method that he would insist upon. For infection thus to occur, they would seem to require prolonged contact with the patient, a face-to-face contact in direct line with the cougher and at a distance that is not greater than a yard. If, as Flügge contends, this is by far the most fertile method of infection, then tubercle bacilli that have been scattered abroad and have become attached to all the articles of traffic and commerce and domestic life that are in daily use by man are relatively harmless; for Flügge would make a condition resembling moist spray as almost necessary for inhalation infection.

The plausibility of Flügge's theory is considerably weakened by Heymann's scanty results that eventuated from unusually vigorous attempts to give susceptible animals pulmonary tuberculosis by having consumptives actually cough at them. Much doubt is also cast upon it by the fact that of the millions and millions of human beings who are infected it is perfectly impossible to trace except in a very small minority the existence of any such prolonged and intimate contact with coughing consumptives that Flügge would make necessary for infection to take place. Under ordinary conditions and unless an experiment were being performed one coughing consumptive could at the most infect only one person at a time. And it is almost beyond the powers of the imagination to conceive that the relatively small numbers of coughing consumptives would in the manner put forward by Flügge succeed in tuberculizing two-thirds of all human beings of cities before these reached the age of ten and three-fourths by the age of fifteen. That a not inconsiderable number of individuals are made tuberculous by moist spray and that this spray is the mouth spray of consumptives, is not to be doubted. But that the generality of mankind acquires tubercle in the Flügge way is extremely unlikely.

The ingestion idea presumes that tubercle bacilli arouse lesions after they are swallowed and carried to the intestine; and since the discovery of the bovine bacillus as a separate and distinct variety, it presupposes further that cow's milk is our most common and potent source of infection. This latter assumption is wholly dependent on the possibility that bovine bacilli are parasitic for human beings.

Our inquiry has shown that in man the conditions necessary to ingestion infection by bovine bacilli are fulfilled. Experiments, examination of the cadaver and clinical observation all agree that intestinal infection occurs; and bacteriological investigation has revealed the presence of the bovine bacillus in a fair proportion of human beings, particularly children. Before, however, we can accept the cow's milk theory and attach to it the importance that some of its proponents, like Calmette, would give it, we must clear three weighty obstacles. These are, the overwhelming preponderance of apparently primary pul

monary tubercle over apparently primary intestinal and abdominal tuberculosis; the sudden and baffling reversal of bovine statistics at about the age of puberty, (from about 25 per cent. of bovine infections before this age to practically none after it); and the apparent excessive rarity of bovine tubercle in the human lung. These three puzzles all await further discussion.

None of these three prominent theories— Cornet's, Flügge's and the ingestion theoriespay much attention to the frequent probability of primary infection of the respiratory and digestive tracts higher up than the lungs and intestines. They fail to do so because they were put forward and elaborated at a time when in the insufficiency of our knowledge of tuberculosis we thought that the first site of manifest tuberculous disease represented the primary localization of tuberculous infection. Twenty or thirty years of intensive study of tuberculous infection are, however, beginning to make us ponder, and likewise wonder whether this assumption is ever justified without exhaustive inquiry into every individual case.

We have found that the bacillus may reside in us for years perhaps without making its presence noticeable, that in the meantime the descendants of the first infecting bacilli may be carried far from the original portal of entry, and that during the intervening years all traces of transient residence of the bacilli between the portal of entry and a remote resting place may be obliterated. In any analysis of tuberculous infection these are facts of the first importance, and to-day they can no longer be even questioned. They make it certain, therefore, that in any given case we can be dogmatic about the portal of entry only when we find lesion or infection contiguous or almost so to an undeniable portal of entry. It is otherwise scarcely permitted us theorize about portals of entry and modes of infection from examination of cadaver or of patient or as concerns the human being to discuss anything more than possibilities on the basis of what we have learned from animal experimentation. We must go carefully into epidemiological data. We must inquire carefully into the habits of the people and strive to discover how these most commonly bring them into contact with tubercle bacilli. We must then attempt to harmonize pathological, clinical and experimental findings with what the methods just cited disclose

to us.

to

The

An insignificant number of human beings have been accidentally infected by inoculation, i. e., by wounds. But in the ordinary course of things the only portals of entry that we need consider as playing a part in tuberculous infection are the mouth and the nose. nose can play a part only in inhalation or contact infection since only air with dust or droplets normally enters it, except as the contaminated finger may touch its external parts. The mouth serves as a portal of entry for

material that is normally inhaled or for anything that is ingested or for any object that comes in contact with it such as the dirty hand. The nose tends to remove optical particles from the air by filtering them or by arresting them with its hairs and sticky mucus. The mouth strives to cleanse itself by the continual secretion of fluid and its incessant movements that pass this on to be swallowed. The throat or pharynx is common to both the digestive and respiratory tracts. So that, theoretically at least, particles can begin their entrance to the body by being inhaled through the nose and end by being swallowed, or by being prepared for swallowing by the mouth and end by being inhaled into the larynx and trachea and perhaps further. It is a very

narrow point of view that looks upon all inhalable particles, such as bacilli in dust or droplets, as entering the body through the nose. A large proportion must undoubtedly also enter by way of the mouth; for if the human face is exposed to any atmosphere then the lips and open mouth present a vastly larger surface of contact to it and are placed in a more exposed position than is the case with the nostrils. And in this connection we must always keep in mind the innumerable activities that impel us to open the mouth. Viewing

the matter from a practical standpoint, therefore, we should say that as regards any infection whatever except those that can exert their effects only after they have passed into the lower respiratory tract and so far as we know this has never been proved for any infection-the mouth presents the largest probability of its being the most common portal of entry for infections in general (except those that must be inoculated) and for tuberculous infection in particular.

From every side evidence has been accumulating that primary infection occurs in places that are more superficial than lungs or intestines much more frequently than we had formerly imagined. The Pirquet test has revealed the enormously important epidemiological fact that the greater part of mankind is infected first in childhood, yet the application of every modern and refined method of detection fails to reveal pulmonary or abdominal lesion in any but the veriest fraction of young children. Superficial tuberculosis, especially of the lymphatic nodes of the neck, is perhaps the most common manifestation of the disease in childhood. These cases point almost compellingly to the mouth as the major portal of entry in the individuals concerned. Francis Harbitz, who has made the most exhaustive studies of the organs of children that have died of diseases other than tuberculosis, has found that as he proceeded from the lungs or lower digestive tract toward the neck and mouth there was more and more infection demonstrable the higher he wentthat is, the nearer he approached the mouth and nose. Careful examinations of structures like the tonsil in children who show no evidences of clinical tuberculosis have revealed

the astonishing fact that an almost unbelievable proportion of such tonsils-and adenoids tooharbor tubercle bacilli.

Epidemiological studies disclose that a full half and more of all human beings receive their initial infection in a particular three or four years of childhood; that is, between about three and seven years. While infants are comparatively helpless and more or less confined to the home about 10 to 20 per cent. become infected. Such a proportion would be about what we should expect as the gross result of a combined Flügge droplet, ingestion, and contact infection; for the number of "open" consumptives in any civilized community can at any one time hardly be larger than one per cent. The helpless, much-fondled and milk-drinking infant would naturally be peculiarly liable to infection from its most intimate associates. But as the child begins to run abroad the opportunities for infection change and expand. It is too much to believe that most of these children come into the intimate contact with consumptives such as Flügge's theory would make necessary for infection. Some undoubtedly will ingest tuberculous cow's milk and thus become infected. Some will to a certainty take in mouth spray sufficient to infect. A few will presumably receive to themselves virulent dust. But babies should have almost equal opportunities to become infected in all these ways indoors, yet though highly susceptible they remain relatively free from tubercle.

We would therefore incline to the opinion that primary infection of the human being, which in the larger number of people means infection in childhood, occurs not so much in the lungs and abdominal organs as has generally been taught, but more frequently in the lymphatic appendages of the mouth, throat and nose than has heretofore been appreciated. Such an infection probably acts like most infections anywhere else in the body, that is, it tends to remain latent or is overcome. In support of this view we may recall the undoubtedly high incidence of tonsillar infection without manifest tuberculous disease.

The modus operandi of such an infection is presumably by contact with any material that carries tubercle bacilli-whether food, droplets, dust, or contaminated hands. The effective portal of entry is most likely to be the mouth; but to think of dust and droplets entering the body in this way and thus producing infection is a very different concept than Cornet's or Flügge's views of infection. As a potent and important source of infection we have essayed to give to raw sputum a much more prominent place than has ordinarily been assigned to it, whether this is the raw sputum in our public highways or that which has been directly deposited in the home or carried on our shoes and clothing from the street into the home. There can be no doubt that the average child at play frequently befouls his hands with raw sputum that is picked (Continued on page 118)

Tuberculosis is in our midst. To what extent should be determined by a proper method of record keeping, simple, yet comprehensive, even to determining the locality responsible for the contraction of the disease-, a method which shall be more than the mere recording of statistics of cases reported and deaths listed. How best can such a method of recordkeeping be accomplished? What, from the point of view of the larger unit, the State, is essential to such a plan? What from the point of view of the small units of community service, the dispensary, the private tuberculosis association, the hospital and branch clinics, existing temporary boards (such as examining or exemption) should be required in their contribution to such a plan? What, from the point of view of the other units of service, the local health authorities and the county authorities, is necessary to such a plan? What demands are to be made on these various authorities so as not to interfere with their plans already formulated?

Various units have methods which are good, and many small units that have no methods are receptive to suggestions that might bring about methods to fit in with others, so that there may be uniform data submitted for central recording and checking. Taking into consideration the points of view of all, should we not emphasize the point of view of a State in its effort, as a big unit, to accumulate and put to constructive use the data? Why not use as a basis or foundation, data received in accordance with the notification law requiring that tuberculosis shall be reported?*

Supplementary to this legal report, other sources of information should be utilized, such as applications for admission to hospitals and sanatoria, admission and discharge notice to and from hospital and sanatoria, laboratory findings of sputum exminations, death returns, exemption board returns, correspondence, regular field reports, special investigation reports, etc., etc.

For example, a State desires to begin a system of record-keeping whereby information from all sources shall be utilized in general, and separately, in that each individual's history shall ultimately be recorded in one place on one "set-card." It would seem needless to

* Such laws exist in most states.

mention that this system should be confidential between the various units so that patients' names would not be promiscuously revealed.

What is the first move? Why not begin the first of a calendar year and make a card index (4" x 6" is a good size) of every case of tuberculosis brought to the attention of the central authority with brief data, using as a basis the legal report before mentioned? The sources of information should be kept distinctive, for the purpose of study, for instance such as determining how many cases "get by" the legal report, or how long a time has elapsed since a very old report, and the per cent. reaching various sources without report, etc.

To keep the sources of information distinctive, different colored cards may be used. The clerk who handles these data may watch with interest the merging and evolutionary process in determining the why and wherefore of the various moves of the patients, and the tracing of each variation to a satisfactory conclusion, preparatory to the linking of the data constructively.

At the very start, no doubt, the question will come to mind as to which is more important, a community or a straight alphabetical index? Why not have both? One answer may be limited assistance. Then from the point of view of the field worker, probably the argument would be in favor of the community index; from the point of view of a statistician the straight aphabetical. But, from the point of view of the one overseeing the record-keeping, foreseeing the need of tracing each variation to its end-with limited assistance-one will consider a wide compass and decide upon a combination method, realizing that all engaged in the carrying out or contributing to the method, are to know through conferences, correspondence, etc., its simple workings, with special emphasis laid upon the need of a plan of notification when a patient leaves one community for another. This combination method will be a community index, in which there can be an alphabetical index also.

Why should there be a community index first? Because (1) perhaps the State in question has small units of self-government, and therefore the point of view of the community is of first consideration, and as different workers of the various smaller units cooperate throughout the State, the community

will always stand out; (2) if special work is to be done by the central big unit, the town or city will be a unit to be considered,-for instance (a) a survey is to be made; (b) a list of cases in a given community is to be analyzed. One wants to go immediately to the file and see the picture, so far as known to him, of the community in question. If it is to be a county survey, the towns can, in a few minutes, be put into a county group, or a health district survey into a "health district" group.

The argument for the straight alphabetical index from the statistician's point of view will be to check off duplicate cases. This, in a large measure, can be accomplished in the combination method. Each morning before the tuberculosis cases-which may come to the central authority from the various communities with name and address, age and form of diseases are counted by the statistician and entered, perhaps, numerically on community cards (with other diseases) the tuberculosis clerk can go over them to see if she has them recorded as having been reported before by the community, and if so, can make a note to that effect for her knowledge and that of the statistician in which event the case would not be counted again.

If the tuberculosis clerk has kept up her cross reference index, and followed clues to trace patients, practically all duplicates can be found. The community index is important in this connection, because names, especially of the foreign type, may be spelled variously, and the community clue is the important one, for some community must bear the count once (correspondence may be necessary occasionally to determine the question whatever method is in use) but should not repeatedly.

Too much emphasis cannot be laid upon the need of correct cross reference work. A file with a cross reference carefully kept is not a file of duplicate cases. Lack of intelligence in a beginner, or one not understanding records, will perhaps lead one to consider this cross reference work useless, and endeavor to short-cut, to the detriment of tracing each variation to a satisfactory conclusion.

The dispensary will be an important unit of a clearing house character, and if the dispensaries are supervised by the larger unit, or State, after a set of minimum requirements are made and each dispensary visited by the supervisor of records and started right in keeping records in harmony with those of the central agency, and then periodically visited, records will be kept uniformly, and the various other units will help cement this procedure by understanding the uniform methods in use. For instance, there should be in the dispensary, and in other units, minimum requirements for a straight alphabetical index and a street index, with medical history card and nurse's card as approved by the central unit; and a suggestion for certain classification, for the sake of uniformity, such as may be necessary to record patients dying, leaving town, or not tuberculous. This should result in a

simple vital working method, to be considered ultimately along with a State alphabetical index and a State community and alphabetical index (which in the start may have to be a combination method). By following the foregoing and being careful not to divide data permanently into too many groups, viz., "deaths by years," "cases by years,' to the detriment of giving up the simple method previously mentioned, a long step will be taken toward knowing exactly the extent of the disease in correct figures.

In handling cards, when years are to be considered in special tabulation work, it is simple enough to arrange by years at the time such a report is in the making. Too much emphasis cannot be laid upon the need of keeping records simply, always being able to locate by name and community without having to look in too many places. The State agency will expect that the various communities are to look to it for certain information about patients, and, on the other hand, the communities will expect the State to ask them for information as previously stated.

The supervisor of records may go into the field for the pupose of helping cement the workings of the central method, and may direct that certain data be copied (1) on blank detailed investigation card, (2) memorandum supplemental card, from the State register: (a) of the cases not reported on in detail,-the name, address, and date of report to the local authority, or in regard to the cases not reported to local authority which came to the knowledge of the State through other sources, the data as recorded by the central authority; (b) of the cases which have been reported upon in detail,-the name, address, date of report and whatever questions, after careful reading of detailed report on file, are to be answered in regard to progress of patient toward recovery or death. These cards should be taken up with the supervisor of field work or directly with the field workers of State or intermediary agencies after which they should be returned to the State for checking.

If a special survey is to be made along a number of lines of inquiry, a community group of cases by the State on cards, can be easily sorted in any manner necessary for checking data with local communities, and for collecting statistics in community reports, so that the retrogressive method of keeping case data on lists will soon be extinct.

Sometimes it may happen that field workers doing special survey work will go direct to the local records for first information, in which case it is well to indicate the records obtained through local sources for the sake of efficiency in linking the field work with the central office.

The State workers in making a survey, will no doubt, find it convenient, in planning for house to house visits, to take the district assigned, and mark off streets to be visited, and in a small filing case, jot the names of the streets on plain guides in pencil, placing in the

order of numbers, and as soon as a case is visited or disposed of, relegate it to the back of the case following a guide marked perhaps "call again," "finished history," "evening calls," etc., thus saving time in going over the same cards many times. When the day's field work is finished, and certain clerical work is to be done, it will be convenient to reclassify for another day's routine, erasing the pencil guide notes for the next day's classification.

Supplementary to keeping clear records of patients, a manual and directory gotten out by State or counties giving an index of all agencies, hospitals, etc., in respective counties, with timely suggestions in regard to tuberculosis would be of value.

OUTLINE OF ABOVE PLAN

I. State Records:

A. Sources:

1. Legal reporting of cases.

2. Application for admission to State Sanatoria.

3. Admission to:

(a) State Sanatoria.

(b) County Sanatoria.

(c) Local Sanatoria.

4. Discharges from:

(a) State Sanatoria.

(b) County Sanatoria.
(c) Local Sanatoria.

5. Deaths reported.

6. Sputum examinations.

7. Aliens with defects.

8. Special temporary boards. 9. Correspondence.

10. Field reports.

II. Uniform Minimum Records by other units such as Local Board of Health, Dispensary, Hospital, etc.:

A. Local Board of Health (Register):
1. Alphabetical index by name.
2. Street index of same.

B. Dispensary or Private Association:
1. Alphabetical index by name.
2. Street index of same.

3. Medical history card.

4. Nurse's card.

C. Hospital:

1. Alphabetical index.

2. Street index of same.

3. Medical history card or sheet.

4. Clinical chart.

D. Overseers of Poor:

1. Alphabetical index.

2. Street index of same.

E. City or Town Clerk:

1. Alphabetical index.

2. Street or place index of same.

III. Field Records of State and Intermediary Agencies:

A. State Agents' records.

B. Others submitting records:

1. Data recorded as required on detailed history card.

2. Supplementary data as requested by State.

1. Legal reporting of cases submitted to central office, index as follows:

(Green card 4′′ x 6′′).

Manchester, January 1, 1919.
Pul. Tb. Smith, Isaac, age 36,

100 Arlington Street.

Also reported to Springfield board of health, Jan. 8, 1919, from City Hospital. (This card will be filed under the town of Manchester in "S".)

(If a report is made of one person from more than one town, a cross reference is made, and if more than one report of a person is made from one town, each date of report is placed on the one card bearing the person's home address. A person should be counted but once.)

(Probably duplicate cases will be received from time to time at the central office. This would make a community appear responsible for more cases than it really has. Through a checking system one can ascertain the true situation. For instance, if it should happen that Isaac Smith was sent to a hospital in Springfield and the Springfield board of health should report the case, a card like the following would be made out, but the case would not be considered a Springfield case. Since it had been counted once the statistician would not want to count it again. And if the case of Isaac Smith should be reported again later in the year from Manchester, the date would be placed on the card bearing Isaac Smith's name, but he would not be counted again. The Springfield card, recording case of Isaac Smith is theoretically a part of the original Manchester card. Manchester being the home of the patient, any subsequent information will be filed under the town of Manchester. Again, if the patient should change his residence to another town in the state, his card may be transferred to the town in question, and a cross reference memorandum, stating the fact, remain under Manchester, etc.) Springfield, January 8, 1919.

Pul. Tb., Smith, Isaac,

100 Arlington Street, Manchester. "In City Hospital."

See report made to Manchester board of health, January 1, 1919.

2. Application for admission to State San

atoria.