposed,
from their imperfect means of diagnosis.

In some districts it is, in fact, common, particularly
among the English troops; as in the plain of Upper
Bengal stretching along the foot of the Himalaya, in the
district of Madras (among natives as well), at places on
the Malabar coast such as Cochin and Cannanore, at
Bombay, in certain localities of the Northwest Prov-
inces, and in the Punjaub, where Hinder found it very
prevalent among the natives of Amritsur. It does not
occur so often in Lower Bengal and Assam nor in
Upper Siude, extremely seldom on the plateaus of the
Western Ghauts at levels of 4,000 to 7,000 feet, or in
the Nilghiri Hills, or on the northern and southern
slopes of the Himalaya.

On one point all the authorities in India are agreed
that the disease in that country is of an extremely per-
nicious type ; and the same is true of it in all other tropi-
cal regions of Eastern Asia, including Ceylon, the East
s F'lrther India (Cochin-China in particular),
China, and Japan. In Ceylon, consumption is found
mostly among the black population. In the Malay
Archipelago the disease is far from rare, as we may in-
for from the above reference to the great mortality caused
by it among the native troops; all the authorities write
in that sense, mention being made more particularly of

56 PHTHISIOLOGY.

its common occurrence in Amboina and in the Philip-
pines, especially at Manilla.

In Sumatra it would seem to be rare. The French
medical officers are entirely agreed as to the great
frequency and pernicious type of phthisis in Cochin-
China.

There are reports to the same effect from various
parts of China, such as Canton and Hong-Kong, Chang-
fu, Tientsin, and Pekin ; at other ports, such as Shang-
hai and Hankow, it is not so common.

In Japan, phthisis holds one of the first places among
the causes of death.

Consumption is prevalent to a most disastrous extent
among the native races of the Southern Pacific. We
have more particular accounts for Fiji and Tonga, Samoa,
Tahiti, the Marquesas, and Hawaii (Honolulu). In New
Caledonia the death-rate from consumption among the
Kanakas is estimated at two fifths of the mortality from
all causes. Almost all the authorities are of opinion that
the great prevalence of the malady in these islands dates
from the time when the natives began to come into more
intimate relation with European immigrants, and there-
with to make considerable changes in their mode of life ;
and that opinion is borne out by the fact that in the
Hawaiian Islands, where phthisis at the present time
commits great ravages among the natives, it was of rare
occurrence forty or fifty years ago. On the other hand,
it follows, from "Wilson's account (1800) of the state of
health in Tahiti, that phthisis had been widely prevalent
in that group as early as the beginning of the century ;

GEOGRAPHICAL DISTRIBUTION. 57

and there are accounts to the same effect from the Tonga
group, New Caledonia, and other of the archipelagoes
of Polynesia.

The reputation that Australia used to enjoy for the
rarity of consumption, and for the favorable influence of
its climate upon the course of the malady, has of late
been shown to be a mistaken one. In Victoria, where
the disease, it is true, has become a good deal more com-
mon only within recent years, the mortality from phthisis
in 18G6 was six per cent of the mortality from all causes,
while in Melbourne itself the death-rate rose between
1865 and 1869 from 2-22 to 2-52 per 1,000 of the popu-
lation. In Tasmania it would not seem to be common ;
during five years' practice Hall saw 235 cases at Hobart,
only 37 of whom had been born in the colony, all the
rest being immigrants from Europe. In New Zealand
phthisis has made frightful ravages among the Maoris,
and has been one of the chief causes of the gradual ex-
tinction of that race.

Among the islands on the eastern side of Africa,
Mint, -it i us and Reunion are the two most subject to
consumption. On Nossi-B6, also, the malady is not un-
common among the colored races, particularly the Caffris.
In Madagascar and Mayotte it is as common as in
Europe, and rapidly fatal, as it mostly is in the tropics.
In Zanzibar, Lostalot did not happen to see many cases,
but it is said to be especially common among the Arabian
women of the higher class. In Cape Colony phthisis is
oftenest met with among the Hottentots inhabiting the
plains nearest the coast ; in other classes of the popula-

58 PHTHISIOLOGY.

tion it is much rarer than in the East African islands
within the tropics, just spoken of ; while on the interior
plateau of Southern Africa it hardly occurs at all.

There is a lack of information of a trustworthy kind
as to the state of health on the southern part of the
west coast of Africa, the coast of Lower Guinea.
Around the Sights of Benin and Biafra (country of
the Cameroons and of the Gaboon), as well as in the
adjoining island of St. Thomas, it appears, from the
entirely trustworthy writings of Daniell, that phthisis is
widely prevalent and very malignant among the negroes.
As regards the French settlements on the Gaboon coast
that statement is fully borne out by the French medical
practitioners ; and we have an account to the same effect
regarding its occurrence on the island of Fernando Po.

The circumstances in respect to phthisis are more
favorable among the natives of the Gold Coast and of
Sierra Leone. Among the islands of the Cape Verde
group, Mayo is but little afflicted by the malady, while
St. Jago and Fogo are much subject to it. We are un-
able to form a trustworthy conclusion of the extent of
its prevalence on the coast of Senegainbia ; the older
accounts, by Thevenot and Berville, speak of it as very
rare ; and so far in agreement therewith Chassaniol,
Borius, Gauthier, and others state that it is at all events
rarer than in France. On the other hand, Carbonell
shows, from the statistics of mortality at St. Louis, that
consumption makes up a considerable proportion of the
deaths ; while Def aut, writing of Gor6e, says : " La
phthisic pulmonaire est frequent, et on peut dire que

GEOGRAPHICAL DISTRIBUTION. 59

toutes les classes cfhabitants y sont expos6es; en effet,
les noire foumissent un contingent considerable, et les
blaucs en sont souvent atteints."

Among the nomade tribes of the interior, as Carbo-
nell states, the malady is of rare occurrence. According
to the same authority, the death-rate from phthisis among
the French garrison, from 1862 to 1865, was 2'7 per 1,000
of the total strength, and from 1869 to 1871, 2'72 ; in a
battalion of natives numbering 450 men there were 23
deaths from consumption in fifteen years, giving a mor-
tality of 3-4 per 1,000. He adds that " la population
noire du Senegal est, corame partout ailleurs, tres sujette
a la phthisic." As in tropical countries generally, the
disease among the Europeans resident there runs a very
rapid course.

Several of the territories on the north coast of Africa
enjoy a notable exemption from phthisis. In Mogador,
Morocco, and other places on the coast of the sultanate
of Morocco, the disease is mentioned as one that rarely
occurs. In Algiers, also, it is a good deal less prevalent
than in Europe, although the extremely favorable re-
ports by French physicians of a former period as to its
rarity in that country have not been fully confirmed.
Hut nil the more recent observers are agreed that phthisis
is comparatively rare among the French, both civilians
and military ; while among the native population, and
particularly among those li ving outside the towns, either
occupied in agriculture or leading a nomadic life, it is
still less frequently met with. The accounts from the
province of Oran are especially favorable ; in the capital

60 PHTHISIOLOGY.

town of that name, with a population of 25,000, not more
than twelve cases of phthisis had occurred in eight years,
and these were strangers, of whom only three or four had
been taken ill subsequent to their arrival. In the last
two years of the period not a single case had been known
there. At two other places in the province, whose in-
habitants numbered 2,130 Europeans and 4,300 natives,
Gaucher met with only ten cases of phthisis in three
years.

Pietra Santa, who writes of the province of Alger,
and assigns to the capital the somewhat high average
death-rate from phthisis of 2'7 per 1,000 inhabitants over
a period of eight years, goes on to say of the agricultural
or nomadic population of the province : " Tous les docu-
ments s'accordent & prouver, que la phthisie est extreme-
ment rare chez les divers ebranchements de la race arabe."
There is information to the same effect for the native
population of the cultivated oases in the Algerian Sahara,
particularly for the nomadic inhabitants of Great Ka-
bylia, who enjoy, according to all authorities, an almost
absolute immunity from consumption. In Algiers, as in
many other tropical or sub-tropical countries, it is the
negro race that seems to be most subject to the disease.

Along the seaboard of Tunis, Egypt, and Abyssinia,
phthisis is found more often than in Algiers, among the
natives as well as in others. In Egypt, as Pruner tells
us, the disease becomes less in exact proportion as we
proceed southward from the shore of the Mediterranean ;
in Central and Upper Egypt it is decidedly uncommon ;
but in Khartoum and Sennaar, as well as over the whole

GEOGRAPHICAL DISTRIBUTION. 61

basin of the Nile beyond the tropic, it again becomes
somewhat prevalent. The plateau of Abyssinia is almost
free from consumption ; Blanc states that he did not see
a single case of it among thousands of patients during a
lengthened residence in that country.

In the Western Hemisphere the inhabited regions
within northern latitudes, and with an arctic climate,
offer a marked contrast to the corresponding territories
of Europe in respect to the great frequency of phthisis
in them. In North Greenland that disease is one of
the commonest causes of death. At a trading-station
on the northern shore of Hudson Bay, phthisis is preva-
lent among the scanty population to an enormous ex-
tent, according to the evidence of a practitioner who
had been five years on the station ; and there are re-
ports to the same effect from New Archangel and the
Aleutian Islands (Alaska). It is common also in New-
foundland, New Brunswick, and Canada, in the last
particularly among the native Indians (Stratton).

The elevated plains and mountain valleys of Mexico
and other Central American countries, over 3,000 feet
above the sea-level, enjoy, like those of the United
States, an immunity from consumption more or less pro-
nounced ; on the other hand, the disease is very widely
spread, and at the same time of a very malignant type,
on their low plains and coasts.

Thus, while the authorities are unanimous in asserting
the rarity of phthisis on the Anahuac or table-land of
Mexico, and on the lofty plains of Honduras, San Salva-
dor, Costa Kica, and Panama, we have particular infor-

62 PHTHISIOLOGY.

mation of its frequency and malignancy in Tampico and
Yera Cruz (east coast of Mexico), in Campeche and
Merida (coast of Yucatan), in Guaymas and Mazatlan
(west coast of Mexico), on the Nicaraguan or Mosquito
coast, and on the Panama coast.

The large amount of consumption in the West Indies
had been remarked upon by many of the earlier ob-
servers, and their statements have been fully borne out
by the more recent accounts from Cuba, St. Thomas,
St. Martin, St. Yincent, St. Bartholomew, Guadeloupe,
Martinique (where phthisis causes more deaths than any
other disease except dysentery), St. Lucia, Barbadoes,
and Trinidad. The disease is equally common and per-
nicious on the coast and- plains of Guiana, whereas it
is almost unknown among the natives inhabiting the
mountainous part of the country.

Within the last fifty or sixty years there has been
a very extensive diffusion of phthisis along the whole
littoral of Brazil, from Pernambuco to Santa Catarina,
as well as on the littoral of Uruguay and the Argentine
Republic, and in the basin of the Rio de la Plata, in-
cluding Paraguay. It is the large seaports that suffer
most : thus, Beringer gives the mortality from phthisis
in Pernambuco as 5'2 per 1,000 inhabitants, the negroes
and mulattoes furnishing the greater part of it. In
Rio de Janeiro, as we learn from Rey, the mortality
from consumption has been on the increase ; from 1855
to 1858, 14 per cent of the deaths from all causes
(which came to 35 per 1,000 inhabitants) were from
phthisis; whereas from 1867 to 1869, when the total

GEOGRAPHICAL DISTRIBUTION. 63

death-rate had fallen to 24 per 1,000 inhabitants, that
of phthisis had come to be 20 per cent of the total,
or the comparatively excessive fraction of one fifth. In
the interior, also, of Brazil, phthisis is very common,
more especially in the larger towns. The mountainous
region of the Argentine Republic and of Bolivia, like
other mountainous regions, forms an exception. Even
at Salta, Jujuy, and other places situated, no higher than
1,000 to 1,200 metres (3,000 to 4,000 feet), the disease is
rare ; it is almost unknown in the capital towns of the
provinces of Cochabamba, Chuquisaca, and Potosi, at
elevations of 2,000 metres (6,500 feet) and upward, as
well as throughout the whole mountain-range of Bolivia.
In complete accord with the accounts of its frequency on
the east coast of South America, and its considerable
increase there within the last thirty or forty years, is the
information about its progressive diffusion in the coast
districts of Chili, Peru, and Ecuador. It is met with
not uncommonly also among the deep valleys of the
Andes, with a warm and moist climate, and in the
forest region of Peru, even at elevations of 500 metres
(1,600 feet) ; but the high plateaus are almost entirely
free from it.

III.

GEOGRAPHICAL DISTRIBUTION OF
CONSUMPTION IN THE UNITED STATES.*

LOCALITY IX KELATION TO DEATHS.

"!N order to study the influence upon the health
of the inhabitants exerted by peculiarities of topography,
drainage, climate, etc., the country has been divided into
regions, the physical characteristics of which are more or
less distinct. This divisi6n was made by Mr. Gannett,
the geographer of. the census-office, and in the following
account of these grand groups his descriptions of each
of them are included, together with notes on peculiari-
ties of climate, density of population, etc., and refer-
ences to some of the causes of death which are either
unusually frequent, or the reverse, for each locality ."f

The first four of these regions, which comprise the
whole Atlantic and Gulf coasts, possess primarily a sea-
climate. In this region, to a greater or less extent, the
extremes of heat and cold are lessened and mitigated by
the presence of that great balance-wheel of temperature,

* Compiled from the tenth (1880) United States census and Government
reports, and from Rand-McNally's "Atlas," Chicago, 1887.
f Tenth United States census.

CONSUMPTION IN THE UNITED STATES. 65

the ocean. The atmosphere is moister and, as a rule, the
rainfall is greater, than that of the country farther in-
land. This region, however, varies in its different parts
very greatly in respect to temperature and surface, in
such a manner as to produce very decided differences
in its relations to certain causes of disease.

1. NOETH ATLANTIC COAST REGION.

This comprises a strip of land, from 50 to 75 miles
wide, along the coast of Maine, New Hampshire, Massa-
chusetts, Rhode Island, and Connecticut. The surface
is mainly undulating and hilly, becoming less varied
toward the south. The coast is bold and rocky in
Maine, but mostly sandy and low in Massachusetts,
Rhode Island, and Connecticut. There is comparatively
little swamp or undrained land. The mean annual tem-
perature is from 40 to 50 Fahr. The mean annual
rainfall is from 40 to 50 inches. The mean elevation
is from 100 to 500 feet, sloping toward the shore. The
ry of population is over 45 persons to the square
mile, and over 90 in Massachusetts and Rhode Island.
The colored population forms less than 7 per cent of
the whole. The foreign population is from 20 to 35
per cent of the whole, except on the coast of Maine,
where it is below 5 per cent.

The principal causes of death, which are reported as
causing more than the average number of deaths out of
the whole number reported, are, for this group: Scarlet
fever, cholera infantuin, old age, consumption, hydro-
cepluilus, cancer, diseases of the nervous system, espe-

66 PHTHISIOLOGY.

cially apoplexy and paralysis, diseases of the circulatory
system, especially diseases of the heart, bronchitis,
Bright's disease, drowning, and suicides.

The causes of death, in which the proportion is de-
cidedly lower in this grand group than for the average
of the United States, are : Measles, whooping-cough,
enteric fever, diarrhoea and dysentery, malarial fevers,
puerperal septicaemia, scrofula and tabes, dropsy, pneu-
monia, abortion, childbirth, diseases of the spleen, burns
and scalds.

The proportion of deaths from consumption is high
on the Maine coast, diminishing somewhat as we go
south.

2. MIDDLE ATLANTIC COAST REGION.

This includes a strip of land comprising the coast
counties of New York, New Jersey, Delaware, Mary-
land, and Virginia. The climate is somewhat milder
than that of Grand Group I. The surface is low and
sandy, and along the New Jersey coast we find charac-
teristic sandy reefs, shoreward from which are lagoons,
succeeded by extensive areas of swamp. Farther inland
the country is low, nowhere rising more than 100 feet
above the level of the sea. The mean annual tempera-
ture is from 45 to 50 Fahr. in the northern portion,
and 55 to 60 in the southern portion. The mean an-
nual rainfall is from 45 to 55 inches. The average den-
sity of population is over 45 to the square mile. In New
York and Northern New Jersey it is over 90 to the
square mile. In the northern part the colored popula-

CONSUMPTION IN THE UNITED STATES. 67

tion is below 7 per cent of the whole, while in the
southern part it forms from 35 to 60 per cent of the
population. The foreign population is below 5 per cent,
except in New York and Northern New Jersey, where
it is from 20 to 34 per cent.

The following are the causes to which are attributed
a decidedly greater proportion of deaths out of all those
reported than is the case for the average of the United
States : Diarrhoea, cholera infantum, inanition, premature
birth, stillbirth, debility, consumption, hydrocephalus,
apoplexy, convulsions, diseases of the heart, bronchitis,
dentition, Bright's disease, and peritonitis.

The proportion of deaths from the following-named
causes is below the average : Measles, diphtheria, whoop
ing-cough, enteric fever, malarial fever, erysipelas, dropsy,
diseases of the brain, croup, pneumonia, abortion and
childbirth, and accidents and injuries.

The proportion of deaths from consumption is com-
paratively high in Delaware, lower in New Jersey, New
York, and Maryland, and lowest on the Virginia coast.

The proportion of deaths from different causes in this
grand group is influenced to a great extent by the pres-
ence in it of the large cities of New York, Brooklyn,
Riltimore, and "Washington.

3. SOUTH ATLANTIC COAST REGION.

This includes the coast counties of North Carolina,
South Carolina, and Georgia, with extensive reefs inclos-
ing large bays and soimds. A large proportion of the
area is low and swampy. It includes that portion of the

68 PHTHISIOLOGY.

States above mentioned which lies below what is called
the " fall line " that is, the line which forms the bound-
ary of the metamorphic region. The mean annual tem-
perature is from 60 to 65 Fahr. ; the mean annual
rainfall is from 50 to 60 inches. The density of popu-
lation on the coast of North Carolina and the northern
portion of South Carolina is from 6 to 18 to the square
mile. For the rest of the group it varies from 18 to 45
per square mile. The average elevation above the sea
is less than 100 feet. The proportion of foreign popula-
tion is less than 5 per cent of the total population. The
colored population is over 50 per cent. The following
causes of death are given as causing a greater proportion
of the whole number of deaths reported than the average
for the United States, namely : Measles, whooping-cough,
diarrhoea, worms (in the rural districts), dropsy, tetanus,
trismus nascentium, dentition, urinary calculus, child-
birth, bums and scalds, exposure and neglect, and gun-
shot-wounds.

The following are the causes from which the propor-
tion of deaths is reported as being less than the average,
namely : Scarlet fever, cholera infantum, erysipelas, puer-
peral septicaemia, old age, consumption, hydrocephalus,
cancer, diseases of the nervous system, diseases of the
circulatory system, croup, bronchitis, pneumonia, Bright's
disease, and other diseases of the kidneys, and diseases of
the bones and joints.

The proportion of deaths from consumption is low
on the Carolina coast, and slightly higher on the Georgia
coast.

CONSUMPTION IN THE UNITED STATES. 69

4. GULF COAST REGION.

This region includes the entire State of Florida and
the coast counties of Alabama, Mississippi, Louisiana, and
Texas. In Florida and Louisiana a large portion is un-
inhabited swamp-land. The mean annual temperature is
from 70 to 75 Fahr. ; the mean annual rainfall is over
55 inches. The density of the population is nowhere
above 45 to the square mile, and over a large portion of
this region it is below 6 to the square mile. The eleva-
tion above the sea is less than 100 feet, with the excep-
tion of a small part of the interior of Northern Florida,
where it is from 100 to 500 feet. The colored popula-
tion of this group forms from 35 to 60 per cent of the
whole ; the foreign population is below 5 per cent, ex-
cept on the Texas coast, where it rises to 30 per cent
and over.

The causes of death in this region, to which are at-
tributed more than the average proportion of deaths, are
cliiefly: "Whooping-cough, diarrhoea and dysentery, ma-
larial fever, debility, consumption, dropsy, tetanus and
trismus nascentiura, dentition, diseases of the liver,
Bright's disease, childbirth, and gunshot-wounds.

The causes of death, to wliich in this region the pro-
portion of deaths attributed is below the average, are as
follows, namely: Measles, scarlet fever, diphtheria, en-
teric fever, cholera infantum, erysipelas, puerperal sep-
ticaemia, old age, croup, pneumonia and diseases of the
respiratory system in general, and diseases of the bones
and joints.

70 PHTHISIOLOGY.

5. NOKTHEASTERN HlLLS AND PLATEAUS.

Grand Groups Y, YI, and IX include the area of
highlands stretching from northeast to southwest which
has generally received the name of the Appalachian re-
gion. It comprises the broken, hilly country of Maine,
the White Mountains of New Hampshire, and the Green
Mountains of Yermont, the hills of central Massachusetts
and of northern Connecticut, the Adirondacks and Cats-
kills of New York, the multitudinous ridges and ranges
of Pennsylvania, Yirginia, West Yirginia, the Carolinas,
Tennessee, Kentucky, Georgia, and Alabama.

The northeastern Appalachian region, or Grand
Group Y, includes all that portion of Maine, New Hamp-
shire, Massachusetts, and Connecticut not comprised in
the coast strip, with all of Yermont, and the northern
portion, including the Adirondacks, of New York. The
area is by no means all strictly mountainous country. It
includes a large amount of hilly, broken country. It
was originally covered with dense forests, which hare in
the settled portions been largely cut away. The climate
is severe, being affected comparatively little by the sea,
and the mean annual temperature over most of this area
is less than 45 Fahr. In some parts, although not the
most thickly settled ones, it falls below 40 Fahr. The
annual rainfall is from 35 to 45 inches. The mean
density of population is below 45 per square mile. The
elevation is mostly above 500 feet, and in considerable
parts rises to mountains from 3,000 to 5,000 or even
6,000 feet in height. The colored popuktion is below

CONSUMPTION IN TIIE UNITED STATES. 71

7 per cent of the whole, and the foreign population is
below 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 : Diphtheria, old age, consump-
tion, hydrocephalus, cancer, tumors, glycosuria, apoplexy
and paralysis, diseases of the heart and Bright' s disease,
and diseases of the kidney and bladder.

The rate for consumption is very high in Maine, and
is also high in Vermont, Massachusetts, and Connecticut ;
it is somewhat lower in New Hampshire and New York.

The causes of death in Grand Group V, to which are
attributed less than an average proportion of the deaths
reported, are mainly as follows : Measles, scarlet fever,
whooping-cough, enteric fever, diarrhoea, dysentery, chol-
era infantum, malarial fever, puerperal septicaemia, pre-
mature birth, scrofula and tabes, convulsions, croup, bron-
chitis, dentition, childbirth, abortion, and accidents and
injuries.

6. THE CENTRAL APPALACHIAN REGION.

This comprises the Catskill region of southeastern
New York, the central portion of Pennsylvania, and the
western part of Maryland, and chiefly consists of narrow
parallel ridges, with singularly uniform crests, broken by
few gaps, and rising from 1,000 to 2,000 feet above the
narrow valleys separating them, which, in their turn, are
from 500 to 1,000 feet above the sea. The mean annual
tcmi>erature 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<rli in Ohio, and somewhat lower in the rest
of the group.

The causes of death in this region, to which are at-

78 PHTHISIOLOGY.

tributed less tlian an average proportion of the deaths
reported, are as follows : Diphtheria, malarial fever, de-
bility, diseases of the heart, diseases of the respiratory
system, more especially croup, pneumonia, and pleurisy,
diseases of the digestive system, Bright's disease, child-
birth, and accidents and injuries.

11. SOUTHERN INTERIOR PLATEAU.

This includes the section of the Atlantic plain which
extends across South Carolina and Georgia, with the
region in central Alabama and Mississippi lying be-
tween the Appalachian region and the Gulf coast belt.
It is for the most part level and heavily timbered, princi-
pally with pine, a large extent of the surface being what
is popularly known as " pine barrens." It has a warm
climate, and during summer the temperature rises much
higher than on the coast. The mean annual temperature
is from 60 to 70 Fahr. The annual rainfall is heavy
from 50 to 60 inches. The density of population is from
18 to 45 persons per square mile. The elevation is for
the most part below 1,000 feet. The colored population
forms about 60 per cent of the whole. The foreign
population is below 1 per cent, except in a few small
localities.

The causes of death in this region, to which are
attributed more than an average proportion of the deaths
reported, are as follows: Measles, whooping-cough, en-
teric fever and fever unspecified, diarrhoea, dysentery and
enteritis, malarial fever, puerperal septicaemia, worms,
scrofula and tabes, dropsy, diseases of the respiratory

CONSUMPTION IN THE UNITED STATES. 79

Bjstem, and especially croup, pneumonia, and pleurisy,
urinary calculus, dentition, childbirth, accidents and in-
juries, more especially burns and scalds, exposure and
neglect, and gunshot-wounds.

The causes of death in this region, to which are
attributed less than an average proportion of the deaths
reported, are as follows : Scarlet fever, diphtheria, cholera
infantum, erysipelas, debility, old age, consumption, hy-
drocephalus, cancer, tumor, diseases of the nervous sys-
tem, diseases of the heart, bronchitis, Bright's disease,
and diseases of the kidney and of the bones and joints.
From consumption the proportion is very low in Georgia
and Alabama, and slightly higher in South Carolina and
Mississippi.

12. SOUTH MISSISSIPPI RIVER BELT.

Along the Mississippi and Missouri Rivers lie nar-
row belts characterized by a considerable extent of low
bottom-land with rich, deep, moist soil. All this region
that borders the lower Mississippi from the neighbor-
hood of the coast to the mouth of the Ohio is included
in this group, and has very characteristic features. It
includes the river counties of Kentucky, Tennessee, Mis-
souri, Arkansas, Mississippi, and Louisiana. It is an
alluvial bottom-land, lying very low with relation to the
river, and subject to overflow. The drainage is poor,
;uil there are large areas of ewamp-land and stagnant
water. Vegetation is very rank, being almost tropical
in its luxuriance. The mean annual temperature is from
G() to 70 Fahr. The annual rainfall is from 50 to 55

80 PHTHISIOLOGY.

inches. The density of population is from. 18 to 45
persons per square mile. The elevation is between 100
and 500 feet. The colored population is about 60 per
cent of the whole. The foreign population is from 1
to 5 per cent.

The causes of death in this region, to which are
attributed more than an average proportion of the deaths
reported, are as follows : Whooping-cough, malarial fever
and fever unspecified, diarrhoea, dysentery, worms, dropsy,
pneumonia, dentition, childbirth and abortion, and acci-
dents and injuries, especially gunshot-wounds. The pro-
portion of deaths from consumption is low in this group,
with the exception of that part of Kentucky bordering
on the river.

The causes of death in this region, to which are
attributed less than an average proportion of the deaths
reported, are as follows : Measles, scarlet fever, diphtheria,
enteric fever, cholera infantum, premature birth, debility,
old age, consumption, cancer, tumor, apoplexy and pa-
ralysis, diseases of the circulatory system, and especially
diseases of the heart, croup, bronchitis, Bright's disease
and diseases of the kidney, diseases of the bones and
joints, and suicides. From consumption the proportion
is very low in Arkansas, low in Louisiana, Mississippi,
and Tennessee, and considerably higher near the mouth
of the Ohio River in Kentucky.

13. NOKTH MISSISSIPPI RIVER BELT.

This extends from the mouth of the Ohio to the
head of the Mississippi River, including portions of Mis-

CONSUMPTION IN THE UNITED STATES. 81

souri, Iowa, and Minnesota on the western, and of Illi-
nois and Wisconsin on the eastern bank. The mean
annual temperature is from 40 to 45 Falir. in the north-
ern portion, and from 50 to 55 Fahr. in the southern
portion. The annual rainfall is from 30 to 40 inches
in the northern part and from 40 to 50 inches in the
southern part. The density of population is from 18 to
45 persons per square mile, except in the extreme north,
where it is from 6 to 18 per square mile. The elevation
in the southern portion is less than 500 feet, and rises
toward the north to points from 500 to 1,000 feet. The
proportion of the colored population in the southern
portion is from 7 to 17 per cent, decreasing toward the
north, in the extreme part of which it is below 1 per
cent. The foreign population varies from 10 to 35 per
cent.

The causes of death in this region, to which are
attributed more than an average proportion of the deaths
reported, are as follows : Enteric fever, diarrhoea and
dysentery, cholera infantnm, malarial fever, erysipelas,
septicaemia and puerperal septicaemia, inanition, still-
births, debility, convulsions, tetanus and trismus nascen-
tium, and diseases of the respiratory system, especially
pneumonia.

The following are the causes of death in this region
t< which are attributed less than an average proportion
of the- number of deaths: Scarlet fever, diphtheria and
whooping-cough, old age, scrofula and tabes, consumption,
Imlrocephalus, cancer, dropsy, diseases of the heart,
15 right's disease, urinary calculus and diseases of the

82 PHTHISIOLOGY.

kidney, diseases of the bones and joints, and accidents
and injuries.

14. SOUTHWEST CENTRAL REGION.

This includes the northwestern part of Louisiana, the
southern part of Missouri, all of Arkansas except such
portions of these States as belong to the south Missis-
sippi River belt, and central Texas. It is mainly up-
land, and, with the exception of parts of Texas, is heav-
ily timbered. In Louisiana it is traversed by a narrow
strip of bottom-land along the Red River. A consider-
able part of this region in Missouri and Arkansas is
occupied by the Ozark Hills, which rise to 1,000 feet or
more above sea-level, or 400 to 500 feet above the sur-
rounding country. The mean annual temperature is
from 60 to 70 Fahr. The annual rainfall is from 35
to 50 inches. The density of the population is from 6
to 18 persons per square mile, rising to from 18 to 45 in
some small districts. The elevation is from 100 to 500
feet, with some peaks rising to 1,000 feet. The colored
population forms from 17 to 60 per cent of the whole.
The foreign population is below 5 per cent, except in
southern Texas, where it rises to from 20 to 30 per cent
and over.

The causes of death in this region, to which more
than an average proportion of the deaths reported are
attributed, are as follows : Small-pox, measles, whooping-
cough, enteric fever, diarrhoea and dysentery, malarial
fever, erysipelas, puerperal septicaemia, worms, diseases
of the respiratory organs, more especially croup and

OONSUMPTIOB IN THE UNITED STATES. 83

pneumonia, diseases of the digestive organs, childbirth
and abortion, and gunshot-wounds.

The causes of death in this region, to which are
attributed less than an average proportion of the deaths
reported, are as follows : Scarlet fever, diphtheria, cholera
infatitum, debility, old age, consumption, cancer, tumors,
paralysis, convulsions, diseases of the heart, bronchitis,
Bright's disease and diseases of the kidney, diseases of
the l)ones and joints, and suicides. The proportion of
deaths from consumption is very low throughout this
region.

15. CENTRAL REGION, PLAINS AND PRAIRIES.

This includes the plateau running across the northern
part of Ohio and Indiana, and the central portions of
Kentucky and Tennessee, and is essentially what is left
of the eastern portion of the Mississippi Valley after
taking from it other characteristic regions.

The surface is for the most part undulating, present-
ing neither the dead level of the prairies on the one
hand, nor the broken character marking the western
foot-hills of the Appalachians on the other. The timber
which originally covered it has been largely cut away.
The mean annual temperature is from 50 to 60 Fahr.
The mean annual rainfall is from 40 to 45 inches. The
density of the population is from 45 to 90 persons per
square mile. The elevation is from 500 to 1,500 feet
The colored population is below 7 per cent of the whole
in the northern part, and from 7 to 35 per cent in the
southern. The foreign population is below 1 per cent

84 PHTHISIOLOGY.

in the southern part, and from 5 to 10 per cent in the
northern portion.

The causes of death in this region, to which are
attributed more than an average proportion of the deaths
reported are as follows : "Whooping-cough, enteric fever,
scrofula and tabes, consumption, glycosuria, diseases of
the nervous system, croup, pneumonia, and diseases of
the bones and joints.

The proportion from consumption is high in Ken-
tucky and Tennessee, and somewhat lower in Ohio.

The causes of death, to which are attributed in this
region less than an average proportion of the number
of deaths reported, are as follows : Scarlet fever, diph-
theria, debility, old age, cancer, tetanus and trismus nas-
centiurn, convulsions, diseases of the circulatory system,
diseases of the digestive system, Blight's disease, child-
birth, and accidents and injuries.

16. THE PEAIRIE REGION.

This comprises most of the State of Illinois, the
southern part of Wisconsin, nearly all of Iowa, south-
ern Minnesota, the northern part of Missouri, the east-
ern half of Kansas, and a considerable portion of Ne-
braska, with that part of Dakota lying east of the
Missouri belt. Though not entirely treeless, forests
covei but a small portion of the area, and these are
distributed along the water-courses, on the faces of bluffs
and the tops of knolls. The surface is nearly level, ex-
cept where cut or scored by streams. The soil is deep,
extremely fertile, and generally very retentive of moist-

CONSUMPTION IN THE UNITED STATES. 85

ure. Originally there were larger areas of swamp-land
and standing water than at present. The mean annual
temperature is from 50 to 55 Fahr. in the southern
part, and 40 to 45 in the northern part. The mean
annual rainfall is from 35 to 40 inches in the eastern
part, and from 20 to 25 inches in the western part. The
density of the population is from 18 to 45 persons per
square mile in the southern and eastern sections ; it is
below 6 per square mile in the northern and western
parts. The elevation is from 500 to 1,000 feet in the
eastern portion, gradually rising to from 2,000 to 3,000
feet in the west. The colored population is below 1 per
cent of the whole, except in the southern portion, where
it is from 1 to 7 per cent. The foreign population in
the southern part is from 1 to 5 per cent ; in the north-
em part it is from 20 to 35 per cent.

The causes of death in this region, to which are
attributed more than an average proportion of the deaths
reported, are as follows: Measles, scarlet fever, diph-
theria, enteric fever, cholera infantum, erysipelas, puer-
peral septicaemia, rheumatism, glycosuria, diseases of the
respiratory system (more especially croup and pneumo-
nia), childbirth, and diseases of the bones and joints.

The causes of death in this region, to which are at-
tributed less than an average proportion of the deatlis
recorded, are as follows : Inanition, debility, consump-
tion, hydrocephalus, cancer, dropsy, diseases of the nerv-
ous system (more especially apoplexy, paralysis, and con-
vulsions), diseases of the heart, bronchitis, dentition,
Bright's disease, and accidents and injuries.

86 PHTHISIOLOGY.

The proportion of deaths from consumption is very
low in Nebraska and Kansas, and low in Minnesota and
Iowa, being somewhat higher in the remainder of the
group.

17. THE MISSOUEI BIVEB BELT.

This comprises a narrow strip across Missouri, with
portions of eastern Nebraska, western Iowa, and central
Dakota, including in the main a broad area of bottom-
land of deep, rich soil, subject to overflow in the south-
ern portion. Higher up the river, in Dakota, we enter
the sub-huinid section of the country, the atmosphere
being drier and the rainfall less. The mean annual tem-
perature is from 40 to 45 Fahr. in the northern part,
and from 50 to 55 in the southern part. The mean
annual rainfall is from 10 to 20 inches in the northern
part, and from 30 to 40 inches in the southern part.
The density of population is from 18 to 45 persons per
square mile in the southern portion, and it is under 2
per square mile in the northern portion.

The elevation is from 500 to 1,000 feet in the south-
ern and central portion, and from 1,500 to 2,000 feet in
Dakota. The colored population forms from 7 to 17
per cent of the whole in the southern part, and it practi-
cally sinks to nothing in the northern part. The foreign
population is from 10 to 20 per cent in the southern and
central portions of this region.

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 (more especially in
Kansas City), diphtheria, enteric fever, diarrhoeal dis-

-LMPTION IN THE UNITED STATES. 87

eases, malarial fever, erysipelas, puerperal septicaemia,
lead-poisoning, croup (especially in Kansas City), pneu-
monia, 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 (with the excep-
tion of Kansas City), whooping-cough, inanition, debility,
consumption, hydrocephalus, cancer, dropsy, diseases of
the nervous system, and especially apoplexy, paralysis,
tetanus and trismus nascentiurn, convulsions, diseases of
the heart, diseases of the digestive system, Bright's dis-
ease and diseases of the kidneys, and accidents and in-
juries.

The proportion from consumption is very low in the
northern part, gradually increasing toward the south.

18. REGION OF THE WESTERN PLAINS.

This extends westward from the border of the prairie
region, including parts of Texas, Kansas, Nebraska, Col-
orado, Wyoming, Dakota, Montana, and New Mexico.
The characteristics of the prairie region are here inten-
sified in every particular. The timber is scarce, being
found only along the water-courses. The surface is a
monotonous rolling expanse, covered only with sparse
clumps of bunch-grass, cactus, yucca, and other plants
characteristic of a dry climate. The temperature varies
from 65 to 70 Fahr. in the southern part, and from
40 to 45 in the northern portion. The mean annual
rainfall is from 10 to 20 inches. (The rainfall is in gen-
eral b;jlo\v 2'5 inches ; indeed, this isohyetal line may be

88 PHTHISIOLOGY.

taken in general terms as the boundary-line between this
and the prairie region, although in the north the cooler
climate and smaller evaporation tend to throw the bound-
ary westward, while the reverse condition in the south
tends to throw it eastward.) The extremes of tempera-
ture in this region are very great, being exceeded only
in the still more arid region farther west. The density
of the population is under 2 persons per square mile.
The elevation is 1,500 feet in the eastern portion, rising
to 4,000, 5,000, and 6,000 feet in the west. The colored
population in some parts of Colorado and Kansas is from
1 to 5 per cent of the whole ; in the remainder of the
group it is less than 1 per cent. The foreign population
is less than 1 per cent, except in some parts of Colorado,
Kansas, and Nebraska, where it is from 5 to 34 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 : Small-pox, measles, scarlet fever,
diphtheria, whooping-cough, fever unspecified, enteric
fever, puerperal septicaemia, pneumonia (especially in
Denver), pleurisy, and accidents and injuries, more espe-
cially exposure and neglect, gunshot- wounds, and homi-
cide.

The causes of death in this region, to which are at-
tributed less than an average proportion of the deaths
reported, are as follows: Malarial fever, still-births, de-
bility, old age, rheumatism, scrofula and tabes, consump-
tion, hydrocephalus, cancer, tumor, dropsy, diseases of
the nervous system, more especially meningitis, apo-

CONSUMPTION IN THE UNITED STATES. 89

plexy, paralysis, tetanus and trismus nascentium, and
convulsions, diseases of the heart, dentition, Bright's dis-
ease and diseases of the kidney, and diseases of the bones
and joints.

The proportion of deaths from consumption is very
low in Texas, New Mexico, "Wyoming, Kansas, and
Montana ; it is somewhat higher in Colorado.

19. HEAVILY-TIMBERED REGION OF THE NORTHWEST.

This comprises parts of Minnesota, Wisconsin, and
Michigan. It is heavily timbered and well watered, con-
taining large numbers of small lakes and considerable
areas of swamp, especially in "Wisconsin and Minnesota.
This large water surface, together with the dense forests,
tend to give to this region a moist atmosphere, although
the rainfall is not great. The mean annual tempera-
ture is from 40 to 50 Fahr., and below 40 in north-
ern Wisconsin and Minnesota. The mean annual rain-
fall is from 30 to 40 inches.

The density of population in Wisconsin and Michi-
gan is from 45 to 90 persons per square mile. The
elevation is from 1,000 to 1,500 feet. The colored popu-
lation is below 7 per cent of the whole. The foreign
population is from 20 to 30 per cent and over.

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, rheumatism, cancer, tumor, paralysis, diseases of the
heart, childbirth, diseases of the bones and joints, and
accidents and injuries.

90 PHTHISIOLOGY.

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, enteric fever, diar-
rhea and dysentery, cholera infantum, malarial fever,
puerperal septicaemia, still-births, debility, scrofula and
tabes, hydrocephalus, dropsy, diseases of the nervous
system, especially convulsions, diseases of the respira-
tory organs, more especially croup and pneumonia, dis-
eases of the digestive system, dentition, and peritonitis.

From consumption the proportion is low in Wis-
consin, and considerably higher in Minnesota and
Michigan.

20. THE CORDILLERAN REGION.

This includes the region westward from the Rocky
Mountains to the Cascades and Sierra Nevada, consist-
ing mainly of the high plateau crowned by a succession
of mountain-ranges forming systems of a greater or
less degree of complexity. It comprises Arizona, Utah,
Nevada, and portions of Colorado, Montana, Wyoming,
New Mexico, California, Oregon, and Washington Ter-
ritory. The climate is arid, the rainfall is small, and
the extremes of temperature are great between summer
and winter, and day and night. As a general thing, the
mountains only are timbered, the valleys and level country
being covered with herbaceous plants characteristic of an
arid climate. The slopes are everywhere amply sufficient
to insure good drainage, and therefore swamps and stag-
nant water are rare. The mean annual temperature is
from 40 to 50 Fahr. in the northern and central por-

CONSUMPTION IN TIIE UNITED STATES. 91

tions, and from 60 to 65 in the southern portion.
The mean annual rainfall is below 10 inches in the
central and southwestern portions, and somewhat greater
in the eastern and northern portions.

The density of population is below two persons to the
square mile. The elevation is from 4,000 to 10,000
feet and above. The proportion of the colored popula-
tion is so small as not to be worth taking into account,
and the same may be said in regard to the foreign popu-
lation, except in a few settlements in Colorado, Utah,
Montana, and Washington Territory, where it forms
from 5 to 34 per cent of the whole.

The causes of death in this region, to which are at-
tributed more than an average proportion of the deatlis
reported, are as follows : Measles, diphtheria, whooping-
cough, fever unspecified, erysipelas, puerperal septi-
caemia, alcoholism, rheumatism, dropsy, diseases of the
respiratory organs, more especially pneumonia, child-
birth, and accidents and injuries, more especially gun-
shot-wounds, homicide, infanticide, and suicide.

The causes of death in this region, to which are at-
tri l)ii ted less than an average proportion of the number of
di-atlis reported, are as follows : Diarrhoea and dysentery,
cholera infantum, debility, old age, scrofula and tabes,
consumption, hydrocephalus, cancer, tumor, diseases of
the nervous system, more especially apoplexy, paralysis,
ti'hmus and convulsions, diseases of the heart, croup,
dUuses of the digestive system, Bright's disease and
disc-uses of the kidney, and diseases of the bones and
joints.

92 PETHISIOLOGY.

The proportion of deaths from malarial fever is very
low throughout the greater part of this group. The
same may be said as regards consumption, heart-disease
and dropsy, croup, enteric fever, and old age.

21. PACIFIC COAST REGION.

This comprises the coast portions of Washington,
Oregon, and California lying between the ranges of the
Cascades and Sierra Nevada and the Pacific coast. It
has a well-defined wet and dry season, the former corre-
sponding to the winter in the eastern portion of the
country, and the latter to the summer. The northern
part receives much more rain than the southern part.
The surface consists of a complex range of mountains
known as the Coast Range, running parallel to the coast,
east of which is a great valley extending from Puget's
Sound to the southern part of California. This is occu-
pied in Oregon by the Willamette and other rivers ; in
California by the Sacramento and the San Joaquin. East
of this valley is a great uplift, represented in Washing-
ton Territory and Oregon by the Cascade Range, and in
California by the Sierra Nevada. The mean annual tem-
perature is from 55 to 65 Fahr. in the southern por-
tion, and from 45 to 55 in the northern portion. The
mean annual rainfall is above 60 inches in the north, and
below 20 inches in the south. The mean density of popu-
lation is below two persons per square mile, except in
the vicinity of San Francisco, Los Angeles, Sacramento,
and Portland. The elevation varies from the coast-line
to 3,000 feet. The colored population is below 7 per

> 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.

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

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.

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<

SUMPTION IH

OM>

ti and

U tad

>v> is.

IS lo M.

orr.

DM**.

SlolJ.

15 to M.

OTV.

1,090

82,559

4.278

HJHi

:,.'.:--,

I <.:;

81.345

"' ' ' ' *

I ' I

42,407

I ;;

K m

1*1 ' 1

806,699

- "ii

Rural

IJBK

815

tt,' : i

1,688

tr,ou

n MI

,'!- IBB

K2.314

i .;:.;

1,573

- .' " i

) . - * '

i - -.1 .>

67,887

M ' < '

86,660

Cities

673

215

0,788

687

ii m

ttjsn

807,154

;:,: H

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

419

' ' ' - i

801

86,808

98,906

MS,170

:: - '

.
Irish parent- , ,.
in 14 VST
k'rand groups \ '

103
89

761

116

I M

I -

I.:...

M
M
1

r,.:;i

151,957

ujut

MI n .

:..-.-. ;
,;: Ml

< ... . i

-..: ;

in j>i\r- t ,.
entage, in 14 -.
grand groups \

M
79

46
60

;.;'-r

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.

><j for Rural and Cities, with Distinction of Sex, and for
White and Colored, Irish and German Parentage, the Pro-
portion -of Deaths from Consumption in 1,000 Deaths from
Known Causes.

GRAND GROUPS.

URAL.

CITIES.

WUU

C,l-
orad.

Irfch
I- 1 ''
fc

ptnut-
*

Mlt

Ft-

ml.

*-.

Total

101-9

146-6

197-8

!,-:>
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

:>\ :,

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

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

t,"i

A! k iMSa.S

14 812

6-3

California

11 530

1 v ,

16-5

Colorado

2,547

110

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

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

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

5'3

Nebraska

5,930

416

7-0

Nevada

728

8-3

5,584

866

15-5

New Jersey

18,474

2,630

14-2

New Mexico

2,436

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

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

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
<le;iths from this cause is tolerably uniform throughout
the year, although somewhat larger in the winter and
spring months, reaching its maximum in the month of
March:

104

PHTHISIOLOGY.

D <}. r t- St rl ^1 O 3 O T-l

mcjOTi-KNi-n-lOjT-lOCOWOOpCTiOOi-HCDC
050OTi-<n-lOJ05UJ'-<'-llN'-i ; S'l-l UJrlC

i-iO<5O>-li-HOJOOJ>(JJr-ci-cKli-IT)<IMi-l(J<T-cC

IV.

TOPOGRAPHY AND CLIMATE OF STATES,*

AND SUMMARY FOR STATES, GROUPS, CITIES, AND

FOR COUNTIES OF TEN THOUSAND POPULATION AND UPWARD,

SHOWING T1IE NUMBER OF DEATHS FROM CONSUMPTION

PER ONE THOUSAND INHABIT ANTS, f

STATE OF MAINE.

Topography. Maine has an extreme length north
and south of 300 miles, an extreme width of 210 miles,
and an area of about 33,040 square miles or 21,145,600
acres. The surface of the State is hilly, with some
considerable elevations in the center, the highest being
Katahdin, 5,385 feet above the sea. North and south
of the highland belt, which is an extension of the
White Mountains of New Hampshire, the country is
more level, and slopes gradually to the valley of the
river St. John and to the ocean. The sea-coast, al-
though only 270 miles in length in a straight line, is
so deeply indented that, including the numerous islands,
the shore-line is over 2,400 miles. Mount Desert is
the largest of the islands, and has an area of 60,000
acres. Others of importance are Isle de Haut and

* The Rand-McNally Atlas, Chicago, 1887.

f Compiled from the United States Census Reports for 1880.

106 PHTHISIOLOGY.

Deer, Fox, and Long Islands. Maine contains a great
number of lakes, mostly of moderate dimensions. The
largest is Moosehead, thirty-five miles long and about
seven miles wide ; next to this are Umbagog, Portage,
Eagle, Long, Madawaska, Schoodic, Sebec, and Millino-
ket. The inland waters rivers and lakes cover a total
area of 3,200 square miles, and the lakes alone of 2,300
square miles, or about one fifteenth part of the State.
On the coast there are fine granite-quarries, in the in-
terior altered Silurian and Devonian rocks, containing
limestone and argillaceous slates.

Climate. The winters are long and cold, and snow
lies on the ground from three to five months. Frosts
occur as early as the middle of September, and occasion-
ally as late as June. The summers are pleasant but
very short, and the temperature varies greatly during
the year, the thermometer sinking sometimes as low as
25 below zero, and on a few days in July or August
reaching 90 Fahr. The mean temperature for the year
at Portland is about 45, and in the extreme north at
least 5 lower. At Belfast the mean for the year is 43 ;
highest recorded, 85; lowest, 32. The mean rain-
fall, including snow, is 43'24 inches, 60 per cent of which
passes into her rivers. In the spring and early summer
the sea-breezes from the Atlantic are laden with cold
fogs, and the inhabitants are subject to pulmonary com-
plaints. With this exception the general health of the
State is good, and the death-rate is low.

Population, 648,936.

Inhabitants to the square mile, 19.

TOPOGRAPHY AND CLIMATE OF STATES. 107

Deaths per 1,000 Inhabitant*.

The State 2'8

Group 1 2-9

Androscoggin 2'8

Cumberland 2'6

Hancock 8'4

Kennebec 8'0

Knox S'O

Lincoln 2'7

Sagadahoc l'

Waldo.. . 8-6

Washington 2'5

York 8-0

Oi-oup S 2*5

Aroostook 1-5

Franklin 3'4

Oxford 2-7

Penobscot 2*1

Piscataquis 8*2

Somerset. . . 8 - 7

STATE OF NEW HAMPSHIRE.

Topography. The length of New Hampshire from
north to south is 180 miles ; greatest breadth, 93 miles
in the south ; average breadth, about 45 miles ; area,
9,305 square miles, or 5,955,200 acres. Portsmouth is
the only harbor for large vessels. The White Mountains,
which cover an area of 1,270 square miles, run through
the northern division of the State, in a direction a little
east of north, the height of the peaks ranging from
2,000 to 6,000 feet. They are broken by a number of
or " notches " at an average height of 1,200 feet.
The general elevation of the State is about 1,200 feet
above sea-level, sloping from north to south. The largest
river is the Connecticut, which forms the greater part
of the western boundary. Next come the Merrimac,
the Androscoggin, and the Piscataqua, with their numer-
ous tributaries. The harbor of Portsmouth is formed
by an estuary known as Great Bay, and is never frozen,
even in the severest winters. The principal lakes are
Winnipiseogee, which has an area of seventy-two square
miles ; Lake Umbagog, the source of the Androscoggin

108 PHTHISIOLOGY.

River; and the four Connecticut lakes in the north,
which form the source of the river of the same name.
The Isles of Shoals lie ten miles southeast of Portsmouth,
and form a part of New Hampshire.

Climate. Owing to the difference in elevation, the
temperature varies considerably. In the Merrimac Yal-
ley and generally in the southern division the extremes
are not so great, but the winters in the "White Mountains
are excessively cold, and characterized by violent winds
and snow-storms.

The summers are short and hot, the thermometer
sometimes rising to 98 ; cold weather begins with
November and lasts to the end of April, and snow lies
on the ground the winter through, and on the tops of
the White Mountains for eight months of the year.
The precipitation of rain and snow ranges from 46
inches in the lowlands to 55 inches on the mountains.
The climate is healthy.

Population, 346,991.

Inhabitants to the square mile, 37.

Deaths per 1,000 Inhabitants.

The State 2'4

Group 1 2'Y

Belknap 2'0

Hillsborough 2'6

Merrimac 3'0

Rockingham . . . 2'8

Group 2 2-0

Carroll 2'2

Cheshire 1-6

Coos l - 5

Grafton 2-1

Sullivan.. . 2-5

Strafford 2'3

STATE OF VERMONT.

Topography. Vermont has a length north and south
of about 150 miles, a breadth of from 35 to 50 miles,

TOPOGRAPHY AND CLIMATE OF STATES. 109

and an area of 9,565 square miles, or 6,121,600 acres.
The Green Mountains intersect the State from north to
south, and contain a number of peaks from 3,000 to
4,500 feet high. A second range, of inferior height,
branches off at Killington Peak and trends northeast.
There are also some detached peaks, of which Mount
Ascutnej, 3,320 feet high, is the most conspicuous. Lake
Champlain extends for 105 miles along the western bor-
der, and receives many small rivers and creeks. The
entire territory east of the mountains is drained by the
Connecticut River and its numerous tributaries the
Connecticut separating Vermont from New Hampshire.
The Connecticut is the only navigable river. Lake
Champlain, 126 miles in length, and from forty rods to
fifteen miles in width, has a depth of from fifty to nearly
300 feet, and is navigable throughout by the largest
vessels. It contains a number of islands, which collect-
ively form the county of Grand Isle, and its shores are
deeply indented. The chief harbor is that of Burling-
ton, the seat of the Vermont lumber-trade. The outlet
of Lake Champlain is the Sorel or Richelieu River,
which empties into the St. Lawrence.

Climate. Vermont is subject to great extremes of
temperature, although not liable to sudden changes, and
the winters are severe. The annual mean temperature
in the northeast is about 40 ; in the south 44 to 46 ;
and the range of the thermometer is from 15 below to
90 Fahr., the summers being short and hot. The rain-
fall is greatest in the southern part and along the valley

of the Connecticut, where it averages 44 inches per an-
10

110 PHTHISIOLOGY.

num, and decreases gradually until in the northwest not
more than 35 inches per annum are recorded. Much
snow .falls, especially on the mountains. The State is
extremely healthy; miasmatic diseases are entirely un-
known, pulmonary complaints much less common than
in the coast States in the same latitude, and the death-
rate is very low only 1'07 per cent per annum.

Population, 332,286.

Inhabitants to the square mile, 34.

Deaths per 1,000 Inhabitants,
The State (forms one group) 2'4

Addison 2'1

Bennington 2'6

Caledonia 2-6

Chittenden 2'7

Franklin 1'8

Lamoille.. . 2'8

Orange 3'5

Orleans 2'1

Rutland 2'1

Washington 2-6

Windham 1-9

Windsor 2'4

Remainder of group 2'4

STATE OF MASSACHUSETTS.

Topography. Massachusetts has an extreme length
from northeast to southwest of about 160 miles ; a
breadth varying from 47 miles in the western to about
100 miles in the eastern part ; and an estimated area of
8,315 square miles, or 5,321,600 acres. The Elizabeth
Islands, Martha's Vineyard, Nautucket, and some smaller
islands lying to the south, belong to the State. The sea-
coast is extremely irregular and deeply indented, and
there are numerous good harbors. Of the large rivers
the Merrimac alone falls into the sea within the limits
of the State. The Connecticut traverses the western part
of Massachusetts from north to south, and is not now
navigated within the State. The Housatonic, Black-

TOPOGRAPHY AND CLIMATE OF STATES. HI

stone, and Taunton flow tli rough Massachusetts, and the
Charles and Mystic Rivers empty into Boston Bay.
N curly all the rivers afford valuable water-power, but
none are navigable except the Merritnac. Two chains
of the Green Mountains traverse the western division
from north to south, and are known as the Taconic and
Hoosac ridges ; Saddle Mountain, in the extreme north-
west (3,600 feet high), being the highest peak. The
i nd northeast divisions are hilly and broken, and
the southeast is low and sandy.

diiitittc. The winters of Massachusetts are severe
and protracted, the summers short and warm, and the
range of the thermometer from 10 below zero to 100
Fuhr. The mean annual temperature is from 45 to
50 that of spring, 43 ; summer, 71 ; autumn, 51 ;
winter, 21. Snow falls usually during seven months,
October to April. The average annual rainfall is about
42 inches.

Population, 1,783,085.

Inhabitants to the square mile, 214.

Death* per 1,000 Inhabitant*.

The State 2-9

(Ji-'tiip 1 8-0

K;inistable 8'2

Hiistol 2-5

1 .ill River (city) 27

Essex 3*0

Lawrence (city) 8'8

Lynn (city) 2'9

2'4

(city). 2'6

Lowell (city) 3-5

Norfolk 2'3

Plymouth 24

Suffolk 2-4

Boston (city) 3'3

Remainder of group 7'2

Group 2 2-5

Berkshire 2'0

Franklin 2'3

Ilampdcn 2'9

Hampshire 2'7

Worcester -J *

Worcester (city) 2'5

112 PHTHISIOLOGY.

STATE OF RHODE ISLAND.

Topography. Rhode Island has an extreme length
north and south of 47 miles, an extreme width of 40
miles, and an area of 1,250 square miles, or 800,000
acres. Narragansett Bay divides it into two unequal
parts, the western section being much the larger, and
extending north from the Atlantic Ocean about 28 miles.
The width of the bay varies from 3 to 12 miles, and it
contains several islands, of which Aquidneck or Rhode
Island, Canonicut, and Prudence Islands are the most im-
portant. Block Island, 10 miles to the south and at the
western entrance of the bay, also belongs to this State.
Rhode Island has a broken and hilly surface. Rivers are
plentiful, though small, of no use for navigation, but, from
their rapidity and their numerous waterfalls, of great
service for manufacturing purposes. The chief rivers
are the Pawtucket and Pawtuxet, emptying into Narragan-
sett Bay, and the Pawcatuck, which falls into Long Isl-
and Sound. There are numerous small lakes in this State.

Climate. Owing to its nearness to the sea, the cli-
mate of Rhode Island is mild and equable, resembling
that of southern Massachusetts and eastern Connecticut.
The mean annual temperature varies from 49 to 51
Fahr., and the annual rainfall averages about 42 inches.
Owing chiefly to its mild and equable temperature, New-
port has become the great fashionable summer resort of
the country.

Population, 276,531.

Inhabitants to the square mile, 221.

TOPOGRAPHY AND CLIMATE OF STATES. 113
Death* per 1,000 Inhabitant*.

The State 2-3

Group 1 2-4

Bristol 1'6

Kent.. . 1-3

Newport 2'0

Providence 2-4

Providence (city) 2'9

Washington 2'3

STATE OF CONNECTICUT.

Topography. Connecticut is the third smallest of
the States, following next after Rhode Island and Dela-
ware. Its average length is 86 miles ; average breadth,
55 miles; area, 4,990 square miles, or 3,193,600 acres.
The country is beautifully diversified by hills and valleys,
although the scenery is less rugged than that of the
States on its north. The Green Mountain range termi-
nates in this State in a series of hills, and the highest
land is about 1,000 feet above the sea-level. The Housa-
tonic, Thames and Quinebaug, and Connecticut Valleys
extend north and south through the State, and contain
much of its best land. The sea-coast is over 100 miles
in length, and is deeply indented by numerous bays and
harbors, affording excellent anchorage for sea-going ves-
sels. New Haven, Bridgeport, New London, Stoning-
ton, and Saybrook are the most important of these.

Climate. Connecticut is not subject to such great
extremes of temperature as Massachusetts, Vermont, and
northern New York, and the climate is mild and healthy.
The mean annual temperature is about 50 Fahr. ; that
of spring, 46 ; summer, 70 ; autumn, 53 ; and winter,
30 Fahr. Occasionally the thermometer sinks to zero,
and considerable snow sometimes falls.

The summers are warm and pleasant, and the tern-

114

PHTHISIOLOGY.

perature rarely exceeds 90 Fahr., even in July. The
annual precipitation of rain and snow is about 48 inches.

Population, 622,700.

Inhabitants to the square mile, 124.

Deaths per 1,000 Inhabitants.

The State 2-2

Group 1 2-1

Fair-field 2'2

Middlesex 2"0

New Haven 2'1

New Haven (city) l - 9

New London. . .2-3

Group 2 2-3

Hartford. . . . 2-0

Hartford (city) ?-8

Litchfield 1-6

Tolland 2'3

Windham . . .2-6

STATE OF NEW YORK.

Topography. The extreme length of New York
east and west is 412 miles; greatest breadth from the
Canadian boundary to Staten Island, 311 miles ; area,
49,170 square miles, or 31,468,800 acres. The outline
of the State is very irregular, and two thirds of the
boundaries are formed by navigable waters, giving New
York a total water frontage of 880 miles. Long Island,
Manhattan, and Staten Islands are by far the most im-
portant divisions, distinct from the mainland. The nar-
row belt lying east of the Hudson River Yalley is inter-
sected by spurs of the Hoosac and Green Mountains,
while the rolling table-lands to the west are traversed
by the Blue Kidge and the Highland chains, the Catskill,
Helderberg, and Adirondacks.

The chief river is the Hudson, which rises in the
Adirondacks, and has a southerly course of 300 miles to
New York Bay. The Alleghany and its tributaries

TOPOGRAPHY AND CLIMATE OF STATES. 115

drain the southwest, and the Susquehanna the southern
central division. The Mohawk is the chief affluent of
the Hudson. The State is noted for the beauty of its
lakes. In the west are Chautauqua and Cattaraugus;
in the central division Canandaigua, Cayuga, Onondaga,
Oneida, and others, having the Oswego River for their
outlet.

Climate. No State has a greater diversity of climate
than New York. The mean temperature for the State
for the year is 46*50 Fahr., while in the Adirondacks
the annual mean does not exceed 40, and in the ex-
treme south it is about 50. The average annual precipi-
tation is about 42 inches, the greatest fall being in the
lower Hudson Yalley, and the least (32 inches) in the
valley of the St. Lawrence.

Population, 5,082,871.

Inhabitants to the square mile, 113.

Deaths per 1,000 Inhabitants.

The State 2-6

Group 1 8-1

Kings 1-1

Brooklyn (city) 2'9

New York (city) 3'5

Queens 1*6

Richmond 2'8

Huckland 1'9

Suffolk 20

Westchester 2'0

GrovpS 2-0

Clinton . . .2-2

Essex 2-1

Franklin 1'6

Ilerkimcr 1'9

St. Lawrence 2'0

Warren 1'6

Remainder of group 2-6

Group S 2-0

Delaware 1'2

Greene 2'7

Orange 2'1

Sullivan* I'D

Ulster.. . 2-3

* The immediate neighborhood of Liberty, Sullivan County, is one of
the best regions, particularly during the summer and autumn months,
within a day's journey of New York city, for consumptives and others who

116

PHTHISIOLOGY.

Deaths per 1,000 Inhabitants.

Group j. 1-9

Chautauqua 1-7

Erie ." 1-4

Buffalo (city) 1*8

Genesee 1-9

Jefferson 1'7

Monroe 1*9

Rochester (city) 2'3

Niagara 2'0

Orleans 2*2

Oswego 2-0

Wayne 1-7

Group 5 2'7

Albany. 2'8

Albany (city) 2-5

Allegany 1-1

Broome 2'1

Cattaraugus 1-3

Cayuga 1-9

Chemung 1*3

Chenango 2'0

Columbia 1'6

Cortland 2']

Duchess 2'5

Fulton 1-6

Lewis 1-5

Livingston 2'3

Madison 2'0

Montgomery 2'0

Oneida 2'0

Onondaga 1'9

Syracuse (city) 2'6

Ontario 2'0

Otsego 1-8

Putnam l - 8

Rensselaer 2'1

Troy (city) 3'5

Saratoga 2'6

Schenectady 2'8

Schoharie 2*1

Schuyler 1'7

Seneca 2'4

Steuben T5

Tioga 1-6

Tompkins 2-0

Washington 2-2

Wyoming 2-2

Yates. . , .26

STATE OF NEW JERSEY.

Topography. New Jersey has an extreme length
north and south of 157 miles ; a breadth of from 37 to
70 miles ; and an area of 7,815 square miles, or 5,001,-
600 acres. The highest ground is found in the north-
west, where the Blue Mountains attain an elevation of
from 1,000 to 1,750 feet. The Highland Range consists
of a series of hills rising 300 to 600 feet above their
alternating valleys, and separated from the Blue Mount-

require a pure atmosphere with moderate elevation. This opinion is sup-
ported by statistics and also by clinical experience.

TOPOGRAPHY AND CLIMATE OF STATES. 117

ains by the Kittatinny Valley, which has a width of
about ten miles. The elevation of this range is from
1,000 to 1,400 feet above the sea. The Palisades of the
Hudson, on the northeast, consist of rough ridges of trap
formation, never exceeding 600 feet in height. The
center of the State is an undulating plain, and the south-
ern division is low and leveL The Hudson forms part
of the eastern border, and the Delaware River and Bay
the western. The Atlantic coast-line is 120 miles long,
and the water frontage on Delaware Bay is almost as
great, while the Hudson River and the Raritan, New
York, and Newark Bays afford splendid harbor facili-
ties. The coast from Cape May to Sandy Hook is
bordered by long strips of sand-beach inclosing consid-
erable bodies of water connected by narrow passages.
Vessels of light draught can sail round much of the
coast in these protected lagoons, and thus avoid the
rough sea of the Atlantic. In the northern highlands
there are several small pictnresque lakes, and the
watering-places on the Atlantic coast, including Long
Branch, Squan Beach, Atlantic City, and Cape May,
are among the most popular summer resorts in the
East.

Climate. The temperature varies considerably in
different parts of New Jersey, the annual mean in the
northern highlands being from 48 to 50 Fahr. ; while
in the south, where the elevation is slight and the influ-
ence of the ocean is felt, it reaches 54. The uplands
are healthy, but marsh-fever and ague prevail in some
parts of the south. The precipitation of rain and snow

118

PHTHISIOLOGY.

ranges from 41 inches at Cape May to 50 inches in the
northern highlands.

Population, 1,131,116.

Inhabitants to the square mile, 144.

Deaths per 1,000 Inhabitants.

The State 2'3

Group 1 2'4

Atlantic 2'0

Bergen 2'5

Burlington 2'2

Camden 2'0

Camden (city) 2'6

Cumberland 2 - 4

Essex 2-1

Newark (city) 2'8

Gloucester 1'5

Hudson 2-6

Jersey City 2'7

Middlesex.. . 1'6

Monmouth 2'3

Ocean 2'0

Salem i'5

Union T8

Remainder of group 2 '3

Group 2 2-0

Hunterdon 1'9

Mercer 2'7

Morris 1'1

Passaic 1 '5

Paterson (city) 2'9

Somerset 1'4

Sussex 1'5

Warren. . . 1*4

STATE OF PENNSYLVANIA.

Topography. The greatest length of Pennsylvania
east and west is 303 miles ; greatest width north and
south, 1T6 miles ; mean length, 280 miles ; mean breadth,
158 miles; area, 45,215 square miles, or 28,937,600
acres. That part of Pennsylvania between the Blue
Mountains and the Delaware River rises from a few
feet above tide-water, at Philadelphia, to nearly a thou-
sand feet at the base of the hills, the ascent being gradual.
The country is one of great beauty. The Cumberland
Yalley forms a part of the great depression which ex-
tends through the entire length of the Appalachian
system as far south as Alabama. The mountain belt of

TOPOGRAPHY AND CLIMATE OF STATES. 119

the State is bounded east and west by the Kittatinny
and Alleghany Mountains. The third great division of
the State is the extensive elevated table-land which occu-
pies about one half its area, and extends from the western
elope of the Alleghanies to the Ohio border. The Sus-
quehanna drains nearly one half the area of the State.
Its chief tributary is the Juniata. The Delaware, which
rises in the Catskill Mountains, in New York, is a tidal
stream 132 miles from the sea, at Trenton. The Alle-
ghany rises in the " oil country," and at Pittsburg forms
a junction with the Monongahela. The Ohio, below
their junction, is a great thoroughfare for steam naviga-
tion.

Climate. The temperature of the southern and east-
ern divisions of the State differs considerably from that
of the north, and of the portion west of the mount-
ains. In the Alleghany, central, and northern uplands,
the winters are severe and protracted, with heavy falls
of snow. Along the Delaware the summer temperature
often ranges from 90 to 100 Fahr., and the valleys of
the Sasquehanna and Juniata have a climate closely re-
sembling that of the valley of the Rhine, the summer
heat being prolonged far into October. West of the
mountains the summers are shorter and hot; the win-
ters cold. The average fall of rain and snow is from
3G to 45 inches, varying in different parts of the State.
The climate is healthy ; and vegetation is about a week
earlier than in New York State.

Population, 4,282,891.

Inhabitants to the square mile, 94.

120

PHTHISIOLOGY.

The State

Group 1

Adama

Bedford

Blair

Bradford

Cambria

Carbon ,

Centre

Clearfield

Clinton ........

Columbia

Cumberland

Dauphin

Fayette ,

Franklin ,

Fulton

Huntington

Indiana

Juniata

Lacka wanna. . . ,

Scranton (city) . .

Lebanon

Luzerne

Lycoming

Mifflin

Monroe

Mentour

Northumberland

Perry

Schuylkill

Snyder

Somerset

Susquehanna . . .

Tioga

Union . .

Deaths per 1,000 Inhabitants.

Wayne TO

Westmoreland 1*2

Wyoming 1-9

Remainder of group 0'6

Group 2 2-1

Allegheny 1-5

Allegheny (city) 1-1

Pittsburg (city) 1-8

Armstrong T7

Beaver 1*6

Berks 1-8

Reading (city) 2'5

Bucks 2-3

Butler 1-5

Chester 2'2

Clarion 0'9

Crawford 1*5

Delaware 1-7

Elk 0-7

Erie 1'7

Greene 1*7

Jefferson 1 -6

Lancaster 1'7

Lawrence I'l

Lehigh 2-0

McKean 1-2

Mercer 1*4

Montgomery 1-9

Northampton 1'4

Philadelphia (city) 3'1

Potter 0-8

Venango 1-6

Warren 1-1

Washington 2'3

York 1-1

Remainder of group 0'9

1-8
1-4
1-8
1-4
1-2
1-5
1-5
1-4
1-6
1-1
1-1
1-1
1-8
1-4
1-4
2-2
2-4
1-6
1-1
1-5
1-6
1-2
1-7
1-1
1-3
2-7
1-3
0-8
1-3
1-3
1-4
1-6
1-0
1-6
1-0
0-9

STATE OF DELAWABE.

Topography. -The State has an extreme length north
and south of 96 miles ; a breadth of about 36 miles on

TOPOGRAPHY AND CLIMATE OF STATES. 121

the south line and 10 miles on the north ; and an area of
2,050 square miles, or 1,312,000 acres. There are no
mountains in Delaware. The southern portion is almost
level, and sandy, with large marshes abounding in cypress,
cedar, and other trees; but the northern half is undu-
lating, and contains some beautiful though not striking
scenery. The coast is low and swampy, with 'salt
marshes and shallow lagoons separated from the sea by
sandy beaches. The water-shed is formed by a low
tuble-land or sand-ridge running north and south near
the western border, and not more than 60 to 75 feet in
height. Drainage is into the Chesapeake and Delaware
Bays, but the streams are unimportant, and, with the
exception of Christiana Creek, only available for small
craft. The tide runs up to Wilmington, where there is
a depth of 18 feet of water, and Rehoboth Bay, at the
mouth of Indian River, admits vessels drawing six feet
of water.

Climate. The climate is mild, and tempered by the
sea-breezes. The mean annual temperature is from 51
to 53 Fahr., and the rainfall about 50 inches per annum.

In the northern division the climate is salubrious
and pleasant, but in the swampy parts of the south there
is considerable malaria.

Population, 146,608.

Inhabitants to the square mile, 71.

Deaths per 1,000 Inhabitant*.

Ue (forms one group) ... 2'4

Kent 1-f,

Newcastle 1 -9

Wilmington (city) 8*6

Sussex. . . 2-0

122 PHTHISIOLOGY.

STATE OF MARYLAND.

Topography. Maryland has an extreme length east
and west of 196 miles ; its breadth varies from less than
10 miles in the west to abont 120 miles in the eastern
peninsula ; while the area, not including Chesapeake Bay,
which comprises 2,835 square miles, is 12,210 square
miles, or 7,814,400 acres. Chesapeake Bay extends
almost through the entire breadth of the State. Mary-
land has over 500 miles of frontage on tide-water and
several navigable rivers, of which the chief are the Poto-
mac, Patuxent, Patapsco, and Susqnehanna, all of which
empty into Chesapeake Bay. The extreme western part
of the State is drained by the Youghiogheny, a tributary
of the Monongahela. Chesapeake Bay contains numer-
ous small islands, and its shores are indented by many
bays and inlets. The peninsular section is low and
sandy, and the western division, lying between Chesa-
peake Bay and the estuary of the Potomac, is of the
same general character ; but in the northwest the Blue
Eidge and Alleghany Mountains attain a moderate eleva-
tion, and the country is rugged and broken.

Climate. The climate is mild and salubrious, being
modified by the vicinity of the ocean, and the State
generally is healthy, although malarial diseases are not
unknown in the lowlands along the bay. The mean
annual temperature in the northwest is about 50 Fahr.,
in the central division about 56, and at Baltimore about
54. The rainfall averages from 45 to 50 inches per
annum.

TOPOGRAPHY AND CLIMATE OF STATES. 123

Population, 934,943.

Inhabitants to the square mile, 77.

Deaths par 1,000 Inhabitants.

The State 2'4

Group 1 2-6

Anne Arundcl 2'6

Baltimore 2'1

Baltimore (city) 3'4

Calvert 1*8

Caroline 2'1

Carroll 1'3

Cecil 1-9

Charles 2'4

Dorchester 2'0

Harford I'O

Howard 2'4

Kent . . .2-8

Montgomery ._. 1-6

Prince George's 2 - 6

Queen Anne 27

St. Mary's 17

Somerset 2 - 5

Talbot 2-0

Wicomico 2'0

Worcester 1-8

Group 2 1-8

Allegany T7

Frederick 1'6

Garrett 09

Washington 17

DISTRICT OF COLUMBIA.

Topography. Contains 70 square miles. It was
originally 10 miles square, but, by the retrocession of
Alexandria County to Virginia in 1846, it was reduced
to its present dimensions. It borders on the Potomac
River, is situated low, and is more or less swampy.

Climate. The climate is mild but not salubrious;
malarial diseases are quite common, particularly in the
rural districts. The mean annual temperature is about
56 Fahr. The rainfall averages from 45 to 50 inches
per annum.

Population, 177,624.

Inhabitants to the square mile, 2,537.

Deaths per 1,000 Inhabitants.
District of Columbia, total 4 -4 I Washington (city) 4/1

District of Columbia 5'7

124 PHTHISIOLOGY.

STATE OF VIRGINIA.

Topography. The greatest length of Virginia east
and west is about 440 miles ; greatest breadth north and
south, 190 miles; area, 42,450 square miles, or 27,168,-
000 acres. The Shenandoah, Alleghany, and Cumber-
land Mountains extend along the West Virginia border
from Harper's Ferry to the Tennessee line. The six
great topographical divisions are known as the Tide-
water, Middle, Piedmont, Blue Kidge, Valley, and Appa-
lachian sections, all of which extend across the State
from northeast to southwest, and have a general trend
corresponding to that of the Atlantic coast and the Appa-
lachian range. More than three fourths of Virginia is
drained by the Potomac, Rappahannock, Rapidan, York,
Elizabeth, James, and their tributaries, all of which find
their way at last to the Atlantic.

Climate. Owing to the differences in elevation and
situation, the climate of Virginia varies greatly in the
several sections. The mean annual temperature is from
55 to 60 on the sea-coast, and from 48 to 52 Fahr.
in the Blue Ridge and Appalachian districts. Observa-
tions taken at Lynchburg give the mean temperature at
different seasons as follows : Spring, 51 ; summer, 75 ;
autumn, 55 ; winter, 40 ; the year, 56*5 Fahr. There
is an abundant rainfall, the annual precipitation being
from 44 to 55 inches, most rain falling in the south-
east.

Population, 1,512,565.

Inhabitants to the square mile, 35.

TOPOGRAPHY AND CLIMATE OF STATES. 125

Deaths per

The State

Orovjt 1

Accomac

Elizabeth City

Essex . :

Gloucester

Isle of Wight

King and Queen

Nansemond

Norfolk

Prince George

Southampton

Sussex

Remainder of group

Group 2 .

Alexandria

Amelia

Appomatto.x

Brunswick

Buckingham

Campbell

Caroline

Charlotte

Chesterfield

Culpcper

Cumberland

Dinwiddic

KaiKjuier

Fulvanna

Goochland

Il.ilif.lX

Hanover

Ilrnrico

Richmond (city)

llmry

Louduun . .

1,000 Inhabitants.

Louisa 3-3

Luncnburg 2'7

Mecklenburg 1-5

Nottoway 2-6

Orange 3'1

Pittsylvania T3

Prince Edward 2'0

Spottsyl vania 2'8

Remainder of group 3'1

GroupS 1'5

Albemarle 1-9

Amherst 1 '5

Augusta 2'3

Bedford 1'6

Botetourt 2*4

Carroll 1-5

Floyd 1-1

Franklin 1'3

Frederick 2'3

Grayson. I'O

Lee 1-2

Madison T4

Montgomery I'O

Nelson 2'0

Patrick 0-6

Roanoke 1*2

Rockbridge 1'6

Rockingham 2'1

Russell 0-9

Scott 0-8

Shenandoah 1*5

Smythe 1'2

Tazewell 0'5

Washington 1'8

Wythe 1-0

Remainder of group 1*1

STATE OF WEST VIRGINIA.

Topograpky. The greatest length of the State north
and south is about iJ4n miles; givutest breadth, ICO

126 PflTHISIOLOGY.

miles ; area, 24,780 square miles, or 15,859,200 acres.
West Virginia is extremely hilly. The Alleghany range
on its eastern boundary contains several large peaks, and
west of this range and running parallel with it, at an
average distance of 30 miles, are a series of mountains
scarcely inferior in height, which inclose many fertile
valleys. The scenery of the mountain-regions is very
fine, and forms a special attraction for tourists. A few of
the smaller streams in the east are tributary to the Poto-
mac, but the rivers generally drain into the Ohio. The
western division is a rolling table-land, with a gradual
slope from the mountains, where its elevation is nearly
2,500 feet, to the banks of the Ohio, 900 feet above the
sea-level. The Potomac forms part of the eastern bound-
ary. The Big Sandy, Great and Little Kanawha, Guyan-
dotte, and Monongahela are all navigable. The slack-
water navigation of the Kanawha and Monongahela is of
much service to the commerce of the State, and by means
of the Ohio the Southern and Southwestern cities can be
reached.

Climate. The climate is generally equable, and is
not marked by any great extremes. The mean annual
temperature is about 52 : that of winter, 31 ; spring,
50 ; summer, 72 ; autumn, 54 Fahr. The average
rainfall is from 43 to 45 inches, and except in the more
elevated sections little inconvenience is experienced in
the winters. The climate much resembles that of Yir-
ginia, and is well adapted for all agricultural purposes.
The State is very healthy, the death-rate being less than
1 per cent.

TOPOGRAPHY AND CLIMATE OF STATES. 127

Population, 618,457.

Inhabitants to the square mile, 24.

Deaths per 1,000 Inhabitants.

The State 1'5

Group 1 1-4

Harbour T5

Berkeley 2'0

Fayette 1'7

Greenbrier 1-8

Hampshire 0'8

Harrison T8

Jefferson 2'2

Lewis 1-5

Marion l - 6

Monongalia 1'8

Monroe 1-3

Preston 0-5

Taylor 2'0

.ur 1-2

Remainder of group 1-3

Group g 1'6

Cabcll 2-1

Doddridge T5

Jackson 1'5

Kanawha 1*9

Marshall 1-2

Mason .... 1'6

Ohio 1-8

Putnam 1*4

Ritchie 2'5

Roane 1-2

Tyler 1-4

Wayne M

Wctzel 1-0

Wood 2-1

Remainder of group 1-4

STATE OF NORTH CAKOLINA.*

Topography. North Carolina is about 450 miles in
length east and west, and has an extreme breadth of 185
miles, and an area of 52,250 square miles, or 33,440,000
acres. The west is mountainous, the center hilly, and
the coast-lands low and swampy. That part of the
Allcgliany range which separates this State from Ten-
nessee has a number of local names. The several ridges
inclose an extensive plateau, having a general elevation
of about 3,500 feet. The Black Mountains in the north-

* For special information regarding the Ashville region of this State,
the reader is referred to a valuable contribution on the subject, by T. Mor-
timer Lloyd, M. D., which was published in the " New York Medical Jour-
nal " for April 9, 1887.

128 PHTHISIOLOGY.

west contain Clingman's Peak, 6,940 feet, and Mount
Mitchell, 6,732 feet. In the Blue Kidge are Sugar
Mountain, 5,312 feet, and Grandfather Mountain, 5,900
feet. Ashville is situated in the center of western North
Carolina. This region embraces an area of 6,000 square
miles, having a considerable general elevation, and lies
between the Blue Kidge and Smoky ranges. The geologi-
cal formation is of the oldest, and the water is soft and re-
markably pure. The coast-line extends over 400 miles.
The coast proper is deeply indented, and contains spacious
harbors at Wilmington, Beaufort, Edenton, and New
Berne. Much of the land is sandy, but more of it is
fertile and abounds in valuable timber. The Great Dismal
Swamp extends north from Albermarle Sound into Yir-
ginia r and covers an area of about 150,000 acres. The
chief river is the Cape Fear. The Roanoke and Chowan
rise in Virginia, and empty into Albemarle Sound. The
Tar and Neuse have their sources in the north, and flow
into Pamlico Sound. The Yadkin and Catawba become,
in South Carolina, the Great Peedee and the Santee.

Climate. The climate of the State is varied. In
the low country it is warm and moist ; on the mount-
ains, cool and dry. The mean annual temperature at
Asheville is 55 : that of spring, 53 ; summer, 72 ;
autumn, 54 ; winter, 38 Fahr. Frosts are light and
seldom occur before November, while wheat is harvested
in June, and corn in the early part of September. The
annual rainfall averages about 46 inches.

Population, 1,399,750.

Inhabitants to the square mile, 26.

TOPOGRAPHY AND CLIMATE OF STATES. 129

Deaths per

The State

Group 1

Beaufort

Bertie

Bladen

Columbus

.iven

Cumberland

Duplin

Hertford

Lenoir

Martin

New Hanover

Pasquotank

Pcnder

Pitt

Robeson.

Sampson

Wayne

Remainder of group

Group 2

Alamance

Anson

c il>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 :

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<ra. . . ............ 2'5

Lake 1-7

Lorain 1-8

Lucas 2-3

Toledo (city) 0'9

Ottawa 1-8

Sandusky 1-3

Wood... . 1-5

TOPOGRAPHY AND CLIMATE OF STATES. ]37

Deaths per l t OC
2-2

W Inhabitant*.

1*0

1-7

Crawford

... 1*1

1-9

Darkc

. 1'4

1-6

. 1'9

8-4

. 1*7

2-1

. 1-6

1-9

Clinton

2-7

Fulton

. ... 1'7

Piirfield

1-9

... 1-8

Fayctte

1-6

Hancock . .

1-3

Gallia

Hardin

. .. 1'6

2-6

2-0

Henry . .

1-1

Cincinnati (citv).

2-7

Ilohncs

1-3

2-3

1-7

2-0

Knox

1-7

2-2

1-5

Logan .

2-0

1-0

Madison

1-6

Yi-i

2-2

1-3

2-1

Marion ...

0-8

2-6

Medina . . . . .

1-4

2-1

1-5

1-8

1-9

Noble

1-3

1-7

Perrv

1-1

1-7

Pickaway . . . .

2-6

1-8

Pike

2-1

0-9

Preble

1-9

Putnam

1-2

Ross

2-3

Richland

1-4

2-1

1-2

Vlnton

2-2

1-9

Warren

2-5

Stark

1-1

Washington . . .

1-7

Summit

1-1

Group 3

1-6

Trumbull

1-1

Allen

1-5

1-0

Ashland

1-3

2-1

'aizc

1-7

1-0

Carroll

1-0

Wayne

1-5

Champai<ni . .

.... 1'6

1-4

Clarke

.,..,

1-4

Columbiuna..

. 1-2

138 PHTHISIOLOQY.

STATE OF TENNESSEE.

Topography. The greatest length of Tennessee east
and west is 432 miles ; greatest breadth, 109 miles ; and
area, 42,050 square miles, or 26,912,000 acres. The
Appalachian Mountains separate Tennessee from North
Carolina. The State is popularly divided into three
sections : East Tennessee, extending from the North
Carolina border to about the middle of the Cumberland
table-land; Middle Tennessee, thence to the Tennessee
Kiver; and West Tennessee, occupying the territory
between the Tennessee and Mississippi Rivers. The
Mississippi forms the western boundary, and, with the
Tennessee and Cumberland, drains about three fourths
of the State. Other rivers are the Clinch, the Holston,
the Forked Deer and its branches, the Big Hatchie and
the Wolf River. The Tennessee and Cumberland are
navigable for a considerable distance, and the other rivers
afford valuable water-power.

Climate. The climate of the State is mild and re-
markably salubrious. Owing to the great elevation of
the eastern division and the level plains of the west,
Tennessee has a climate embracing the characteristics of
every State from Canada to Mississippi. The yearly
rainfall is about 46 inches, and the range of the ther-
mometer about 45 Fahr. The mean temperature of
winter is 37-87; spring, 56-71; summer, 74-40; and
autumn, 57'54. As a rule the snow-fall is light, and
there is but little ice. The eastern portion of Tennessee
is regarded as the healthiest section of the State.

TOPOGRAPHY AND CLIMATE OF STATES. 139

Population, 1,542,359.

Inhabitants to the square mile, 36.

The State

Deaths per 1,000 Inhabitant*.

2'4 Henderson

2-8

Oroup 1

2-1

Ilenry

... 2-3

2'5

McNairy

.... 1-7

Blount

2-5

Madison

... 2-1

2-4

Weakley

. . 2-0

Campbell. . .

1-6

Remainder of group

. 1*5

Carter

1*7

Group S

... 2'3

0'6

Dyer.. .

. . . 2*1

Cocke

1*7

... 3*3

Coffee

2'4

Obion

... 3*7

DC Kalb

2-2

Shelby

... 1*5

Franklin ....

2-4

Tipton

... 2*2

Grainier . . .

2-7

Remainder of group.. .

... 77

Greene

2-8

Group 4

... 2-8

Hainblin ....

2-4

Bedford

... 3'6

Hamilton .

3-0

Cannon

... 2-4

JI;i\vkins ....

1-9

... 2-5

Jefferson ....

2-3

Nashville (city)

... 3'1

Knox

2-9

Dickson

... 2-8

McMiim

2'6

Giles

... 3-5

Marion

2-2

... 1*4

Monroe ....

1-3

Uickman

... 1*1

Overton . .

0'9

Humphreys

... 2*4

Putnam

1-3

... 0*7

Roanc . .

Lawrence

... 1-7

Scvicr

. . . .. 2-3

Lincoln

... 8'0

Sullivan

1-8

Marshall

... 8-6

I'liiull ... .

1-8

... 37

Wurren

1-8

... 2-7

Washington .

8-0

... 4-6

White

2'5

Rutherford

... 2'6

Remainder of
Group 2

group 1*6

Smith

... 2-3

2*1

Stewart

... 2-4

2'3

Sumncr

8'8

Crockett

. 2'8

Wayne

0'9

Favette

1-7

Williamson

... 2-4

Gibson

:;:;

Wilson. . ...

3-6

1 1 UP Ionian .. .

1*2

... 2'5

v ood . .

. 2'B

140 PHTHISIOLOGY.

STATE OF KENTUCKY.

Topography. Kentucky has an area of 40,400 square
miles, or 25,856,000 acres ; its greatest length east and
west being 350 miles, and its greatest breadth ITS miles.
The whole of Kentucky lies within the Mississippi basin,
and it is essentially a table-land, sloping gradually from
the southeast to the northwest. There is a mountainous
area of about 4,000 square miles in the southeast, and
the eastern half of the table-land has an average height
of about 1,000 feet above sea-level, with ridges 500 feet
higher. Kentucky is amply provided with large rivers,
the Ohio and Mississippi being navigable all along its
borders, and the Big Sandy, Cumberland, Licking, Ken-
tucky, Green, Salt, Big Barren, Tennessee, and other
important streams flowing through the State.

Climate. The climate is very pleasant, though some-
what variable, and is favorable to agriculture. The
average temperature is about 55 Fahr., and in winter
the thermometer seldom falls below zero. The winters
are of medium length, and snow does not remain long
on the ground. The average annual rainfall is 50'30
inches, the greatest fall being in spring and winter ; the
summers and autumns being usually dry. The mean
summer temperature is about T5, and the weather,
though warm, is not oppressive. The healthfulness of
Kentucky is exceeded by that of but few States or coun-
tries in the same latitude.

Population, 1,648,690.

Inhabitants to the square mile, 40.

TOPOGRAPHY AND CLIMATE OF STATES. 141

Death* per

The State

(j'ruujt 1

Boyd

Carter

Clay

Knox

Lawrence

Pike

Pulaski

Wayne

Whitloy

Remainder of group

Group 2

Boone

Bracken

Breckenridgc

Campbell

Crittendcn

Davicss

Greenup

Henderson

Jefferson

Louisville (city)

Kenton.

Lewia

McCracken

Mason

Meade

Union

iiider of group

Group S

HalLird

Hickman

inler of group

Group ,'f

Ailair

Hath

Bourbon

Boyle

Butler . .

2-2
1-4
2'3
0-8
1-1
1-1
1-9
1-8
1-3
21
1-7
1-4
1-3
2-3
1-7

6
6
3
9
3
7
2-6
3-2
2-0
1-4
1-7
2-5
2-6
1-3
2-6
1-7
1-8
1-9
1-2
2-4
35
2-3
2-7
2-3
2'3
8-9
2-0

Inhabitants.

Caldwell 2-2

Galloway 2-8

Casey 1'6

Christian 2'6

Clark 2-7

Fayette 3'9

Fleming 2*4

Franklin 8'9

Garrard 3*4

Grant 27

Graves 1'6

Gray son 1*5

Green 2'6

Hardin 2'0

Harrison 2'3

Hart 2-5

Henry 3'3

Hopkins 1'8

Jessamine 3'3

Lincoln 1*6

Logan 2-1

Marion 8'7

Mercer 2'8

Monroe 1 '3

Montgomery 2'8

Muhlenburg 2*1

Nelson 3'0

Nicholas. 3'3

Ohio 1-3

Owen 1-8

Pendleton 2-5

Scott 1-8

Shelby 2'2

Simpson 1'8

Todd 1-8

Trigg 1'7

Warren 2'6

Washington 2'9

Webster 1'4

Woodford 2'2

Remainder of group 2'2

142 PHTHISIOLOGY.

STATE OF INDIANA.

Topography. The surface of Indiana is extremely
level, and it has no mountains or even hills of any size.
At least two thirds of the State consists of level or
undulating land, and it is only along the river-valleys
that the landscape is diversified and relieved by bluffs
and hills. Along the Ohio, which forms the southern
boundary of the State, these hills attain a height of 200
to 300 feet. The land slopes gradually from north and
northeast to the southwest, and the lowest point is found
at the mouth of the Wabash. The rivers mostly run
southwest and empty into the Ohio. The Wabash, Kan-
kakee, White, Maumee, and other less important streams
furnish an ample supply of water-power. The State has
a shore-line of 40 miles on Lake Michigan. Its extreme
length, north and south, is 276 miles ; average breadth,
140 miles ; area, 36,350 square miles, or 23,264,000 acres.
The country near the lake is sandy and low, except at
Michigan City, where there are extensive hills of sand.

Climate. The climate is somewhat variable, espe-
cially in the winter, when the winds are from the north
and northwest. The mean temperature of the year is
52 ; that of winter, 31 ; spring, 51 ; summer, 76 ;
and autumn, 55 ; and the average rainfall is about 38
inches. Indiana is well suited for agriculture, and the
fruit-trees blossom in March and the beginning of
April.

Population, 1,978,301.

Inhabitants to the square mile, 54.

TOPOGRAPHY AND CLIMATE OF STATES. 143

Deaths per

The State

Group 1

Lake

La Porte

Porter

Group S

Clarke

Crawford

Dearborn

Dubois

Floyd

Gibson

Harrison

Ji-fterson

Jennings

Orange

Perry

Pike.

Posey

Ripley

Spencer

Switzerland

Vanderburg

Warrick.

Washington

Remainder of group

Group 3

Adams

Allen

Bartholomew

Benton

Boonc

Brown

Carroll

Cass

Clay

Clinton

1,000

1-9

11
1-5

iv,

If
M

H
25

j -
:,..'
If

2 1
o,,

I'l
.,.,,

2-0
M

2-0
W

j I
If
M

:.:;
If

!::
1 :;
1-
1-j
!,

1-H

1-5

:r 2'8

DC Kalb 11

Delaware 2'0

. 1-0

Inhabitant I.

Fayette T8

Fountain 2'0

Franklin 2'2

Fulton 1-6

Grant 1-3

Greene 1'7

Hamilton 1-7

Hancock 1*8

Hendricks 1*9

Henry 1-9

Howard 2'4

Huntington 1*4

Jackson 1*8

Jay 0-8

Johnson 2'4

Knox 1-4

Kosciusko 1*2

Lagrange. 1'7

Lawrence 0'8

Madison 1'3

Marion 1*9

Indianapolis (city) 2'4

Marshall 1-0

Martin 2'2

Miami 1*6

Monroe 1*9

Montgomery 2*7

Morgan 2*5

Noble 2-1

Owen 2'3

Parke 1'7

Putnam 2'3

Randolph 2'0

Rush 2-8

Saint Joseph 1*6

Shelby 2'4

Steuben 1'4

Sullivan 2'4

Tippecanoe 1'8

Tipton 1-8

Vcrmillion 1'6

Vigo 2-7

144: PHTHISIOLOGY.

Death* per 1,000 Inhabitants.

Wabash M

Warren I'l

Wayne 1'8

Wells... . 1-2

White 1-8

Whitley 1'7

Remainder of group 2*0

STATE OF ILLINOIS.

Topography. Illinois has been very appropriately
called the "Prairie State." Next after Louisiana and
Delaware it is the most level State in the Union, and
fully one third of its whole area is composed of high,
level, grassy plains. The average elevation of these
above tide-water is not over 500 feet. At Cairo, the
extreme southern angle of the State, the elevation of the
land is only 340 or 350 feet above the Gulf of Mexico ;
and at Chicago, in the northeastern section, the elevation
of the business portion of the city is only 592 feet above
the sea-level. The highest land in the State is in the
northwestern corner, where, between Freeport and Ga-
lena, the extreme elevation is 1,150 feet above the sea.
Its extreme length north and south is 385 miles; ex-
treme width east and west, 218 miles ; area, 56,650 square
miles, or 36,276,000 acres. The Wabash, Ohio, and Mis-
sissippi Eivers form part of the eastern and southern
and all of the western boundary-lines, thus giving the
State immense frontage on navigable waters.

Climate. The climate is generally salubrious. The
upland prairies are almost entirely free from endemic
diseases, and the death-rate in the cities is low. The
mean annual temperature on the fortieth parallel is about
54, that of summer 77, and of winter 33^ Fahr.

TOPOGRAPHY AND CLIMATE OF STATES. 145

Vegetation begins with April, and the first killing frosts
occur about the end of September. The summer heat
is greatly modified by the ever-present breezes, and the
climate is generally favorable for out-door occupations.
The mean annual rainfall is 35 inches.

Population, 3,077,871.

Inhabitants to the square mile, 54.

Deaths per

The State

Group 1

Chicago (city)

Cook

Lake

Group 2

Adams

Alexander

Carroll

Gallatin

Hancock

Henderson

Jackson

Jersey

Jo Daviess

Johnson

Madison

Massac

Mercer

Monroe

Pike

Pope

Randolph

Rock Island

Saint Clair

1'ni'in

Whiteside

Remainder of group

Group 3

Bond

Boone

1-4
1-4
1-6
0-4
1-8
1-6
2-3
1-2
1-1
1-5
1-9
1-4
1-3
1-4
0-7
1 >
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

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.
' <//,,//,. Although Wisconsin is far north, the cold

150

PHTHISIOLOGY.

of winter is tempered by the vicinity of Lake Michigan,
and the excessive heat of the short summers is modified
by the breezes from that body of water and from Lake
Superior. The mean annual temperature of the south-
ern section is 46 Fahr. ; that of winter, 20 ; of spring
and autumn, 47 ; and of summer, 72. The winters
are uniform, with heavy snows in the north preceding
the hard frosts, and in the south snow often falls to a
depth of 18 inches. Spring is backward, summer short
and hot, and the autumn mild and pleasant. The north-
ern part of Lake Michigan is frozen over most winters,
but the ice never extends so far south as Milwaukee.
The Milwaukee Biver is frozen up from the end of
]STovember to about the middle of March, or an average
of 100 days. The prevailing winds in autumn and
winter are from the west, in summer from the southwest,
and in spring from the northeast, and the climate is
healthful and invigorating. The annual quantity of rain
and melted snow averages about 32 inches.

Population, 1,315,497.

Inhabitants to the square mile, 23.

Deaths per 1,000 Inhabitants.

The State 1'2

Group 1 1-3

Brown 1'4

Door 0-2

Kenosha . . 2'4

Kewaunee 1'2

Manitowoc 1*0

Milwaukee 0'4

Milwaukee (city) 1'7

Ozaukee... 1'S

Racine. ... 1'2

Sheboygan 1'2

GroupS 1-0

Buffalo 0-5

Crawford 1'2

Grant I'O

La Crosse I'O

Pierce I'O

Saint Croix I'O

Trempealeau 0'9

TOPOGRAPHY AND CLIMATE OF STATES. 151

Deaths per

l t O(
0-9
1-9
1-8
1-1
1-6
1-3
1-2
1-5
1-5
1-5
1-3
1-3
1-6
1-0
1-4
1-4
1-3
0-9
1-4

JO Inhabitants.
Washington

... 1-2

Hem liudcr of group . .

Waukesba

... 1-1

Waushara

... 1-2

... 1-5

... 1-6

Pane

.. I'O

Dod^e

Chippewa.

... i-o

Fond du Lac

Clark

... 0'6

Green

Dunn

... 17

Green Lake

Eau Claire

... i-o

Iowa . . ...

.. 0-9

JfsSenoo

... 0-4

Juneau

... I'l

Lafavetle

Polk

... i-o

Monroe . . ....

... 1-2

Rii'hland ....

... 1-2

Rock

... 1-8

Sunk

Remainder of group

... 0-7

Wai worth . .

STATE OF IOWA.

Topography. Nearly the whole State consists of
gently undulating prairie, and is destitute of mountains
or even hills of any size. There are some bluffs on the
river-margins, and in the northeastern part the surface is
more elevated and the scenery more diversified. The
country is well watered and extremely beautiful, abound-
ing with natural meadows and verdant plains. The
strains, without exception, flow into one or the other of
the great boundary rivers, and give unrivaled natural
drainage for the whole State. In the northern portion
there are numerous small, beautiful lakes, which are a
part of the system extending northward into Minnesota.
Its general extent north and south is 208 miles, and east
and west about 300 miles; and its area is 56,025 square

152

PHTHISIOLOGY.

miles, or 35,856,000 acres, being almost exactly the same
as that of Illinois. The highest point in the State is at
Spirit Lake, in the northwest part, which is 1,650 feet
above the sea-level, and there is a gradual slope thence
to the southeast, until, at the mouth of the Des Moines
Kiver, the elevation is only 444 feet.

Climate. It is a healthy region malarial, epidemic,
and endemic diseases being rare. The winters are severe,
owing to the prevalence of north and northwest winds,
which sweep at will over the prairies, but they are not
unhealthy. In summer the constant breezes relieve the
heat of the season. The mean annual temperature is
about 48 Fahr. ; that of summer, 70|, and of winter;
23^ ; and the temperature is seldom lower than 10 or
higher than 90. The mean annual rainfall for thirty
years was 44*27 inches ; the least 23'35 inches, and the
greatest 74'49 inches. Taking the whole year, the cli-
mate is moderate, and favorable for agriculture ; fruit-
trees blossom early in May, and wheat ripens in August.

Population, 1,624,615.

Inhabitants to the square mile, 28.

Deaths per 1,000 Inhabitants.

The State M

Group 1 1-0

Allamakee 1'3

Clayton I'l

Clinton I'O

Des Moines 1'6

Dubuque 1'2

Jackson I'l

Lee 2-0

Louisa 1'9

Muscatine 1-4

Scott 0-8

Gh-oup 2 l-l

Adair 0'7

Adams O'Y

Appanoose 1-3

Benton 1-7

Black Hawk 1-0

Boone. 1-1

Bremer , . 0'9

TOPOGRAPHY AND CLIMATE OF STATES. 153
Deaths per 1,000 Inhabitant*.

1-2

Madison

1-6

Butler

0-9

Mabaska

1-3

Carroll . .

0-6

Marion

1-1

Cass

0'6

Marshall

1-3

Cedar

1-0

Mitchell

... 1-7

Cerro Gordo

.. 0-9

Monroe

... 1-7

Chickasaw . .

0-8

... 05

Clarke

.. 1-3

Page.. .

... 0-9

0*6

Polk

... 1-4

Dallas .

0-9

Poweshick

... 0-7

Davis

0'9

... 0-5

Docatur

. 1-3

Shelby

... 1-4

Delaware

. 1'4

Story

... 0-8

1*5

Tama

... 0'9

Floyd

1-1

Taylor

... i-o

Franklin

I'l

.. .. I'O

Greene . . .

0*9

... 1-5

Grundy

0*5

Wapello

.... 1-7

Guthric

.. 1*2

Warren

... I'l

Hamilton ...

0-5

Washington

... 1-3

IJardiu .

1-1

Wayne

... 0-7

. 2'1

Webster

... 2-0

0*4

.... i-o

Iowa

1-6

Remainder of group

... 0-4

. 1*4

Group S

... 0-8

2*0

Fremont.

... 0-7

1'2

... i-o

2'0

Mills

... 0-4

Keokuk

. 1'2

Pottawattamie.

... 0-9

1*2

Woodbury

... 1-6

Li;, a- .. .

. 0-7

Remainder of group

... 0-7

STATE OF MISSOURI.

Topography. Missouri has a length north and south
of 275 miles; an average breadth of about 245 miles;
ami an area of 69,415 square miles, or 44,425,600 acres.
That part of the State which lies north of the Missouri
River consists of rolling or level prairies, with deep river-

151

PHTHISIOLOGY.

valleys, and a general slope from northwest to southeast.
The southern division, which is much the larger of the
two, is more broken and rugged, with a number of hills
ranging from 500 to 1,000 feet in height, and mount-
ain-ranges (the Iron Mountains and Ozark Mountains)
in the extreme south. The uplands cover more than
half of this section ; and west of the Ozark region the
prairies are undulating, and the valleys of the rivers
both wide and deep. The principal rivers are the
Mississippi (which washes the entire eastern boundary
nearly 500 miles) and the Missouri. The Missouri has
numerous tributaries within the State, chief of which
are the Osage and Gasconade.

Climate. The range of temperature is great, and the
climate is subject to frequent changes. The summers
are hot and the winters severe, even the largest rivers
being sometimes frozen entirely over. The mean annual
temperature of the central part is 55 ; that of spring,
56 ; summer, 76 ; autumn, 55 ; and winter, 39 Fahr.
Southerly winds predominate, and the annual rainfall is
about 32 inches, the greatest precipitation being in May.

Population, 2,168,380.

Inhabitants to the square mile, 31.

Deaths per 1,000 Inhabitants.

The State 1'6

Group 1 2-0

Bellinger M

Cape Girardeau 2'2

Clarke 1'4

Jefferson 0'9

Lewis 1'6

Lincoln 2 - l

Marion 1-7

Perry 2'3

Pike 2-3

Saint Charles 1'9

Sainte Genevieve 0'8

Saint Louis. . .1*4

TOPOGRAPHY AND CLIMATE OF STATES. 155

Saint Louis (city)

... 22

Stoddard

... 1-7

Rails

... 1-3

iiainder of group

... 1-9

Oroup S

... I'l

Barrv

.. 1-2

Barton

... 0-3

Bates

... 1-6

Bcnton

... 10

... I'l

Cedar

.... 1-3

Crawford

... 1-8

D.ide

.. 0-7

Dent

... 1-2

Greene

... 1'6

Henry

... i-o

Jasper

... 1-4

Johnson

... 0-9

Ladede

... I'l

Lawrence

... 0-9

Morgan

... 1-8

Newton

... 1-7

Pettis

... 1-2

Phelps

... 1-3

Polk

... 1-3

Saint Clair

... 0-4

Texas

. ... 0-9

Vernon

... 09

Washington

... i-o

Webster

... i-o

Remainder of group. . . .

...I'O

Oroup S

... 1-6

Adair

... 1-3

Audrain

. ... 1-5

Caldwell

... 1-2

Clinton

... 1-7

Daviess

2-0

DeKalb

.... M

(irlltrv

.... 1-2

Grundy

1-5

Harrison

.... 1-7

Deaths per 1,000 Inhabitants.

Knox 1-8

Linn T7

Livingston 1-3

Macon 1'6

Mercer 1'7

Monroe. 2"2

Nodaway 1-3

Putnam I'O

Randolph 1'9

Schuylcr. 1*3

Scotland. 1-4

Shelby 1-7

Sullivan I'O

Remainder of group 2'3

Group 4. 1'7

Andrew 1'8

Atchison 1*2

Boone 2*4

Buchanan II

Calloway 1-6

Carroll 0'8

Chariton 0'7

Clay 1-4

Cole 1-9

Cooper 2'2

Franklin I'O

Gasconade 1'2

Holt 1-9

Howard 2-9

Jackson 1*3

Kansas City M

Lafayette 2'1

Monitcau 2'3

' Montgomery 2'2

Osage 2-1

Plattc 2-0

Ray 2-1

Saint Francois 0'9

Saline 1-7

Warren.. 1*0

156 PHTHISIOLOGY.

STATE or ARKANSAS.

Topography. Arkansas has an extent north and
south of 280 miles ; a breadth from east to west of
from 170 to 250 miles; and an area of 53,850 square
miles, or 34r,4r64,000 acres. The eastern portion of Ar-
kansas is low and flat, but toward the west the land
gradually rises and becomes somewhat hilly. The Ozark
Mountains in the northwest are little more than hills,
seldom attaining an elevation of over 2,000 feet, and the
extreme west consists of an elevated plain, with a gradual
ascent toward the Indian Territory. The most impor-
tant river is the Arkansas, which rises in the Rocky
Mountains, flows through Colorado and Kansas, and
thence southeast through the Indian Territory and Ar-
kansas, to its junction with the Mississippi at Napoleon.
It has a course within the State of 500 miles. The Red,
St. Francis, White, and Ouchita Rivers are all large
streams, and of much service in commerce. The Missis-
sippi, here of great width, washes the eastern boundary
of Arkansas, and gives it an additional water frontage
of nearly 400 miles. All parts of the State are finely
timbered. There are extensive pine-forests ; also an
abundance of oak, hickory, walnut, linn, locust, cypress,
cedar, and many other useful trees. The Hot Springs
form one of the most remarkable natural phenomena to
be found in this country. They are of great medical
value, and around these famous springs a town has
grown up.

CUmate. The temperature is moderate, ranging

TOPOGRAPHY AND CLIMATE OF STATES. 157

from 15 to 100 Fahr., and frosts are seldom known.
The mean annual temperature is about 63 ; that of
winter, 45'82 ; summer, 80 ; and the thermometer rises
above 90 only during July and August. The rainfall
varies from 40 to 55 inches per annum, the heaviest fall
being in the southeastern part of the State, and the least
in the northwest. In general the climate is very pleasant
and healthful. The northwestern portion of the State
bears a liigh reputation as a sanitary resort.

Population, 802,525.

Inhabitants to the square mile, 14.

Death* per 1,000

The State M

Group 1 1-4

Chicot 0-2

Jefferson 1'S

Lee 1-3

Phillips 1-8

Remainder of group 1'4

OroupS 1-1

Ashley 1-2

Bcnton I'O

Boone 0'9

Carroll 0-9

Clark 0-6

Columbia 0'8

Conway 0'7

Crawford I'O

Drew 1-2

Faulkner I'O

Franklin.. . 1-2

Inhabitants.

Hempstead 0'6

Independence 1-4

Izard 1-9

Jackson I'O

Johnson 0'6

Logan 0'9

Lonoke 1*3

Madison 0'7

Nevada 0'8

Ouachita 0'8

Pope 2-0

Pulaski 2'6

Randolph 1*2

Sebastian I'O

Union. 0'5

Washington 0'9

White 1'9

Yell 1-2

Remainder of group 10

STATE OF LOUISIANA.

Topography. Louisiana has an extreme length east
and west of 300 miles ; the greatest breadth is 240

158 PHTHISIOLOGY.

miles ; area, 48,720 square miles, or 31,180,800 acres.
It is low-lying, and much of the southern part is only a
few feet above the sea-level. Hills there are none, except
in the northwest, where there are some low ranges, never
exceeding 200 feet in height ; and on the east bank of
the Mississippi, where the bluffs rise gradually between
Baton Rouge and Natchez to the height of 200 feet.
The coast-line extends over 1,200 miles, and is exceed-
ingly irregular. Few States, if any, are so well watered,
and many of the streams are navigable. The Mississippi
flows for 800 miles through or on the borders of Louisi-
ana, and reaches the sea by means of numerous branches,
forming an extensive delta. The Red, Atchafalaya,
Amite, Pearl, and Washita Rivers are all navigable for
considerable distances. In many cases the rivers expand
into large bayous or lakes. Of these, the principal are
Lakes Pontchartrain, Borgne, Yerret, Grand, Sabine,
"White, Black, Bistineau, Catahoula, Maurepas, and
"Washa. There are many bays and inlets on the coast,
and numerous small islands in the Gulf of Mexico.

Climate. The mean annual temperature at New
Orleans is 68, and at Shreveport, in the northwest, 64
Fahr., and the rainfall ranges from 50 to 65 inches, most
of it being in spring and summer. The summers are
protracted and occasionally very hot, and the winters are
colder than those of the Atlantic States in the same lati-
tude, owing to the free sweep which the northern winds
have over the State. The climate is favorable to the
growth of all agricultural productions, but can not be
considered healthy, at least for persons who have not

TOPOGRAPHY AND CLIMATE OF STATES. 159

become acclimated. In 1853, 1867, and again in 1878,
yellow fever prevailed as an epidemic in New Orleans
and other cities, causing great loss of life, and an almost
entire suspension of business.

Population, 939,946.

Inhabitants to the square mile, 19.

Deaths per

The State

Group 1

Ascension

Assumption

Calcasieu

But Baton Rouge

Iberia

Ibcrville

Jefferson

Lafayette

Laf ourcbe

New Orleans (city)

Plaquemines

Saint James

Saint Landry

Saint Martin

Saint Mary

Terrebonne

Remainder of group

Group 2

Avoyelles

Concordia . .

1-6
2-1
0-7
0-8
0-4
1-9
0-9
0-8
1-6
0-4
0-6
3'9
1-5
0-4
0-7
0-8
M
0-9
0-8
1-0
0-2
0-8

Inhabitants.

East Carroll 0'9

East Feliciana 2'2

Madison 0'7

Point Coup6e 0'8

Tensaa 1-3

West Feliciana 0-9

Remainder of group 0'9

Group S 0-8

BSenville 0'2

Bossier 0'9

Caddo 1-1

Catahoula 0'8

Claibornc 0'6

DeSoto 0-7

Lincoln 0'7

More-house 0*8

Nachitoches 0'7

Ouachita 2'3

Rapidea 0*6

Union 0'8

Webster 0'3

Remainder of group 05

STATE OF MISSISSIPPI.

Topography. The extreme length of Mississippi,
north and south, is 332 miles; extreme breadth, 189
miles ; average breadth, 142 miles ; area, 46,810 square
miles or ^'.t.958,400 acres. The surface is undulating,
with an elevation in the north and northeast of from

160 PHTHISIOLOGY.

400 to 700 feet, some of the hills rising 200 to 300 feet
above the adjoining country, and has a general slope south
and southwest. In the north, from Yicksburg to the
Tennessee border, is the Mississippi bottom, a low, flat,
swampy country, though extremely fertile. The central
and southern divisions are generally hilly, with an aver-
age elevation of from 100 to 200 feet above sea-level.
There are extensive marshes in the extreme south. The
actual coast-line on the Gulf of Mexico is about 90
miles, but owing to irregularities the measurement is
almost doubled. There are harbors at Biloxi, Mississippi
City, and on the Bay of St. Louis, but the depth of water
is not great. Cat and Ship Islands, and some half a
dozen other small, sandy islands, lie about ten miles off
the coast. The drainage of the State is by the Missis-
sippi and its tributaries, the Big Black, Tazoo, and
Bayou Pierre, and by the Pearl and Pascagoula Rivers,
directly into the Gulf. The Tennessee forms a part of
the boundary in the northeast, and the Tombigbee rises
in the same section and flows into Alabama.

Climate. The climate is very mild, and snow and
ice are unknown. The summers are long and hot, July
and August being the warmest months, and having a
mean temperature of 82 to 85 Fahr. The mean an-
nual temperature is from 65 to 66 Fahr. ; and the
rainfall varies from 45 to 48 inches in the north, and
from 55 to 60 inches yearly on the Gulf coast. The
higher lands are healthy enough, but along the rivers
malarial diseases are frequent, and occasionally assume
an epidemic character, resulting in great loss of life.

TOPOGRAPHY AND CLIMATE OF STATES. 161

Population, 1,131,597.

Inhabitants to the square mile, 24.

Death* per 1,000 Inhabitants.

The State 1*0

Group 1 I'l

Oroupg 1-1

Aloorn 1'9

Amite 0'7

Attala 0-7

Benton 1'3

Calhoun 0'8

Carroll 1'4

Chickaaaw 1-6

Clarke 0'3

Clay 1-5

Copiah 0-9

Grenada 1'6

Hinds 1-3

Holmes 0'6

Itawamba 0'9

Jasper 0'4

Kcmper 0'8

Lafayette 1'5

Laudcrdale 0-5

Leake 0-2

Lee 1-3

Lincoln 0'3

Lowndes T5

Madison 1'6

Marshall 1-9

Monroe I'l

Montgomery 0'8

Newton . . , . 0'8

Noxnbee 1-5

Oktibbeha 0'7

Fanola 1'2

Pike 0-7

Pontotoc 1-4

Prentiss 1*3

Rankin 0'8

Scott 0-8

Tate 1-0

Tippah 1-3

Union 1'9

Winston 1-0

Yalobusba 1-9

Remainder of group 0'7

Group S. I'l

Adams 1 '2

Bolivar I'l

Claiborne 0'4

Coahoma I'l

DeSoto 1-7

Issaquena 0'4

Jefferson 0'6

LeFlore 1-8

Tallahatchie 1-8

Warren 1'3

Washington 0'7

Wilkinson 1'4

Yazoo 1-1

Remainder of group 0*6

STATE OF ALABAMA.

Topography. Alabama is 330 miles in length, and,
on the average, 154 miles in breadth ; and has an area of
.'.L'. _'.')() square miles, or 33,440,000 acres. In the north-
east the country is ragged and uneven, and the southern

162 PHTHISIOLOGY.

extremity of the Alleghany Mountains extends thence
west, forming the dividing line between the head-waters
of the Tennessee and the rivers which flow south to the
Gulf of Mexico. The slope from this to the south is
gradual, with rolling prairies in the center of the State,
and the extreme southern portion is flat, and but slightly
elevated above the sea-level. There are' about 60 miles
of sea-coast, including Mobile Bay, the finest harbor on
the Gulf. The Mobile River is formed by the junction
of the Alabama and Tombigbee ; and the Chattahoochee,
Coosa, and Tennessee all have a part of their course in
Alabama.

Climate. Although Alabama lies within seven de-
grees of the tropics, its climate is not unpleasant, the mean
annual temperature being about 63 Fahr. In the north-
ern and more elevated sections the temperature is moder-
ated by the sea-breezes, and seldom exceeds 95, except
in July, when the thermometer has been known to record
104. In the winter months the range is from 20 to
80, and in spring from 25 to 90 Fahr. Snow very
seldom falls, and ice is almost unknown. The rainfall
varies from 46 to 49 inches per annum.

Population, 1,262,505.

Inhabitants to the square mile, 24.

Deaths per 1,000 Inhabitants.

The State 1'3

Group 1 2-7

Mobile 3-1

Remainder of group 1'2

Group 2 2-1

Blount . 1'6

Calhoun 2'1

Cherokee 1'2

Cleburne 0'5

Colbert 1-8

DeKalb 1-7

Etowah . . .1-9

TOPOGRAPHY AND CLIMATE OF STATES. 163

DeatJit per 1,000 Inhabitant.

Jackson

Jefferson

Lauder dale

Lawrence

Limestone

MadUon

Marshall

Morgan

Saint Clair

Shelby

Remainder of group.

Oroup S

Autau^a

Barbour

Bullock

Butler

Chambers

Chilton

Choctaw

Clarke .'...

Clay

Conecuh

Coosa

Crenshaw

Dale . . ,

2-2
VI
2-6
1-9
8-1
8-8
2-4
2-8
1-2
1-1
2-5
0-9
1-6
06
0-7
0-4
1-0
0-6
1-0
0-7
0-8
0-5
0-4
0-4
0-8

Dallas 1-4

Elmore I'O

Fayette., 0-4

Green 0-7

Hale 1-4

Henry 01

Lui nar 0*5

Lee I'l

Lowndes 1'5

Macon 0'5

Marengo I'l

Monroe 0'3

Montgomery I'l

Perry 0'7

Pickens I'O

Pike 0'6

Randolph 0'7

Russell 0'8

Sumter 1'5

Talladega I'l

Tallapoosa 0'6

Tuscaloosa. 0'6

Wilcox I'O

Remainder of group I'l

STATE OF TEXAS.*

Topography. Greatest length of the State, 825
miles ; greatest breadth, 740 miles ; area, 265,780 square
miles, or 170,099,200 acres. Its sea-coast, of about 400

* Loomis (" Practical Medicine ") says : " The extraordinarily dry belt of
country which runs northward from San Antonio, Texas, has begun to en-
danger the supremacy of Florida as a winter health resort for the con-
sumptive. That this belt offers some climatic advantages for weak lungs
over the mild but rather humid air of Florida can not be doubted."

Boernc, Krud.ill County the principal health resort for consumptives
in this State is about 80 miles northwest of San Antonio; it has an eleva-
tion of 1,300 feet, an average mean temperature for the winter of 66,

164 PHTHISIOLOGY.

miles, is irregular and bordered by many small islands.
The mountains of the district lying between the Pecos
and the Eio Grande attain an elevation of from 4,000
to 6,000 feet ; the west and northwest sections are an
elevated table-land, and thence the slope is gradual
to the sea, the south and southeast divisions being flat
and low. The largest and most accessible bay is that of
Galveston, which extends inland 35 miles from the Gulf
of Mexico, and has 13 feet of water in the channel.
The Rio Grande is navigable for over 400 miles; the
Red River, Neuces, Angelina, Trinity, and some other
streams are navigable during the season for considerable
distances. The Canadian River, in the north, and the
Brazos, Colorado, Guadalupe, and San Antonio are among
the best-known streams.

Climate. The climate of Texas shows considerable
variation, ranging from the temperate to the semi-tropi-
cal, but in general it is remarkably salubrious. The
mean annual temperature in the highlands of the ex-
treme northwest is about 56, in the central division,
65 to 66, and in the southwest, 72 ; and the range of
the thermometer is from 35 to 95 Fahr. The rainfall
is greatest along the coast and in the south. The aver-

and for the summer of 79' Fahr. The rainfall varies from 28 to 32
inches. The prevailing winds are from the Gulf of Mexico, and " northers "
(cold wind and rain-storms from the north) are of seldom occurrence.
The climate is a happy medium between the humidity and heat of the coast
region and the highly rareified and cold air of the Rocky Mountains. The
atmosphere is balmy, and at times invigorating. Combining, as it does, the
stimulating effects of mountain air with the mildness of a semi-tropical
climate, consumptives, under the writer's personal observation, have fre-
quently recovered appetite and strength through its influence.

TOPOGRAPHY AND CLIMATE OF STATES. 1G5

age precipitation at Austin for a series of years was
found to be 34-51 inches, at Fort Belknap, in Young
County, about 22 inches, and in the northwest from 12
to 16 inches.

Population, 1,591,749.

Inhabitants to the square mile, 5-9.

Death* per

The State ....................

Group 1 ....................

Cameron ..................

Galveston .................

Harris ....................

Remainder of group .........

J ....................

Anderson ..................

Austin ....................

Bastrop ...................

Bell ......................

Beiar .....................

Bosque.

Bowie

Brazos

Caldwell

Cass

Cherokee

Collin

Colorado

Cooke

Corycll

Dallas

Denton

I).- Witt

Ellis

Ernth

1,000 Inhabitant*.

r'linnin

Freestone
Gonzales..

1-0
1-3
2'8
1'4
1-6
0*9
09
1-2
0-6
0'6
0-7
1-5
0'8
1-4
0'9
1-1
16
1 '4
0-8
0'7
1-2
09
1-6
0'7
0-4
1-3
0'6
0'7
1*0

i-o

0-2

Grayson ................... 1'6

Grimes .................... 1*5

Guadalupe ................. 0'7

Harrison .................. 1-9

Hill ...................... 07

Hopkins ................... T2

Houston. .................. 0'4

Hunt ..................... 1-2

Johnson ................... 0'9

Kaufman .................. I'l

Lamar .................... 1-2

Lavaca .................... 0*8

Leon ...................... 0'2

Limestone ................. 1*1

McLennan ................. I'l

Marion .................... 1'4

Milam ..................... 0'6

Montague .................. 0'8

Montgomery ............... 0'7

Nacogdochcs ............... 0'9

Navarro ................... 0'8

Tanola .................... 0'8

Parker .................... 0-9

Red River ................. 0'4

Robertson ................. 0'8

Rusk ..................... 1-0

Smith ..................... 0'9

Tarrant ................... I'O

Travis .................... 1'5

Upshur ................... 1-7

Van Zandt ................. 1'2

Walker.. . 0'8

166 PHTHISIOLOGY.

Deaths per 1,000 Inhabitants.

"Washington 0'6

Williamson 0-8

Wise.. . 0'4

Wood I'l

Remainder of group 0'7

Group S 0-8

STATE OF KANSAS.

Topography. Kansas has an extreme length east and
west of 410 miles ; a breadth of about 210 miles ; and an
area of 82,080 square miles, or 52,531,200 acres. The
general surface is an undulating plateau, with a gentle
slope from the western border to the Missouri. The ex-
treme elevation reached is 3,800 feet, while at the month
of the Kansas River the land lies 750 feet above the level
of the sea. The average altitude is about 2,375 feet.
There are no mountains in Kansas, but the scenery is re-
deemed from monotony by the rich grass-covered hills and
the fertile river-valleys, while the Arkansas and Republi-
can Rivers are bordered by bold bluffs from 200 to 300
feet in height. The Missouri furnishes a water frontage
of 150 miles on the east, and near the Missouri State line
receives the Kansas, which is formed by the confluence
of the Republican and Smoky Hill Rivers near Junc-
tion City, and intersects the State throughout its entire
length. The Smoky Hill River rises near the Rocky
Mountains, in Colorado, and receives in Kansas the Sa-
line and Solomon Rivers, each over 200 miles long.
The Republican River rises in southern Colorado, flows
through northwestern Kansas into Nebraska, and turn-
ing southeast joins the Kansas. The Arkansas River
has its sources in the Rocky Mountains in Colorado, and
passes through Kansas in an easterly and southeasterly

TOPOGRAPUY AND CLIMATE OF STATES. 167

direction, having nearly 500 miles of its windings within
this State. The Osage River rises in the east, and, after
a southeast course of 130 miles, enters Missouri ; while
the Neosho has its source in the central part of the
State, and after a southeast course of 200 miles, during
which it receives the Cotton wood and other important
streams, passes into the Indian Territory. Few of the
rivers are navigable, but nearly all furnish abundant
water-power.

Climate. The winters of Kansas are comparatively
mild, the summers warm but not oppressive, and the
atmosphere extraordinarily pure and clear at all seasons.
The mean annual temperature is about 53 Fahr. ;
spring, 52 ; summer, 76 ; autumn, 54 ; winter, 29.
The highest temperature recorded is 100 Fahr., and the
lowest 6, these extremes having been only reached on
a very few occasions since the settlement of the country.
The rainfall averages from 31 to 45 inches per annum,
the greatest precipitation being in the eastern division.
The western part of Kansas consists of an extensive
plateau, which has a general elevation of from 1,500 to
4,000 feet. The mean annual temperature is 49 Fahr.,
with a moderate range throughout the year, notwithstand-
ing its considerable diurnal changes. Kansas is a very
healthy State, entirely free from miasmatic diseases, and
highly favorable to consumptives and those suffering
from bronchial or pulmonary complaints, to whom the
pure, free atmosphere seldom fails to afford relief.

Population, 996,096.

Inhabitants to the square mile, 12.

168

PHTHISIOLOGY.

Deaths per 1,000 Inhabitants.

The State 1-1

Group 1 1-1

Allen 1-9

Atchison 1*3

Bourbon I'l

Brown 1'3

Butler 0-5

Chautauqua 0'5

Cherokee 1*0

Clay 1-2

Cloud 0-6

Coffey 0'9

Cowley 1-2

Crawford 0'8

Dickinson _. 1'7

Doniphan 0'9

Douglas 1-1

Elk 0-7

Franklin l - 4

Greenwood 0'9

Harvey 1-3

Jackson 0'8

Jefferson 1'6

Jewell 1-2

Johnson 1 '4

Labette 0'8

Leavenworth 1'2

Linn 1'3

Lyon 0'9

McPherson 1-1

Marion . 0'4

Marshall 0*9

Miami 1-7

Mitchell 0-6

Montgomery 1-3

Nemaha 1-2

Neosho 1-3

Osage TO

Ottawa 1-0

Pottawatomie 1-4

Keno T6

Republic 0'6

Riley 1-8

Saline 0'7

Sedgwick - 9

Shawnee 1-9

Sumner 0'5

Washington TO

Wilson 1-2

Wyandotte 1-8

Remainder of group I/O

Group 2 1-0

Barton 1-5

Osborne O'S

Phillips 0'9

Smith 1-2

Remainder of group 0'9

STATE OF NEBRASKA.

Topography. The surface of Nebraska constitutes a
vast plain, with undulating prairies of great extent, diver-
sified by a few low hills or ridges, and without mount-
ains of any size, except in the extreme west and north-
west, where the lower slopes of the Rocky Mountains
and the broken country of the Black Hills begin. From
the west and northwest the land slopes gradually to the

TOPOGRAPI1Y AND CLIMATE OF STATE& 169

Missouri "River, which washes the eastern and north-
eastern borders of the State. The drainage is toward
the Missouri by the Platte River and its tributaries, the
Niobrara, and the Republican and Blue Rivers, which
extend into Kansas. The valley of the Platte, which
stretches across the center of the State from west to
east, and the whole southern portion of Nebraska, are
mely fertile and well watered. The western half
is best adapted for grazing purposes, being a constant
succession of natural pastures. About 30,000 square
miles of the eastern division consist of bottom and
prairie lands of exuberant fertility. Nebraska has a
width from north to south of about 210 miles ; its great-
est length in the central part is about 420 miles ; area,
76,855 square miles, or 49,187,200 acres.

L llmate. Nebraska might with propriety be termed
a highland State, forming as it does a part of the great
interior slope which extends from the base of the Rocky
Mountains to the Missouri River. Over the wide prai-
ries the mountain-breezes sweep at will, and, owing to
the splendid drainage facilities, the dry, exhilarating at-
mosphere is untainted by any malaria. The mean annual
temperature at Omaha is about 48 Fahr. ; winter mean,
_'_' : and summer, 70. The total snow- and rain-fall
east of the 100th meridian is 26 inches, the greatest
amount of rainfall being in May and June. In the west
and southwest it is much less, and in some places not
more than 17 to 19 inches annually.

Population, 452,402.

Inhabitants to the square mile, 5'8.
15

170

PHTHISIOLOGY.

Deaths per 1,000 Inhabitants.

The State 0-9

Grvup 1 0-6

Adams 0'6

Clay 0-3

Dodge 0-4

Fillmore 0'3

Gage 0-9

Lancaster 0'9

Saline I'O

Saunders 0'9

Seward... ,. 0'4

York 0-9

Remainder of group 0'9

Group 2 1-0

Cass 0-4

Douglas 0'7

Nemaha 0'7

Otoe 1-7

Richardson 1 '1

Remainder of group I'l

Group 3 0-8

STATE OF MINNESOTA.

Topography. Minnesota occupies nearly the center
of the Continent of North America. The surface of the
State is an undulating plain, with an average elevation of
1,000 feet above the sea, but in the northeast there is a
group of low sand-hills known as the "Hauteurs des
Terres," or " Heights of Land," which rise about 600
feet higher. Its extreme length north and south is 380
miles, and its breadth varies from, 183 miles in the mid-
dle to 262 miles on the southern and 337 near the north-
ern line ; the total area being 83,365 square miles, or
53,353,600 acres. There are over 7,000 small lakes in
the State, varying from 1 to 30 miles in diameter, while
several of them have an area of from 100 to 400 square
miles. The Mississippi rises in Lake Itasca, and flows
for nearly 800 miles through the State, receiving the
Minnesota at Fort Snelling, 5 miles above St. Paul.
The Red Eiver of the North rises in Elbow Lake, turns
southwest and north, and empties into Lake Winnipeg.
The St. Louis River, which rises in the northeast, falls

TOPOGRAPHY AND CLIMATE OF STATES. 171

into Lake Superior, and forms the first link in the chain
of rivers and lakes of the St. Lawrence system. There
is much really beautiful scenery in Minnesota, and, al-
though it is destitute of mountains, the limestone cliffs
of the upper Mississippi, and the perpendicular walls of
rock between which the St. Croix forces its way, are very
picturesque. The celebrated Falls of St. Anthony, at
Minneapolis, are the best known of the many cataracts
to be found in this State.

Climate. The salubrity of the climate of Minnesota
is well known, and the purity of the air and dryness of
the winters render the State a chosen place of recupera-
tion for those suffering from pulmonary complaints.
The summers are warm, with breezy nights, and two
thirds of the total rainfall of 35*50 inches occurs during
the months of June, July, August, and September. The
winters are cold, clear, and dry, and the snowfall generally
light. The range of temperature is considerable the
summer mean being 70*50 ; winter mean, 25 ; and the
annual mean at St. Paul, 47 Fahr.

Population, 780,773.

Inhabitants to the square mile, 9.

Deaths per 1,000 Inhabitants.

Th State 1-0

/ 1-1

Dakota 1*6

Goodhuc 0-9

llrimrpiii 0'6

Minneapolis (city) 1*7

Houston 1-3

Saint Paul (city) 1-1

Stearns . . .1-3

Wabasha 0'7

Washington 09

Winona 1-2

Wri-ht 0-7

Remainder of group 07

Group g I'O

Blue Earth 0'7

Brown 10

Carver.. . I'O

172 PHTHISIOLOGY.

Deaths per 1,000 Inhabitants.

Dodge 1-8

Faribault T2

Fillmore 0-8

Freeborn 1'7

Kandiyohi 0'8

Le Sueur 0*3

McLeod I'l

Meeker O5

Mower , 0'8

Nicollet 1-1

Olmsted... . 1-0

Renville O'Y

Rice 1-2

Scott 1-0

Sibley 0'6

Steele 1-2

Waseca 1 - 2

Remainder of group 0'9

Groups 1-1

Otter Tail 0'9

Polk 0-3

Remainder of group 1'6

TERRITORY OF DAKOTA.

Topography. Dakota lias an average extent north
and south of 450 miles, a breadth of 350 miles, with an
area of 149,100 square miles, or 95,424,000 acres. There
are still 27,550 Indians in the Territory, seven eighths of
the whole number being Sioux. These are divided into
numerous bands, and are mostly on reservations west of
the Missouri and north of the Nebraska frontier. The
amount of land held by them is 41,999,456 acres, of
which over 5,000,000 acres are tillable ; only 10,500 acres,
however, are under cultivation. The Territory forms a
vast elevated plateau, crossed by several minor ranges of
hills, which in the southwest almost deserve the name of
mountains. The general elevation of the country is from
1,000 to 2,500 feet above the sea, and the highest peaks
of the Black Hills are nearly 7,000 feet above sea-level.
The Missouri River crosses Dakota from the northwest
to the southeast corner, and is navigable throughout the
Territory. It receives the Yellowstone on the Montana
border, in latitude 48 north, and has also as tributaries

TOPOGRAPHY AND CLIMATE OF STATES. 173

the Little Missouri, White, Big Cheyenne, and Niobrara
Rivers, the latter having most of its course in Nebraska.
The Dakota rises in Devil's Lake, in the northeast, and
has a length of 400 miles to its junction with the Mis-
souri near Yankton. The Red River of the North, flow-
ing north into British America, forms the eastern bound-
ary for about 250 miles, and receives no less than eight
considerable streams from Dakota. The Yermillion and
Big Sioux in the southeast are each more than 150 miles
long. There are a large number of lakes and ponds,
mostly in the east and north. Devil's Lake, the water
of which is brackish, is 40 miles long and from 4 to 12
miles wide. Other important lakes are Albert, Poinsett,
Tchanchicaha, Traverse, "Whitewood, and Big Stone.

Climate. The temperature varies during the year
from 20 below zero to 100 Fahr. ; July and August
being the warmest months, and December, January, and
Tebruary the coldest. In the north the winters are
severe and much snow falls, but the climate of the south
is mild and pleasant. The atmosphere is clear and
dry, and, owing to the elevation, malarial diseases are
unknown, while pulmonary complaints are rare. Spring
opens earlier than in the Eastern States in the same lati-
tude. The annual rainfall averages 20 inches.

Population, 135,177.

Inhabitants to the square mile, 0'9.

Deatht per 1,000 Inhabitant*.

The Territory 0'8

Oroup 1 0'9

0'8

Group S 0*2

Lawrence 0-8

Remainder of group 0*0

174: PHTHISIOLOGY.

TERRITORY or MONTANA.

Topography. The length of the Territory from east
to west varies from 460 to 54:0 miles ; its average breadth
is 275 miles; and its area is 146,080 square miles, or
93,491,200 acres, of which 80,651,676 are still unsur-
veyed. The eastern division embraces the great plains
or rolling table-lands, which cover three fifths of the
area of the Territory ; the Rocky Mountains, with other
ranges, occupying the west. The Rocky Mountains form
the southwest boundary, from the west line of Wyoming
to the intersection of the parallel 45 40' north latitude
with the 114th meridian of longitude; thence run east
for some distance, and from the 112th meridian con-
tinue in a northwestern direction to the British posses-
sions. The Bitter-Root Mountains branch off at the east-
ern extension of the Rockies, and form the western
boundary of the Territory for a considerable distance.*
Other important ranges are the Snow Mountains in the
south, and the Belt, Highwood, Judith, and Little Rocky
Mountains. The peaks are from 6,000 to 12,000 feet
above the sea-level, and the valleys average about 4,000
feet, the mountain-belt having an average breadth of
180 miles. The plains slope gradually toward the east,
having an elevation of about 4,000 feet at the base of
the mountains, and of 2,000 feet at the Dakota line.
The Rocky Mountains form the water-shed, and give
rise to the Jefferson, Madison, and Gallatin Rivers,
which unite near Gallatin City and form the Missouri.
The latter runs north, northeast, and finally east; and

TOPOGRAPHY AND CLIMATE OF STATES. 175

the Yellowstone, which has its source in the National
Park, in Wyoming, runs north and northeast through
Montana, and joins the Missouri near its eastern bound-
ary. Other /important streams are the Flathead, Mis-
soula, Big Blackfoot, Bitter Root, and Milk Rivers. The
largest body of water is Flathead Lake, which is about
30 miles long by 10 miles wide, and there are several
smaller lakes in the northwest. Timber is abundant on
the mountain-slopes, and consists of pine, cedar, fir, and
hemlock, estimated to cover in all over 25,000,000 acres.
Cottonwood, willow, and alder are found along the
streams, and in this respect Montana is much better off
than many of her immediate neighbors.

Climate. The climate of Montana is warmer than
that of the Eastern States in the same latitude, and is
very dry, the rainfall seldom exceeding 12 inches per
annum. In the east the mean annual temperature varies
from 41 to 49 Fahr., but in the mountainous region it
is lower. The snowfall is heavy in the mountains but
light in the valleys, and the climate is favorable for out-
door and agricultural occupations, and the raising of
stock.

Population, 39,159.

Inhabitants to the square mile, 0'2.

Deatht per 1,000 Inhabitant.
The Territory 0'4

TERRITORY OF IDAHO.

Topography. Idaho has an irregular shape. It is
485 miles in length north and south, on the western

176 PHTHISIOLOGY.

boundary, and 140 miles on the Wyoming border; 45
miles wide in the north, and nearly 300 miles in the
south; and contains, as now constituted, 84,800 square
miles, or 54,272,000 acres, of which 47,739,368 are still
nnsurveyed. The surface is an elevated table-land, from
2,000 to 5,000 feet above the sea-level, with many deep
river-valleys, and crossed by numerous mountain-ranges
or spurs of the Rocky and Bitter-Root Mountain chains.
Many of the peaks are of considerable height, and rise
above the snow-line. The most important are the
Kootenay Mountains, in the extreme north; the Coeur
d'Alene range, south of these; the Salmon and Clear-
water Mountains, along the rivers of the same names, and
the successive ranges on the head-waters of the Snake
River. In the southeast are the Bear River Mountains,
and in the south the Three Buttes. Of the total area,
about 4,480,000 acres are suitable for agriculture, and
5,000,000 for grazing. One third of the entire area is
sterile, and yields nothing but sage-brush and a little
buffalo-grass, but it is believed that part of this section
can be reclaimed by irrigation. There are 8,000,000
acres of timber and as much of mineral land, while
numerous lakes occupy an area of 200,000 acres. The
lower slopes of the mountains are covered with extensive
pine and cedar forests, and there is much timber in the
north. "Wheat, oats, barley, and rye flourish in the val-
leys, and wherever irrigation is possible, but the climate
is not suited to corn. The Boise Valley, which is 55
miles in length by 3 in width, and sheltered by the Boise
Mountains, is the chief agricultural region. The Terri-

TOPOGRAPHY AND CLIMATE OF STATES. 177

tory is drained by the Snake River and its tributaries,
the Bruneau, Boise, Weiser, Salmon, Clearwater, Payette,
and other smaller streams. The Snake, or Shoshone,
River rises in the Yellowstone Park, in western Wyo-
ming, describes an immense curve through southern Ida-
ho, and forms the western boundary of the Territory for
about 200 miles, after which it turns west into Washing-
ton Territory, where it joins the Columbia. It is navi-
gable for a considerable distance within and upon the
borders of Idaho for light-draught vessels. The Ameri-
can and Shoshone Falls, and the rapids above the latter,
are considered scarcely inferior to the falls of the Yellow-
stone, the Shoshone having a perpendicular descent of
over 200 feet.

Climate. The winters on the mountains are severe,
and much snow falls. On the plains the winter tempera-
ture is about the same as that of Wisconsin or northern
Iowa. In the valleys the climate is milder, with much
less snow, and the springs and summers are pleasant, and
: oppressively hot. Idaho belongs to the dry region,
or dry plains. The annual rainfall scarcely equals one
fourth that of the Atlantic States, although a considerable
precipitation occurs on the Bitter Root and Rocky Mount-
ains, but in the north and west and in the lower valleys
the rainfall is much less, and irrigation is a prerequisite
to successful agriculture.

Population, 32,610.

Inhabitants to the square mile, 0-3.

Death* per 1,000 Inhabitant.
The Territory 0'6

178 PHTHISIOLOGY.

STATE OF COLORADO.*

Topography. Colorado lias an average length east
and west of 380 miles, a breadth of 280 miles, and an
area of 103,925 square miles, or 66,512,000 acres, di-
vided into thirty-nine counties. There are still unsur-
veyed 40,657,679 acres. It consists of three natural
divisions the mountain - range, the foot-hills, and the
plains. The Rocky Mountains run north and south
through the center of the State, and consist of three
parallel ranges, with many peaks over 13,000 feet
high. Within the space inclosed by these immense
mountains are the "Parks," which constitute the most
remarkable natural feature of Colorado. These consist
of extensive plateaus at an elevation of 9,000 to 10,000
feet above the sea-level, hemmed in on all sides by the
mountains, and containing some valuable agricultural
land. The plains occupy the eastern part of the State,
and comprise about one third of its area. The great
"divide" traverses Colorado northwest and southeast,
separates the waters of the South Platte and the Arkansas,
and forms the water-shed of many of their tributaries.
Colorado has numerous streams, the principal ones
being the North and South Platte, and the Arkansas,
Snake, White, and Green Rivers, most of which flow

* Valuable data regarding the principal health resort for consumptives,
in this State, may be found in a paper, " Comparing Colorado Springs with
Davos-Plaz, as Winter Health Resorts," by Clinton Wagner, M. D., which
was read before the "New York Academy of Medicine," October 20,
1887, and published in the "New York Medical Journal" for October 29,
1887.

TOPOGRAPHY AND CLIMATE OF STATES. 179

through rocky cations and are not navigable. The South
Plutte has a fall of 6,000 feet between Montgomery and
Denver, and one of the cafions of the Arkansas is 1,500
feet in depth. The Rio Grande del Norte rises in the
Saguache range of mountains and flows south through
the San Luis Park ; but the Colorado River can scarce-
ly be considered as belonging to the State from which
it derives several of its principal tributaries, and to
which it gave a name.

Climate. The air is drier and the range of tem-
perature less than in the Eastern States in the same
latitude. The winters are mild, the summers cool and
bracing, and the mean annual temperature is about
49 Fahr. The rainfall ranges from 15 to 20 inches
annually, and most of it occurs between May and July.
On the mountains the winters are, as a rule, severe,
with heavy falls of snow in November and December ;
but on the plains and in the valleys the mildness and
purity of the atmosphere are such as to render Colo-
rado the paradise of invalids, thousands of whom re-
sort there. An abundance of sunshine is one of the im-
portant features of this climate, over three hundred clear
days in a single year having been noted for certain locali-
ties in this State. Heavy wind-storms are common, but
cloudy and foggy weather is unknown, and snow seldom
remains more than twenty-four hours on the ground ex-
cept upon the mountains, many of which reach above
the snow-line.

Population, 194,327.

Inhabitants to the square mile, 1*8.

180 PHTHISIOLOGY.

Deaths per 1,000 Inhabitants.*

The State M

Group 1 1-9

Denver (city) 1*7

Remainder of group 2'1

Group 2 0-5

Lake , O'l

Remainder of group 0'6

TEEKITOKT OF WYOMING.

Topography. The surface is elevated and mountain-
ous, the main chain of the Rocky Mountains extending
across the Territory from southeast to northwest, and
forming what is known as " the divide." The principal
ranges are the Wind Biver, Big Horn, Laramie, Bishop,
and Medicine -Bow Mountains. The Black Hills lie
partly in this Territory and partly in Dakota. The Big
Horn, Tongue, and Powder Rivers flow north and join
the Yellowstone in Montana ; the Green River drains the
southwest and the Little Missouri the northeast, while
the North Platte, rising in Colorado, receives the Medi-
cine-Bow, Laramie, and Sweetwater Rivers in Wyoming
and enters Nebraska from the southeast, where there are
some smaller streams of little importance. The most in-
teresting of the natural features of Wyoming, and those
which have most attracted the attention of travelers, are
found in the extreme northwest corner of the Territory,
in the section known as the Yellowstone National Park.
This wonderful park has a length of 65 miles north
and south by 55 miles in width, and an area of 3,575
square miles. No part of it is less than 6,000 feet

* Almost all the deaths reported as occurring from consumption in this
State were of persons who had contracted the disease elsewhere.

TOPOGRAPHY AND CLIMATE OF STATES. 181

above the sea, and the snow -covered mountains that
hem in the valleys on every side rise to a height of 12,-
000 feet It is a land of wonders, with its grand cafions
and geysers, its beautiful lakes and rivers, with cataracts,
cascades, and rapids of unexampled beauty, and mount-
ains towering far above the deep and rugged valleys
through which the rapid streams flow. The geysers, or
boiling springs, are situated near the Firehole River, the
Middle Fork of the Madison, which forms one of the
three principal sources of the Missouri. There are sev-
eral hundred springs, of which the Beehive, Giantess,
Old Faithful, the Turban, the Giant, and the Grand
Geyser are the largest. Wyoming is situated between
latitude 41 and 45 north and longitude 104 and 111
west. It has a length east and west of about 350 miles
and a breadth of about 275 miles, and forms an almost
perfect quadrangle, with an area of 97,890 square miles,
or 62,649,600 acres, of which 9,079,186 are surveyed
into sections and 42,638 are improved.

Climate. The climate is severe in the mountainous
regions, but mild and salubrious in the sheltered valleys.
The air is pure and bracing and the rainfall light, not
exceeding 15 inches per annum, and in some parts even
less. The mean temperature at Cheyenne (6,058 feet
above the sea) in July, the warmest month, is about 71 ;
in January, the coldest, 12 ; and the mean for the year
not lower than 43*6 Fahr. A maximum of 98 is re-
corded in one year, and a minimum of 38 Fahr. The
soil of the valleys is a fertile loam, but irrigation is

needed for the successful prosecution of agriculture.
16

182 PHTHISIOLOGY.

Population, 20,789.

Inhabitants to the square mile, 0'2.

Deaths per 1,000 Inhabitants.
The Territory 0'2

TEEKITOEY OF ARIZONA.

Topography. The area of the Territory of Arizona
is 113,020 square miles, or 72,332,800 acres, of which
67,098,366 are unsurveyed. The middle and north-
eastern portions of the Territory consist of plateaus
which have an elevation of from 3,000 to 8,000 feet
above the sea, and are here and there dotted by volcanic
cones rising 2,500 feet above the plateaus. The south-
ern portion is a plain with a slight elevation above the
sea, amounting to only 200 feet at the mouth of the Gila.
The mountain-ranges, of which there are many, have
generally a northwest and southeast course, with the
exception of the Mogollon range in the east, which runs
nearly east and west, joining the Sierra Blanca. The
Sierra Prieta and the Aztec range, in central Arizona,
are flanked by foot-hills, which sink gradually to the
level of the table-land on the northeast, and of the mesas
sloping toward the Colorado River in the southwest.
The highest mountain is the San Francisco, a volcanic
cone, whose summit is 11,000 feet above the sea. The
Colorado, which is the largest and the only navigable
river, is formed by the junction, in southern Utah, of
the Green and Grand Rivers, and flows southerly along
the western boundary of Arizona, emptying into the
Gulf of California just south of the southern line of the

TOPOGRAPHY AND CLIMATE OF STATES. 183

Territory. This river has during the course of centuries
cut for itself a deep channel through the rocks, so that
for long distances it flows between perpendicular walls
7,000 feet in height. It is navigable for a distance of
612 miles from its mouth ; above that point it becomes
shallow, except in the rainy season, has a very, swift
current, and is filled with rapids. Its principal tributaries
are the Gila, which has its source in New Mexico, and
flows in a southwesterly course until it joins the Colo-
rado, about 180 miles above the Gulf of California ; the
Colorado Chiquito, which rises in the northwest; and
the Bill Williams Fork. Here, as in New Mexico, agri-
culture can be carried on only where irrigation is prac-
ticable, which applies to about five per cent of the total
area. There are desert tracts covered with shifting
sands, which are utterly unfit for cultivation, and much
of the Territory south of the Gila is an arid waste. But
the soil in the river-bottoms and in the mountain-valleys
of middle and eastern Arizona is of great richness. Pine
and cedar grow on the mountains in the central and
northern part of the Territory, and walnut, cherry, and
cottonwood are found along the streams. On the plains
south of the Gila only the cactus, artemisia, and mesquite
can live.

Climate. The climate is mild and generally health-
ful, lung and malarious diseases being almost unknown.
The summer temperature of the treeless plains in the
south is intensely hot, the thermometer often indicating
118 Fahr., ami raivly falling in winter below 34. In
the central and more elevated portion of the Territory

184: PHTHISIOLOGY.

the temperature is moderate, seldom exceeding 90 in
summer. Snow falls on the mountains, but remains only
a short time. The rainfall along the Gila averages from
4 to 5 inches, while at the base of the range it rises to 25
or 30. Showers are most frequent in July and August.

Population, 40,440.

Inhabitants to the square mile, 0*3.

Deaths per 1,000 Inhabitants.

The Territory (forms one group). 0'4
Pima.. . 0-2

Remainder of group 0'6

TERRITORY OF NEW MEXICO.

Topography. New Mexico has a length on the east-
ern boundary of 345 miles, and on the western of 390,
with an average breadth, north of the thirty-second par-
allel, of 335 miles. Its area is 122,580 square miles, or
78,451,200 acres, of which 67,024,990 are unsurveyed.
The region now known as Arizona, obtained from Mexico
by the Gadsden Treaty of 1853, was annexed to New
Mexico the following year, and formed a part of the
Territory until 1863. In 1861 a tract of 14,000 square
miles, lying east of the Rocky Mountains, between the
thirty-seventh and thirty-eighth parallels, was annexed
to Colorado. New Mexico as now constituted consists
of a number of high, level plateaus, intersected by mount-
ain-ranges, often rising into high peaks, between which
lie fertile valleys. The Rocky Mountains, before enter-
ing the Territory, divide into two ranges : the one on the
east, the loftier of the two, ending near Santa Fe ; and
the other, known as the Sierre Madre, of lower elevation,

TOPOGRAPHY AND CLIMATE OF STATES. 185

and with numerous passes, extending to the southward
until it reaches the Sierra Madre of Mexico. Almost
two thirds of the Territory is east of this range. The
region to the west, which has not been thoroughly ex-
plored, consists of high table-lands and isolated peaks.
East of the eastern range the land slopes gradually to
the Mississippi. The Staked Plain, an elevated region,
unwatered and without wood, extends into the south-
eastern part of the Territory. The principal river is the
Rio Grande del Norte, which, rising in Colorado, flows
south through New Mexico, and, continuing on its course
toward the Gulf, forms the boundary between Texas and
Mexico. Its principal affluent is the Pecos, which, rising
in the eastern part of the Territory, empties into the Rio
Grande in Texas. In the northeast rises the Canadian,
which empties into the Arkansas ; and in the southwest
the Gila, which flows into the Gulf of California. The
valley of the Rio Grande has an elevation of 3,000
feet above the sea near the southern boundary, and of
nearly 6,000 feet at the point where it crosses the Colo-
rado line. On each side of this river, which is not navi-
gable, the mountain-ranges rise to an altitude of from
6,000 to 12,000 feet above the sea, the summits of the

r peaks being above the snow-line. Timber is not
abundant. The mountains are covered with pine, spruce,
and fir ; nut-pine and cedar grow on the foot-hills, and
sycamore and cottonwood in the river-valleys.

Eft, Owing to the differences in elevation, the
climate vari>-- 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.

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
I

1 -

Ftr cnt of caammp-
Uon to all other

dlUMH.

; 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

2,184

uwo

170

4,618
IJU4
537
72

17
8
7
2

0036
0019
0130
0279

:
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

0043

-i

0864

Southern and Ovlf
<*ts.
Ft. Monroe, Va

58-18

42-16

1,861
601

606

LflBfl
BOB

875
LJtB

16
5
4
4

0097
0055
0045
0030

-
B

8
2

1
3

2307

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

0056

2500

Northern Interior.
West Point, N Y d

Ft. above

-M |."..-1

157
186
840
9GO

"1 -Jl

!.,. :

!-J M

39-91

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

0040

-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
<OBOB

0020

r:
18

1546
1333
OOQO

0625

Jackson Barracks, La. 6 .
RiiurgoM, Tex

Ft Lea Yen worth, Kan. g.
Average

68-62

41-60

3,8007,833

0036

0825

Int, -nor, 1,000 to 2,500 ft.
i Ga

1,078
LM

!.">
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

;,'>

8
9
8

1
2
8

0046
0063

0011
DM
tBH

i-
;,'

7
in
-'!

8
8

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

5,941

9,584

1MB

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

BBO
460

!.>;
241

:.'"''
OH
-:.
81

802

5
2
2

0008
D07I

een
oon

0066

I'-
ll
1
1
:
1

1
1

n i

: - ' . '.
001)0

,.-.!

1666

48-07

15-05

Average,

51-34

18-81

LJ01

ooio

0900

200

PHTHISIOLOGY.

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T-T r4oi" T-T of

METEOROLOGY.

201

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202

PHTHISIOLOGY.

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5 55 S 55 55 55 S S 55 55 51 5ici 55 55 55 55 55 55 5*

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METEOROLOGY.

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204

PHTHISIOLOGY.

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STH Ifl >O CO $- CO O ICiiOOOTCjJ*-^ M Xi-tCr??* .T ~i-J-
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55 OT i} 55 5i s> S ;5 55 5*

J O O O 5 T- ;

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2 ~ ^1 ~. L- C-. X i . X - i- . .- :
i- ; 7> o x TO H- -^ =5 . c- . ~. i- x x :

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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.

206

PHTHISIOLOGY.

N
a;

"e
s

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

and Annua

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

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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

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-2 e

208

PHTHISIOLOGY.

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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!-'!-<cb

t- Tf t- I- t- 00 t- t-

aDipopi^pco^-apTJ'coi-op-r-cacspTJi-^oo

t- 1-< m ^^ o i: r: r? c c c^ c* 10

t~ t- O OC t- CO - - CS 1- O t- t- OC 55

^ a- j s

III1Rliiilii!lIl||lil|li!ll||

Ssgsssafc^ziz^ssizizoooeH

METEOROLOGY.

209

y- 9 -jr x oa r- p

S88

8989MI

, . - - - --

sssirs

- MMMI ->

csp wososp

t- e> o ee o

H ; e ^- 05 1- * e * o> ^

/ r. .*. / ~ r .

210

PHTHISIOLOGY.

J5-

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-

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

r /

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'<J<pTi<CaecQepO

co ro oo 10 10 1~ oa 10 fl" * v 10

i-io woo

- Z> t- I- t- i- I-

t-p

ICO

woiososoujoooot-oopiaoiip

cppt-pppgopt-pwwp

O 00 t O O i-- O O t-- O X CD t

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<f
!S~

: fc.

^J : -K

p^ipipefjrcooopeo^^paoso 'o

9lo3g{3?Sg?3&8{:SS is

: Je :

io> \rnet?
iJJ :Sri?{-n!

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

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

:- 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 <O CO <-- 00

CO ij < S5

OiM* O OS 6> t- OD OS

re .- .- c .- -i

r? - ~- : /

:V^ ;-

IO I0 11 00

&tf8%

^tjrfi?
iisiii

216

PHTHISIOLOGY.

^> -^ B *

S g t-co^-v t-i-ioa 00 latoi-tt-ot j-i-w oo " ~~ooooeoi

'ii-ido oo

co TIT-I o ri so T-I cb at at ri 60 " oo oj a* T-I TH ~ obi

<v<

^ "g

g OOC*" TJ" C* CO 1-1 i-i O 1 00 OOil OD

* ^N Tl< 00 * ib tn CO IN <* i-c OJ 3 V-i 00 1-1 3T)"-< i-iOt ii

^0 a obi-i" e* " cMi-iiooo ! " i-cej ri V-c r-i 60 11 at ' oji" " CM " ot^ist

iS 1 5io^O5f^cp7ios*3Si3SSc

rfrtr-ieo" ' rnt-' ' eo " ' ' rt " iiii rcoo n n e> 11 et T-I " iicb^-i

1 ~"~

.< 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

^ 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 <N r-i O i-i-fl-SJO

'pmioj2-a.\oq
jo nonsiaia

i
^

- - a -

)O=3=3-"-'-----O33sScJci r 5_.t.'/:-S4JjJ<J+i*j.i->

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<o)o eo n <-i e< >-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 <b o " * o ot at r-i t.

B!H!

-i^-i'Si

218

PHTHISIOLOGY.

e
6

^
3

. Ot t- TO OS OO t~ i-l . O
. Tf OS 1O O IO CD <O .-fli

s <- =s i <;: s .esjasss

1-1 o rH OO CO * K C!

Si-H O T)< 00 1-1 9 00 CO 1-1 O t^ * M 7J
co 1-1 co <5jO ao ( i-i T <.- i- ^ t- x T-,

e* oo c< P oo <N oo io CD co r-i 10

- <jj co eb ib eb i- ia oo * ib <j beOTi<

<JDTi i-cib

t-co c> 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

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

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<eo toot o 10 ee<-i

-^- :i

CO ii Ot 95 03 i-> ' 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

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

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

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

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

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

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

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

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.

830-1,000

760

933,773

8-36

1,000-1,600

837

224,210

2'75

1 600-2,000

160

81,066

2'60

2 000-2,600

190

104,289

2'76

2,600-3,000

69,166

2-33

Above 8,000

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.

3-11

4-06

2-73

3-08

2-49

4'99

2'71

4-72

2-29

3-06

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

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.

Ft in. in.
4 10 68

24 years

5 6J 66}

21 years

5 4 64

341

5 60

80 years

5 41 641

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

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.

100- 500

2'3

500- 1,000

2'6

1,000- 2,000

3-0

2,000- 4,000

8-4

4,000- 8,000

S-5

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 <rood things that come in his way, because of his
anxiety to prepare for a rainy day. His fondness for
beer, a beverage that he manages to secure wherever he
goes, may likewise have some influence in shielding him
against phthisis."

250 PHTHISIOLOGY.

Hirsch believes that " the exceedingly common occur-
rence of phthisis among the new arrivals themselves is in
part the explanation of the progressive increase of phthi-
sis in the cities of the United States, that goes on hand
in hand with immigration on a large scale ; but a not less
considerable part of it is due to an increase of the malady
among the settled population of the towns. It must be
connected, therefore, with influences of a general kind
proceeding from a change in the mode of living within
the current century, and particularly within the more
recent years of it, with social errors such as mostly ob-
tain in large towns and in the centers of industrial traffic
errors from which no city or manufacturing town can
escape. Among those detrimental things in the social
life, we have, according to nearly unanimous opinion, to
assign the first place, along with insufficient or bad food,
to the bad domestic hygiene, to the influence of continu-
ous residence in crowded living-rooms and work-rooms,
tainted with organic and inorganic exuviae, ill ventilated,
and damp. In fact, it would be hard to find any factor
in the production of phthisis which can claim more im-
portance than that."

" The effect of sedentary habits," says Clark, " in all
classes and conditions of society is, in my opinion, most
pernicious, and there is perhaps no cause, not even ex-
cepting hereditary predisposition, which exerts such a
decided influence in the production of consumption as
the privation of fresh air and exercise ; indeed, the result
of my inquiries leads to the conviction that sedentary
habits are among the most powerful causes of tubercu-

ETIOLOGY. 251

lous diseases, and that they operate in the higher classes
as the principal cause of its greater frequency among
females." " All modes of life," says Andrew, referring
to the origin of phthisis, " all occupations which are car-
ried on indoors, contrast unfavorably with out-door pur-
saits. The naked savage, whatever ills he may have to
bear, rarely finds phthisis among them ; but with every
addition to his clothing, and to the comfort of his tree or
cave, his proneness to it increases." Flint sums up his
many years' experience of hospital and private practice as
follows : * " The general conclusion is, that occupation has
an agency in the etiology of pulmonary tuberculosis, in
so far as it is sedentary and involves confinement within-
doors. If it be said that this conclusion is in accord-
ance with what is already known, I answer that the cor-
rectness of the conclusion is thereby made the more cer-
tain."

Lindsay f says : " There is now a vast mass of evi-
dence which conclusively proves that consumption is
comparatively rare among those who follow an out-door
life under normal and healthy conditions ; that it is com-
paratively common among those who live habitually in-
doors ; and that it attains its maximum incidence among
those whose occupation involves prolonged confinement in
a vitiated atmosphere. Thus, of 1,000 fishermen who die,
only 108 succumb to consumption, while among grocers
the mortality rises to 1C7, among drapers it mounts to 301,
and anmn<r printers attains the truly appalling total of 461.

* "New York Medical Record," January, 1873, p. 49.
f " Climatic Treatment of Consumption."

252 PHTHISIOLOGY.

Hence, it would appear that, if a man chooses the life of
a fisherman, it is about ten to one that he will not con-
tract consumption ; while, if he becomes a printer, it is
almost an even chance that he will fall a victim to that
disease. That the open-air life on the one hand, and the
confinement in vitiated atmosphere on the other, are the
essential factors, becomes evident when further statistics
on the subject are interrogated. Thus, next to fishermen,
the classes whose occupation involves the largest average
of healthy open-air life are those engaged in the cultiva-
tion of the soil. Accordingly, we find that the mortality
from consumption per 1,000 deaths is 103 among farm-
ers, 121 among gardeners, and 122 among agricultural
laborers. Farmers thus even surpass fishermen in their
exemption from consumption a fact due, no doubt, to
their better position and greater immunity from hardship
while gardeners and agricultural laborers only slightly
fall below them. At the other end of the scale, among
the classes which suffer most from consumption, we have
cutlers, with a mortality rate of 371 ; file-makers, whose
rate is 433 ; and earthenware manufacturers, of whom 473
out of every 1,000 die of consumption. If we compare
different in-door occupations, we find that, as the con-
tamination of the air increases, the death-rate from con-
sumption rises pari passu. Thus, the workers engaged
in the hosiery manufacture spend their time in-doors it is
true ; but there is nothing in the nature of the work to
create any special contamination of air. Hence the mor-
tality from consumption among this class of operatives
attains only the very moderate figure of 168 per 1,000,

ETIOLOGY. 253

actually less than that for the community as a whole,
whose rate is 220 per 1,000 ; but among the operatives
engaged in the woolen and cotton manufacture, which
involves the inhalation of particles of dust, the rate rises
to 257 and 272 respectively. The apparent exceptions to
the law that the mortality from consumption is in direct
ratio to the contamination of the air of respiration admit,
for the most part, of a ready explanation. Thus, quar-
rymen, although working in the open air, have a mor-
tality rate of 308 ; but here comes into play the inhala-
tion of particles of stone-dust, which we know to be one
of the most powerful predisposing causes of consump-
tion. Cab and omnibus drivers, also working in the
open air, have a mortality rate from consumption of 359 ;
but when we observe that 1,482 of this class die from all
causes, as compared with 1,000 of the general population,
it seems reasonable to conclude that the excessive mor-
tality from consumption is simply a part of the general
unhcalthiness of the class an unhealthiness due partly to
exposure, partly to intemperance, and partly to the fact
that these occupations are often adopted by men who
have relinquished other trades in consequence of a break-
down in health. One notable exception to the general
law is more difficult to explain, viz., the comparative ex-
emption from consumption enjoyed by the workers in
coal-mines. Their mortality rate from this cause is only
aborrt 12G, or nearly as low as that of the agricultural
laborers, yet they work in a confined atmosphere and
among much dust. Some high authorities have ex-
plained this immunity l>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
le<l-linen, coverlets, clothes, handkerchiefs. Sputum that
has dried in spittoons or on the floor gets detached only
in larger pieces which do not readily float in the air. On
the other hand, one can hardly imagine a more favorable
contrivance for the distribution of the sputum as dust
tlmn that of allowing it to dry rapidly on stuff-garments,
from which at each movement fibers fly off and carry the
infective material into the air, where they remain sus-
pended for some time, and when at last they fall to the
ground the particles are easily caught up again by the
slightest breath of air. The examinations of air under-
taken by Hesse are very instructive on this point, and
confirm fully what I have just stated."

" The following case is of great importance in connec-
tion with the etiology of local tuberculosis. It is nar-
rated by Dr. E. A. Tscherning, in the * Fortschritte des
Medicin,' vol. iii, No. 3, 1885 : *

" Muria P., aged twenty-four years, cook in the house of the late
Prof. II., is of a completely healthy and strong constitution. She

* " Recent Essays by Various Authors on Bacteria in Relation t.

Selected and edited by W. Watson Chcyne, M. B., F. R. C. a. New
;ih:un Society, London, 1886, loe. cit.

270 PHTHISIOLOGY.

has never been affected with any scrofulous or tubercular disease.
There is not the slightest trace of hereditary predisposition to tuber-
culosis in her family.

" Prof. H. died at the end of July (1884), from acute phthisis,
which had lasted five or six months. His sputum toward the end
of his life was almost a pure cultivation of tubercle-bacilli in pus.
A few days before the professor's death, the patient wounded the
palmar side of the first phalanx of her middle finger with a fragment
of a broken vessel containing sputum. I first saw her fourteen days
after the accident, when there were signs of commencing whitlow.
For eight days carbolic fomentations were employed, with subsidence
of the symptoms without suppuration ; but a small nodule about the
size of half a pea could be felt in the subcutaneous tissue. During
the next few weeks the nodule remained somewhat painful and the
tissue around was cedematous. At the end of August I made an
incision and removed by means of a sharp spoon a small granula-
tion-tumor scarcely as large as a pea, which lay between the skin
and the sheath of the tendon. Healing took place in eight days by
first intention under a dressing of iodoform and corrosive sublimate.
For the time, improvement occurred ; but when I saw the patient,
at the beginning of October, she complained of pain on bending the
finger. The skin and subcutaneous tissue were slightly swollen,
and also the palm of the hand close to the phalanx. I could not
make out any circumscribed swelling of the sheath of the tendon.
By the advice of Prof. Studsgaard, she used local vapor-baths for
some weeks, and presented herself again in the middle of Novem-
ber. "We could then feel, through the somewhat redematous skin,
a very distinct swelling of the sheath of the flexor tendon. The
movements of the finger were interfered with and there was con-
siderable pain and tenderness. There were also two swollen glands
above the elbow and two in the axilla. In other respects the pa-
tient was well. There was no trace of lung-disease.

u On November 21st Prof. Studsgaard removed the swollen axil-
lary and cubital glands and amputated the middle finger at the
metacarpo-phalangeal articulation, splitting up the palm and re-
moving the tendon with its sheath as far as the middle of the palm.
The subcutaneous granulation tissue was widely removed and scraped
out. The operation was performed with the usual antiseptic pre-
cautions (corrosive sublimate, 1 per 1,000), and dressed with a sub-
limate wool and gauze dressing. The wounds healed by first in-
tention in eleven days. The patient was well when discharged.

ETIOLOGY. 271

" The following pathological changes were found : The sheath
of the tendon was filled with granulation tissue, its wall thickened.
In the serous covering of the tendon were petechial haemorrhages ;
but there was no pus nor caseous masses. There was no affection
of the joints or bones. The granulation tissue showed under the
microscope (after hardening in alcohol and staining with picro-
caruiine) very numerous young tubercles, with in many cases cen-
tral caseous degeneration, frequently large cells and very beautiful
giant cells often in the center of the nodules.

u The extirpated glands presented to the naked eye the appear-
ance of simple hyperplasia without pus or caseous deposits. Under
the microscope I found large numbers of large cells, with here and
there small tubercles. Both in the granulation tissue and in the
lymphatic glands I found in all the sections, stained by Ehrlich's
method, well-marked tubercle-bacilli partly in the large cells, more
especially in the giant cells, and partly at the margin of the necrotio
places. The bacilli, as a rule, lay singly ; but here and there there
were two or three together, especially in V-shaped groups. Many
of them contained the so-called spores.

" I saw the patient again at the end of January, 1885. She was
quite well, and without chest-symptoms. No fresh lymphatic en-
largements; linear scars with little tenderness; no sign of spread of
the disease, either locally or generally.

" The microscopic appearances described here correspond en-
tirely to what I have formerly found in about thirty cases of surgical
tuberculosis (joints, sheaths of tendons, spondylitis, pyogenio mem-
branes, lymphatic glands, testicles, tongue, and tuberculous kidneys),
which I investigated from this point of view, formerly as prosector,
and lately as assistant physician."

" In a communication made to the Academic des
Sciences, by MM. Spillman and Haushalter,* and re-
corded in 'La Semaine M6dicale,' the question of the
spread of the tubercle-bacillus by means of the common
house-fly is considered. The authors state that they have
.- ( ii flics enter the spittoons containing the sputum of
phthisical patients; they were then caught and placed

* London "Lancvt," Svptojnbrr 10, 1887.

272 PHTHISIOLOGY.

in a bell-jar. On the following day several of these
were dead. Examination of the abdominal contents and
the excrement of these flies on the inside of the jar
showed the presence of many tubercle-bacilli. The
authors point out the wide dissemination of the disease
which may take place in this way, and recommend as a
preventive the employment of covers with a small open-
ing."

" In an article in ' La Clinique,' on the ' Contagiosity
of Tuberculosis,' by MM. Destree and Slosse,* it is stated
that from inquiries and observations made in Dr. Des-
meth's wards during the present year it was found that,
of fifty patients suffering from tuberculosis, contagion
could be regarded as an undoubted etiological factor in
twelve, heredity in thirty, while no cause could be traced
in the remaining eight. The two factors, the authors say,
are frequently present, and it is difficult to determine to
which of them the preponderating influence is to be
ascribed."

" By a number of carefully conducted experiments, f
M. Cadeac and M. Mullet have undertaken to determine
if the air expired by patients suffering with pulmonary
tuberculosis can produce the disease by inhalation or by
inoculation. They publish an interesting account of
their experiments in a recent number of the ' Revue de
Medecine.' The method which they adopted in the first
series of experiments was as follows : A caoutchouc bag,

* London "Lancet," November 6, 1887.

f "New York Medical Journal," editorial, November 5, 1887.

ETIOLOGY. 273

having a capacity of from forty-five to fifty quarts, pro-
vided with a stop-cock, was partially filled by being
breathed into by a patient in an advanced stage of
phthisis. It was then filled to its utmost capacity with
pure air, and in that way a vitiated atmosphere was cre-
ated like that which is usually to be found in a phthis-
ical patient's room. Rabbits, the susceptibility of which
to tuberculosis is well known, were made to breathe in
the air contained in the bag for an hour or two hours
every day, by means of a certain muzzle, fashioned after
the mouth-piece of Paul Bert's anaesthesia-inhaler. This
was repeated for several days, and the three rabbits upon
which the experiments had been performed were killed
after the lapse of from twenty to forty days, and their
organs examined. The results were entirely negative;
all the viscera were found perfectly healthy. In another
series of experiments, rabbits affected with catarrhal
bronchitis were treated in the same way, but in them
also the results were negative.

" The objection might be raised that in these experi-
ments the degree of infection of the mixed air was
variable, and the exposure too limited in duration. To
exclude this source of fallacy, a third series of experi-
ments was undertaken. A small box was divided into
two compartments, in such a way that animals put into
tlu- two compartments had to breathe the same air, but
could not come into bodily contact. Rabbits in which
artificial tuberculosis had been produced were put into
one of the compartments, and Guinea-pigs affected with
induced bronchitis were placed in the other. Thus, for

274 PHTHISIOLOGY.

periods of two or three months, the non-tuberculous
Guinea-pigs had to inspire the emanations from nineteen
tuberculous rabbits ; yet not one of the Guinea-pigs
showed any signs of tuberculosis, either during its life
or after being killed. In a fourth series of experiments,
the vapor contained in the expired air of phthisical pa-
tients was condensed, and the resulting liquid was in-
jected under the skin in rabbits, with antiseptic precau-
tions. Twelve rabbits were thus treated, and the results
were negative in all, with a single exception. In the
rabbit that proved the exception two gray granulations,
of the size of a pin's head, were found in the left lung.
Thirteen Guinea-pigs were treated in the same way, and
in none of them did infection take place. The authors
pushed their experiments still further. There were two
wards in the hospital, one of which was 120 feet long,
24 feet wide, and 21 feet high, containing about forty
consumptive patients, and the other was 105 feet long,
18 feet wide, and of the same height as the first, having
about thirty patients. The majority of the patients ex-
pectorated freely, and no precautions were taken with re-
gard to the sputa. Several of the patients were in such
an advanced stage of phthisis that they had to keep their
beds constantly. Air collected from these wards, quite
close to the beds occupied by patients, was subjected to
condensation of its aqueous vapor, which was used in
the same way as in one of the other series of experi-
ments. Twelve Guinea-pigs were employed in these
experiments, and the results were negative in all but two
of them. In one of these two, a few small, gray granu-

ETIOLOGY. 275

lations, containing tubercle-bacilli, were found in one of
the lungs ; in the other there were numerous foci of
tubercular granulations in both lungs, and in some of
the glands of the body.

" Although these experiments do not entirely disprove
the infectiousness of tuberculosis, it must be said that
thov afford strong presumptive evidence of the innocu-
ousncss of the air expired by consumptive patients. The
t\v instances of positive results obtained in the last series
of experiments emphasize the necessity of disinfecting
the sputa of phthisical patients, whether in a large hos-
pital ward or in small apartments occupied by the sick
and the healthy."

Dr. Cornet* publishes in the "Internationale kli-
nische Rundschau " an account of a series of experimental
investigations on tuberculosis which he has been conduct-
ing for the last two years in the Berlin Hygienic Insti-
tute. The experiments were divided into three groups :
the first of these dealing with the air and dust in dwell-
ing-houses, hospitals, etc. ; the second group comprising
observations directed to the parts of the body affected by
tubercle artificially introduced in different situations ;
and tho third group consisting of attempts to solve the
problem of the possibility of rendering the tissues un-
suitable as a cultivating medium for the tubercle-bacilli.
In order to examine the walls and floors of rooms, the
surfaces were washed over with sterilized sponges, which
were then used to inoculate broth, the resulting culture

* London "Lancet," May 19, 1888, loc. cii.

276 PHTHISIOLOGY.

being injected into the abdominal walls of three Guinea-
pigs. The animals (if they did not die of some intercur-
rent affection) were killed forty days later and a careful
necropsy made. Twenty-one hospital wards, in which
most of the patients were phthisical, were examined in
this way, the result being that from the dust of fifteen
of them tuberculosis was set up. Similar observations
made in lunatic asylums showed that the walls of these
establishments are very frequently infected with tuber-
cle. Private houses where persons affected with phthisis
had lived gave likewise very distinct positive results ;
out-patient departments and surgical wards appeared, on
the other hand, to harbor no tubercle. One important
observation made was that, where phthisical people had
been in the habit of expectorating on the floor, this was
certain to yield infectious cultures ; whereas, in cases
where handkerchiefs or spittoons had always been used,
the liability of the dust to prove infectious was very
greatly diminished. Regarding the organs affected, Dr.
Cornet fully confirms Koch's observation that, except the
actual point of introduction, the organs most affected are
the nearest lymphatic glands. Thus, when inhalation is
the mode of infection adopted, the bronchial glands are
the organs most affected ; when injections are made into
the abdominal walls, the inguinal glands of the side se-
lected show the greatest degree of tuberculous infection ;
and, when the virus is introduced directly into the ab-
dominal cavity, the omentum is the part most affected.
The therapeutical observations were made with tannin,
"pinguin," sulphureted - hydrogen water, menthol, cor-

ETIOLOGY. 277

rosivc sublimate, creolin, and creosote, all of which were
given in much larger doses in relation to the body weight
than any one would think of prescribing for human be-
ings. In the case of corrosive sublimate, toxic symptoms
were induced before the tubercle was injected, and care
was taken with all the other remedies that the system
was well saturated with them. Notwithstanding all this,
however, every animal died, not the slightest hindrance
being apparently caused to the development of the tuber-
cle-bacilli by any of the remedies.

Dr. Comet remarks that of course the results of ex-
periments on Guinea-pigs must not be taken as necessarily
holding good for human subjects, as he has himself re-
peatedly proved the great value of creosote in the treat-
ment of phthisis. Again, some infected Guinea-pigs
were sent to Davos, others being kept in Berlin, the con-
ditions of life of the two sets of animals being rendered
as similar as possible. All of them died in about the
same time, and no perceptible difference was found in
the degree of tuberculous infection of the tissues in the
two classes of cases.

Brown-Sequard, Stokes, and others, claim that cer-
tain of the lower animals do not become tuberculous after
inoculation with phthisical sputum if they are permitted
to enjoy out-door life in pure air and are supplied with
abundant nutriment, and that they rapidly become tuber-
culous after inoculation if these hygienic influences are
<li nied tlu-ui. Trudow's experiments, in which pure cult-
ures of the tubercle bacillus were used for inoculation,
corroborate these statements.

278 PHTHISIOLOGY.

Councilman * states : " That tuberculosis is an infec-
tious disease, and that the tubercle-bacilli are the infect-
ing agents, are facts too well established to need further
discussion. Probably the greatest advances in our knowl-
edge of the disease that have been made since Koch's
discovery of the bacillus have been as to the modes of
infection ; and this has been, not so much the question of
the infection of the individual, but how further infection
of the different tissues and organs takes place after the
disease has established itself. It is especially to the work
of Weigert that the most of our knowledge on this sub-
ject is due. We know now that the extent and char-
acter of the lesions produced are for the most part due
to the number of bacilli which enter a part and to the
manner in which they enter. We have the acute miliary
tuberculosis, presenting all the clinical features of an
acute infectious disease, which is due to general blood-
infection by large numbers of bacilli entering the blood-
current ; then the general disseminated tuberculosis, in
which there is also a general infection of the blood (but
the bacilli which enter the blood are fewer, or they enter
it at intervals) ; then the tuberculous pneumonia, affect-
ing larger or smaller portions of the lung parenchyma,
and due to the aspiration of large numbers of bacilli fur-
nished by a focus of the disease, usually a cavity, in some
other part of the lung. The miliary tubercles are most

* An address on "Predisposition in Tuberculosis," delivered before the
Society of the Alumni of Bellevue Hospital, New York, April 4, 1888, by
William T. Councilman, M. D. Published in the " New York Medical Jour-
nal " for April 21, 1888.

ETIOLOGY. 279

probably due to a comparatively small number of bacilli
carried to a part by means of the blood-vessels or lymph-
vessels.

"These are only some of the various lesions which
may depend on the manner in which the bacilli enter a
part and their number. The ways along which the ba-
cilli can enter a part can be only three : they can enter
it only by means of canals or ducts which penetrate it, or
by the blood or lymphatic vessels.

" Infection of the individual can take place by means
of the respiratory system, the alimentary canal, the genito-
urinary tract, and the outer surface. Infection by the
respiratory tract is the most common, and, next to this,
infection by the alimentary canal, this being more com-
mon in children than in adults. The genito-urinary tract
furnishes the route of infection in a much smaller num-
ber of cases, and a few instances have been known of
infection from the outer surface of the body. It is not
always easy to ascertain with certainty the primary lesion
of the disease. This is often of so little moment ana-
tomically, in comparison with the secondary lesions, that
it may readily be overlooked, or placed in the same cate-
gory with these.

" The epithelial covering of the surface of the body
forms so perfect a protecting mantle that it is extremely
improbable that infection of this ever takes place without
a 1 -.-ion. The bacilli may, however, enter the body by
nu-ans of the alimentary canal without causing any lesion
at the place of entry. This mode of infection is seen in
the mesenteric phthisis of children, in which the mesen-

280 PHTHISIOLOGY.

teric glands are the seat of an extensive tuberculous in-
flammation, often with no lesion of the intestine, or the
bacilli may pass through the epithelium of the mouth or
pharynx and the first seat of the disease be in the cer-
vical lymph-glands. We know that the bacilli do pass
through the epithelial covering of the small intestine,
and in cases of intestinal tuberculosis the first formation
of tubercles is in the lymphatic tissue beneath this.

" They may pass into the lymphatics without produc-
ing any lesions at the place of entry, and first make their
presence known by a tuberculous inflammation of the
glands. The anatomical structure of an organ must also
influence the character and the extent of the tuberculous
lesions produced in it. Thus the lungs, by means of the
branching system of the bronchi into which the bacilli
soon enter, favor the conveyance of the virus from one
point to another more than the liver, for example.

" Not only do the lungs favor a primary infection,
but, when once the disease is established, further infec-
tion of other parts easily takes place."

Predisposition to Phthisis. Hirsch, in considering
congenital or acquired predisposition to phthisis, says
that "the disposition must be assigned exclusively to
abnormal states of the respiratory organs themselves,
which had either been congenital or been called forth
by external influences acting upon the lungs directly
or indirectly. In the same class of directly noxious
things predisposing to an attack of phthisis, we have to
reckon passing the time in crowded and ill-ventilated
places, the air of which is laden with organic decoin-

ETIOLOGY. 281

position-products or minute particles of mechanical or
fliL-mical irritants; also, chronic bronchial catarrh (de-
pending sometimes upon the causes just mentioned, and
sometimes upon the weather) and chronic pneumonias
(or pneumonias that had not cleared up), particularly
broncho-pneumonias.

" Among the influences operating indirectly we havs
to include all those things that are detrimental to the nu-
trition of the organism in general, making it vulnerable
through defective repair of the tissues ; and that vulner-
ability, so far as concerns the lungs, is the cause of their
predisposition to morbid processes in general and to con-
sumption in particular. This is the explanation of the
disease being so notoriously common among persons liv-
ing in miserable circumstances and reduced to struggle
with want and cares, also of its development in those
who have been entirely worn out and reduced by severe
sickness.

" On the other side, we may thus explain the exemp-
tion from phthisis of many parts of the world by reason
of their favorable weather-conditions and the consequent
rarity of all pulmonary affections therein. The immu-
nity from consumption enjoyed by the natives of ele-
vated regions seems to me to be referable to a peculiarly
strong development of their breathing-organs and a cor-
responding power of resistance in them to noxious influ-
ences from without. It is proved that this is not at all
an affair of * purity of the atmosphere,' as some have
supposed, by the fact that the Ktate of hygiene in the
towns of Ecuador, Bolivia, and Peru, situated at great

282 PHTHISIOLOGY.

elevations, is by no means distinguished for its excel-
lence, for cleanliness in the houses and streets, adequate
ventilation of rooms, and the like."

Koch states that " although a good many of the phe-
nomena classed together under the head of ' predisposi-
tion' may be referred to simple and easily explained
conditions, some facts remain difficult or impossible to
interpret, compelling us for the present to accept the
view of a varying liability. Most important of all is the
striking difference between the course of tuberculosis in
children and in adults, and again the undeniable predis-
position to tuberculosis that exists in some families.

" In the latter instance, many of the cases of illness
where predisposition is supposed to be an important fac-
tor might rather be ascribed to increased opportunities of
infection, and there are also peculiar predisposing in-
fluences connected with the family constitution to be
thought of, such as a tendency to catarrhal affections of
the respiratory organs and imperfect development of the
thorax. Still, many carefully observed cases remain
which can not be explained in this manner. Further,
individual cases of the disease have often shown that a
person is not at all times an equally favorable subject
for the development of the parasites, for it not infre-
quently happens that tubercular foci which had reached
a fair size contract, cicatrize, and heal up. That means,
however, that the same body which afforded a suitable
soil for the tubercle-bacilli on their first invasion, so that
they were able to multiply and spread, has by degrees
lost the qualities favorable to them and has changed into

ETIOLOGY. 283

a bad soil, thus preventing further growth of the bacilli ;
so that hi the same person there was at one tune a lia-
bility to tuberculosis and again at another time none.
Further investigation is required to show what occasions
this difference, whether it is due to a change in the
chemical composition of the juices of the tissues or to
physical conditions. So much is certain, that these dif-
ferences exist; and there is nothing against the view
that conditions similarly favorable or unfavorable to the
tubercle-bacilli are present in some human beings not
only temporarily, but for the whole lifetime."

Leichtenstern, speaking of Koch's brilliant discovery,
says, "there are still many lacunae and open questions
facing us in the etiology of consumption, and these offer
to the practitioner, to the statistician, to the pathologist
who studies the history and geography, to the pathologist
who experiments, and to the bacteriologist, a wide field
wherein to co-operate. It is not by the power of any
sudden enthusiasm, treating the infective nature of phthi-
sis as if it were already made perfectly clear, that the
new doctrine will be made secure of its position, but by
earnest work and prolonged study."

VII.
CONCLUSIONS.

KINDFLEISCH says: "Any one who wishes to give a
special account of tuberculosis of the lungs must neces-
sarily commence by stating his views on the subject in
general ; for so much has been written, and so many dif-
ferent opinions prevail concerning tubercle, that, unless
an author first states to what condition he applies this
word, he can not be understood."

In the first chapter of this work I have attempted
to record the opinions of prominent writers on pulmo-
nary consumption, from the time of Hippocrates up to
the present day, believing that a knowledge of their
views, and of the points upon which they have failed to
agree, will give a better understanding of the subject
than may be otherwise obtained.

The statistical data given in the foregoing pages of
this work are, as I have previously observed, the most
accurate attainable at the present time.

The climatological study of the future must be based,
as Gihon * has stated, " upon rational methods of in-
vestigation. The mere recording of meteorological fac-

* The opening address of the president, Albert L. Gihon, M. D., U. S. N.,
of the " Section in Medical Climatology and Demography." " International
Medical Congress," Washington, D. C., September 5, 1887.

CONCLUSIONS. 285

tore is not sufficient. Determinate climatic characters
are not easy to formulate. . . . There are few specific
climatic diseases. Local conditions of insanitation are
more responsible for the production of diseases than the
general influences of climate. By appropriate regula-
tions of habits, clothing, and diet, the morbific effects of
climate may be modified or averted, or its sanitary or
therapeutic influence heightened.

" The data for future generalizations must be fur-
nished by accurate and laborious collective investigation.
Vital statistics must in future be something more than
mere records of so many deaths, births, or marriages.
Morbility records must form the principal data for the
vital statistics of the future. To have these records ac-
curate, voluntary effort can not be depended upon ; they
must be made under governmental authority, if our vital
statistics shall serve as the basis of trustworthy generali-
zations."

In the tenth "United States Census Mortality and
Vital Statistics Reports," concerning which Pepper*
says : " Nor can I neglect this opportunity of referring
to the great practical value of this colossal work. De-
spite the serious defects of the statistics resulting from
the absence of any national system of registration of
vital statistics, such as is relied upon by all other civU-
>rwf 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

Softening

Excavation

Total..

154

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.

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joct is marked up to date and contains In Medical Record.

New York: D. APPLETON & CO., 1, 8, & 5 Bond Street

THE SCIENCE AND AKT OF MIDWIFEKY.

By WILLIAM THOMPSON LUSK, M. A., M. D.,
Professor of Obstetrics and Diseases of Women and Children in the Bellevne
Hospital Medical College ; Obstetric Surgeon to the Maternity and Emergency
Hospitals ; and Gynaecologist to the Bellevue Hospital.

Second edition, revised and enlarged.

Complete in one volume 8vo, with 226 Illustrations. Cloth, $5.00;
sheep, $6.00.

" It contains one of the best expositions
of the obstetric science and practice of
the day with which we are acquainted.
Throughout the work the author shows
an intimate acquaintance with the litera-
ture of obstetrics, and gives evidence of
large practical experience, great discrimi-
nation, and sound judgment. We heartily
recommend the book as a full and clear ex-
position of obstetric science and safe guide
to student and practitioner." London
Lancet.

" Professor Lusk's book presents the
art of midwifery with all that modern sci-
ence or earlier learning has contributed to
lt."Medicai Record, New York.

"This book bears evidence on every
page of being the result of patient and la-
borious research and great personal experi-
ence, united and harmonized by the true
critical or scientific spirit, and we are con-
vinced that the book will raise the general
standard of obstetric knowledge both in
his own country and in this. Whether
for the student obliged to learn the theo-
retical part of midwifery, or for the busy
practitioner seeking aid in the face of prac-
tical difficulties, it is, in our opinion, the
best modern work on midwifery in the
English language." Dublin Journal of
Medical Science.

"Dr. Lusk's style is clear, generally
concise, and he has succeeded in putting
in less than seven hundred pages the
best exposition in the English language
of obstetric science and art. The book
will prove invaluable alike to the student
and the practitioner." American Practi-
tioner.

" Dr. Lusk's work is so comprehensive
in design and so elaborate in execution
that it must be recognized as having a
status peculiarly its own among the text-
books of midwifery in the English lan-
guage." New York Medical Journal.

" The work is, perhaps, better adapted
to the wants of the student as a text-book,
and to the practitioner as a work of refer-
ence, than any other one publication on

the subject. It contains about all that is
known of the ars obstetrica, and must
add greatly to both the fame and fortune
of the distinguished author." Medical
Herald, Louisville.

" Dr. Lusk's book is eminently viable.
It can not fail to live and obtain the honor
of a second, a third, and nobody can fore-
tell how many editions. It is the mature
product of great industry and acute obser-
vation. It is by far the most learned and
most complete exposition of the science
and art of obstetrics written in the Eng-
lish language. It is a book so rich in sci-
entific and practical information, that no-
body practicing obstetrics ought to deprive
himself of the advantage he is sure to gain
from a frequent recourse to its pages."
American Journal of Obstetrics.

" It is a pleasure to read such a book
as that which Dr. Lusk has prepared;
everything pertaining to the important
subject ol obstetrics is discussed in a mas-
terly and captivating manner. We recom-
mend the book as an excellent one, and
feel confident that those who read it will
be amply repaid." Obstetric Gazette,
Cincinnati.

"To consider the work in detail would
merely involve us in a reiteration of the
high o'pinion we have already expressed of
it. What Spiegelberg has done for Ger-
many, Lusk, imitating him but not copy-
ing him, has done for English readers, and
we feel sure that in this country, as in
America, the work will meet with a very
extensive approval.'" Edinburgh Medi-
cal Journal.

"The whole range of modern obstet-
rics is gone over in a most systematic
manner, without indulging in the discus-
sion of useless theories or controversies.
The style is clear, concise, compact, and
pleasing. The illustrations are abundant,
excellently executed, remarkably accurate
in outline and detail, and, to most of our
American readers, entirely fresh." Cin-
cinnati Lancet and Clinic.

New York: D. APPLETQN & CO., 1, 3, & 5 Bond Street.

e library from which It wa. bommed.

LIBRARY
UNIVERSITY OF CALIFORNIA, IRVINE
IRVINE, CALIFORNIA 92664

Date Due

'*Y 2 ] 1877

WTHERN REGKMAi. LBRARY F*r

A 000502503 e