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very briefly considered. If I go over a little of the well crowded past history of quarantine, you will bear with me. (See page 201.)
After the reading of Dr. Smith's paper, the Association adjourned to visit the quarantine station, New York harbor, upon the invitation of Dr. Smith.
EVENING SESSION.-8 O'CLOCK P. M.
The PRESIDENT.-The Association will come to order. I believe the Chairman of the Local Committee of Arrangements has some announcements to make.
Dr. RAYMOND.-The President of the Brooklyn Board of Education, Mr. Henry Henriques, extends a cordial invitation to the members of the Association to visit the public schools of the city during their stay. Through Dr. Harrigan, a member of the staff of St. Mary's hospital, the authorities of that institution extend a similar invitation.
I received to-day from Henry Chadwick, brother of Sir Edwin Chadwick, whom we all know so well as an efficient laborer in the cause of hygiene, a letter, transmitting several pamphlets upon sanitary subjects, written by the latter, which have been placed in the hands of the secretary.
THE PRESIDENT.-The first paper of the evening will be by Dr. Sternberg, on "Recent Researches Relating to the Etiology of Yellow Fever." (See page 170.)
The PRESIDENT.-The next paper of the evening, gentlemen, is by Dr. Theobald Smith, of Washington, D. C., on "Preliminary Observations on the Micro-organism of Texas Fever." (See page 178.)
The PRESIDENT.-The next paper, ladies and gentlemen, will be upon a kindred subject, by Dr. Salmon, chief of the Bureau of Animal Industry, of Washington, D. C., entitled "Some General Remarks on the Subject of Texas Fever." (See page 176.)
The PRESIDENT.-The next paper, ladies and gentlemen, is one which I am sure will interest you all. It pertains to a subject in which not the doctors alone, but the ladies, also, and the young sanitarians, are much interested. It is on "The Art of Cooking," by Mr. Edward Atkinson, of Boston. The ladies and gentlemen will be interested in seeing his kitchen, I know.
Mr. ATKINSON.-Ladies and gentlemen, it seems to me almost absurd to bring such a prosaic subject before you at the present time; but I will endeavor to do it as well and as fully as the time and circumstances will permit. I propose to call in the cook. I shall not give you much of a supper, but will, at least, give each of you a taste. (See page 151.) The meeting adjourned to Thursday, October 24, at 9 A. M.
THURSDAY, October 24, 1889.
MORNING SESSION.-9 O'CLOCK A. M.
The PRESIDENT.-The Association will come to order. Announcements and reports from the Executive Committee are in order.
The SECRETARY.-Mr. President, the members of the Association will take notice that the afternoon session will be held at the Hoagland Laboratory instead of in this hall.
I have here the applications of twelve persons for membership, which have been approved by the Executive Committee. I therefore move that the President declare them elected as members of the Association. This motion was duly seconded and carried.
The PRESIDENT.-Their names have been approved, and they are declared elected members of the Association.
The roll of members of the Advisory Council was called yesterday. There were some vacancies. From Colorado, Dr. A. A. Clough reported and has been appointed; from Vermont, Dr. C. L. Allen. That, I believe, is all. The states not responding yesterday will be called, and if there are any members of the Association present from those states, they will please report, in order that their names may be placed upon the list of the Council: Alabama, Dakota (either of the Dakotas), Montana, Delaware, Georgia, Mississippi, Texas, Virginia, West Virginia, Manitoba, New Brunswick, or either of the provinces of Canada,-with it Columbia.
There seem to be no additional reports to be made, and the Council is requested to meet at 10 o'clock.
Dr. J. D. PLUNKET.-Mr. President, I want to add that, suppose the member from Tennessee, whose name appears, should not accept: what would be the proper thing to do?
The PRESIDENT.-If an alternate for him is not present, I will designate Dr. Plunket.
The PRESIDENT.-The discussion of the papers on "The Disposal of Garbage" will take place at the end of the forenoon session, and not after the reading of the paper. I mention that fact for the information of the members of the Advisory Council who might desire to be present at that discussion. The paper upon tuberculosis, written by Dr. Hunt, read by Dr. Lindsley yesterday, was not discussed. Dr. Billings will open the discussion.
Dr. BILLINGS.-Mr. President and gentlemen, I regret very much to find myself differing greatly in opinion from my friend Dr. Hunt in a matter of this kind, especially as the difference is not only as to the scientific position of the question, but also as to the desirability of giving to the public the idea that the American Public Health Association is in doubt as to what should be done to prevent the spread of tuberculosis. In preventive medicine, and in the practice of medicine, we have to deal
very largely with probabilities, not with mathematical certainties. diagnosis of a case of a disease is, for the physician, a matter of probability, and attempts at preventive medicine are very seldom founded on absolute certainty. It is not certain, if you let a little child of two or three years of age, who has not had scarlet-fever, sleep in a bed with another child suffering from that disease, that it will have scarlet-fever; nor is it certain that an unvaccinated person going into a room containing a small-pox patient will contract small-pox, or that a man who drinks water polluted from a privy vault will get typhoid fever. All of these things are matters of probability, some greater, some less. It is nine to one that the person will contract scarlet-fever or small-pox under the circumstances mentioned, but the probabilities may not be over one in one hundred that a person who drinks the polluted water will get typhoid fever. Nevertheless, we all agree that these probabilities are great enough to warrant the taking of strong measures to cut off the supposed cause of disease. Probabilities guide us in all directions in life. The farmer sows the seed on the probability that there will be a crop; you come to this Association on the probabilities that there will be a sufficient number of members here to make an interesting meeting. Hence, though it may not be absolutely certain that the bacillus tuberculosis is the sole cause of tuberculosis, and it is true that the disease is not always communicated by the sputa, since it may be communicated in other ways, the probabilities that the sputa are the most frequent means of its transmission are so great, that it is proper for us to urge special precautions in dealing with them.
For the last five or ten years, in many laboratories, observers of more or less skill have been carrying on experiments with this bacillus, examining not only cases of consumption, but also trying to find this particular specific bacillus in the sputa or secretions of persons affected with other diseases than tuberculosis. They have not succeeded. They have also been endeavoring to find cases of undoubted tuberculosis in which the bacillus tuberculosis was not present. In some cases it has been extremely difficult to find it, and at first, before the subject was well understood, and before the necessity for careful investigation was fully apparent, some cases of tuberculosis were reported in which they failed to find the specific bacillus. Of late years, however, it is admitted by all skilled bacteriologists that the specific bacillus is not only the accompaniment of tuberculosis, but that it is the efficient cause of this disease.
With regard to methods of transmission of this particular form of bacillus, recent observers and experimenters upon this subject, as represented in the reports of the Paris congress on tuberculosis, are all agreed that the transmission of the bacilli from one person to another is usually effected through the means of the sputa, though it may also be effected through food, such as meats and milk. The fact that there is practically no transmission of the bacillus by means of the breath has been ascertained by direct experiment, by the examination of the air expired by persons suffering with tuberculosis as to whether there are
any bacilli in it. Dr. Hunt in his paper speaks rather contemptuously of that mode of experimentation, saying that it is out of the region of biology, and belongs to physics. Physics, however, is an essential part of the foundation of biological and of pathological studies. It has been demonstrated over and over again that bacteria are not taken up by a gentle current of air from fluids or moist surfaces, such as the membranes of the mouth. It was proved experimentally, before this question of the mode of conveyance of the bacillus tuberculosis was brought up, that air could be drawn over putrefying liquids containing bacteria, and then through sterilized culture fluids without inoculating those fluids, showing that germs are not taken up from liquids by gentle air currents. Such experiments were made in Glasgow with fluids in water-closet traps, and also under the direction of the National Board of Health and of Prof. Pumpelly, proving that the evaporation of a fluid does not remove the micro-organisms from it, unless spray or breaking bubbles are formed. Dr. Hunt thinks that this is not certain. Why not? Has he ever tried it? Can he bring up a single example of anybody who ever tried it and got a different result? I speak with some confidence because I have made these experiments myself, quite a number of them, by passing air over putrefying liquids in order to see whether the germ will be removed.
There seems to have prevailed, in times gone by, some very curious ideas about the possibilities of evaporation. For instance, it is stated in Parke's Hygiene that by evaporation small tadpoles have been lifted out of the ponds and carried up into the sky. How a man of so accurate knowledge as Dr. Parke could have accepted such a theory as that, I cannot understand. Of course the theory that the showers of tadpoles are due to whirlwinds carrying into the air the water from small ponds, etc., is quite a different matter from that of the lifting a tadpole or a grain of sand out of a pond of water by the force of evaporation.
Now, putting aside the question of the transmission of tuberculosis by milk or meat, which is now attracting very great attention, all the evidence points to the importance of the transmission of the disease from person to person by the dried sputa, containing the spores of the specific bacillus, in the form of fine dust, such dust being lifted and carried by currents of air and inhaled. The proposal to attempt to reduce the amount of tuberculosis in a country by carefully disinfecting the sputa of consumptive persons as it is formed is not only an eminently rational. and proper proceeding, but it is almost the only thing which can be done. If we reject this as being of little or no value, and attempt to control the spread of the disease by hereditary and climatic conditions, and so on, by the old methods that we have had so much advice about for many years, we can expect no better results than we have had heretofore. Here is a method which, in common with most bacteriologists and sanitarians, I believe can, in the course of a short time, greatly reduce the prevalence of pulmonary tuberculosis in a community. This thing had been practically tried long before anything was known about
the bacillus tuberculosis. For a long series of years in Naples pulmonary phthisis was declared to be a contagious disease, and was treated almost with the rigor with which they treated small-pox or pestilence, with little consideration for the lives or comfort of the unhappy persons afflicted with it. They were set apart, isolated from the rest of the community. If they were allowed to remain in the city, the houses were placarded; generally they were not allowed to remain, but were put in a special hospital. At the beginning of the period, deaths from consumption formed a very large part of the mortality: at the end, the system fell into disuse because the disease had nearly disappeared.
It is a simple matter to disinfect sputa if those affected are willing to take the trouble to do so,-now, when this is generally agreed upon by the clinical physicians, the bacteriologists, and scientific men of the present day who have actually investigated the matter for themselves. I am exceedingly unwilling to allow any paper to go out from this Association which seems to indicate that it is still doubtful whether, on the whole, the bacillus has anything to do with the production of pulmonary phthisis, and if so, whether it is communicated by the sputa or not.
The question of heredity in disease is one of the problems at present upon which the biologist and the pathologist are working, and undoubtedly it has its influence in reproducing a tendency to a condition of things in the organism in which the bacillus can especially flourish. We know that that condition which is favorable to the development of the bacillus can be produced long after birth by foul air. The statistics of the English barracks are sufficient to show that. There is the well known case where they undertook to erect a house for the monkeys in the Zoological Gardens in London, and they made it on the plan of the English drawing-room, very close and warm, and within twelve months the majority of the monkeys died of tuberculosis. So that we have other things to take into consideration beside the bacilli themselves. Nevertheless, the bacillus is the efficient cause; and in so far as we can prevent its spread, so far we prevent the spread of tuberculosis in the community.
To revert to my first proposition: I will admit that there is, perhaps, in estimating the probabilities, one chance in ten thousand that the bacillus tuberculosis is not the cause of tuberculosis. There is, perhaps, one chance in ten thousand that the bacillus might be conveyed in a person's breath, under certain circumstances-if they were spitting and got a few particles of the fluid in the inhalation-but there remain nine thousand nine hundred and ninety-nine chances to one that the bacillus is transferred in the sputa by the tuberculous patient, and there are nine thousand nine hundred and ninety-nine chances to one that the specific bacillus has been the immediate cause of any case of pulmonaris tuberculosis. In advising the people, we do not stop to discuss the formula of nine thousand nine hundred and ninety-nine to one. We would best not confuse them with such exceedingly fine and minute calculations. If we are to use our knowledge to prevent the spread of tubercu