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WHAT IS TABES MESENTERICA IN INFANTS ?
1662 WHAT IS TABES MESENTERICA IN INFANTS ? To the Editors of THE LANCET. SIRS,-The subject of tuberculosis, especially its preven-
i
tion. is just now being brought prominently before the profession and the public; it is therefore of the utmost importance that the figures on which are based the arguments for preventive measures should be as accurate as possible. As you observe in your leading article of Dec. 3rd Sir Richard Thorne in the recent Harben Lectures has brought forward some remarkable statistics to prove that whilst pulmonary phthisis is steadily decreasing, tabes mesenterica in children under one year-not, be it noted, in older children-is decidedly increasing, and from these figures he draws some important deductions. It seems, however, desirable first to inquire what the term "tabes mesentericareally means when applied to children under one year. Broadly, and yet strictly, it may be taken, I imagine, to signify one or more of the following conditions : tuberculous peritonitis, tuberculous enteritis, and caseation of the mesenteric glands. How frequently do these conditions occur in children under one year and to what extent are they diagnosable ? 1. Tuberculous peritonitis, I take it all authorities are agreed, is rare in children under two years-almost unknown in those under one year. I have only met with one example-viz., in a child aged one year and nine months-in a series of 300 consecutive post-mortem examinations upon children under two years which I have myself performed at the Victoria Hospital, Chelsea, and in the post-mortem records of the hospital for the last ten years I can only find one other case and that was in a patient of exactly the same age. 2. Tuberculous ulceration of the bowel and caseation of the mesenteric glands may best be considered together, for when either one is at all advanced the other is rarely absent. That they occur with considerable frequency in young children is undoubted. In the series of 300 necropsies just referred to tuberculous mischief was present in the intestines or mesenteric glands, usually in both, in 36 cases (18 under one year and 18 between one and two years). At first this
comparatively large number seems to coincide with the recorded frequency of tabes mesenterica in the national death statistics, but on further examining the - clinical and pathological records of these cases it was found that in nearly all the abdominal lesion was merely a part, usually quite a subsidiary part, of a more general tuberculosis. 12 were ordinary examples of tuberculous meningitis and certainly could never be regarded as cases of tabes mesenterica; in most of the others pulmonary mischief was predominant during life and was found post mortem to be far more extensive and advanced than the abdominal lesions ; in fact, in only 3 of the cases (1 being the case of tuberculous peritonitis already mentioned and the other 2 being by no means typical) was there any probability of tabes mesenterica being diagnosed with reasonable confidence during life. Moreover, on what is a diagnosis of caseation of the mesenteric glands to be based ? If they can be felt well and good, but probably everyone will admit that they are rarely palpable, whilst if the diagnosis be made from such symptoms as wasting, fever, &c., the possibilities of error are But it may be said that at any rate tuberculous enormous. enteritis gives rise to more definite and characteristic symptoms. What symptoms ?-pain, diarrhoea, wasting, a big abdomen, fever. Are there not plenty of other causes for these in infants? What justification have we, without confirmatory evidence elsewhere, for assuming them to have a tuberculous origin, especially if the records of pathological experience give no support to such a view ? In children over two years of age the matter is of course different. I fully agree therefore with the statement in Ashby and Wright’s "Diseases of Children" that "mesenteric disease is much more frequently diagnosed than discovered post mortem"; but, if so, what is the real nature of the thousands of fatal cases of so-called tabes mesenterica in young children ? Simply, I believe, marasmus the result of chronic gastro-intestinal catarrh. An infant is brought up by hand ; its food disagrees, it gets gastro-intestinal catarrh which leads to distension of the abdomen, griping pains, chronic and very intractable diarrhoea, and occasional vomiting. Of course the child wastes steadily; it has perhaps irregular pyrexia (though I suspect that the temperature is not as a rule very systematically taken
in these cases). The mother suggests that the child has "consumptive bowels," the medical practitioner agrees ; it is the simplest way out of the difficulty and saves the necessity of taking much further trouble in treatment, and after death he writes " tabes mesenterica" on the certificate it is an attractively impressive term and no doubt conveys much consolation to the afflicted parents. These cases are to be seen, of course, by the hundred at any children’s hospital, but they are not tuberculous-the necropsy proves that. I have notes of nearly 100 post-mortem examinations on such cases, all children under two years of age In only one was any abdominal tuberculous lesion present and that was merely early caseation in the mesenteric glands and one" nodule in the intestine, yet in very many tabes mesenterica" might have been diagnosed with much confidence but for the wholesome corrective of pathological experience. We need to know definitely how we stand in this matter and I hope to elicit expressions of opinion from other hospitals for children. If tabes mesenterica be common in infants by all means let us deal with it, but if, as I firmly believe, it is comparatively rare, let us try to diffuse a knowledge of the fact throughout the profession and so put an end to much erroneous certification. Do not let me be misunderstood. I fully believe that milk may and frequently does convey tuberculosis and that if the supply were pure the mortality from genuine tuberculous diseases would be materially diminished, though I maintain that so-called tabes mesenterica in infants would be almost unaffected, except in so far as any improvement in the milk-supply would diminish the dangers of gastrointestinal catarrh. But if we persuaded the public to adopt the precautions with regard to cows and to milk which we recommend and afterwards found that the chief disease we had attributed to infective milk was as rampant as ever, assuredly a very harmful reaction would follow ; the public would look to us for an explanation, and what satisfactory one could we give compatible with our professional selfrespect ?? Another point arises in Sir R. Thorne’s lectures. He states that tuberculous meningitis has increased and that this disease, like tabes mesenterica, is essentially due to the reception of the tuberculous infection into the alimentary tract. This statement raises two questions. First, has tuberculous meningitis really increased, or is the increase more apparent than real and due to increased correctness in diagnosis ? for many cases now properly described as tuberculous meningitis would no doubt in former years have been included under "hydrocephalus,""convulsions," &c. Secondly, is it, as a matter of fact, usually due to infection through the alimentary canal ? It is, of course, as a rule merely part of a general miliary tuberculosis, and to produce this an infective centre must exist somewhere, if in the abdomen in caseous mesenteric glands or possibly in old tuberculous ulcers of the bowel. This raises questions too wide to be brought within the limits of a letter, and it is the less necessary inasmuch as I have discussed them in a paper read before the Medical Society of London and published in THE LANCET of May 12th, 1894. In that paper I tried to prove on post-mortem evidence that tuberculous disease in children started much more frequently in the thoracic than in the mesenteric glands, and that presumably therefore (though this does not necessarily follow) the infection is derived more frequently from the respiratory than from the alimentary tract. Statistics published by Dr. Colman from the records of the Hospital for Sick Children, Great Ormond-street,l coincide closely with mine. I know that Dr. Sims Woodhead, from post-mortem results in Edinburgh, attaches much greater relative importance to the mesenteric glands and it seems very desirable that the whole subject should be further .investigated. So far, however, as Sir R. Thorne’s statement about tuberculous meningitis is concerned, I have gone through my notes of 44 necropsies on cases of that disease in children specially examined with a view to determining the primary focus of infection, and in 31 the infective centre was almost certainly in the chest, usually in the bronchial or tracheal glands ; in only 2 was it certainly in the abdomen ; in 6 it might have been either in the chest or in the abdomen; and in 5 it was in other parts of the body or was not found. In 14 of the cases there was not even any sign of tuberculous mischief in either the mesenteric glands or intestine, whilst in nearly every case there were caseous and softening glands in 1
Brit. Med Jour., vol. ii. 1893.
1663 the thorax. Certainly, so far as they go, these figures do not authorities seem to’be agreed upon the importance of safesupport the idea that tuberculous meningitis is mainly due to guarding our food supplies, but although most elaborate the reception of tuberculous infection into the alimentary precautions are taken for this purpose one of the prime tract-unless, indeed, as is possible, the bacilli obtained sources of danger, at any rate as regards tubercle, is .access through the alimentary canal but without necessarily ignored. Take, for instance, the inspection of bakehouses which is giving rise to any local lesion either there or in the mesenteric carried out in a fairly thorough fashion. The drains, the glands. .glands. I am, Sirs, yours faithfully, structure, &c., and all the appliances must be kept in a sanitary condition-i.e., in such a condition that germs will not J. WALTER CARR. .Cavendish-place, W., Dec. 6th, 1898. be likely to flourish about them-but no notice is taken of the attendants, one or more of whom may be and often is suffering from phthisis, his body full of dangerous germs which are THE ANTI-TUBERCLE CRUSADE. constantly fouling the atmosphere; the expectoration finds a rapid drying-ground and a temperature favourable to the life To the Editors of THE LANCET. of bacilli, while the crevices in the already baked bread and SIRS,—In a book written by Gideon Harvey, M.D., about other foodstuffs form a ready nidus for their reception and 1660, consumption is described as an endemic and epidemic propagation. In these days, when hardly any bread is made - disease and the following passage gives some idea of the then in the homes, it is a question whether there is not even more Prevalent belief in its infective nature: "And considering danger from bread than from milk, for it is well known that with all its malignity and contagious nature, it may be phthisis is a prevalent disease amongst bakers. True, I have numbered among the worst Epidemicks or popular diseases, not got the scientific proof of my assertion and I might ,since next to the Plague, Pox, and Leprosie, it yields to none examine many loaves before I found tubercle bacilli. Many in point of contagion ; for it’s no rare observation here in samples of milk might be examined with a negative result, England, to see a fresh coloured lusty young man yoake to a but given the presence of tubercle bacilli in a bakehouseconsumptive female, and him soon after attending her to the and I suppose few would deny their existence there if the .grave. Moreover nothing we find taints sound lungs sooner, baker was suffering from phthisis-I do not think it is - than inspiring or drawing in the breath of putrid ulcered necessary to resort to scientific experiment to prove consumptive lungs ; many having fallen into consumptions, the danger. When phthisical subjects are being solemnly only by smelling the breath or spittle of Consumptives, others enjoined to carry receptacles for their sputum in order by drinking after them ; and what is more, by wearing the to avoid the danger of infecting the atmosphere of our Cloaths of Consumptives, though two years after they were towns surely there is no difficulty in realising the far left ofE." greater risks in a bakehouse. Again, if it is necessary With the exception of the last sentence this opinion to rigidly supervise the sanitary conditions in order to ensure =so nearly accords with the views of to-day that it is an atmosphere where food may be produced without fear of - difficult to understand why it remained in abeyance for so its being infected, surely it is approaching well nigh the many years. Of course it was not founded upon a scientific ridiculous to permit an infected individual to be there basis and, I suppose, as we became more exact we were present, to prepare the food, to handle it when prepared, to unable to accept the clinical facts unless supported by foul it with his exhalations and to deposit the products of ,experimental proof. Thanks to the discovery of Koch we his disease in and about the building. In the flour mill too are now emerging from the path of error into which we had phthisical workmen will often be found, and though the temporarily strayed and in doing so I think we must admit process of baking will perhaps sterilise the flour it is used ’that we should have been wiser, or at any rate conferred for many other culinary purposes which may not. ,more benefit on mankind, if we had accepted the teachings Although I give the first place to bread my remarks apply of our predecessors who, if they had not the advantage of to all consumable stores. If it is necessary to inspect the ’so much scientific knowledge to assist them, evidently slaughter-house and to examine the meat, why except the .possessed considerable clinical acumen and were able to butcher ?? Cooking should kill tubercle bacilli, but so should make accurate deductions therefrom. There are, of course, it destroy the eggs of the tapeworm, and yet in spite of ,errors in Gideon Harvey’s book, but who can say that some this we annually extract many yards of this disagreeable - of the statements are not in advance of even our boasted ’knowledge of to-day ?? As an instance we may take the reference to cancer as infective. Although we are still dis-inclined to accept it the disease affords us indications which support the view that it is to some extent communicable. The great factor which upsets all our calculations is the individual peculiarity which favours the development of a -disease, and it is because we are unable to solve this problem ’that we must use every means in our power to prevent the products of infection being brought into contact with any member of the community. A society has been established for this purpose the members of which intend to propagate information which ’will enable the laity in some measure to assist in the -endeavour to control the disease. An eminent member of the profession has delivered a discourse on this subject wherein he chiefly lays stress on the danger - of drinking milk and indicates the necessary means of avoiding this danger. He also recommends asses’ milk as superior because less likely to be infected with tubercle. In this connexion it is interesting to note that Gideon Harvey had noticed this although he did not know the reason. Writing on the subject he says, " Asses’ milk is Qlniversally,preferred," and he goes on to give directions as to the diet of the ass-a matter which may or may not be of importance. In speaking of the treatment he is also very ’strong on the question of fresh air and change of air .and also advocates change of food. " Neither it’s only the change of air that proves so soveraing to Consumptives, but the change of Bread, Beer, Flesh, Company, and other circumstances do very much conduce thereunto." It is necessary to consider this question not "only in the treatment, but also as a preventive, and although we are often met with the remark, " Oh ! if I listen to you it is not safe to eat anything," it is nevertheless our duty to warn the public and teach them how to avoid disease. All
denizen from the intestines which no doubt have been introduced in the same way as much of the tuberculous mischief finds entrance to our bodies. If ham, cheese, and butter require examination, why allow them to be retailed by a phthisical shopman ?? In like manner 1 might pass in review all articles of diet. I might even enter the sacred precincts of the domestic household and question the bodily condition of the cook and those who carry the food to the ultimate consumers. The position of safeguarding the foodsupply and ignoring the condition of those who handle it seems to me a very untenable one and demands the immediate attention of those who are constituted the guardians of the public health. Will it take us as long to insist on the remedy as it has taken us to accept the fact of the infectious nature of tuberculous disease ?? Without expressing any disbelief in the views of Sir Richard Thorne and yourselves as expressed in your leading article of Dec. 3rd I venture to assert that the question I now raise is a point in favour of including phthisis among the dangerous infectious diseases which are compulsorily notifiable to sanitary authorities. I do not say that it proves the necessity of such an inclusion, but it does make for the necessity of investing all sanitary authorities with the power of inspecting not only the premises and the food, but also the bodies of those persons who are occupied with the food. This inspection should be no superficial formality but a rigid and thorough examination carried out at regular intervals. In the meantime at the expense of being called an alarmist I would commend to the serious consideration of all thoughtful men the question of their food-supply. Do not be satisfied with boiling your milk ; try to secure servants free from tuberculous disease and be particularly careful about your bread. I am, Sirs, yours faithfully, J. J. LIONEL LIONEL STRETTON. Kidclerminster, Dec. 5th, 1898.
i
tion. is just now being brought prominently before the profession and the public; it is therefore of the utmost importance that the figures on which are based the arguments for preventive measures should be as accurate as possible. As you observe in your leading article of Dec. 3rd Sir Richard Thorne in the recent Harben Lectures has brought forward some remarkable statistics to prove that whilst pulmonary phthisis is steadily decreasing, tabes mesenterica in children under one year-not, be it noted, in older children-is decidedly increasing, and from these figures he draws some important deductions. It seems, however, desirable first to inquire what the term "tabes mesentericareally means when applied to children under one year. Broadly, and yet strictly, it may be taken, I imagine, to signify one or more of the following conditions : tuberculous peritonitis, tuberculous enteritis, and caseation of the mesenteric glands. How frequently do these conditions occur in children under one year and to what extent are they diagnosable ? 1. Tuberculous peritonitis, I take it all authorities are agreed, is rare in children under two years-almost unknown in those under one year. I have only met with one example-viz., in a child aged one year and nine months-in a series of 300 consecutive post-mortem examinations upon children under two years which I have myself performed at the Victoria Hospital, Chelsea, and in the post-mortem records of the hospital for the last ten years I can only find one other case and that was in a patient of exactly the same age. 2. Tuberculous ulceration of the bowel and caseation of the mesenteric glands may best be considered together, for when either one is at all advanced the other is rarely absent. That they occur with considerable frequency in young children is undoubted. In the series of 300 necropsies just referred to tuberculous mischief was present in the intestines or mesenteric glands, usually in both, in 36 cases (18 under one year and 18 between one and two years). At first this
comparatively large number seems to coincide with the recorded frequency of tabes mesenterica in the national death statistics, but on further examining the - clinical and pathological records of these cases it was found that in nearly all the abdominal lesion was merely a part, usually quite a subsidiary part, of a more general tuberculosis. 12 were ordinary examples of tuberculous meningitis and certainly could never be regarded as cases of tabes mesenterica; in most of the others pulmonary mischief was predominant during life and was found post mortem to be far more extensive and advanced than the abdominal lesions ; in fact, in only 3 of the cases (1 being the case of tuberculous peritonitis already mentioned and the other 2 being by no means typical) was there any probability of tabes mesenterica being diagnosed with reasonable confidence during life. Moreover, on what is a diagnosis of caseation of the mesenteric glands to be based ? If they can be felt well and good, but probably everyone will admit that they are rarely palpable, whilst if the diagnosis be made from such symptoms as wasting, fever, &c., the possibilities of error are But it may be said that at any rate tuberculous enormous. enteritis gives rise to more definite and characteristic symptoms. What symptoms ?-pain, diarrhoea, wasting, a big abdomen, fever. Are there not plenty of other causes for these in infants? What justification have we, without confirmatory evidence elsewhere, for assuming them to have a tuberculous origin, especially if the records of pathological experience give no support to such a view ? In children over two years of age the matter is of course different. I fully agree therefore with the statement in Ashby and Wright’s "Diseases of Children" that "mesenteric disease is much more frequently diagnosed than discovered post mortem"; but, if so, what is the real nature of the thousands of fatal cases of so-called tabes mesenterica in young children ? Simply, I believe, marasmus the result of chronic gastro-intestinal catarrh. An infant is brought up by hand ; its food disagrees, it gets gastro-intestinal catarrh which leads to distension of the abdomen, griping pains, chronic and very intractable diarrhoea, and occasional vomiting. Of course the child wastes steadily; it has perhaps irregular pyrexia (though I suspect that the temperature is not as a rule very systematically taken
in these cases). The mother suggests that the child has "consumptive bowels," the medical practitioner agrees ; it is the simplest way out of the difficulty and saves the necessity of taking much further trouble in treatment, and after death he writes " tabes mesenterica" on the certificate it is an attractively impressive term and no doubt conveys much consolation to the afflicted parents. These cases are to be seen, of course, by the hundred at any children’s hospital, but they are not tuberculous-the necropsy proves that. I have notes of nearly 100 post-mortem examinations on such cases, all children under two years of age In only one was any abdominal tuberculous lesion present and that was merely early caseation in the mesenteric glands and one" nodule in the intestine, yet in very many tabes mesenterica" might have been diagnosed with much confidence but for the wholesome corrective of pathological experience. We need to know definitely how we stand in this matter and I hope to elicit expressions of opinion from other hospitals for children. If tabes mesenterica be common in infants by all means let us deal with it, but if, as I firmly believe, it is comparatively rare, let us try to diffuse a knowledge of the fact throughout the profession and so put an end to much erroneous certification. Do not let me be misunderstood. I fully believe that milk may and frequently does convey tuberculosis and that if the supply were pure the mortality from genuine tuberculous diseases would be materially diminished, though I maintain that so-called tabes mesenterica in infants would be almost unaffected, except in so far as any improvement in the milk-supply would diminish the dangers of gastrointestinal catarrh. But if we persuaded the public to adopt the precautions with regard to cows and to milk which we recommend and afterwards found that the chief disease we had attributed to infective milk was as rampant as ever, assuredly a very harmful reaction would follow ; the public would look to us for an explanation, and what satisfactory one could we give compatible with our professional selfrespect ?? Another point arises in Sir R. Thorne’s lectures. He states that tuberculous meningitis has increased and that this disease, like tabes mesenterica, is essentially due to the reception of the tuberculous infection into the alimentary tract. This statement raises two questions. First, has tuberculous meningitis really increased, or is the increase more apparent than real and due to increased correctness in diagnosis ? for many cases now properly described as tuberculous meningitis would no doubt in former years have been included under "hydrocephalus,""convulsions," &c. Secondly, is it, as a matter of fact, usually due to infection through the alimentary canal ? It is, of course, as a rule merely part of a general miliary tuberculosis, and to produce this an infective centre must exist somewhere, if in the abdomen in caseous mesenteric glands or possibly in old tuberculous ulcers of the bowel. This raises questions too wide to be brought within the limits of a letter, and it is the less necessary inasmuch as I have discussed them in a paper read before the Medical Society of London and published in THE LANCET of May 12th, 1894. In that paper I tried to prove on post-mortem evidence that tuberculous disease in children started much more frequently in the thoracic than in the mesenteric glands, and that presumably therefore (though this does not necessarily follow) the infection is derived more frequently from the respiratory than from the alimentary tract. Statistics published by Dr. Colman from the records of the Hospital for Sick Children, Great Ormond-street,l coincide closely with mine. I know that Dr. Sims Woodhead, from post-mortem results in Edinburgh, attaches much greater relative importance to the mesenteric glands and it seems very desirable that the whole subject should be further .investigated. So far, however, as Sir R. Thorne’s statement about tuberculous meningitis is concerned, I have gone through my notes of 44 necropsies on cases of that disease in children specially examined with a view to determining the primary focus of infection, and in 31 the infective centre was almost certainly in the chest, usually in the bronchial or tracheal glands ; in only 2 was it certainly in the abdomen ; in 6 it might have been either in the chest or in the abdomen; and in 5 it was in other parts of the body or was not found. In 14 of the cases there was not even any sign of tuberculous mischief in either the mesenteric glands or intestine, whilst in nearly every case there were caseous and softening glands in 1
Brit. Med Jour., vol. ii. 1893.
1663 the thorax. Certainly, so far as they go, these figures do not authorities seem to’be agreed upon the importance of safesupport the idea that tuberculous meningitis is mainly due to guarding our food supplies, but although most elaborate the reception of tuberculous infection into the alimentary precautions are taken for this purpose one of the prime tract-unless, indeed, as is possible, the bacilli obtained sources of danger, at any rate as regards tubercle, is .access through the alimentary canal but without necessarily ignored. Take, for instance, the inspection of bakehouses which is giving rise to any local lesion either there or in the mesenteric carried out in a fairly thorough fashion. The drains, the glands. .glands. I am, Sirs, yours faithfully, structure, &c., and all the appliances must be kept in a sanitary condition-i.e., in such a condition that germs will not J. WALTER CARR. .Cavendish-place, W., Dec. 6th, 1898. be likely to flourish about them-but no notice is taken of the attendants, one or more of whom may be and often is suffering from phthisis, his body full of dangerous germs which are THE ANTI-TUBERCLE CRUSADE. constantly fouling the atmosphere; the expectoration finds a rapid drying-ground and a temperature favourable to the life To the Editors of THE LANCET. of bacilli, while the crevices in the already baked bread and SIRS,—In a book written by Gideon Harvey, M.D., about other foodstuffs form a ready nidus for their reception and 1660, consumption is described as an endemic and epidemic propagation. In these days, when hardly any bread is made - disease and the following passage gives some idea of the then in the homes, it is a question whether there is not even more Prevalent belief in its infective nature: "And considering danger from bread than from milk, for it is well known that with all its malignity and contagious nature, it may be phthisis is a prevalent disease amongst bakers. True, I have numbered among the worst Epidemicks or popular diseases, not got the scientific proof of my assertion and I might ,since next to the Plague, Pox, and Leprosie, it yields to none examine many loaves before I found tubercle bacilli. Many in point of contagion ; for it’s no rare observation here in samples of milk might be examined with a negative result, England, to see a fresh coloured lusty young man yoake to a but given the presence of tubercle bacilli in a bakehouseconsumptive female, and him soon after attending her to the and I suppose few would deny their existence there if the .grave. Moreover nothing we find taints sound lungs sooner, baker was suffering from phthisis-I do not think it is - than inspiring or drawing in the breath of putrid ulcered necessary to resort to scientific experiment to prove consumptive lungs ; many having fallen into consumptions, the danger. When phthisical subjects are being solemnly only by smelling the breath or spittle of Consumptives, others enjoined to carry receptacles for their sputum in order by drinking after them ; and what is more, by wearing the to avoid the danger of infecting the atmosphere of our Cloaths of Consumptives, though two years after they were towns surely there is no difficulty in realising the far left ofE." greater risks in a bakehouse. Again, if it is necessary With the exception of the last sentence this opinion to rigidly supervise the sanitary conditions in order to ensure =so nearly accords with the views of to-day that it is an atmosphere where food may be produced without fear of - difficult to understand why it remained in abeyance for so its being infected, surely it is approaching well nigh the many years. Of course it was not founded upon a scientific ridiculous to permit an infected individual to be there basis and, I suppose, as we became more exact we were present, to prepare the food, to handle it when prepared, to unable to accept the clinical facts unless supported by foul it with his exhalations and to deposit the products of ,experimental proof. Thanks to the discovery of Koch we his disease in and about the building. In the flour mill too are now emerging from the path of error into which we had phthisical workmen will often be found, and though the temporarily strayed and in doing so I think we must admit process of baking will perhaps sterilise the flour it is used ’that we should have been wiser, or at any rate conferred for many other culinary purposes which may not. ,more benefit on mankind, if we had accepted the teachings Although I give the first place to bread my remarks apply of our predecessors who, if they had not the advantage of to all consumable stores. If it is necessary to inspect the ’so much scientific knowledge to assist them, evidently slaughter-house and to examine the meat, why except the .possessed considerable clinical acumen and were able to butcher ?? Cooking should kill tubercle bacilli, but so should make accurate deductions therefrom. There are, of course, it destroy the eggs of the tapeworm, and yet in spite of ,errors in Gideon Harvey’s book, but who can say that some this we annually extract many yards of this disagreeable - of the statements are not in advance of even our boasted ’knowledge of to-day ?? As an instance we may take the reference to cancer as infective. Although we are still dis-inclined to accept it the disease affords us indications which support the view that it is to some extent communicable. The great factor which upsets all our calculations is the individual peculiarity which favours the development of a -disease, and it is because we are unable to solve this problem ’that we must use every means in our power to prevent the products of infection being brought into contact with any member of the community. A society has been established for this purpose the members of which intend to propagate information which ’will enable the laity in some measure to assist in the -endeavour to control the disease. An eminent member of the profession has delivered a discourse on this subject wherein he chiefly lays stress on the danger - of drinking milk and indicates the necessary means of avoiding this danger. He also recommends asses’ milk as superior because less likely to be infected with tubercle. In this connexion it is interesting to note that Gideon Harvey had noticed this although he did not know the reason. Writing on the subject he says, " Asses’ milk is Qlniversally,preferred," and he goes on to give directions as to the diet of the ass-a matter which may or may not be of importance. In speaking of the treatment he is also very ’strong on the question of fresh air and change of air .and also advocates change of food. " Neither it’s only the change of air that proves so soveraing to Consumptives, but the change of Bread, Beer, Flesh, Company, and other circumstances do very much conduce thereunto." It is necessary to consider this question not "only in the treatment, but also as a preventive, and although we are often met with the remark, " Oh ! if I listen to you it is not safe to eat anything," it is nevertheless our duty to warn the public and teach them how to avoid disease. All
denizen from the intestines which no doubt have been introduced in the same way as much of the tuberculous mischief finds entrance to our bodies. If ham, cheese, and butter require examination, why allow them to be retailed by a phthisical shopman ?? In like manner 1 might pass in review all articles of diet. I might even enter the sacred precincts of the domestic household and question the bodily condition of the cook and those who carry the food to the ultimate consumers. The position of safeguarding the foodsupply and ignoring the condition of those who handle it seems to me a very untenable one and demands the immediate attention of those who are constituted the guardians of the public health. Will it take us as long to insist on the remedy as it has taken us to accept the fact of the infectious nature of tuberculous disease ?? Without expressing any disbelief in the views of Sir Richard Thorne and yourselves as expressed in your leading article of Dec. 3rd I venture to assert that the question I now raise is a point in favour of including phthisis among the dangerous infectious diseases which are compulsorily notifiable to sanitary authorities. I do not say that it proves the necessity of such an inclusion, but it does make for the necessity of investing all sanitary authorities with the power of inspecting not only the premises and the food, but also the bodies of those persons who are occupied with the food. This inspection should be no superficial formality but a rigid and thorough examination carried out at regular intervals. In the meantime at the expense of being called an alarmist I would commend to the serious consideration of all thoughtful men the question of their food-supply. Do not be satisfied with boiling your milk ; try to secure servants free from tuberculous disease and be particularly careful about your bread. I am, Sirs, yours faithfully, J. J. LIONEL LIONEL STRETTON. Kidclerminster, Dec. 5th, 1898.