various specific products of the bacillus-tuberculins have done not a little good in one or two very special types of cases, but only the thoroughly trained physician, experienced in their use, should administer them. Sunlight and various other forms of radiation, in the hands of experts, are apparently exerting a very favorable influence in the more superficial types of tuberculosis; in lung tuberculosis they have yet to win their place. Yet drugs, tuberculins, and sunlight and irradiation would not show much effect if at the same time rest was not part of the treatment; that is, the patient allowed to go his own way, with life unregulated and activities unrestrained, would in most cases "crumble" nevertheless.

Treatment by artificial pneumothorax involves the direct application of rest to the diseased lung. The injection of an inert gas, like nitrogen, into the chest cavity, under higher pressure than the lung can expand against, brings about a condition which compresses the lung, and fixes it and makes the rhythmic movements of breathing impossible. It is a measure to employ in selected cases, in which less drastic treatment, like bodily rest, has failed to arrest the disease. It has saved many patients, and ameliorated and prolonged the lives of many more. First suggested by an Italian forty years ago, and vigorously advanced by an American almost twenty-five years ago, it has, during the last decade, gradually won recognition as the one effective weapon against advanced pulmonary tuberculosis, which the period since the discovery of the tubercle bacillus (1882) has disclosed.

When the treatment of lung tuberculosis is successful, the foci of disease either disappear or are replaced by scar tissue, or they are surrounded by thick, globular envelopes of scar tissue, which prevent the egress of bacilli remaining within and make impossible the absorption of focal materials. In most patients who recover, the latter event very likely oc

curs.

As long as living bacilli remain in the body,

in such walled-off tubercles, the possibility remains that active disease can again flare up. And it is a lamentable fact that only too many who have recovered from one or more attacks of tuberculosis relapse.

Most break down again because they cannot withstand the strain of the life to which they return after treatment. They cannot or will not continue the regulated life that restored their health, and sooner or later they "crack."

This event is so common that the conscientious and wise practitioner insists upon the continuance of a modified treatment long after the patient has left his intimate care. He insists that the patient carry back to active life some of the maxims learned at the sanatorium; that he so regulate his affairs that he can always live with as little strain and fatigue as possible for fatigue is his danger signal that what is work for a normal man requires longer and more complete intervals of rest for him who was once a tuberculous patient; that overindulgence in any activity, while fatiguing to the healthy, may precipitate the relapse of a former tuberculous patient. Many patients, amenable to this advice, escape relapse. Most who are forgetful of it return -always a little worse off than before-to resume the "cure."

A man who has had active tuberculosis, who has recovered, and who returns to take his former place in society is "like a man with one leg trying to run a race with a man with two"; and he should arrange his life accordingly. A tremendous lot of the world's work has been done by men with tuberculosis or by those who were often on the brink of active disease-by Spinoza, John Locke, Chopin, Keats, Sterne, Raphael, Moliere, Canova, Schiller, Laennec, Emerson, Cecil Rhodes, and a host of others. But most of these had to do one of two things: either "put all their eggs in one basket" and live by rule to fairly mature and even old age, or seize the passing moment and burn themselves out in youth to leave imperishable monuments behind them.

Rational eugenic teachings of recent years have had their effects on the large and growing portion of our population which exercises prudential foresight before entering matrimony, and avoids reckless procreation when there is any doubt as to the probable physical and mental qualities of the newborn. Owing to its wide prevalence, its chronic course extending over many years in a large proportion of cases, and its tendencies to remissions during which the patients feel comparatively well, tubercu

* Read before the Sociological Section, seventeenth annual meeting of the National Tuberculosis Association, June 14 to 17, 1921.

losis very often creates problems of marriage and maternity. The unmarried ask whether they may marry; the married inquire whether they may have children with safety to themselves and to future generations.

A large number of physicians have answered these queries in the negative in practically all cases. Not only patients with active disease have thus been enjoined but also those who have had tuberculosis, but have more or less completely recovered, and some physicians have even gone so far as to prohibit, or at least to discourage, matrimony and parenthood of those whom they

considered "predisposed" to the disease.

The grounds for these prohibitions are not far to seek. Primarily, it has been argued, marriage endangers the healthy consort who is likely to contract the disease by intimate contact with the tuberculous spouse. Marriage is also said to be dangerous to patients, especially of the female sex. Moreover, on eugenic grounds, it has been alleged that inasmuch as tuberculosis, or a tendency to this disease, is transmitted by heredity, parenthood on the part of persons suffering from this disease is sure to increase the number of tuberculous individuals in generations to come.

Dangers to the Healthy Consort

an

It is a striking fact that admissions to sanatoria of both husband and wife, either simultaneously or consecutively, are exeedingly rare. Similarly, in the tuberculosis clinics in our large cities, in which enormous number of married tuberculous patients are treated, it is very rare to find that both husband and wife are under treatment for active tuberculosis. This fact becomes more significant when we bear in mind that it is different with other transmissible diseases, like typhus, influenza, smallpox, syphilis, gonorrhea, etc.

Five years ago I made an investigation of this problem among 170 married couples in which one of the consorts was tuberculous. They lived under conditions favoring the transmission of the disease, most of them sharing the same room and bed. Still it was a remarkable fact that only in 5, or 2.9 per cent. of the cases, were both the husband and wife affected with "open" tuberculous disease. Considering its prevalence among the general population, we should expect that between 6 and 7 per cent. of husbands of tuberculous wives, or wives of tuberculous husbands, would be affected with the same disease. As it is, we find that the chance of "contracting" tuberculosis from a sick consort is about the same as contracting diabetes, cancer, or insanity.

There is another way of testing this problem. A very large number of well known and great men and women were tuberculous. I have looked up many of those who were married and in not a single case have I discovered that their consorts were also affected by the disease. Moreover, many of the physicians working in sanatoria all over the world have taken up this work because of the condition of their own lungs. Among those who are married it is exceedingly rare to find that their wives have contracted the disease.

These facts prove conclusively that the dangers to the unaffected consort are negligible, and should have no influence when a contemplated marriage between a tuberculous person and a healthy person is considered.

Dangers to the Tuberculous Consort When discussing the effects of married |

We

life on a tuberculous individual we must diiferentiate between the various types of the disease which pass under the term pulmonary tuberculosis. On the one hand have the acute fulminating cases, commonly known as hasty consumption, as well as the final acute stage of the disease which ushers out many of those who have suffered from any of the chronic forms for months or years. Patients with these forms of the disease are acutely sick, just as those who have pneumonia, typhoid, acute articular rheumatism, etc. The problem hardly ever arises in this class of cases, excepting in rare instances when, as a result of the euphoria characteristic of some tuberculous cases, they delude themselves into thinking that they must be united in matrimony, but as a rule, the consorts-to-be refuse to enter into the bargain. In the rare instances in which for either sentimental or emotional, or because of some valid material reasons, marriage is demanded, it may be permitted because obviously no harm can result to either of the contracting parties, or eugenically.

The problem of marriage confronts us mainly with patients who suffer from the chronic forms of tuberculosis. Among them we have those with active disease, requiring prolonged treatment; those in whom the disease is quiescent, and they are fairly well able to attend to some occupation, barring the incidental exacerbations of the process which disables them now and then for some time; and those in whom the disease has been arrested, and the only problem that arises is whether they are likely to suffer from a relapse. It has been maintained that married life often proves disastrous to all these, especially women. Indeed, it appears that persons with the stigma of tuberculosis often find it difficult to marry because of the alleged dangers to themselves, as well as to the progeny.

It is clear that those with arrested lesions should not be restrained in this regard. Whether a relapse will occur hardly depends on the matrimonial state. Moreover, celibacy by no means implies abstinence, and extramarital relationship usually involves excesses and additional risks. Inasmuch as there is no danger to the healthy consort, as we have seen above, it is decidedly unjust and in many cases anti-social to prohibit marriage to these patients.

With active chronic tuberculous disease things are different. Here considerable caution is to be exercised, especially in the case of women. Experience with many of this class has taught the writer that here again. we must discriminate between those in whom the lesion is of the kind which we call "early," and those in whom it has been running a sluggishly chronic course for months

or years. In the former, a prognosis cannot be formulated with safety. They may recover within a few months, or the disease may run a progressive course; in the latter case the prognosis can be made with a reasonable degree of certainty. Inasmuch as in addition to the problems of clinical pathology there are, in the majority of cases, also involved material problems, our decision in this sort of cases must be guarded.

In early cases marriage should be postponed until an idea is gained as to the course pursued by the disease. If arrest is attained-and with proper treatment it is in a large proportion of cases-there is no reason for prohibiting marriage. If the course is progressive, the patient will not think of marriage, excepting in the rare instances mentioned above.

It is different with the exceedingly chronic cases which constitute the majority of patients who consult us in this regard. They have been sick for years, have had remissions in the disease which made them think that they had completely recovered, but sooner or later they have been disabused by exacerbations which proved conclusively that the lesion is still smouldering. The signs elicited by physical exploration of the chest also show clearly that they have active lesions; in many, cavities are found. But having adapted their organism to the toxic state, they feel more or less happy, though always apprehensive of an exacerbation of the disease.

I can see no reason why many of these patients should be prohibited from marrying, provided they find suitable partners who realize the tasks they undertake and are willing to face them. Our patient, who may have been despondet from lonesomeness which tuberculosis often bestows, may thus find a companion and Samaritan. The dependent young woman, unfit for continuous work for her support, but unwilling to spend the rest of her days in an institution, may thus find a man who takes good care of her, affords her frequent vacations, and thus keeps her in good condition for years despite the fact that physical signs show that she has a tuberculous lesion in her lungs. A tuberculous man, who has been shunned by members of his family and friends because of the exaggerated notions of infection which have been instilled into the general public during recent years, or who may not have been able to obtain lodgings in the city, may thus find a woman who is brave and willing to extend him a helping hand at a time when others treat him as an outcast.

We have seen that there is no danger of infection of the healthy consort. There has never been adduced uncontrovertible proof that marriage will harm the tuberculous consort. It is open to serious question whether unmarried tuberculous individuals live longer than those who are married. The scanty statistics on this subject that are

available tend to show that the reverse is true. Moreover, as has already been maintained, we must never lose sight of the fact that celibacy by no means implies continence, and extramarital relationship involves excesses and additional risks to the tuberculous.

Another class of patients who often inquire as to their fitness for marriage are those whom some physicians have grouped under the term "predisposed." It may not be generally known, but it is a fact that we do not know who is predisposed to tuberculosis and who is not. I have practiced medicine for twenty-five years, and have cared for many thousands of patients, yet I can candidly state that I cannot say, after carefully examining a person and subjecting him or her to the most approved clinical tests, whether he will at any time develop tuberculous disease, or not.

We are at present beginning to realize that the signs which were considered as predisposing, such as the flat and narrow chest, scars indicating ancient glandular disease, feeble musculature, etc., are indications of actual but smouldering tuberculous disease, as a rule. Moreover, experience has taught that when developing active disease of the lungs these persons are usually in less danger of being carried off by a fulminating or hasty process than those who are physically unblemished. It is the muscular, athletic and the vigorous who goes fast when developing tuberculosis.

Maternity

Because many women date back the onset of their lung disease to pregnancy, labor and lactation, many physicians have prohibited maternity to all who have active tuberculous disease, as well as to those who had been cured of an attack several years back, and many have warned those whom they considered predisposed. Because of the alleged hereditary transmission of the disease, or of a tendency to it, the teaching has been that, even when maternity is eagerly sought, the chances in favor of raising a healthy child at the risk of the mother's life are very slight.

Careful observation among numerous pregnant tuberculous women has, however, shown that not in every case is the disease aggravated by maternity, and that not every child born to a tuberculous woman is doomed. Many women under my care disregarded my warnings, and passed through pregnancies, labor and lactation without any apparent harm to themselves, and raised healthy children. In some cases the lesions in the lungs were arrested or healed, but in others far advanced, cavitary lesions were found, yet they passed through these physiological processes unscathed. Moreover, it appeared that the ancient observation thatsome tuberculous women are distinctly benefited by marriage and maternity is sus

tained very frequently. There is no doubt that many chlorotic girls, showing indefinite symptoms and signs of incipient tuberculous lesions, are often cured by marriage and pregnancy. The internal secretory activity of the female generative organs have an immense influence on the symptomatology and course of tuberculosis of the lungs. Observant clinicians have noted this relation in cases of tuberculosis in adolescent girls and in women during the menopause.

But we meet in books and monographs on tuberculosis statistics showing that while during pregnancy the lung lesion may be in abeyance, soon after labor the disease flares up and kills the patient sooner or later. These statistics have mostly been gathered by obstetricians, and concern patients with active and progressive disease. Some state that over 90 per cent. of tuberculous women are doomed by pregnancy and maternity; others put the percentage down as 75, still others, 60, 40, 20, and even as low as 10. The wide divergence of these proportions, running from 90 to 10 per cent., shows that they are either inaccurate, or based on clinical material which is not comparable.

Statistics published by internists, who have classified their clinical material, show that when the active and progressive cases are eliminated, and only the chronic cases are considered, irrespective of the so-called stages of the disease, pregnancy and maternity have little, hardly any, deleterious influence on the course of tuberculosis. Of fourteen tuberculous women under my care who had become pregnant during the past two years, twelve are now alive, and to my mind find themselves in the condition in which they would be expected to be had they not become pregnant. Likewise, Norris and Landis found that among the patients at the Phipps Institute 85 per cent. showed no change in their condition as a result of pregnancy, though 70 per cent. of the women were in the advanced stages of tuberculous disease. But when we deal with a large number of tuberculous patients, men or women, pregnant and sterile, about 20 per cent. will show aggravation of the disease during the course of two years which pregnancy and lactation involve.

Similar statistics have recently been published in Europe. Forssner calculated that 881 patients observed during the period 1907-1912 were not better off than 133 who became pregnant. Shäffer, in a study of the after-histories of married women discharged from a sanatorium, arrived at about the same conclusion. Of 425 patients thus observed during a period of 3 to 18 years, 136 had not become pregnant, and 189 had undergone from 1 to 7 pregnancies each since discharge. In 76.2 per cent. the women were still fit for ordinary or light work despite the fact that they had been pregnant and gave birth to and raised children. He found that only 18.4 per cent. had died of tuberculosis, but in only 13.7 per cent. was death

due to progress of the disease in connection with pregnancy.

From these figures, and many others that could be cited, it appears that if we exclude acute and progressive cases of tuberculosis who should not marry or procreate because of the acute disease, the dangers of pregnancy for tuberculous women have been exaggerated. Even when repeatedly occurring, pregnancy and maternity is well borne by the vast majority of women suffering from the chronic forms of pulmonary tuberculosis. To be sure, from 20 to 25 per cent. may suffer an aggravation of the lung disease during the period of pregnancy and lactation. But this may be considered coincidental in most instances. A similar proportion of tuberculous patients suffer from exacerbations of the disease during a period of two years involving pregnancy and lactation.

Labor in Tuberculous Women

Obstetricians agree that labor is no more likely to be difficult and protracted than in non-tuberculous women. It is indeed often amazing to witness an emaciated woman give birth to an infant in record time. The loss of blood during this process may be considered negligible. It has been estimated that the amount of blood lost during normal labor is between 300 and 500 grams, and experience has shown that it is soon regenerated by extra labor of the hematopoietic organs. More blood is often lost during pulmonary hemorrhages and the patient soon regains it; after labor the blood-forming organs are even better prepared for the task.

The New-born Infant

Congenital tuberculosis is extremely rare, and may by left out of consideration when speaking of inheritance of this disease. In fact, experience has shown that physically the newborn infants are, on the average, about the same size and weight as those born to non-tuberculous mothers, Stillbirths also are no more frequent than among non-tuberculous women.

It appears that infection with tubercle is the more dangerous the younger the infant. Thus, when infected during the first month of life, the infant is in great danger, though not invariably doomed, as some writers have maintained. I have seen many infants raised by mothers with open tuberculous lesions. But on the whole, the mortality among these infants is extremely high owing to infection with tubercle, bottle feeding, etc. However, if removed from the mother immediately after birth and fed by a wet nurse, or with properly prepared milk, most of these infants may be, and are raised to healthy maturity. As was already stated, many are raised by their mothers. This is seen in any clinic caring for tuberculous patients. Numerous women, with open tuberculous