FEMALES  . AGES .

Period . All Under 5 10— 15— 20— 25— 35— 45— 55— 65 Ages. ye a rs . 1851-186o 2774 1281 620 1293 3516 4288 4575 4178 3121 2383 1635 1861-187o 2483 947 477 1045 3112 3967 4378 3900 2850 2065 1239 1 871-188o 2028 750 375 846 2397 3140 3543 3401 2464 1777 1093 1881-1885 1738 553 350 749 2006 2596 3070 2927 2197 1541 995 1886-1890 1497 483 307 658 1626 2075 2552 2563 1936 1490 966 I 1891-1895 1303 421 260 561 1428 1740 2155 2305 1742 1294 800 ' 1896-1899 1141 334 201 410 1165 1547 1862 2096 1597 1242 787 1900-1904 1042 316 203 417 1002 1274 1593 1807 1481 1136 670 1903-1907 975 308 194 391 959 1194 1488 1643 1382 1075 666 1908 931 229 192 441 1270 1438 1761 1407 1156 945 654 In English counties containing populations of ioo,000 or over the highest rates were—in 1908—London, 1806; Lancashire, 1848; Northumberland, 1947; Carnarvonshire, 2025; and Carmarthen-shire, 2328 per million living . Of the fifteen counties in England and Wales with the highest tuberculosis mortalities, no fewer than seven are Welsh . Cardiganshire, with 2270 for both sexes, has a rate nearly double that of England . According to the United States census of 1900, the death-rate from tuberculosis in the area chosen for registration which embraced ten registration states, namely, Connecticut, Maine, District of Columbia, Massachusetts, Michigan, New Hampshire, New Jersey, New York, Rhode Island and Vermont, and 153 registration cities outside these states, was: Number of Deaths from Death-rate per 100,000 . Tuberculosis . 1890 48,236 245.4 1900 54,898 190.5 The returns of the mortality statistics of the United States for the year 1908 cover an area of 17 states, the district of Columbia and 74 registration cities, representing an aggregate population of' 45,028,767, or 51.8 % of the total estimated population of the United States . Mortality from Tuberculosis in the United States in given areas . Annual Tuberculosis Pulmonary Number Tuberculosis (all Average, (all forms), Phthisis, forms) per ioo,000 of the 1901-1905 .

62,835 . 55,251. population, 193.2 . 1904 66,797 58,763 201.6 1905 65,352 56,770 193.6 1906 75,512 65,341 184.2 1907 176,650 66,374 183.6 1908 78,289 67,376 173.9 In the United States tuberculosis of the lungs forms from 86 to 87 % of all cases . The death-rate, as we see, is steadily decreasing . It is, however, difficult to estimate the ravages of the disease in that

country owing to the fact that rather less than half the United States is still unprovided with an adequate system of registration . The following was the death-rate from tuberculosis (all forms) per ioo,000 of the population of the chief cities of the United States during 1908: New Orleans 298.3 Sacramento, California 294.3 Washington 264.0 Baltimore 249.9 Jersey City 241.1 New York .. " unoccupied," suffer excessively from tubercle . According to Dr Mott, pathologist to the London County Council, tuberculous lesions are found in more than one-third of the bodies of inmates examined post mortem . The majority contract the disease in the asylums . Medical opinion has undergone a great change with regard to the influence of heredity . The frequent occurrence of consumption among members of the same family used to be explained by assuming the existence of a tuberculous "diathesis" or inherent liability to consumption which " ran in families " and was handed down from one generation to another . As the real nature of the disease was not understood, the inherited diathesis was regarded as a sort of latent or potential consumption which might develop at any time and could hardly be avoided .

The

children of consumptive parents had the " seeds " of the disease in them, and were thought to be doomed with more or less certainty . Great importance was therefore attached to heredity as a factor in the incidence of tuberculosis . The discovery that it is caused by a specific parasitic infection placed Heredity. the question in a different light, and led to a more careful examination of the facts, which has resulted in a general and increasing tendency to minimize or deny the influence of heredity . At the Berlin Congress on Tuberculosis in 1899 Virchow pronounced his disbelief in the theory on pathological grounds . " I dispute this heredity absolutely," he said . " For a course of years I have been pointing out that if we ex-amine the bodies of infants newly born, who have had no life apart from the mother, we find no tuberculosis in them . I am convinced that what looked like tuberculosis in the newly born was none of it tuberculosis . In my opinion there is no authenticated case of tubercle having been found in a dissected newly-born infant." Observations on animals similarly tend to disprove the existence of congenital tuberculosis (Nocard) . The theory that the germs may remain latent in the offspring of tuberculous parents (Baumgarten) is unsupported by evidence . The occurrence of disease in such offspring is ascribed to infection by the parents, and this view is confirmed by the fact that the incidence in consumptive families is greater on female children, who are more constantly exposed to home infection, than on the male (Squire) . The statistical evidence, so far as it goes, points in the same direction . It is even denied that the children of consumptives are specially pre-disposed .

Recognition of the communicability of tuberculosis has directed

attention to the influence of conditions in which people live massed together in close proximity . The pre- Density of valence of the disease in large centres of popula- and Otlon tion has already been noted, and the influence of and Over- Over- crowding. aggregation is no doubt considerable; but it does not always hold good . The distribution in England and Wales does not correspond with density of population, and some purely rural districts have a very high mortality . Broadly, however, the rural counties have a low mortality, and those containing large urban populations a high one . In France in the department of the Oise, in purely industrial villages, the mortality from pulmonary phthisis is from 56 to 6r per Io,00o; in, a village in which part of the population worked in the fields and part in factories the mortality was 46 per 10,000; and in purely agricultural villages it ranged from o to lo per I0,00o . The following table is taken from the Supplement to the Registrar-General's 65th Report for England and Wales:diseases in relation to overcrowding, the same authority found that " while associated with overcrowding is a tendency of the population to die from disease generally, this tendency is especially manifested in the case of phthisis, and is not manifested in the case of every disease." Other Conditions.—Poverty, insufficient food and insanitary dwellings are always more or less associated with overcrowding, and it is difficult to distinguish the relative influence of these factors . An analysis of 553 deaths _n Edinburgh according to rentals in 1899 gave these results: under £1o, 230; from £IO to £20, 190; above £20, Io6 (Littlejohn); but the corresponding population is not stated . An investigation of selected houses in Manchester gave some interesting results (Coates) . The houses were divided into three classes: (I) infected and dirty; (2) infected but clean; (3) dirty but not infected; infected meaning occupied by a tuberculous person . Dust was taken from all parts of the rooms and submitted to bacteriological tests . The conclusions may be summarized thus: The effects of overcrowding were not apparent; a large cubic space was found to be of little avail if the ventilation was bad; the beneficial effects of light and fresh air were markedly shown even in the dirtiest houses; ordinary cleanliness was found not sufficient to prevent accumulation of infectious material in rooms occupied by a consumptive; no tuberculous dust was found in dirty houses in which there was no consumption . The upshot is to emphasize the importance of light and air, and to minimize that of mere dirt .

This is quite in keeping with earlier investigations, and particularly those of Dr Tatham on back-to-back houses . Darkness and stuffiness are the

friends of the tubercle bacillus . So much has the question of cleanliness, and of housing in a sanitary district, to do with the prevalence of the disease, that the following table taken from the Report of the Registrar-General for Ireland for the year 1909 shows the marked class incidence in all forms of tuberculosis . Distribution of Tuberculosis Mortality by Classes in Ireland, CDC) . All forms of Pulmonary Other forms of Tuberculosis . Phthisis . Tuberculosis . Professional and independent 1.41 0.64 0.77 class . Middle class, civil service and 1.82 I.30 0.52 smaller officials . . . . Large traders, business mana- I.59 1.04 0 55 gers " . Clerks 2.92 2'33 0'59 Householders in 2nd-class 2.52 1.85 0.67 localities Artisans 2.94 2.23 0.71 Petty shopkeepers and other 3'85 3'00 0.85 traders Domestic servants .

. . I.31 1.04 0.27

Coach and car drivers, and 4'24 3.06 1.18 vanmen . . . . Hawkers, porters and labourers 4'83 2'88 1'95 In relation to the last two classes the effect of exposure and also of alcoholic excess must be added to overcrowding and privation . The low rate noticeable for domestic servants must be ascribed to the better food and housing they enjoy while in situations . In Hamburg the mortality was ro•7 per io,000 in those whose income rose above 3500 marks, 39.3 where the income was 900 to 1200 marks, and 6o per Io,000 where the income fell below that figure . It is now generally accepted that tubercle bacilli may enter the body by various paths . At the International Congress on Tuberculosis held in Vienna in 1907 Weichselbaum summarized the channels of infection in pulmonary tuberculosis as follows: All occupied Males . Occupied Males (London) . Occupied Males Occupied Males (industrial districts) . (agricultural districts) . 1900—1902 .

1890—1892 . 1900—1902 . 1890—1892 . 1900—1902 . 1890—1892 . 1900—1902 . 1890—1892 . All Causes . . . 100 I19 I19 143 12I 156 72 86 Tuberculous Phthisis.

loo 122 156 183 I15 147 71 90 It will be noted that the rate in the agricultural districts is low compared to the industrial districts or purely urban district chosen . There is obviously a close relation between density of population and the prevalence of phthisis . Comparing phthisis with other (I) By inhalation directly into the bronchioles and pulmonary alveoli, or by way of the bronchial glands through the blood and lymph channels into the lung .

(2) Through the mucous membrane of the

nose, mouth or tonsils into the neighbouring lymphatic glands, and thence through the blood or lymph Path of into the lungs . (3) By ingestion of tubercle bacilli Infection, into the lower part of the gastro-intestinal tract in the food; thence the bacilli may pass through the lining membrane, infect the neighbouring glands and pass by the blood or lymph stream to the lungs . (4) By penetration of other mucus membranes (such as the conjunctival or urogenital) or through the skin . (5) Possible, though very rare, placental infection . Tubercle bacilli may not produce any anatomical lesion at the point of entrance, or they may remain latent for a very long time; and it has been experimentally proved that they may pass through mucous membranes and leave no trace of their progress . As reported to the Royal Commission, the introduction of bacilli into the alimentary canal is not necessarily followed by the development of tuberculosis . The writings of Von Behring have led to renewed attention being paid to intestinal infection, particularly through the milk supply . Von Behring suggests that the bacillus itself may become modified in the human body . Measures for the prevention of tuberculosis may be divided into two classes: (1) general; (2) special . Great attention Prevention. has been paid to the latter since the infectious nature of the disease was established . The former include all means by which the conditions of life are improved among the mass of the people . The most important of these are probably housing and food supply .

The reduction of the disease recorded in England is attributed to the great changes which have gradually taken

place in such conditions since, say, 1850 . Wages have been raised, food cheapened, housing im- proved, protection afforded in dangerous trades, air spaces provided, locomotion increased, the ground and the atmo- sphere have been cleaned and dried by sanitary means . In addition to these general measures is the provision of consump- tion hospitals, which act by segregating a certain amount of disease . Yet all these things, beneficial as they may be, do not wholly account for the reduction, for, if the records can be trusted, it was in progress before they had made any way or had even been begun . This observation, coupled with the appar- ently general tendency to diminution among civilized races, suggests the operation of some larger agency . The theory of acquired resistance, which has been already mentioned, would explain the diminution; and it is also in keeping with other facts, such as the great susceptibility of savage races, which have not been long exposed to tuberculosis, and the results of labora- tory experiments in artificial immunity . The point is of great importance, and deserves careful attention; for if the theory be correct, the special measures for preventing tuberculosis, which are occupying so much attention, may eventually have unexpected results . Their general aim is the avoidance of infection, and they include (1) the provision of special institu- tions—hospitals, sanatoria and dispensaries; (2) the prevention of spitting; (3) the notification of consumption; (4) the administrative control of tuberculosis in animals; (5) the dissemination of popular knowledge concerning the nature of the disease . The greatest stress is laid upon the prevention of spitting, because the germs are contained in the sputum of consumptive persons, and are scattered broadcast by expectoration . The sputum quickly dries, and the bacilli are blown about with the dust . There is no question that infection is so conveyed . The Manchester scientific experiments, mentioned above, are only one series out of many which prove the infectivity of dust in the proximity of consumptive persons, and they are confirmed by actual experience .

Several cases are recorded of healthy persons having contracted the disease after occupying rooms in which consumptive persons had previously lived . It is a legitimate inference that spitting in public is an important means of disseminating tuberculosis, though it may be noticed that international prevalence by no means corresponds with this disgusting practice, which is a perfect curse in Great

Britain, and far more common both there and in the United States than on the continent of Europe . Prohibition of spitting under a statutory penalty is attended with certain difficulties, as it is obviously impossible to make any distinction between tuberculous and other persons; but it has been applied in New York and elsewhere in America, and some local authorities in Great Britain have adopted by-laws to check the practice . Another means of controlling dangerous sputa is more practicable, and probably more effective, namely, the use of pocket spittoons by consumptive persons . Convenient patterns are available, and their use should always be insisted on, both in public and in private . The most effective way of destroying the sputa is by burning . For this purpose spittoons of papier macho and of turf have been successfully used in the Vienna hospitals (Schrbtter) . When glass spittoons are used the contents can be sterilized by disinfectants and passed down the drain . Notification is of great service as an aid to practical measures of prevention . It has been applied to that purpose with good results in several cities and states in America, and in some towns in Great Britain . New York has made the most systematic use of it . Voluntary notification was adopted there in 1894, and in 1897 it was made compulsory .

The measures linked with it are the sanitary supervision of infected houses, the

education of the people and the provision of hospitals . In England, Manchester has led the way . Voluntary notification was adopted there in 1899: it was at first limited to public institutions, but in 1900 private practitioners were invited to notify their cases, and they heartily responded . In Sheffield notification was made compulsory by a local act in 1904 for a limited period, and was found so valuable that the period was extended in 1910 . The objects aimed at are to visit homes and instruct the household, to arrange and provide disinfection, to obtain information bearing on the modes of infection, to secure bacteriological examination of sputum, and to collect information to serve as a basis of hospital provision . Disinfection is carried out by stripping off paper, previously soaked with a solution of chlorinated lime (1a oz. to the gallon), and washing the bare walls, ceiling, floor and everything washable with the same solution . This is found effective even in very dirty houses . In clean ones, where the patients have not been in the habit of spitting about the rooms, it is sufficient to rub the walls with bread-crumb and wash the rest with soap and water . Clothing, bedding, &c., are disinfected by steam . The advantages of these sanitary measures are obvious . Notification is no less important as a step towards the most advantageous use of hospitals and sanatoria by enabling a proper selection of patients to be made . It is compulsory throughout Norway, and is being adopted elsewhere, chiefly in the voluntary form .

In 1908 the Prevention of Tuberculosis (Ireland) Act was passed, which conferred on local authorities the right to make notification compulsory in their districts, and provided that certain sections of the Public

Health (Ireland) Act 1878 and the Infectious Diseases Prevention Act 1890 should apply to tuberculosis . By this act also the county councils were enabled to establish hospitals and dispensaries for the treatment of tuberculosis and were empowered to borrow money or levy a poor rate for the erection of sanatoria for the treatment of persons from their respective counties suffering from the disease . The prevalence of tuberculosis in cattle is of importance from the point of view of prevention of the probability that abdominal tuberculosis, which is a very fatal form of the disease in young children, and has not diminished in prevalence like other forms, is caused by the ingestion of tuberculous milk . Whether it be so or not, it is obviously desirable that both meat and milk should not be tuberculous, if it can be prevented without undue interference with commercial interests . Preventive measures may be divided into two classes . They may deal merely with the sale of meat and milk, or they may aim at the suppression of bovine tuberculosis altogether . The former is a comparatively easy matter, and may be summed up in the words " efficient inspection." The latter is probably impracticable . If practicable, it would be excessively costly, for in many herds one half the animals or even more are believed to be tuberculous, though not necessarily the sources of tuberculous food . Unless the danger is proved to be very much greater than there is any reason to suppose, " stamping out " may be put aside . Efficient inspection involves the administrative control of slaughter-houses, cowsheds and dairies . The powers and regulations under this head vary much in different countries; but it would be useless to discuss them at length until the scientific question is settled, for if the reality of the danger remains doubtful, oppressive restrictions, such as the compulsory slaughter of tuberculous cows, will not have the support of public opinion . Whatever measures may be taken for the public protection, individuals can readily protect themselves from the most serious danger by boiling milk; and unless the source is beyond suspicion, parents are recommended, in the present state of knowledge, so to treat the milk given to young children .

A great deal has been done in most countries for the dissemination of popular knowledge by forming

societies, holding conferences and meetings, issuing cheap literature, and so forth . It is an important item in the general campaign against tuberculosis, because popular intelligence and support are the most powerful levers for setting all other forces in niotion . In Ireland, where an attempt had been made to deal with the question by arousing the interest of all classes, tuberculosis exhibitions have been held in nearly every county, together with lectures and demonstrations organized by the Women's National Health Association; and an organized attempt was made in the autumn of 1910 in England, by a great educational campaign, to compel the public to realize the nature of the disease and the proper precautions against it . The improved outlook in regard to the arrest or so-called " cure " of tuberculosis is mainly derived from the improved Diagnosis methods of diagnosis, thus enabling treatment to and be undertaken at an earlier and therefore more Treatment, favourable stage of the disease . The physical signs in early stages of the lung affection are often vague and inconclusive . A means of diagnosis has therefore been sought in the use of tuberculin . The methods are three: (1) The subcutaneous injection method of Koch; (2) the cutaneous method of Von Pirquet; (3) the conjunctival method of Wolff-Eisner and Calmette . The first method depended on the re-action occurring after an injection of " old tuberculin." It is unsuitable in febrile conditions, and has now been relegated to the treatment of cattle, where it has proved invaluable . In Von Pirquet's method a drop of old tuberculin diluted with sodium chloride is placed on a spot which has been locally scarified . The presence of tuberculosis is demonstrated by a local reaction in which a hyperaemic papule forms, surrounded by a bright red zone . Reaction occurs in tuberculosis of the bones of joints and skin . Von Pirquet in loco cases obtained a reaction in 88% of the tuberculous, and io%, of those clinically non-tuberculous .

In the latter there may have been latent cases of tuberculosis . In the conjunctival or opthalmo-reaction of Calmette and Wolff-Eisner the instillation of a drop of a dilute solution of tuberculin into the conjunctiva is followed in the tuberculous subject by conjunctivitis . The reaction generally appears in from 3 to 12

hours, but may be delayed to 48 . In a series of cases observed by Audeoud a positive reaction was obtained in 95% of 261 obviously tuberculous cases and in 8.3 % of 303 cases which presented no clinical symptoms . Very advanced cases fail to react to any of these tests, as do general miliary tuberculosis and tuberculous meningitis . As well as the three methods mentioned above the occurrence of a " negative phase " in the phagocytic power of the leucocytes following an injection of Koch's tuberculin T.R. may be said to be diagnostic of tuberculosis . Another valuable aid in diagnosis is that of the X-rays . By their help a pulmonary lesion may be demonstrated long before the physical signs can be obtained by ordinary examination . To discuss at all fully the treatment of the various forms of tuberculosis or even of consumption alone would be quitebeyond the scope of this article . It must suffice to mention the more recent points . The open-air treatment of consumption has naturally „attracted much attention . Neither the curability of this disease nor the advantages of fresh air are new things .

Nature's method of spontaneous healing, explained above, has long been recognized and understood . There are, indeed, few diseases involving definite lesions which exhibit a more marked tendency to spontaneous arrest . Every case, except the most acute, bears signs of Nature's effort in this direction; and

complete success is not at all uncommon, even under the ordinary conditions of life . Perhaps it was not always so: the ominous character popularly attributed to consumption may once have been justified, and the power of resistance, as we see it now, may be the result of acquired immunity or of the gradual elimination of the susceptible . However this may be, the natural tendency to cure is undoubtedly much assisted by the modern system of treatment, which makes pure air its first consideration . The principle was known to Sydenham, who observed the benefit derived by consumptives from horse exercise in the open air; and about 183o George Boddington proposed the regular treatment of patients on the lines now generally recognized . The method has been most systematically developed in Germany by the provision of special sanatoria, where patients can virtually live in the open air . The example has been followed in other countries to a certain extent, and a good many of these establishments have been provided in Great Britain and elsewhere; but they are, for the most part, of a private character for the reception of paying patients . Germany has extended these advantages to the working classes on a large scale . This has been accomplished by the united efforts of friendly and philanthropic societies, local authorities, and the state; but the most striking feature is the part played by the state insurance institutes, which are the outcome of the acts of 1889 and 1899, providing for the compulsory insurance of workpeople against sickness and old age . The sanatoria have been erected as a matter of business, in order to keep insured members off the pension list, and they are supported by the sick clubs affiliated to the institutes . They number forty-five, and can give three months' treatment to 20,000 patients in the year .

The clinical and economic results are said to be very encouraging . In about 70% of the cases the disease has been so far arrested as to enable the patients to return to

work . In England, where more than 14 millions of the population belong to friendly societies, it is estimated that the sick pay of consumptive members costs three times as much as the average sick pay to members dying of other causes . An effort has been made by the National Association for the Establishment and Maintenance of Sanatoria for Workers Suffering from Tuberculosis to establish such sanatoria, together with training for suitable work during convalescence, the gradual resumption of wage-earning being resumed while in touch with the medical authorities . The important features of the sanatorium treatment are life in the open air, independently of weather, in a healthy situation, rest and abundance of food . The last has been carried to rather extravagant lengths in some institutions, where the patients are stuffed with food whether they want it or not . The sanatorium movement on the German model is rapidly extending in all countries . For those who are able to do so advantage may be taken of the combined sanatorium and sun treatment . In certain high altitudes in Switzerland, which are favoured by a large amount of sunshine and a small percentage of moisture, much benefit has been derived from the exposure of the unclothed body to the sun's rays . The power of the sun in high altitudes is so great that the treatment can be continued even when the snow is on the ground . Not only is the sun-treatment applicable to pulmonary tuberculosis, but also to the tuberculosis of joints, even in advanced cases . The treatment has to a great extent replaced surgical procedure in tuberculosis of joints, but it requires to be persevered in over a considerable period of time .

It should be remembered that the benefits of fresh air are not confined to sanatoria . If the superstitious dread of the

outer air, particularly at night, could be abolished in ordinary life, more would be done for public health than by the most costly devices for eluding microbes . Not only consumption, but the other respiratory diseases, which are equally destructive, are chiefly fomented by the universal practice of breathing vitiated air in stuffy and overheated rooms . The cases most suitable for the treatment are those in an early stage . Other special institutions for dealing with consumption are hospitals, in which England is far in advance of other countries, and dispensaries; the latter find much favour in France and Belgium . In Great Britain the pioneer work as regards the establishment of tuberculosis dispensaries was the establishment of the Victoria Dispensary for Consumption in Edinburgh in 1887, where the procedure is similar to that in Dr Calmette's dispensaries in France . In connexion with the dispensary home visits are made, patients suitable to sanatoria selected, advanced cases drafted to hospitals, bacteriological examinations made, cases notified under the voluntary system, and the families of patients instructed . There is an urgent need for the multiplication of such dispensaries throughout the United Kingdom . The recent act providing for the medical inspection of schools has done much to sort out cases of tuberculosis occurring in children, and to provide them with suitable treatment and prevent them from becoming foci for the dissemination of the disease . In Germany special open-air schools, termed forest-schools, are provided for children suffering from the disease, and an effort is being made in England to provide similar schools . Of specific remedies it must suffice to say that a great many substances have been tried, chiefly by injection and inhalation, and good results have been claimed for some of them . The most noteworthy is the treatment by tuberculin, first introduced by Koch in 189o, which, having sunk into use as a diagnostic reagent for cattle, received a new lease of life owing to the valuable work done by Sir Almroth Wright on opsonins .

The tuberculins most in use are Koch's " old " tuberculin T.O., consisting of a

glycerin broth culture of the tubercle bacilli, and Koch's T.R. tuberculin, consisting of a saline solution of the triturated dead tubercle bacilli which has been centrifuged . This latter is much in use, the dosage being carefully checked by the estimation of the tuberculo-opsonic index . The injections are usually unsuitable to very advanced cases .. Marmorek's serum, the serum of horses into which the filtered young cultures of tubercle bacilli have been injected, and in which a tuberculo-toxin has been set free, has proved very successful . Behring's Tulase is a tuberculin 'preparation formed by a process of treating tubercle bacilli with chloral, and Bereneck's tuberculin consists of a filtered bouillon culture treated with orthophosphoric acid . The variety of cases to which these treatments are suitable can only be estimated from a careful consideration of each on its own merits . In the treatment of tuberculous lesions, the surgeon also plays his part . Tuberculosis is specially prone to attack the spongy bone-tissue, joints, skin (lupus) and lymphatic glands—especially those of the neck . Recognizing the infective nature of the disease, and knowing that from one focus the germs may be taken by the blood-stream to other parts of the body, and so cause a general tuberculosis, the surgeon is anxious, by removing the primary lesion, to cut short the disease and promote immediate and permanent convalescence . Thus, in the early stage of tuberculous disease of the glands of the neck, for instance, these measures may render excellent service, but when the disease has got a firm hold, nothing short of removal of the glands by surgical operation is likely to be of any avail . The results of this modem treatment of tuberculous disease of the skin and of the lymphatic glands has been highly gratifying, for not only has the infected tissue been completely removed, but the resulting scars have been far less noticeable than they would have been had less radical measures been employed . One rarely sees now a network of scars down the neck of a child, showing how a chain of tuberculous glands had been allowed towork out their own,cure .

A few years ago, however, such conditions were by no means unusual .