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should certainly be the duty of the health officer to make inquiry into each case; he should specially direct his investigation as to the previous confinements which either doctor or nurse has attended, and as to whether the medical attendants used disinfectants in washing their hands, or as to whether antiseptic vaginal injections had been used. The drainage and sanitary condition of the house should also be strictly investigated.

Since these maladies are not easily communicated unless by direct inoculation, or unless persons in the vicinity of the sick have abrasions of the skin, cuts, or wounds, it is not absolutely necessary to remove the patient to hospital on public grounds; but if the lodging is itself insanitary or overcrowded, it may then be advisable to urge such removal.

(337) Disinfectants in the Puerperal Condition.

A 1 per 1,000 solution of corrosive sublimate for general use-that is, both for washing the hands and as a vaginal injection-or a 5 per cent. solution of carbolic acid, will be found the best. (Reference may be also made to the trichloride of iodine, see page 345.) After an obstetric physician has attended a case of puerperal fever, it has been found most difficult to get free from infection. The main trouble probably is to disinfect the recess between the nail and the finger. From experiment it has, however, been shown that, if the hands are washed with as hot water as can be borne, then with strong alcohol, and then with a strong disinfectant, such as a solution of iodine trichloride, the hands may be made to yield sterile scrapings even when such scrapings are derived from under the nail. This, with two or three Turkish baths, followed by sponging the whole body over with a 1 per 1,000 solution of corrosive sublimate and absolutely fresh clothing, the clothing taken off being sent to the disinfecting chamber, will, if carried out honestly and intelligently, most certainly free the physician's body from any infective particles.

CHAPTER XXX.

TUBERCULAR MALADIES.

TUBERCULOSIS.

TUBERCULOSIS is an infectious malady, caused by a micro-organism to which has been given the name of the Bacillus tuberculosis. The bacillus once planted in the tissues may give rise to a mere local lesion, as for instance when it is inoculated into the skin; or may affect one particular organ, such as the lung, far more than any other part; or may be generally diffused.

(338) Statistics of Tubercular Mortality.

Hitherto we have had no trustworthy guide as to the number of cases of tuberculosis, save that of the death returns. In the Registrar-General's returns tuberculosis is divided into phthisis, tabes mesenterica, tubercular meningitis, and "other forms of tubercular disease and scrofula." Some of the latter are probably not correctly diagnosed, but on the other hand it may be safely affirmed that a number of cases escape diagnosis, and that the mortality is rather likely to be under- than over-stated.

During the twenty-five years ending 1886, the average total deaths from phthisis have been 50,000 yearly in England, and those from other tubercular affections 17,700-in all, nearly 68,000.

An interesting summary is given by the Registrar-General of the deaths from tubercular diseases of children under five years of age for the three decades from 1871 to 1880:-"The death-rate from phthisis in the years 1851-60 was 1,305 per million; from

tabes mesenterica and scrofula, 1,920. In 1861-70 the figures are 968 for phthisis, 2,213 for hydrocephalus and tubercular meningitis, and 2,267 for tabes mesenterica and scrofula; whilst in 1871-80 the figures are 767, 1,800, and 2,550."

In relation to these Dr. Sims Woodhead1 remarks:-"The differences in the proportions between these figures in the various years might be due in part to more accurate diagnosis, but in part they are to be accounted for by the increase in the death-rate from tabes. Including, as these cases do, the diagnoses of physicians both skilled and unskilled, it would appear from the results of post-mortem examination of the cases described that the last group might safely be multiplied by five to give the actual number of cases in which the mesenteric glands were affected, giving no less than 12.75 per 1,000 as the rate of disease. If, in addition, those cases are taken in which the tubercular is followed by a reparative process, the number must be enormously greater."

(339) The Influence of Age and Sex.

Females are more liable to tubercle than men, in the proportion of about 0.2 per 1,000 of the population. It may be stated generally that the mortality is greatest at birth, diminishes rapidly till the fifth year, more gradually till about the fifteenth, and then begins to rise, at first slowly, then rapidly to the end. In the early years taken as a whole, the mortality is low, but from fifteen to twenty-five it is high; after this age the mortality somewhat declines. It must however be remembered that during the first five years of life errors in diagnosis are most common, and it is probable that many children die from tubercular meningitis and from tabes, the deaths being returned as from convulsions, teething, diarrhoea, and so forth.

Different organs are affected at very different periods of life. Thus Dr. Woodhead remarks that tubercular meningitis occurs much more frequently between the third and the eighth years than it does at any other period of life. Rilliet and Barthez give the results of the examination of 98 cases of this condition. They state that during the first year there were only two cases; be

1 "Abstract of the Researches of Dr. G. Sims Woodhead," Public Health, vol. i., 1888.

tween one and two years and a half, 17; from three to five years and a half, 34; from six to seven years and a half, 23; from eight to ten years, 15; and from eleven to fifteen years, 7 cases.

Of 54 cases of tubercular meningitis examined by Dr. Woodhead, not one was under one year (adopting the same classification); between one and two years and a half there were 15; from three to five years and a half, 21; from six to seven years and a half, 8; from eight to ten years, 8; and from eleven to fifteen years, 2. These figures correspond fairly closely, and might serve as a basis for comparison. In these 54 cases, tuberculosis was in 39 so widely disseminated that it might fairly be said to be general; in only 2 cases could no primary centre of infection be found. In 6 the only foci that could be primary were to be found in the lymphatic glands of the mediastinum alone or along with those of the mesentery; in 3 the lungs were the only other organs affected; and in 1 the lungs and mediastinal glands contained the older tubercle nodules.

In the brain or in its membranes, the embolic tuberculosis must be looked upon as part of a general process. Intestinal tubercle is most common in the years following childhood from twelve upwards for six or seven years. From an analysis of 127 cases of tuberculosis in children it was found that in 43 instances there was tubercular ulceration of the intestine. During the first year after birth there was only 1; between one and two years and a half, 14; from three to five years and a half, 10; from six to seven years and a half, 7; from eight to ten years, 5; and from eleven. to fifteen years there were 6. So that in this series of cases the intestines are frequently affected during very early life as well as in somewhat later years. Although the intestines are directly affected by tubercle in such a small proportion of cases, the mesenteric glands are found to be in some stage or other of tubercular degeneration in no less than 100 instances, or in nearly 79 per cent. of the whole. The age at which these tubercular glands in the mesentery were found is also significant. During the first year of life there were 4 cases; from one to two years and a half, 33; from three to five years and a half, 29; from six to seven years and a half, 12; from eight to ten years, 13; and from eleven to fifteen years, 9 cases. Here again the figures are higher during the earlier periods than during later years, but the maximum is

reached (as with ulceration of the intestine) at a distinctly earlier period than in the case of tubercular meningitis. In 14 cases the glands only were affected-i.e., there was no tubercle found in any other part of the body. In these cases the glands had become calcified, but in the others the structure and degeneration of the glands were tubercular, bacilli were very few in number and in some cases could not be demonstrated, and the nature of the mass could only be determined by inoculation experiments. Here, again, the second and third periods account for more than all the others put together, 5 and 4 from one to two and a half years and from three to five and a half years, against 5 for the other four periods (1 under one year; 1 between six and seven and a half years; 2 from eight to ten years; and 1 from eleven to fifteen years). These 14 cases were accompanied by neither ulceration nor cicatrisation of the intestine; there was no peritonitis, and secondary tubercle could be found in no other parts of the body, so that the tuberculosis of the mesenteric glands must be looked upon as the primary lesion. Continuing the analysis, it was found that in this 100 cases the glands at the root of the lung were simultaneously affected in 69 cases, and in 62 the lungs were also affected; in 13 there was tubercular peritonitis, and in 18 ulceration of the intestine was also found. Of the remaining cases, 4 had tubercular peritonitis and 4 ulceration of the intestine. In 12 cases the mesenteric and mediastinal glands, the peritoneum, the intestine, and the lungs were all affected; whilst in no fewer than 53 of the 100 cases there was evidence of localised peritonitis, recent or old, occurring between the spleen or liver and the diaphragm. Of the whole 100 cases, only 20 were diagnosed as having abdominal tubercle, and this 20 would be considerably reduced were the doubtful diagnoses eliminated. In these cases, then, the symptoms associated with tubercle in other organs are so predominant that the tubercle in the abdomen was practically overlooked. Dr. Goodhart, speaking of this condition, says: "Caseous or tubercular disease of the mesenteric glands is not uncommon; nevertheless, it is rare indeed in comparison with the consumption of the bowels which is so often heard of in the dwellings of the poor. From a large out-patient department of the Evelina Hospital during several years, and when at least 6,000 or 7,000 children must have come under observation, and probably considerably more, I have

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